MEDICAL TRANSFER OF PATIENTS IN PRETERM LABOR:
TREATMENTS AND TOCOLYTICS
Kathleen McCubbin, MD, BSc, BPHE, Sean Moore, MD, Russell MacDonald, MD, MPH,
Christian Vaillancourt, MD, MSc
ABSTRACT
Objective. To examine the epidemiology, effectiveness, and
safety of tocolytics, and the variation in use of standard
treatments and predictive testing for women in preterm la-
bor (PTL) transported to tertiary care. Methods. This was a
health record review of consecutive PTL patients (<38 weeks
gestation) transported to a tertiary care facility by Ontarios
Prehosp Emerg Care Downloaded from informahealthcare.com by Kainan University on 04/02/15
air and land critical care transport service between January
1, 2006 and January 1, 2011. The primary outcome was the
effectiveness of tocolytics in decreasing the frequency of con-
tractions and incidence of delivery. Secondary outcomes in-
cluded the type of tocolytics used, adverse events (defined
a priori), use of standard treatments (corticosteroid, antibi-
otic), and use of predictive tests (cervical length measure-
ment, fetal fibronectin). We report descriptive statistics and
relative risk of contractions decreasing with tocolytics with
95% confidence intervals. Results. Of the 510 transports re-
viewed, 488 met all inclusion criteria with the following
For personal use only.
characteristics: mean age 26.1 years, mean gestational age
31.2 weeks, mean transport time 80 minutes, 61.0% mul-
tiparous, 13.3% twins, mean initial dilatation 1.8 cm, con-
traction <8 min apart 67.7%, and 66.8% from Northern On-
tario. Tocolytics were used in 206 (42.2%), with nonsteroidal
anti-inflammatory drugs and nitroglycerine being used most
frequently. Eleven (2.3%) patients delivered during trans-
port, 4 (36.4%) of which received tocolytics with relative risk
Received December 17, 2013 from the Department of Emergency
Medicine, University of Ottawa, The Ottawa Hospital, Ottawa,
Canada (KM, SM, CV), Ornge, Mississauga, Canada (SM, RM), Di-
vision of Emergency Medicine, Department of Medicine, Faculty of
Medicine, University of Toronto, Toronto, Canada (RM), and Ottawa
Hospital Research Institute, University of Ottawa, Ottawa, Canada
(SM, CV). Revision received June 8, 2014; accepted for publication
June 9, 2014.
This paper was presented at the Canadian Association of Emergency
Medicine conference, Vancouver, BC, June 4, 2013.
The authors report no conflicts of interest. The authors alone are re-
sponsible for the content and writing of the paper.
The authors acknowledge Angela Marcantonio, Dept. of Emergency
Medicine Research facilitator; Flo Veel, Ornge, and Greg Harring-
ton, Ornge, who helped with chart collection; and all of the flight
paramedics and physicians from Ornge, who helped by caring for
and transporting these patients.
Address correspondence to Dr. Kathleen G.M.S. McCubbin, Ot-
tawa Hospital, Civic Campus, Department of Emergency Medicine,
1053 Carling Ave., Ottawa, ON, Canada K1Y 4E9. E-mail:
kate.g.mccubbin@gmail.com
doi: 10.3109/10903127.2014.942475
103
(RR) 0.8 (95%CI 02.0), and number needed to treat (NNT)
165 (31.5299.3). Among the 311 (63.7%) patients for which
change in contractions was documented, 140 (45%) received
tocolytics and of these patients, contractions decreased in 94
(67%), with an RR 0.6 (95%CI 0.30.9) and NNT 4.6 (3.16.2).
