American Journal of Obstetrics
and Gynecology Founded in J920
volume 162
number 1 JANUARY 1990
CLINICAL SECTION Clinical Opinion Treatment in an obstetric intensive care unit William C. Mabie, MD, and Baba M. Sibai, MD Memphis, Tennessee A three·bed intensive care unit was opened in the labor and delivery area of a city-county hospital having approximately 7500 deliveries annually. The utilization rate of 0.9% and the severity of illness were sufficient to justify such a unit. Main indications for admission were hypertensive disorders (46%), massive hemorrhage (10%), and medical problems of pregnancy (44%). Identifiable benefits of the unit were as follows: (1) Intensive observation and organization allowed for prevention or early recognition and treatment of complications; (2) familiarity with invasive monitoring permitted personnel to exert prompt, rational treatment of hemodynamically unstable patients; (3) continuity of care was improved before and after delivery; (4) residents and fellows learned a great deal about intensive care and the management of rare medical complications of pregnancy. We conclude not only that critically ill pregnant women can be managed successfully in an obstetric intensive care unit but also that critical care is a bona fide part of obstetric practice and has been incorporated into our training program. (AM J OesTET GVNECOL 1990;162:1-4.)
Key words: Intensive care, Swan-Ganz catheter, medical complications of pregnancy
Maternal-fetal medicine, along with reproductive endocrinology and gynecologic oncology, was recognized as a subspecialty by the American Board of Obstetrics and Gynecology in 1972. I The first examinations were given and the first certificates of special competence were issued in 1974 .. These developments were in response to practice patterns already well established at the time. A 1972 survey of 11,689 diplomates of the board revealed that 14.1 % of the respondents limited their practice to an area of special interest such as obstetrics, reproductive endocrinology, or gynecologic oncology.' Although in utero diagnosis and fetal therapy are the primary focus of current research in maternalfetal medicine, a major clinical role of the sub specialist in maternal-fetal medicine continues to be that of an "internist for pregnant women." The obstetric intensive From the Department of Obstetrics and Gynecology, UnzveTSlty of Tennessee, MemphIS. Repnnt requests: William C. Mable, MD, Department of Obstetncs and Gynecology, Unzvemty of Tennessee, 853 Jefferson Ave., Room E-102, Memphis, TN 38163 .
6/1/14580
care unit can thus be seen as a product of the evolution of maternal-fetal medicine. The intensive care unit had its origin in the postoperative recovery room. In 1863, Florence Nightingale wrote that it was not uncommon in community hospitals to have a small area set aside near the operating rooms for patients recovering from the immediate effects of surgery. Walter Dandy started a postoperative neurosurgical unit at Johns Hopkins in 1923. Dwight Harkin established a cardiac surgical unit in Boston in 1951. During the Scandinavian polio epidemic of 1952, a special lOS-bed respiratory care unit was set up at Blegdam Hospital in Copenhagen for endotracheal intubation and intermittent positivepressure ventilation in patients with polio .. The first coronary care unit was established by Hughes Day 5 in Kansas City in 1962. There were many other pioneers in the development of adult, pediatric, and neonatal intensive care units , but the philosophy was the same: Put the sickest patients in a room with the best nurses in a 1: 1 or 2: 1 patient-to-nurse ratio. The purpose ofthis communication is to describe the
2
Mabie and Sibai
January 1990 Am J Obstet Gynecol
Table I. Main indications for intensive care unit admission Hypertensive disorders (eclampsia, n = 21; pulmonary edema, n = 10) Massive hemorrhage (abruptio placentae; n = 9, placenta accreta, n = 3) Medical problems of pregnancy Cardiac Pulmonary Renal Sepsis Gastrointestinal Endocrine Central nervous system Other
92 21
87 19
14
12 9 8
7 7
11
development of and initial experience with an obstetric intensive care unit detailing equipment, staffing, types of patients treated, and lessons learned. Population served
In January 1986 a three-bed obstetric intensive care unit was opened in the labor and delivery area of E. H. Crump Women's Hospital and Perinatal Center, a tertiary care, city-county hospital that serves as the main obstetric and gynecologic teaching hosp'ital at the University of Tennessee, Memphis. The hospital has approximately 7500 deliveries annually and receives maternal transfers from a five-state area including Tennessee, Arkansas, Mississippi, Missouri, and Kentucky. The referral area has approximately 40,000 deliveries per year, and there are no towns with a population > 100,000 within a 100-mile radius of Memphis. Facilities
