Critical Care in Obstetrics Guideline: NHSCT/12/515
Critical Care in Obstetrics Guideline: NHSCT/12/515
Critical Care in Obstetrics Guideline: NHSCT/12/515
in any way
NHSCT/12/515
Target audience:
N/A
Type of Document:
Directorate Specific
Approved by:
Date Approved:
8 February 2012
9 May 2012
NHSCT Mission Statement
To provide for all the quality of services we would expect for our families
and ourselves
Critical Care in Obstetrics Guideline
December 2011
Critical Care in Obstetrics Guideline
1.0 Introduction
Most pregnancies and deliveries are normal. Occasionally women will require
High Dependency Care. This requires the right environment and right staff
(www.ics.ac.uk/levels)
Women requiring
More detailed observation or intervention including basic support for a
single failing organ system, post-operative care and those stepping down
from higher levels of care
Stabilisation before transfer to Intensive Care Unit (ICU) where the
following is required:
o support for 2 or more organ systems
o artificial ventilation
o renal replacement therapy
o risk of sudden catastrophic deterioration
2.0 Purpose
o Admission criteria
o The responsibilities for each staff group
o Availability of correct equipment
o When to involve clinicians outside the maternity unit
o Agreed criteria for transfer to HDU/ ICU outside the maternity unit
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Table 1: Examples of indications for admission to HDU
This list is not exhaustive and the need for HDU care should be assessed on
an individual basis. When close monitoring is required, the midwife to patient
ratio must be no more than one midwife to two patients. Basic competency
trained staff should be available 24 hours a day.
3.2.1 Obstetricians
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o Ensure that the woman is in a stable / controlled state for transfer
o Give a full and clear explanation to the woman and her family
about the reasons for transfer.
3.2.2 Anaesthetists
HDU care should be conducted in the appropriate care setting with staff
skilled and trained in this area. The basic equipment available in the close
monitoring room is:
o Piped oxygen
o Suction equipment
o Resuscitation equipment including ready access to defibrillator
o Pulse oximeter
o Non-invasive blood pressure monitor
o ECG waveform monitor
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o Calf compression device
o Invasive haemodynamic monitoring
o Level 1 fluid infuser
In addition:
Transfer out of the maternity unit requires the woman to be assessed jointly
by a senior anaesthetist and a senior obstetrician and in some cases other
disciplines that have been involved in the woman’s care e.g. renal, cardiac.
Senior clinicians from other specialities will be involved in the care of the
women where there is:
This will be when care can be managed on a maternity ward and must
consider staffing levels, skill-mix and workload on the ward. A written
treatment plan, including clear instructions about the continued level of
observation and when to call medical staff, must be documented at the time of
transfer. Continued support from the obstetric and anaesthetic staff may be
required and must be provided. Transfer out of HDU should be a joint
obstetric and anaesthetic decision and fulfil the following:
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o Patient haemodynamically stable, no further continuous intravenous
medication or frequent blood tests required
o No invasive monitoring required
o No active bleeding
o No supplementary oxygen required
o Patient mobilized
When transferring a woman from HDU to the postnatal ward, a personal and
detailed handover of care should be given from the midwife handing over the
care to the receiving midwife using the SBAR tool for communication
(Situation, Background, Assessment, Recommendation).
Women requiring ICU care are generally transferred to the ICU within the
Trust. Following assessment of the woman’s condition, the decision for
transfer will be made by the consultant Obstetrician and the Consultant
Anaesthetist in liaison with other specialities as required.
Woman who require ICU care have usually more than one organ failure
including:
o Women requiring advanced respiratory support (ventilation)
o Women requiring invasive renal support
o Exacerbation of pre-existing medical problem
5.0 Responsibilities
Line managers are responsible for ensuring that staff have a working
knowledge of and adhere to the guidance and that any amendments are
disseminated.
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All practitioners are responsible for familiarising themselves with and adhering
to this guidance.
This document can be made available on request on disc, larger font, Braille,
audio cassette and other minority languages to meet the needs of those who
are not fluent in English
9.0 References
National Institute for Health and Clinical Excellence (2007) Acutely Ill
Patients in Hospital. Recognition of and Response to Adults in Hospital.
London: NICE
O’Neill A.E and Miranda D. (2006) The right tools can help critical care
nurses save more lives. Critical Care Nurse Q. Volume 29, pp 275-281.
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Child Health (2007). Safer childbirth: minimum standards for service
provision and care in labour. London: RCOG Press.
Simpson, H and Barker, D. (2008) Role of the midwife and the obstetrician in
obstetric critical care- a case study from the James Cook University Hospital.
Best Practice & Research Clinical Obstetrics and Gynaecology. Volume 22,
Issue 5, pp 899-916.
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Tissue Fluid Infection
Viability Circulation balance PEWS control
Braddon score VTE assessment Accurate intake/ Track observations as HII care pathways
output required
Hrly documented Active/ passive ANTT- Aseptic non-
pressure care exercises Observe for signs of Scores to act as trigger touch technique
pulmonary oedema for action
Early mobilisation Encourage deep Blood work
breathing exercise Blood work Escalate concerns
Pressure relieving Calf compression Oral hygiene if nil by Analgesia management Swabs, blood culture if
mattress device mouth plan symptomatic
Liaise with tissue Liaise with Liaise with dietician Liaise with pain Liaise with infection
viability nurse physiotherapist if nil by mouth control nurse control