Adverse events were documented in 67 (14%) patients (most
commonly tachycardia 5.8%). Steroids were appropriately
used in 268 (54.9%) patients and antibiotics were appropri-
ately used in 286 (58.6%) patients. Predictive testing was
performed in only 19 (3.9%) patients. Conclusions. Tocolyt-
ics were associated with decreased contraction frequency in
more than two-thirds of those treated. However, nearly half
those who did not receive the treatment also had decreased
contractions, and the effect did not reach statistical signifi-
cance. Variation in the type of tocolytic drug used suggests
a need for clinical practice guidelines for tocolytic use dur-
ing transport of PTL patients. Key words: air ambulances;
patient transfer; tocolysis; pregnancy; obstetric labor, prema-
ture; emergency medical services
PREHOSPITAL EMERGENCY CARE 2015;19:103109
INTRODUCTION
Preterm labor (PTL) frequently leads to preterm birth,
which is the leading cause of perinatal morbidity in
the Western world,1 and the second leading cause of
neonatal mortality in the United States.2 Preterm birth
rate has risen by more than one third since 1981. By
2010 its estimated incidence was 11.99% in the United
States,3 8.0% in Canada,4 and 9.6% worldwide.5 For
patients with PTL living in remote areas, studies have
shown that neonatal morbidity and mortality rates are
lower if they are transferred to a tertiary care facility
equipped to care for the premature infant. These rates
are further reduced if this transfer is done with the fe-
tus in utero, compared to transporting the neonate and
mother separately.6,7 In a Canadian review of maternal
air transfers, two-thirds were initiated due to PTL or
premature rupture of the membranes.10 Although air
transport costs are greater than ground transport,8 air
transport may be the only available mode of transport
for this time-sensitive condition.9
In addition to rapid air transport, tocolytic agents
are used to temporarily reduce the frequency and
intensity of contractions to delay delivery and allow
for in utero transfer of the fetus.11 There remains con-
troversy regarding the safety and efficacy of tocolytics.
Previously approved drugs, such as beta-mimetics
(Ritodrine and Terbutaline) and an oxytocin receptor
antagonist (Atosiban), were removed from the market
 104
due to maternal and neonatal safety concerns and
are no longer approved by the Canadian Food and
Drug Administration.1215 Canada currently has
no approved drugs for tocolysis. However, various
off-label tocolytics are used, including nitric ox-
ide donors (nitroglycerin patch, gel, or infusion),
magnesium sulfate, beta-mimetics (salbutamol), non-
steroidal anti-inflammatory drugs (NSAIDs), and
calcium-channel blockers (nifedipine). Among those,
indomethacin16 and nifedipine17 are believed to be the
most efficacious and cost effective.1822 Indomethacin
is believed to have the fewest maternal side effects.23
There is some evidence that IV fluid administration
alone does not produce tocolysis,24 and that con-
comitant use of more than one tocolytic agent can be
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associated with increased adverse drug reactions.23
Tocolytics may further reduce infant morbidity and
mortality by allowing more time for other medica-
tions such as antibiotics and corticosteroids to be effec-
tive. Ampicillin or ampicillin in combination with ery-
thromycin is recommended in PTL25,26 as both prevent
ascending infection and may delay the progression to
preterm birth.2729 Either betamethasone or dexam-
ethasone is also indicated because both decrease in-
fant morbidity and mortality by increasing fetal lung
maturation.3032 Predictive tests are also available to
For personal use only.
determine the likelihood of preterm birth. Fetal fi-
bronectin testing33,34 and cervical length measurement
(<25 mm)34,35 have both been shown to be strong pre-
dictors of preterm birth. Their use is recommended
to identify those who are at a reduced risk in or-
der to avoid unnecessary intervention, transfer, and
costs.3638
In the absence of clear scientific guidelines, the objec-
tives of this study were to describe the safety and effec-
tiveness of tocolytic drugs to decrease contractions and
avoid in-flight deliveries, and also to examine prac-
tice variation in use of tocolytics, standard treatments
(antibiotics and steroids), and predictive testing, for
women in PTL transported to tertiary care in Ontario.
