Best practice & research. Clinical obstetrics & gynaecology
-
The aims of critical care management are broad. Critical illness in pregnancy is especially pertinent as the patient is usually young and previously fit, and management decisions must also consider the fetus. Assessment must consider the normal physiological changes of pregnancy, which may complicate diagnosis of disease and scoring levels of severity. ⋯ There are also increasing numbers of pregnancies in those with high-risk medical conditions such as cardiac disease. As numbers are small and clinical trials in pregnancy are not practical, management in most cases relies on general intensive care principles extrapolated from the non-pregnant population. This chapter will outline the aims of management in an organ-system-based approach, focusing on important general principles of critical care management with considerations for the pregnant and puerperal patient.
-
Whether seeing a patient in the ambulatory clinic environment, performing a delivery or managing a critically ill patient, obstetric care is a team activity. Failures in teamwork and communication are among the leading causes of adverse obstetric events, accounting for over 70% of sentinel events according to the Joint Commission. ⋯ Given the complexity and acuity of critical care medicine, which often relies on more than one medical team, teamwork skills are essential. This chapter discusses the history and importance of teamwork in high-reliability fields, reviews key concepts and skills in teamwork, and discusses approaches to training and working in teams.
-
Infections in critically ill obstetric patients are observed worldwide, although the incidence, aetiology and patient outcome vary between geographic locations. This chapter focuses on sepsis, with emphasis on the pathophysiology, outcome and specific management issues.
-
Best Pract Res Clin Obstet Gynaecol · Oct 2008
ReviewEthical challenges of treating the critically ill pregnant patient.
Most ethical issues in obstetrics, both in the critical care and non-emergency situations, hinge around the maternal-fetal relationship. With access to the necessary information and support, most women strive to improve their chance of having healthy babies. However, there could be situations where their interests do not correspond with fetal interests, thereby giving rise to conflict situations. ⋯ Where she is not competent to make an informed decision, proxy consent should be obtained or the doctrine of substituted judgement be applied. A decision to withhold or withdraw treatment in the intensive care unit (ICU) should only occur once a definitive diagnosis of terminal illness is made. Standards for the management of the human-immunodeficiency-virus-positive woman in the obstetric ICU situtation should be no different from standards employed to manage a critically ill pregnant patient in ICU with a chronic medical disease.
-
Best Pract Res Clin Obstet Gynaecol · Oct 2008
Role of the midwife and the obstetrician in obstetric critical care - a case study from the James Cook University Hospital.
The role of the obstetrician and the midwife are fundamental to the successful antenatal management, delivery and postpartum management of the critically ill obstetric patient. However, there is a dearth of published literature on the integrated management of these roles. This chapter addresses these issues by reporting on experiences at James Cook University Hospital in developing a more holistic approach to patient management and critical care through appraisal of these roles, and resulting extension of the role of the midwife to encompass physiological assessment, understanding the effects of pregnancy on disease, interpretation of, and acting on, blood results including arterial gases, and development of the service through the development of guidelines and undertaking audits. ⋯ The resulting development of the role of the obstetrician encompasses leadership, clinical knowledge, documentation, guideline development, risk management and the communication functions of debrief, audit and education. Development of the roles has reduced admissions to intensive care and increased patient satisfaction and adherence to policies at James Cook University Hospital. This paper provides a critical appraisal of this role development and discusses some of the lessons learned.