PRINCIPLES & PRACTICE

Fifty Years of Progress in Neonatal and

Maternal Transport for Specialty Care
Shannon E. Perry

Correspondence
Shannon E. Perry, RN, PhD,
FAAN, 4157 Lookout Dr.,
Loveland, CO 80537.
seperry@sfsu.edu
Keywords
maternal (in utero) transport
neonatal mortality
neonatal transport
regionalization
transport
ABSTRACT
Specialty care for preterm and critically ill infants has evolved over many years. Neonatal intensive care nurseries were
developed, and physicians and nurses learned how to provide intensive care for these infants. Neonatal and maternal
(in utero) transport to tertiary centers became common in regionalized systems of care to facilitate the specialized care
of high-risk neonates when childbirth occurred in settings without specialized personnel or equipment. Annually, nearly
70,000 neonatal transports occur in the United States. Although specialty care helps reduce rates of neonatal mortality,
racial disparities and disparities between urban and rural areas exist. The purpose of this article is to review the
progress achieved in neonatal and maternal transport over the past 50 years. The knowledge developed can be used
to improve the care provided to women, their fetuses, and infants.
JOGNN, 50, 774–788; 2021. https://doi.org/10.1016/j.jogn.2021.04.013
Accepted April 7, 2021; Published online June 22, 2021

Shannon E. Perry, RN, PhD,
FAAN, is a professor
emerita, San Francisco State
University School of
Nursing, San Francisco, CA.
I n 2019, 10% of neonates born in the United
States were premature (Centers for Disease
Control and Prevention, 2020), and racial and
ethnic differences were apparent in the incidence
of preterm birth. The rate of prematurity among
non-Hispanic Black women (14.4%) was almost
50% greater than the rates among non-Hispanic
White women (9.3%) and Hispanic women
(10%) (Centers for Disease Control and
Prevention, 2020). Although there has been sig-
nificant progress in the care of vulnerable infants,
much effort is needed to reduce preterm birth
and eliminate racial disparities.
Preterm and critically ill infants continue to be born
in hospitals without skilled personnel or equipment
to adequately address their care needs. Approxi-
mately 15% of U.S. births occur in rural hospitals
(Kozhimannil et al., 2014). For the best chance to
survive, preterm and critically ill infants need an
environment with providers, equipment, and sur-
gical and laboratory capabilities to apply the skil-
led care that has been developed over more than
five decades. This necessitates transport for pre-
term and critically ill infants to nurseries where
intensive care can be provided. More than 68,000
transports to 940 NICUs occur each year in the
United States (Gisondo & Stanley, 2020), and
approximately 5,000 transports occur in Canada
(K.-S. Lee, 2019).
In 1971, the American Medical Association House
of Delegates adopted a statement in which
regionalized systems of graded care for pregnant
women and newborn infants were recommended
to reduce rates of maternal and infant morbidity
and mortality (American Medical Association
House of Delegates, 1971). For women and in-
fants to receive the necessary specialized care,
transport to tertiary centers became common. In
1972, the Canadian Paediatric Society published
Manual for the Transport of High-Risk Newborn
Infants (Segal, 1972). The manual included
detailed descriptions of methods of transport,
transport incubators, equipment needed,
personnel, referral systems, and forms for
recording care provided during the transport. It
described problems that might be encountered
during transport, gave directions for oxygenation
and thermal control, and discussed clinical
problems and special procedures. The sixth
edition of Standards and Recommendations for
Hospital Care of Newborn Infants, published by
the American Academy of Pediatrics (AAP) in
1974, included the chapter “Interhospital Care
of the High-Risk Infant.” This chapter addressed
similar topics to those in Segal’s book. A signifi-
cant addition was a small section on the impor-
tance of the continuum of care between the
referring hospital and the receiving unit. In 2017,
the AAP and American College of Obstetricians