METHODS
We completed a review of patient transport records
to examine the epidemiology of a consecutive co-
hort of PTL patients transported by Ontarios air
and land critical care transport service to tertiary
care between January 2006 and January 2011. The
study was conducted in the province of Ontario,
Canada (1,076,395 km2 /415,600 miles2 ). Ornge is the
provinces sole provider of air and land critical care
medical transport. It provides medical transport for
critically ill and injured patients with three modes
of transport: helicopters, fixed wing aircraft, and
critical care land transfer vehicles staffed by flight
paramedics. Dedicated transport medicine physicians
provide medical oversight of patient care. Ornge co-
PREHOSPITAL EMERGENCY CARE JANUARY/MARCH 2015 VOLUME 19 / NUMBER 1
ordinates approximately 19,000 transports every year,
93% of which are interfacility transfers.
Ornge patient care reports were reviewed to iden-
tify eligible patients. Eligible cases were identified us-
ing the unique problem code identifying a patient
with regular uterine contractions associated with cer-
vical change before the completion of 37 weeks of
gestation.39 Patients were excluded if their gestational
age was greater than 38 weeks or if the pregnancy was
nonviable (less than 20 weeks gestation). This study
received approval by the Ottawa Hospital Research
Ethics Boards (protocol number 2011167-01H).
Our primary outcome was the effectiveness of to-
colytics in decreasing contraction frequency and pre-
venting in-flight delivery. Effectiveness was defined as
any decrease in contraction frequency. Secondary out-
comes were defined a priori and included the type
of tocolytic used, adverse events (tachycardia, ab-
normal fetal heart rate, hypotension, delivery, nau-
sea/vomiting, respiratory distress, arrhythmia, and
death), use of standard recommended treatments (cor-
ticosteroid, antibiotic), and use of predictive tests (cer-
vical length measurement, fetal fibronectin testing).
We used a standardized data collection form to
record a priori defined variables. The primary inves-
tigator (KM) piloted the data extraction form using
ten charts before creating the final tool and abstract-
ing data from all Ornge patients care records. A second
trained reviewer (SM) also extracted data elements for
10% of the charts randomly selected to determine inter-
rater agreement. A change in frequency of contractions
and rate of delivery (main outcome measures) were de-
termined by consensus (KM and SM) for all included
health records.
We report descriptive statistics and measures of
kappa agreement with 95% confidence intervals (CI).
We computed the relative risk (RR) of increasing con-
tractions associated with the use of tocolytic medica-
tions and the number needed to treat (NNT) with 95%
CI. We performed all data analysis using Excel version
14.3.2.
RESULTS
Within the study period, 510 health records were coded
as PTL and 488 met all inclusion criteria (Figure 1).
Characteristics of those who delivered are presented
in Table 1, alongside the characteristics of the entire
cohort. Overall, the reviewers reached good to ex-
cellent agreement for most important variables, with
kappa values 0.72 (95%CI 0.490.95) for membrane
rupture, 0.96 (95%CI 0.871) for steroid use, 0.92 (95%
CI 0.81) for antibiotic use, and 0.79 (95% CI 0.381)
for predictive testing using fetal fibronectin. The kappa
for change in contractions was initially 0.52 (95%CI
0.240.80) when only 10% of the health records were
double data entered. For this reason, all charts were
 K. McCubbin et al. AIR MEDICAL TRANSFER OF PATIENTS IN PRETERM LABOR
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FIGURE 1. Study cohort and exclusions. GA, gestational age.
subsequently reviewed by 2 people (KM, SM) in order
to come to consensus on this variable. The mean pa-
tient age was 26.1 years (SD 6.4) with more than three-
quarters of the patients being between the ages of 17
and 35 years (429/487 or 88.1%). The mean gestational
age was 31.2 weeks (SD 3.9), with less than one-quarter
(86/454 or 18.9%) being extreme PTL (gestational age
For personal use only.
<28 weeks) and 289/474 (61.0%) were multiparous.
