Best practice & research. Clinical obstetrics & gynaecology
-
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.
-
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.
-
In the last 20 years, in developed countries, maternal mortality rates have fallen such that analysis of cases of severe maternal morbidity is necessary to provide sufficient numbers to give a clinically relevant assessment of the standard of maternal care. Different approaches to the audit of severe maternal morbidity exist, and include need for intensive care, organ system dysfunction and clinically defined morbidities. ⋯ The death to severe morbidity ratio may reflect the standard of maternal care. Audits of severe maternal morbidity should be complementary to maternal mortality reviews.
-
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.
-
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.