774 ª 2021 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. http://jognn.org
Published by Elsevier Inc. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).
Perry, S. E.
and Gynecologists published the eighth edition of
Guidelines for Perinatal Care, which included a
chapter titled “Maternal and Neonatal Inter-
hospital Transfer,” which identified transport as an
essential component of regionalization to ensure
that pregnant women and infants receive care in
facilities that provide the necessary level of care
(Kilpatrick & Papile, 2017).
The purpose of this article is to trace the devel-
opment of regionalization and the transport of
infants to designated centers, methods of trans-
port, specialized care needed during transport,
safety, and associated problems and legal is-
sues. I discuss the move from neonatal transport
only to neonatal and maternal (in utero) transport.
Although such progress occurred over many
years and in many countries, I focus on changes
within the United States and Canada from the
early 1970s to the current day. By examining past
practices and changes over time, early in-
novators are recognized, and progress is
appreciated for the major advancements in the
care of preterm and critically ill newborns. The
knowledge gained over the past 50 years can be
used to improve the care provided today to
women, their fetuses, and infants. Standards,
protocols, and guidelines developed during
these years inform nursing and interdisciplinary
practice today.
Background
In 1971, the estimated neonatal mortality rate in
the United States (death at younger than 28 days)
was 14.3 per 1,000 live births; the rate for White
infants was 12.9, and the rate for “all other” in-
fants was 20.8 (Wegman, 1972). In 2018, the
neonatal mortality rate was 3.78 per 1,000 live
births (Ely & Driscoll, 2020), a significant
decrease that attests to advances in health and
the care provided to infants. However, racial dis-
parities still exist (see Table 1), and mortality rates
vary in relation to urbanization. Lower rates occur
in large urban counties, and greater rates occur
in rural counties (Ely et al., 2017). The speciali-
zation in care of the newborn, regionalization of
perinatal care, development of NICUs, transfer of
infants to institutions where they receive special-
ized care, and transfer of women with the fetus in
utero are important factors that help reduce
neonatal mortality. Advances in perinatology and
neonatology as well as the training of neo-
natologists, neonatal nurses, and neonatal nurse
practitioners (NNPs) provide the expertise to care
for high-risk neonates and infants.
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PRINCIPLES & PRACTICE
Between 1971 and 2019, the neonatal mortality rate
significantly decreased in the United States, but disparities
still exist related to race and location.
In the early 20th century, the care of premature in-
fants was focused on physiologic needs: providing
warmth and adequate nutrition, preventing infec-
tion, and handling minimally (Lundeen, 1937;
O’Donnell, 1990). Some infants born at home
needed specialized care and were transported to
hospitals by car, train, taxi, and, when available,
ambulance (Butterfield, 1993). In 1898, Dr. Joseph
DeLee founded the first incubator station in the
United States, in Chicago, IL, and designed a
transport incubator that provided warmth for the
infant during transport. In 1922, at Michael Reese
Hospital in Chicago, Dr. Julius Hess created a pre-
mature station and developed the Hess premature
infant ambulance (see Figure 1). The Chicago
Department of Health, police, and private ambu-
lances provided neonatal transport (Butterfield,
1993; Gartner & Gartner, 1992; Hess, 1951).
Transport to community hospitals was not always
satisfactory for infants who required specialized
care since such care was not always available.
Recognizing the need for special units to care for
premature and critically ill newborns, Dr. Louis
Gluck opened the first NICU at Yale–New Haven
Hospital in 1960 (Gluck, 1992). In the 1960s and
1970s, NICUs proliferated so that, by 2018 in the
United States, there were 942 NICUs and more
than 22,000 NICU beds (American Hospital
Association, 2020).
Specialization in Care of the
Newborn
In 1960, the term neonatology was first used by
Schaffer in the introduction to his book Diseases
of the Newborn. He defined neonatology as “the
art and science of diagnosis and treatment of
disorders of the newborn infant” (Schaffer, 1960).
The first neonatal–perinatal subspecialty exami-
nation was offered by the American Board of
Pediatrics in 1975, and 335 pediatricians were
certified as the country’s first neonatologists
(Raju, 2020). Evelyn Lundeen, RN, and Dr. Julius
Hess at Michael Reese were legendary in the
care of premature infants and published two
editions of The Premature Infant (Hess &
Lundeen, 1941, 1949). Nurses have always
figured prominently in the care of premature in-
fants and, from early on, have published articles
775
PRINCIPLES & PRACTICE Fifty Years of Progress in Neonatal and Maternal Transport for Specialty Care

Table 1: Racial Disparity in Infant Mortality, Infant Deaths/1,000 Live Births

Non-Hispanic

American Indian or Native Hawaiian or Other

Total White Black Alaska Native Asian Pacific Islander Hispanic
3.78 3.00 7.06 4.12 2.67 5.38 3.43

on their care (Meiks, 1937; Wallinger, 1945;
Wuellner, 1939). In the United States, there are
four specialty organizations for neonatal nurses
and one for nurses who provide care during
newborn transport (see Table 2).
Level III/IV centers (American Academy of
Pediatrics, Committee on Fetus and Newborn,
2012; Follett et al., 2017; Freed et al., 2010;
Snapp & Reyna, 2019; Staebler & Bissinger, 2017).

The first NNP prepared at the graduate level, Pat-
ricia Johnson, completed a self-designed grad-
uate curriculum in 1973 to test the feasibility of an
advanced practice role for a nurse in a NICU
setting. Her 7-week internship included indepen-
dent study with neonatologists and maintaining a
traditional resident physician schedule by man-
aging her own group of patients 7 days a week and
being in house every third night. Johnson also
described evaluation of the program (Johnson,
2002). Today, NNPs are essential personnel at all
levels of neonatal care but especially in Level II and
Regionalization of Perinatal Care
The American Medical Association’s 1971 state-
ment on the regionalization of perinatal care
(American Medical Association House of
Delegates, 1971) seemed to provide the answer
to neonatal mortality associated with preterm
birth and the birth of critically ill newborns.
Merkatz and Johnson (1976) suggested that
regionalization would lead to a system of alloca-
tion of resources to the benefit of the newborns.
The designation of hospitals by perinatal levels
began according to their ability to meet the needs

Figure 1. The Hess transport incubator. Used with permission of Ray Duncan, MD.