The most commonly reported risk factors were active
bleeding 108/488 (22.1%) and twins 65/488 (13.3%).
The mean initial cervical dilatation was 1.8 cm (SD
1.6), and more than two-thirds of patients were actively
contracting with a frequency less than 8 minutes apart,
281/488 (67.7%). The mean transport time was 80 min-
utes (SD 37.7), and 324/485 (66.8%) of transfers were
from northern Ontario where tertiary care and high-
risk obstetrical services are not readily available.
Although this study was not designed or powered
to perform statistical comparisons, patients who deliv-
ered were observed to be similar to the entire cohort in
age, gravida, mean transport time, and location (ma-
jority were sent from the north). They were also more
likely to be in extreme PTL 4/10 (40.0%) vs. 86/454
(18.9%), to have ruptured membranes 5/7 (71.4%) vs.
95/377 (25.2%), to be in active labor 8/10 (80.0%) vs.
281/488 (67.7%), and to be further dilated (mean 4.2 cm
(SD 3.0) vs. 1.8 cm (SD1.6). Of those who delivered,
4/11 (36.4%) of the patients received tocolytics, includ-
ing nitroglycerine (n = 3), beta-agonists (n = 1), and
NSAIDs (n = 1).
As illustrated in Figure 2, tocolytics were used in
206/488 (42.2%) of cases, with 285 doses of tocolytics
given in total. NSAIDs 138/285 (48.4%) and nitroglyc-
erine 94/285 (33.1%) were used most frequently. Of
the 311/488 (63.7%) patients for whom change in con-
tractions was documented, contractions decreased in
94/140 (67.1%) patients who received tocolytics. The
relative risk of contractions increasing or staying the
same associated with the administration of tocolytics
105
was 0.6 (95% CI 0.30.9), and the number needed to
treat with tocolytics for one patient to experience de-
creased contractions was 4.6 (95% CI 3.16.2). Those
who received a tocolytic were less likely to deliver
with an RR of 0.75 (95%CI 02.0). The secondary out-
come of adverse events during transport is illustrated
in Table 2. Adverse events occurred in 67/488 (13.7%)
patients, with the most common being tachycardia
28/488 (5.8%), and 11/488 patients (2.3%) delivered
during transport.
Adherence to standard treatments was another sec-
ondary outcome and is outlined in Table 3. Steroids
were appropriately used in 268/488 (54.9%) of pa-
tients, and antibiotics were appropriately used in
286/488 (58.6%) of patients. Predictive testing was per-
formed in only 19/488 (3.9%) patients.
DISCUSSION
In this health record review, the epidemiology of a co-
hort of 488 PTL patients who were transported to ter-
tiary care in Ontario is described. Most of the patients
were sent from the north and were in moderatesevere
PTL, actively contracting, and had transport times
over 1 hour. Tocolytics were used in more than one-
third of cases, and the most commonly chosen were
NSAIDs and nitroglycerine. Most patients who re-
ceived tocolytics had a decrease in contraction fre-
quency and were less likely to deliver. There were
11 deliveries (2.3% of patients) during transport, 4 of
which received a tocolytic. None of the patients who
delivered received a calcium channel blocker as a to-
colytic. Adverse events occurred in less than 15% of
patients, the most commonly being tachycardia. Less
than two-thirds of patients received standard treat-
ments, and predictive testing was done in a minority of
cases.
