Best practice & research. Clinical obstetrics & gynaecology
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Best Pract Res Clin Obstet Gynaecol · Oct 2008
ReviewRole of the anaesthetist in obstetric critical care.
The anaesthetist plays a key role in the management of high-risk pregnancies, and must be a member of the multidisciplinary team that is required to care for the critically ill obstetric patient. Anaesthetists are trained in advanced life support and resuscitation. They are experienced in the management of the critically ill, and provide anaesthesia, sedation and pain management. ⋯ To date, there is little evidence to inform the anaesthetic management of the critically ill obstetric patient; most recommendations and guidelines are based on the management of non-obstetric, critically ill patients. Management must be adapted to encompass the physiological changes of pregnancy. Evidence-based guidelines on management of the critically ill woman with specific obstetric conditions are also lacking.
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The present chapter considers the evolving role of critical care outreach in the general hospital setting and applied to obstetric patients, the mechanics of transferring critically ill obstetric patients to critical care and radiology areas, the scoring systems in use in critical care, and the difficulties in applying these scoring systems to obstetric patients.
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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.
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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.
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Best Pract Res Clin Obstet Gynaecol · Jun 2008
Maternal deaths due to hypertensive disorders in pregnancy.
Hypertensive disorders of pregnancy (HDP) are one of the most common direct causes of maternal mortality worldwide. Cerebral haemorrhage is the main final cause of hypertensive deaths and probably implies that doctors are reluctant to treat sustained high blood pressure effectively during pregnancy. Maternal deaths from HDP can probably be reduced markedly by: (1) promoting antenatal care and instituting a recall system for defaulters; (2) instituting regional centres and regional obstetricians to provide advice on, or care for, women with severe pre-eclampsia; (3) educating health professionals through continuing professional education and the use of clinical guidelines of management; and (4) informing the general public on complications associated with the pre-eclampsia/eclampsia syndrome.