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Perry, S. E.
Table 2: Specialty Organizations for Neonatal Nurses
Organization Year Established
National Association of Neonatal Nurses (NANN)
nann.org
Academy of Neonatal Nurses (AAN)
www.academyonline.org
Council of International Neonatal Nurses (COINN)
www.healthynewbornnetwork.org/partner/council-of-
international-neonatal-nurses-inc-coinn/
National Association of Neonatal Nurse Practitioners 2007 (as a
(NANNP)
nann.org/membership/nannp
Air & Surface Transport Nurses Association (ASTNA) 1980/1981
www.astna.org
of newborns. The American Academy of
Pediatrics, Committee on Fetus and Newborn,
2012 defined levels of care for neonates in 2004:
Level I centers provided basic care; level II
centers provided specialty care, with
further subdivisions of IIA and IIB centers;
and level III centers provided subspecialty
care for critically ill newborn infants with
subdivisions of level IIIA, IIIB, and IIIC fa-
cilities. (p. 588)
Level III NICUs are associated with academic
institutions where neonatologists are trained to
manage and treat high-risk infants. Currently, the
highest level of neonatal care is designated Level
IV/Level IIIC, and a wide variety of surgical spe-
cialists and procedures are available at these
facilities. Only Level IIIC is recognized by the AAP
(Bird, 2020). It is from Level I and II settings with
fewer personnel and resources available for im-
mediate care that the need for transport
developed.
Many articles published in the 1970s and 1980s
described the transport of infants and docu-
mented outcomes (Greene, 1980; McCormick,
1981; McCormick et al., 1985; Merkatz &
Johnson, 1976; Schlesinger, 1973; Shott, 1977;
Usher, 1977). In 1976, Merkatz and Johnson re-
ported that perinatal mortality rates were cut in
half by the provision of care for preterm and
critically ill infants in institutions with an appro-
priate level of care. Several states, including Ari-
zona (Clement, 2005), Illinois (Miller, 1989), and
Colorado (Butterfield, 1993), have a long history
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PRINCIPLES & PRACTICE
Number of
Members Publications
1984 8,000 Advances in Neonatal
Care
2001 6,000 Neonatal Network
2005 6,000 from 60 Affiliated with Journal of
countries Neonatal Nursing
1,300 Consensus statements,
division of standards, position
NANN) papers, white papers
2,500 Air Medical Journal
of perinatal intensive care and regionalization
with positive effects in reducing neonatal
mortality.
In the 1980s, changes occurred in the reim-
bursement system for health care in the United
States, and the prospective payment system was
introduced (Gagnon, Allison-Cooke, & Schwartz,
1988). With the growth of health maintenance
organizations (HMOs) and other managed care
systems, price competition occurred, and hospi-
tals for maternal or neonatal transfer were
selected on the services available and cost
effectiveness. Some deregionalization occurred
as more neonatologists became available and
Level II centers were introduced in community
hospitals (Gagnon, Allison-Cooke, & Schwartz,
1988; Wall et al., 2004). The success of the peri-
natal care delivery system depended on
communication and cooperation among pro-
viders and systems (Gagnon, Allison-Cooke, &
Schwartz, 1988).
Neonatal Transport to Regional
Tertiary Centers
Transport was originally by ground in a local
ambulance service, taxicab, hearse, and, later,
by fixed-wing aircraft (FWA) or rotor-wing aircraft
(RWA). In some instances, parents transported
infants in their own vehicles. Infants were trans-
ported from the referring hospitals in a variety of
conveyances with personnel who had no special
training in the care or transport of premature or ill
newborns (Chance et al., 1973). When critically ill
patients were transported by inadequately
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PRINCIPLES & PRACTICE Fifty Years of Progress in Neonatal and Maternal Transport for Specialty Care
trained staff with inadequate equipment, infants
often arrived at the referral centers in poor con-
dition (Chance et al., 1973; Hood et al., 1983).
Hypothermia in infants awaiting or during transfer
was a significant risk factor because mortality is
greater in infants whose core temperature is less
than that optimal for survival (36–37  C). Gunn
and Outerbridge (1978) reported that hypother-
mia (temperature of less than 36  C) was present
in 25% of 163 infants when the transport team
arrived. During transport, 77% of the infants were
warmed, and only 3% arrived at the NICU with a
temperature of less than 35  C.
With regionalization and the development of
specialized nurseries in tertiary centers, the re-
sponsibility for transport changed from the refer-
ring hospitals to the centers. These centers
developed sophisticated transport vans staffed
by specially trained personnel (Harris & Belcher,
1982; Shott, 1977; Stroud et al., 2013). The main
reasons for transfer were prematurity, low birth
weight, and respiratory difficulties (Blake et al.,
1975). When comparing the morbidity and mor-
tality of infants transported with those born at the
tertiary center, the inborn neonates had shorter
lengths of stay, fewer complications, and lower
rates of morbidity and mortality (Modanlou,
Dorchester, Thorosian, & Freeman, 1979;
Strobino et al., 1993). Clinicians began to
consider maternal transport as the safest trans-
port incubator for the fetus (Gibson et al., 2001;
Troiano, 1989).
Initiation of Transport
When transport is considered, the sending hos-
pital calls the receiving hospital and speaks to the
perinatologist or transport coordinator to
describe the condition of the patient (mother or
newborn), seek consultation, and ascertain if
space is available. In one-way transports, the
sending hospital assumes responsibility for the
transfer, including securing the ambulance and
personnel to accompany the patient. It retains
responsibility for the patient until arrival at the
receiving hospital. At times, this was less than
ideal: inadequately trained personnel, improper
equipment, limited medications and supplies,
and delays in transfer put newborns and/or
pregnant women at risk (Hood et al., 1983; Stroud
et al., 2013). In two-way transports, the regional
center sends a transport team to the sending
hospital to stabilize the patient and transport to
the regional center (Gibson et al., 2001; Stroud
et al., 2013; Troiano, 1989).
778 JOGNN, 50, 774–788; 2021. https://doi.org/10.1016/j.jogn.2021.04.013
Stabilization of the Neonate Before
Transport
When the transport team arrives, a thorough
assessment of the neonate is performed, and
necessary treatment is continued or initiated if not
in place (Diehl, 2018). The neonate may be intu-
bated, require oxygen, or have a chest tube
inserted. Mechanical ventilation, intravenous so-
lutions infused via an umbilical catheter or pe-