Conclusions from the Canadian Tocolysis Consen-
sus Conference, which took place in 2003, highlight
the sparse evidence available in support of the use
of any of the currently available tocolytics. None ap-
pear to be associated with improved perinatal out-
comes, and often result in detrimental effects on the
mother.13 The trials leading up to this decision, how-
ever, typically studied women at relatively advanced
gestational ages, with predictably good outcomes, en-
rolled them in tertiary centers where they could not
benefit from in utero transfer, and had low levels of
corticosteroid administration. These studies were fo-
cused on using tocolytics to delay delivery to term ges-
tation and were not powered to detect the clinically
meaningful outcome of temporarily preventing deliv-
ery for hours to days to allow for transport.40 Sim-
ilarly, a 2010 Cochrane review suggested there was
insufficient evidence to support tocolytic therapy for
women with preterm premature rupture of the mem-
branes (PPROM), as there was an increase in maternal
 106 PREHOSPITAL EMERGENCY CARE JANUARY/MARCH 2015 VOLUME 19 / NUMBER 1

TABLE 1. Patient and system characteristics: comparison between successful transfer and in-flight delivery
Entire cohort, n = 488 Deliveries, n = 11

Mean age (SD) [range] 26.1 (6.4) [1448] 24.8 (6.3) [1637]
Age categories, n (%)
<17 years 15 (3.1) 1 (9.1)
1735 years 429 (88.1) 9 (81.8)
>35 years 43 (8.8) 1 (9.1)
Mean gravida (SD) [range], n = 474 3 (2.1) [116] 3.0 (2.7) [110]
Mean para (SD) [range], n = 474 1.3 (1.6) [013] 1.3 (2.2) [07]
Primapara, n (%) 185 (39.0) 3 (33.3)
Multipara, n (%) 289 (61.0) 6 (66.7)
Mean aborta (SD) [range], n = 474 0.7 (1.3) [012] 0.7 (0.9) [02]
Mean GA (SD) [range], n = 454 31.2 (3.9) [2037] 28.7 (4.6) [2134]
Categories of PTL, n (%)
Late PTL (3437 weeks) 166 (36.6) 2 (20.0)
Moderatesevere PTL (2833 weeks) 202 (44.5) 4 (40.0)
Extreme PTL (<28 weeks) 86 (18.9) 4 (40.0)
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Risk factors, n (%)

Bleed 108 (22.1) 3 (27.3)
Twins 65 (13.3) 0 (0.0)
UTI 54 (11.1) 1 (9.1)
Rec drugs 51 (10.5) 1 (9.1)
Previous C/S 45 (9.2) 0 (0.0)
DM 36 (7.4) 0 (0.0)
PID 13 (2.7) 0 (0.0)
HTN 8 (1.6) 0 (0.0)
Trauma 7 (1.4) 0 (0.0)
GBS 5 (1.0) 0 (0.0)
Other 3 (0.6) 0 (0.0)
BV 0 (0.0) 0 (0.0)
For personal use only.

Membrane rupture, n (%); n = 377 95 (25.2) 5 (71.4)

Mean dilation (SD) [range], n = 372 1.8 (1.6) [010] 4.2 (3.0) [010]
Contractions reported
Contracting, n (%) 401 (82.2) 10 (100.0)
Mean frequency (SD) [range];n = 415 6.1 (8.8) [090] 4.5 (3.6) [212]
Frequency q < 8 min, n (%) 281 (67.7) 8 (80.0)
Sending hospital, n (%)
Northern 324 (66.8) 6 (54.5)
Out of province 0 (0.0) 0 (0.0)
South 161 (33.2) 5 (45.5)
Receiving hospital, n (%)
Northern 177 (36.5) 4 (36.4)
Out of province 104 (21.4) 2 (18.2)
South 204 (42.1) 5 (45.5)
Mean transport time (min) (SD)[range] 80.4 (37.7) [10320] 76.4 (26.6) [26112]
SD, standard deviation; northern, Local Health Integration Network (LHIN) 13 (North Bay, Timmins, Salut Ste Marie, Sudbury) or 14 (Kenora, Thunder Bay); south-
ern, LHIN 112; transport time calculated from arrival at patients site to arrival at destination; GA, gestational age; PTL, preterm labour; C/S, cesarean section;
HTN, hypertension; DM, diabetes mellitus; UTI, urinary tract infection; PID, pelvic inflammatory disease; BV, bacterial vaginosis; GBS, group B Streptococcus.

