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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High-profile inquiries in several countries have helped to raise public awareness of safety issues and driven policy change. In obstetric critical care, various publications have highlighted organizational factors, communication, absence of guidelines, failure to follow local protocols, poor documentation and delay in identifying the deteriorating woman as issues. ⋯ The principles of risk management and its various components can be used to make improvements. A framework to achieve this is as follows: building a safety culture; leading and supporting staff; integrating risk management activity; promoting reporting; involving and communicating with patients and the public; learning and sharing safety lessons; and implementing solutions to prevent harm.
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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.
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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.