ripheral vein, or other therapies may be needed.
Only when the neonate is judged to be stable
enough for transport does the transport team
transfer the neonate to the transport incubator.
Inadequate stabilization before transfer is the
leading cause of complications during transfer;
thus, the time taken to stabilize the neonate is well
spent (Wahab et al., 2019).
Back Transport of Infants
The early success of regionalization with the
transport of infants from Level I and Level II
nurseries led to overcrowding in Level III nurs-
eries, necessitating the transport of infants to
other Level III centers or the transport of conva-
lescing infants back to a Level I or II nursery in a
community hospital (Bourque et al., 2019). The
benefits of back transfer include decreased
crowding in the Level III center; cost savings,
because care in a Level I or II nursery is less
expensive than in a Level III center; increased
participation of primary physicians; and greater
proximity to parents who can then interact with
and begin to parent their infant more readily
(Bourque et al., 2019; Jung & Bose, 1983; Phibbs
& Mortensen, 1992; Zarif et al., 1979).
NICU staff from the tertiary hospital can ease the
transition from the Level III center to the com-
munity hospital (Page & Lunyk-Child, 1995).
Communication among providers is essential
within the NICU and between the staffs of the
NICU and the nursery of the community hospital
(Steeper, 2002). When there were fewer differ-
ences in care between the NICU and the com-
munity setting, mothers reported experiencing
less stress (Slattery et al., 1998). On mailed
questionnaires, parents rated preparation for the
transition more positively when they were con-
tacted by community hospital staff before trans-
port (van den Berg & Lindh, 2011).
As staff identified concerns about the outcome of
infants who were back transported, leadership
teams of many units developed systems to track
outcomes for infants who were transported back
http://jognn.org
Perry, S. E.
to a community hospital and those who remained
in the NICU. Lynch et al. (1988) found that the
convalescent course of infants back transported
was similar to that of infants who convalesced in
the Level III center. In some instances, when
health care providers determine that the infant
cannot survive, and parents request it, the infant
can be returned to the hospital of origin or to the
parent’s home, where parents and family can
spend quality time with their infant until the end of
the infant’s life.
Neonatal Palliative Care
In spite of advances in care of preterm and criti-
cally ill neonates, some have adverse and life-
limiting outcomes. Neonatal palliative care pro-
vides an opportunity to improve quality of life
when the goal of care is no longer prolongation of
life or the prognosis is uncertain (Parravacini,
2017; Sieg et al., 2018). The National
Association of Neonatal Nurses (2015) in their
position statement on “Palliative and End-of-Life
Care for Newborns and Infants” recommended
that all neonatal nurses be trained to offer pallia-
tive and end-of-life services to infants and their
families. The desired outcome of neonatal pallia-
tive care is the provision of comfort; relief of pain,
discomfort, and other negative sequelae for the
infant; and an opportunity for parents to bond with
and participate in the care and decision making
related to their infant (Parravicini, 2017).
Method of Transport: Ground or
Air, FWA or RWA
The first ambulance solely for neonatal transport
was one donated to the Chicago Department of
Health in 1934 by Dr. Martin Couney. During the
Chicago World’s Fair, Dr. Couney had a public
exhibition of premature infants, and when the
exhibit closed, he no longer had use for the
ambulance (Butterfield, 1993). Cars, ambulances,
and hearses were used over the next several de-
cades. In the 1960s, FWA and helicopters were
used for longer transport distances. The first
known helicopter transport of a preterm infant in
the United States occurred in 1967 when an infant
was flown from Zion, IL, to a premature nursery in
Peoria, IL, a distance of slightly more than 200
miles (Perry, 2017; see Figure 2). For the first flights
in the 1960s and 1970s, equipment needed to be
modified; later, helicopters and planes were
specially equipped for patient transport.
The choice of vehicle depends on the availability
of vehicles and transport personnel, need for
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The choice of transport vehicle depends on
vehicle and personnel availability, the need for rapid
transport, distance, weather, and the availability of landing
sites for aircraft.
rapid transport, distance, weather, and availabil-
ity of landing sites (Hackel, 1975; Schneider
et al., 1992). For distances of less than 50 miles
and in a city, ground ambulance is preferred
(Ferrara & Perrotta, 1976; Hackel, 1975). For in-
termediate distances, a helicopter is the vehicle
of choice, and for distances of more than 100
miles, FWA is most often used (Feldman & Sauve,
1976; Hackel, 1975; see Figure 3).
By the 1970s, with increasing regionalization of
perinatal care, the transport of infants needing
intensive care was well established. Personnel,
equipment, supplies, and medications necessary
for a safe transport, as well as the necessity of
evaluation of performance, were identified
(Feldman & Sauve, 1976; Harris & Belcher, 1982).
Personnel skilled in care of the critically ill
newborn or high-risk mother with training in
transport were essential for good outcomes
(Chance et al., 1978).
Transport Team Composition and
Training
Neonatal transport has evolved from the quick
transfer of a sick infant from home or the hospital
of birth to another hospital to the stabilization of a
critically ill neonate and intensive care transport
to a tertiary center (Cunningham & Smith, 1973).
In early transports, pediatric house staff, neonatal
fellows, or anesthesiologists were commonly the
team leaders, with a nursery nurse and respira-
tory therapist (Elliott et al., 1996). More recently,
teams are composed of a combination of two to
three nurses, physicians, paramedics, and res-
piratory therapists (Karlsen et al., 2011). A
physician/nurse team may be used when the
condition of the neonate requires the presence of
a physician. As the distance of transport in-
creases, the number of nurse/nurse teams in-
creases (Danzig, 1984). For economic reasons
and availability of personnel, there has been a
move to nurse/nurse or nurse/respiratory thera-
pist teams for neonatal transport, with the majority
of teams being nurse/respiratory therapist
(Karlsen et al., 2011). In the early 2000s, S. K. Lee
et al. (2002) reported that nurse/nurse teams
were the most cost effective.
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PRINCIPLES & PRACTICE Fifty Years of Progress in Neonatal and Maternal Transport for Specialty Care

