Table 2 An iteration of the simulation protocol for a transfer by vaginal birth

1

Sign-in: Introduction of the entire team, patient, and procedure verification, list of allergies, and anticoagulation.

2

Positioning of the fetus and placenta is determined

3

Instrument check with an extra checklist for and familiarization of the materials.

4

Standard fetal and maternal monitoring modalities are employed such as heart rate and blood pressure monitoring as well as cardiotocography for maternal contraction and fetal monitoring before the procedure.

5

Ultrasound is performed on the Obstetric High Care (OHC) ward before the procedure is started to determine the position of the fetus.

6

The birth canal is measured for depth and width in the supine position to determine the suitability of the device. If measurements are within the designated range the procedure can be continued. If measurements are outside of this range the transfer procedure will be abandoned and a caesarian transfer or rescue procedure needs to be considered by the perinatologist.

7

The mother receives epidural anesthesia for pain management during the procedure.

8

Wait for the necessary cervical dilation by an estimate of the perinatologist. This is determined based on the gestational age of the fetus and its head circumference, ± 5–7 cm for a 24-week GA.

9

Cervical dilation is checked regularly.

10

When the necessary dilation is achieved the perinatologist informs operating theatre personnel to start preparations for the procedure.

11

Other members of the procedural team are also alerted to make their way to the operating theatre.

12

The patient is transported to the operating theatre.

13

All transfer-related necessary materials and devices are prepared.

14

The perineum and vulva are cleaned with sterile water.

15

The transfer device(s) is inserted into the birth canal.

16

Cervical dilation is checked for the final time.

17

Around this point, unruptured membranes are ruptured with the use of an amniotomy hook.

18

Ultrasound is performed to confirm the correct positioning of the device in relation to the spina iliaca of the pelvis [71].

19

Sufficient dilation and positioning of the device(s) are re-confirmed by the perinatologist

20

A sealed passageway in the birth canal is created for the transfer from the perinate from the natural uterus to the artificial liquid environment (transferbag from this point onward).

21

The perinatologist begins filling of the transferbag with AAF to keep the head of the perinate submerged.

22

Contractions, maternal pushing, and guidance by the perinatologist’s hand(s) will ensure the perinate to slide into the birth canal and subsequently into the transferbag.

23

The perinate will now be fully encapsulated by the transferbag.

24

The transferbag is removed from the birth canal. Umbilical cord is still connected to the placenta and fetus.

25

The transferbag is placed in a stable position to allow for safe cannulation. In the meantime, temperature change of the perinate (and AAF) should be prevented.

26

Cannulation of all three umbilical cord vessels should take place within a few minutes to avoid asphyxia [72].

27

The perinatologist proceeds to guide the delivery of the placenta and suture possible ruptures.

28

The perinate is transferred to the LFC of the APAW system where monitoring, oxygenation, and nourishment of the perinate are fully taken over.