chorioamnionitis without significant benefits to the in-
fant. However, these studies did not consistently ad-
minister latency antibiotics and corticosteroids, both of
which are now considered standard of care.41
We found that the most common tocolytics used in
PTL patients transported in Ontario were NSAIDs and
nitroglycerine. The most recent evidence suggests that
NSAIDs and calcium channel blockers16 are the most
efficacious and cost effective1822,31 for short-term pre-
vention of delivery. The use of NSAIDs is therefore
in accordance with the evidence, but the high rate of
nitroglycerine administration and the relative lack of
nifedipine use is unexpected. The Cochrane Review
determined that nitric oxide donors do not delay de-
livery or improve neonatal outcome.20 Although there
are no Canadian guidelines, the Royal College of Ob-
stetricians and Gynecologists recommends nifedipine
as the first-line tocolytic.11
Less than two-thirds of the patients in our study re-
ceived standard treatments despite the National Insti-
tutes of Health, American Academy of Family Physi-
cians (AAFP), and Cochrane Review recommending
maternal corticosteroid therapy based on the strong
association between these drugs and decreased infant
morbidity and mortality.3032 Antibiotics (ampicillin
or ampicillin in combination with erythromycin)25,26
are also recommended by the AAFP, Society of Ob-
stetricians and Gynecologists of Canada (SOGC), and
Cochrane Review, due to their association with re-
duced maternal and fetal/neonatal morbidity29 and
their ability to prevent ascending infection, which may
delay the progression to preterm birth.27,28
 K. McCubbin et al. AIR MEDICAL TRANSFER OF PATIENTS IN PRETERM LABOR 107
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FIGURE 2. Comparison of tocolytic choice. Out of 488 charts reviewed, 206 patients received tocolytics (42.2%). Shown is a breakdown of the
For personal use only.

type of tocolytic chosen. CCB, calcium channel blocker; OXY-AG, oxytocin agonist; Nitro, nitroglycerin; MG, magnesium; B-AG, beta agonist;
NSAID, nonsteroidal anti-inflammatory drug.

The very low use of predictive tests is surprising
as fetal fibronectin testing could be used to avoid un-
necessary intervention or transfer. Cervical length less
than 25 mm has also been shown to be a strong predic-
tor of preterm birth33 and, if negative, can prevent un-
necessary interventions. Indeed, the most recent Italian
guidelines recommend that tocolytic therapy be with-
held if fetal fibronectin or transvaginal ultrasound scan
indicates low risk of spontaneous preterm birth.42 It
may be that testing rates are low due to lack of re-
This study suggests that certain maternal demo-
graphic features may be associated with in flight
delivery. This is consistent with the ACOG prac-
tice bulletin, which states that age less than 17 or
greater than 35 years, vaginal bleeding, and trauma are
TABLE 3. Standard treatments and predictive tests
Treatments and tests

sources in order to preform these tests in nontertiary Number of patients given steroids, n (%) 268 (54.9)
care centers. Type of steroid -n (%)
Betamethasone 227 (84.7)
Dexamethasone 39 (14.6)
Combination steroids 1 (0.4)
TABLE 2. Adverse events during transport Unknown 1 (0.4)
Entire cohort Deliveries Number of patients given antibiotics, n (%) 286 (58.6)
Type of antibiotic, n (%)
Total, n (%) 67 (13.7) 3 (27.3) Ampicillin other 102 (35.7)
Type of adverse events, n (%) Erythromycin 6 (2.1)
Tachycardia 28 (5.8) 1 (9.1) Penicillin G 126 (44.1)
Abnormal FHR 16 (3.7) 2 (18.2) Ancef 9 (3.1)
Hypotension 16 (3.3) 0 (0.0) Clindamycin 26 (9.1)
Delivery 11 (2.3) n/a Combination antibiotics 17 (5.9)
Nausea/vomiting 7 (1.4) 0 (0.0) Number of patients receiving testing, n (%) 19 (3.9)
Respiratory distress 3 (0.6) 0 (0.0) Type of test, n (%)
Arrhythmia 2 (0.4) 0 (0.0) Fetal fibronectin 11 (57.9)
Death 0 (0.0) 0 (0.0) U/S 8 (42.1)
Bishop score 0 (0.0)
n, number of times the event occurred (a patient may have experienced more
than one adverse event); Tachycardia, >120 bpm; Hypotension, sBP < 90; Ab- Combination steroids includes both betamethasone and dexamethasone;
normal FHR, fetal heart rate <120 bpm or >170 bpm; Arrhythmia; anything Combination antibiotics, any of the above combined; U/S, ultrasound of cer-
other than normal sinus rhythm; Respiratory distress, crackles auscultated or vical length; Bishop score, measurement of cervical dilation, effacement, con-
oxygen saturation <92%; Delivery, during transport. sistency, position, and fetal station.