Figure 2. Plaque commemorating first neonatal transport in a helicopter in the United States.

Almost 40 years ago, Cook and Kattwinkel (1983)
compared the care provided by nurse-supervised
teams with that of physician-supervised teams
and found that infants who had similar severities of
illness before transport significantly improved dur-
ing transport and had comparable clinical condi-
tions after transport regardless of team
composition. Thus, the safety of nurse-led teams
was supported and continued to develop.
Neonatal Transport Systems and Teams
The four types of systems of transport are (a)
hospital based, owned and operated by a spon-
soring institution; (b) community based, owned
and operated by private companies; (c) emer-
gency medical services (EMS) based, owned
and often subsidized by government funding
(local, regional, and state); and (d) hybrids, with a
mix of the three systems (Stroud et al., 2013).

Figure 3. Transport nurse Valerie Vickers, ready for two-way transport of a neonate. Courtesy of Valerie Vickers.

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Perry, S. E.
Transport teams may be unit based or dedicated
(Karlsen et al., 2011). Unit-based teams are
composed of personnel from the NICU who carry
out regular patient care or other assignments
between transports. Dedicated teams are based
in a receiving facility with the primary re-
sponsibility of transport or in a service that is
freestanding and not affiliated with a hospital.
Training Nurses for Transport Duty
Training for transport is a subspecialty focus.
Commonly, experienced NICU nurses receive di-
dactic and practical training to enable them to
assess, manage, stabilize, and transport ill neo-
nates. This training can occur “in house” or in
continuing education or college and university
courses with neonatologists, neonatal nurse
practitioners, and respiratory therapists as teach-
ers. The selection of transport nurses is based on
“leadership qualities, organizational skills, and the
ability to prioritize care and deal with stress during
emergency situations” (Skelton, Perkett, Major,
Vaughan, & Stahlman, 1979, p. 63).
Setting Up a Neonatal Air Transport
System/Service
Harris and Belcher (1982) described the essen-
tials of equipment and environment for the heli-
copter transport of newborn infants: a transport
incubator; a warm cabin; adequate light; earcups
that attenuate noise; an intercom system for
communication; an oxygen source, including a
small portable unit for transfer between the
nursery and the helicopter; and an appropriate
electrical supply. The equipment must meet
special requirements and be secured to prevent
movement during flight. Regular testing and
maintenance are essential. Transport incubators
are specially designed to keep the infant free of
contaminants and provide warmth and humidity
to maintain body temperature. The AAP Guide-
lines for Air and Ground Transport of Neonatal
and Pediatric Patients (fourth edition; Insoft et al.,
2015), the Field Guide for Air and Ground
Transport of Neonatal and Pediatric Patients
(second edition; Meyer et al., 2018) and the Na-
tional Association of Neonatal Nurses Neonatal
Nursing Transport Standards: Guidelines for
Practice (Price-Douglas et al., 2010) are valuable
resources, with detailed information on equip-
ment recommendations for transport.
Early incubators were heated by hot water bot-
tles, and oxygen was piped in from a tank. The
Accli-Bator was commonly used in the 1960s,
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PRINCIPLES & PRACTICE
with heat supplied by a plug-in to the ambulance
cigarette lighter (Perry, 2017). Later models of
transport incubators were made of rigid Plexiglas
and were designed so that the infant was visible.
Incubator design became increasingly sophisti-
cated until the transport incubators of today have
the capability of providing ventilation, oxygena-
tion, intravenous fluids, extracorporeal membrane
oxygenation (ECMO), suction, and chest
drainage during transport (see Figure 4). Moni-
tors and infusion pumps incorporated into
neonatal transport should be those specially
designed for use at high altitudes and designed
to tolerate vibration (Harris & Belcher, 1982).
Transport of Neonates With
Specialized Problems and
Procedures
Although most neonates transported in the 1960s
to the 1990s were preterm and critically ill and
needed the services available in a NICU,
increasing numbers of preterm and term infants
with cardiac and respiratory problems or
congenital malformations were transported as
personnel and transport incubators became more
sophisticated (Dräger, n.d.; Morriss & Brumley,
1971; see also Figures 1 and 4.) The increasing
complexity of the conditions of newborns that
may be transported necessitated more special-
ized training, refined procedures, and advanced
equipment for transport.
Researchers determined that technology such
as nasal continuous positive airway pressure