 108
associated with PTL,43 and approximately 30% of
preterm births are associated with premature rupture
of the membranes. Maternal infection has also been in-
dependently associated with preterm delivery.44
LIMITATIONS
First, the relatively small number of in-flight deliver-
ies and the possibility that some charts may have been
miscoded and therefore not included in the analysis
may limit the results of this study The study is, how-
ever, likely representative of transport PTL patients
as we included all patients in the province over a 5-
year period. This study is limited to transports in On-
tario, so extrapolation of findings to transfers carried
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out by land EMS services and to transport in other
jurisdictions may not be possible. Second, there are
limitations common to all health record reviews in
that many items were not consistently documented, in-
cluding our main outcome of change in contractions.
The group analyzed for tocolytic efficacy, therefore,
may represent a selected group who were more likely
to have their contractions documented if they had
changed or improved. To mitigate differences in data
collection that could confound the data, a standardized
For personal use only.
data form, case definitions, and a second reviewer for
10% of the charts were used during data abstraction.
There is good to excellent agreement on most impor-
tant variables, but due to chart legibility there is only
moderate agreement (k = 0.52) on the documentation
of change in contractions. Due to the importance of this
variable, two reviewers re-reviewed 100% of the charts
together in order to come to consensus on the contrac-
tions variable. Third, we did not collect information on
the outcomes of mothers and neonates after transport
due to resource limitations, so this study focuses only
on outcomes during transport. Previous research has
examined the long-term safety and efficacy of tocolyt-
ics but this is not the focus of the current study. Finally,
a further limitation is that the mean transport time in
this series is under 2 hours so it is unknown if there
is sufficient time for the drugs to exert their full effect.
There have been studies in the past showing effective-
ness of indomethacin, nifedipine,45 and atosiban46 over
2 hours. The other tocolytics have not been studied for
fast inhibition of PTL. It is possible that the effect of to-
colytics in reducing contractions was therefore either
over- or underestimated in the data.
CONCLUSION
In preterm labor patients being transported to tertiary
care, tocolytics were associated with a decreased con-
traction frequency in more than two-thirds of those
treated. However, nearly half those who did not re-
ceive the treatment also had decreased contractions,
PREHOSPITAL EMERGENCY CARE JANUARY/MARCH 2015 VOLUME 19 / NUMBER 1
and the effect did not reach statistical significance.
There was variation in the type of tocolytics chosen,
with NSAIDs being most commonly administered.
There was low adherence to the current recommenda-
tions for nifedipine as the preferred agent. Standard
treatments, such as corticosteroid and antibiotic ad-
ministration, as well as predictive testing, were not
preformed routinely. Practice variation suggests a need
for clinical practice guidelines and educational inter-
ventions in northern communities that could increase
use of recommended therapies and predictive tests in
transport of PTL patients.
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