was a safe method of respiratory support during
ground transport (Bomont & Cheema, 2006;
Kapadia et al., 2012). High-frequency ventilation
was used successfully for the air transport of
infants in severe respiratory failure (Honey et al.,
2007). Inhaled nitric oxide was used during
ground, helicopter, and FWA transport and
reduced the referral rates to ECMO centers
(Lutman & Petros, 2008).
Benefits and Challenges of Air
Transportation of High-Risk Infants
Beginning in the 1970s, articles describing the air
transport of high-risk or critically ill infants
appeared in the literature. Air transport had the
advantage of a reduction in the time of transport
over long distances and the ability to reach in-
fants in more remote areas (Schneider et al.,
1992). St. Anthony Hospital in Denver, CO, star-
ted a helicopter service for transport in 1972 and
781
PRINCIPLES & PRACTICE Fifty Years of Progress in Neonatal and Maternal Transport for Specialty Care
Figure 4. A modern transport incubator. Courtesy of the OSF Healthcare System.
is sometimes credited as the first hospital-based
helicopter service in the United States. However,
St. Francis Hospital in Peoria, IL, had established
a helicopter transport program in 1967 (Perry,
2017; Sheehy, 1995).
Stresses Associated With Transport
Flight may have negative effects on the infant and
transport personnel. Hypoxia, changes in tem-
perature, and decreased humidity can negatively
affect passengers. Increases in altitude allow
gases in the intestine, peritoneum, and chest
cavity to expand and may compromise infants
with such conditions as pneumoperitoneum, dia-
phragmatic hernia, pneumothorax, and intracra-
nial bleeds (Hubner & Dunn, 1982; Schierholz,
2010). Hypoxia is the most dangerous stress
with increased altitude. As gas expands, the
pressure in the alveoli is decreased, resulting in
less oxygen pushed into the blood stream. Pres-
surization of the cabin helps alleviate hypoxia
(Hubner & Dunn, 1982; Schierholz, 2010). Hu-
midity in flight is low, increasing the infant’s risk of
dehydration.
Rough roads in ground transport, turbulence in
aircraft, inclement weather, and variations in alti-
tude can cause discomfort for neonates, preg-
nant women, and the accompanying personnel;
air sickness may occur (Ferrara & Perrotta, 1976).
During transport, infants and personnel are sub-
jected to multiple stressors, including vibration,
noise, and temperature changes (Bailey et al.,
782 JOGNN, 50, 774–788; 2021. https://doi.org/10.1016/j.jogn.2021.04.013
2019; Macnab et al., 1995). Acceleration and
deceleration, starting and stopping, and takeoff
and landing all increase vibration (Macnab et al.,
1995). How vibration affects newborns is un-
known, but studies in adults have found untoward
physiologic effects, such as mean arterial pres-
sure changes and pulmonary edema (Clark et al.,
1967; Sherwood et al., 1993). In addition, vibra-
tion makes the practical skills of accurate
assessment and treatment difficult (Shenai et al.,
1981).
Bailey et al. (2019) studied the amount of vibra-
tion present during ground ambulance transfer
and tested a variety of mattresses to reduce the
effects of vibration on the neonate. Vibration
levels in transit may exceed adult limits of vibra-
tion tolerance (Bailey et al., 2019). Using a gel-
filled mattress with or without a foam pad, as
well as modifying the Isolette tray by inserting a
foam restraint between the tray and the track on
which the tray rests and putting a foam pad in the
dead space beneath the tray to reduce move-
ment of the tray, resulted in the least accentua-
tion, or a decrease in vibration, experienced by
an infant or a manikin (Gajendragadkar et al.,
2000; Shenai et al., 1981; Sherwood et al., 1993).
Campbell et al. (1984) compared vibration and
sound levels in infants transported by ambu-
lance, RWA, and FWA. The sound levels in
ambulance transport and FWA were similar,
whereas the highest levels of sound were with
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Perry, S. E.
RWA. Vibration was low when the incubator was
stationary before the transport vehicle began to
move, but vibration increased in transit. The RWA
produced the greatest vibration, and the FWA
produced the least, while cruising (Campbell
et al., 1984). The significant noise in an RWA in-
terferes with assessment of heart and breath
sounds as well as with hearing monitor alarms
(Ferrara & Perrotta, 1976; Schneider et al., 1992).
Although manufacturers have made adaptations
to incubators used in hospitals to monitor and
adjust noise, light, sound, and temperature
(Dräger, 2021; Marks et al., 1981), the attenuation
of noise and vibration during transport is much
more difficult.
Accreditation of Transport Services
There are five organizations that accredit trans-
port services, including the Commission on
Accreditation of Medical Transport Systems
(CAMTS; www.camts.org), the Commission on
Accreditation of Ambulance Services (www.caas.
org), The Joint Commission International (www.
jointcommission.org), the National Accreditation
Alliance of Medical Transport Applications
(intranet.naamta.com), and the European Aero-
medical Institute (eurami.org). As of April 17,
2021, there were 160 transport services
accredited by CAMTS. These services include
RWA, FWA, ground vehicles (including all-terrain
vehicles), boats for water transport, and interna-
tional transport services (CAMTS, n.d.). The
Commission has criteria that transport vehicles,
equipment, and transport nurses/personnel must
meet. Broad categories for evaluation include
management and staffing, quality management,
patient care, communications, rotor-wing stan-
dards, fixed-wing standards, surface standards,
and special operations (CAMTS, 2018).
Safety of Neonatal and Maternal
Transport
Ground ambulances, RWA, and FWA have been
involved in crashes resulting in injuries and some
fatalities. In 2019, there were 31 fatalities in
ground transports (National Center for Statistics
and Analysis, 2020) and 14 accidents and two
fatalities involving helicopters (National
Transportation Safety Board, n.d.; the types of
patients were not specified). When an ambulance
is running with lights and siren, accidents are
more likely to happen, especially at intersections
when other vehicles do not yield (Watanabe et al.,
2019). In most instances, it is preferable to travel
at a safer speed without lights and siren. It is
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PRINCIPLES & PRACTICE
incumbent upon the transport service to maintain
equipment with regular servicing, ensure that
equipment is properly secured in the vehicle, and
that extra supplies are available as needed.
Challenges and Benefits of
Maternal (In Utero) Transport
By the mid-1970s, there was evidence of
improved neonatal survival with maternal (in utero
fetal) transport. Maternal transport is easier and
less expensive than neonatal transport (Giles
et al., 1977; Modanlou, Dorchester, Thorosian, &
Freeman, 1979) and may be accomplished by
ground ambulance, FWA, or RWA. Tertiary cen-
ters assumed responsibility for transport,
including providing personnel and the method of
transport.
The most common reasons for maternal transport
were premature labor, premature rupture of the
membranes, and third trimester bleeding
(Modanlou et al., 1980). Critical care diagnoses,
including hypertensive crisis, hemorrhage,
trauma, and respiratory compromise, accounted
for approximately 25% of maternal transports by
the mid-1990s (Elliott et al., 1996). In 2019, in one
critical care transport program, the top three in-
dications for transport were “preterm labor, hy-
pertensive disorder of pregnancy, and other
maternal life-threatening disorder” (Nawrocki et
al., 2019, p. 377). Exacerbation of hypertensive
disease, hypotension, and alteration in mental
status were clinically significant events that
occurred during transport (Nawrocki et al., 2019).
Many transported patients are in active labor;
thus, time and distance to the tertiary center are
important. A major concern in such transports is
birth and the need for resuscitation of the
newborn during the flight (Jones et al., 2001).
Elliott et al. (1982) reported no in-flight births in
100 helicopter transports. In a national survey,
during 357 RWA transports, there were no births,
and only one birth occurred during 88 FWA
transport flights (Low et al., 1988). Emergency
transport for preterm labor is more common in
rural areas than in nonrural areas, and air trans-
port is more commonly used, which increases the
cost of transport (Vilalta & Troeger, 2020).
Using data from experimental animals, Parer
(1982) expressed concern about potential haz-
ards to a fetus due to altitude during maternal
transport, especially in the presence of some
compromise of placental function. Huch et al.
783
PRINCIPLES & PRACTICE Fifty Years of Progress in Neonatal and Maternal Transport for Specialty Care
The regionalization of care, establishment of NICUs, and
transport of infants and mothers to specialty centers
necessitate specialty education for nurses.
(1986) studied the physiologic changes in 10
healthy pregnant women and their fetuses during
routine commercial flights. There was an increase
in maternal heart rate and blood pressure and
decrease in partial pressure of oxygen (PO2),
whereas partial pressure of carbon dioxide (PCO2)
was unchanged. The women experienced a short
increase in respirations during takeoff and land-
ing. The average fetal heart rate remained
consistent during the flight, with no bradycardia,
prolonged tachycardia, or loss of variability.
Based on the long-distance transport by large
FWA of 329 patients for obstetric indications,
Connor and Lyons (1995) concluded that trans-
port at any gestational age is safe.
Troiano (1989) described indications for maternal
consultation or transfer from Level I or Level II
facilities, transport personnel and equipment
needed, and transport forms for documentation.
Before transport for preterm labor, the patient is
assessed at the originating hospital, with cervical
dilation, effacement, station, and presenting part
determined, along with the rate of the progress of
labor. Any needed therapy, such as terbutaline or
magnesium sulfate for women in preterm labor, is
started. If labor is too far advanced, birth should
occur at the referring hospital with the assistance
of the specialty personnel who have arrived to
facilitate transport (Troiano, 1989).
Medical–Legal Considerations in
Transport
Youngberg (1992) and Reimer-Brady (1996)
provided thorough discussions of legal issues
related to the stabilization and transport of criti-
cally ill neonates, including responsibilities of the
referring and receiving hospitals. By accepting
responsibility for the transport of a neonate or
pregnant woman from a referring hospital to a
tertiary center, a transport team incurs legal risks.
It is incumbent upon the team to know where their
responsibility begins and ends. The referring
hospital must resuscitate and stabilize the patient
and arrange for referral and transport. When the
receiving hospital accepts a call, its responsibility
begins as advice and recommendations are
given. When the transport team arrives, their re-
sponsibility increases, and the referring hospital’s
784 JOGNN, 50, 774–788; 2021. https://doi.org/10.1016/j.jogn.2021.04.013
decreases until the patient arrives at the receiving
hospital (Reimer-Brady, 1996).
The standards and guidelines (Insoft et al., 2015;
Price-Douglas et al., 2010) and field guide (Meyer
et al., 2018) provide guidance for nurses and
others participating in transport. The transport
team members must know and work within their
scopes of practice and within state regulations.
Nurses must ensure the validity of their nursing
license if state lines are crossed when trans-
ferring a patient. Transports involving flights must
comply with Federal Aviation Administration reg-
ulations (Reimer-Brady, 1996).
Summary and Conclusions
During the past 50 years, tremendous changes
have occurred in the understanding of the phys-
iology of preterm and critically ill infants, the care
and treatment of those infants, the equipment
used, the locus of treatment, and the specializa-
tion of the providers in neonatology and neonatal
nursing. The phenomenal growth in knowledge is
evidenced by the more than 765,000 citations
under the heading of “newborn” and 20,500 ci-
tations for “neonatal transport” in the National Li-
brary of Medicine’s PubMed database.
However, high-risk infants continue to be born in
places ill equipped to provide intensive care, and
pregnant women experience complications during
pregnancy while in a variety of locations. Neonatal
and maternal (in utero) transfers continue with
experienced transport personnel. Equipment is
more sophisticated, with efforts to ameliorate noise
and vibration during transport. The safety of
transport vehicles is monitored. Standards and
guidelines are updated periodically.
The regionalization of perinatal care, establish-
ment of NICUs, transport of infants and pregnant
women to specialty centers by various methods,
and understanding of the risks of such transports
have changed the face of the care of premature
and critically ill infants. The development of so-
phisticated equipment to treat and transport in-
fants has occurred in concert with the
development of specific clinical skills for trans-
port personnel. We better understand the effects
on parents of having a preterm or critically ill in-
fant in a NICU and of separation of the infant from
the family by transport. Movement to in utero
transport has improved outcomes, although pre-
term and other high-risk births will continue to
occur in community and rural hospitals without
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Perry, S. E.
the personnel and equipment resources to pro-
vide specialized neonatal care. Therefore, the
need for neonatal transport will continue.
The roles, responsibilities, and contributions of
maternal and neonatal transport nurses require
additional study. Furthermore, research into the
experience of maternal and neonatal transport on
parents and families is important to design
effective nursing interventions to mitigate the
potential adverse effects. Continued develop-
ment of equipment for safe transport is also
essential. There is much to celebrate and learn
from the development of maternal and neonatal
transport over the past 50 years, but it is critical to
look forward to improve and advance this
specialized area of nursing and interdisciplinary
practice.
ACKNOWLEDGMENTS
The author thanks Mary Gibson, RN, PhD, and
Tim Miller, MD for review of the manuscript.
CONFLICT OF INTEREST
The author reports no conflicts of interest or
relevant financial relationships.
FUNDING
None.
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