Our obstetric intensive care unit consists of one large room (700 square feet) located next to the recovery room. Major equipment includes three HewlettPackard three-channel hemodynamic monitors, one Hewlett-Packard cardiac output computer, a strip chart recorder and printer, a Nellcor pulse oximeter, a Wescor colloid oncometer, two electric hospital beds, and one birthing bed that can be used for vaginal delivery of patients in the intensive care unit. Emergency equipment includes a "crash" cart, defibrillator, suction machine, and electrocardiograph machine. Fetal monitors are readily available. Rationale and staffing
The aim of the obstetric intensive care unit is to care for all critically ill pregnant women, except women having major trauma (treated in our institution's trauma
center), neurosurgical disorders, or necessity of mechanical ventilation for >5 days. Maternal-fetal medicine fellows and obstetrics-gynecology residents provide physician staffing for the intensive care unit. The director of the unit is board-certified in internal medicine, obstetrics and gynecology, and maternal-fetal medicine. The unit is staffed by 10 obstetric nurses, who control their own work schedule and assure that at least one is available 24 hours per day, 7 days per week. All nurses have had at least 2 years of labor floor experience; previous medical or surgical intensive care experience is desirable although not essential. All nurses are given a 4-week course in high-risk obstetric nursing, a I-week course in obstetric intensive care, a I-week course in medical intensive care, a 2-day course in hemodynamic monitoring, and a I-day course in mechanical ventilation, and they are encouraged to become certified in advanced cardiac life support. Nurses also gain clinical experience by working in the medical intensive care unit and refresh their knowledge by working there periodically. When there are no patients in the obstetric intensive care unit, those nurses work in the contiguous labor and delivery area. Most common disorders
During the 3-year period from Jan. I, 1986, to Jan. I, 1989, 200 patients were managed in the obstetric intensive care unit. During the same period there were 22,651 deliveries, for an intensive care unit utilization rate of 0.9%. Admission to the intensive care unit was limited to our sickest patients (in some instances because of unavailable nursing). The major categories of problems were hypertensive disorders (46%), massive hemorrhage (10%), and medical problems of pregnancy (44%) (Table I). The average intensive care unit stay was 2.5 ± 2.0 (mean ± SD) days. Only 9 of the 200 patients (4.5%) required transfer to another intensive care unit. The main indication for transfer to the medical intensive care unit was requirement for prolonged mechanical ventilation of patients having viral pneumonia or adult respiratory distress syndrome (n = 6). One patient was transferred for streptokinase therapy of acute massive pulmonary emboli, one for long-term management of thrombotic thrombocytopenic purpura, and one because of ruptured arteriovenous malformation. Managing the 200 patients required several procedures not conventional to obstetrics and gynecology: radial arterial lines (n = 151), pulmonary artery catheterization (n = 74), mechanical ventilation (n = 24), and hemodialysis (n = 8). An indication of the severity of illness was the occurrence of seven maternal deaths from the following causes: (1) ventricular septal defect
Volume 162 Number 1
with Eisenmenger's syndrome, (2) ruptured arteriovenous malformation, (3) varicella pneumonia, (4) malignant hypertension with renal failure, (5) metastatic breast cancer with evisceration, (6) metastatic pancreatic cancer with lactic acidosis and acute renal failure, and (7) thrombotic thrombocytopenic purpura.
Background of the obstetric Intensive care unit director In addition to routine obstetrics and gynecology, certain specialized clinical skills were frequently needed in our intensive care unit-inserting radial and pulmonary artery catheters, performing endotracheal intubation, managing a ventilator, reading an electrocardiogram, directing cardiopulmonary resuscitation, and performing a cesarean hysterectomy or bilateral hypogastric artery ligation. We observed the following emergencies repeatedly: pulmonary edema, massive hemorrhage, disseminated intravascular coagulation, septic shock, adult respiratory distress syndrome, acute renal failure, hypertensive crisis, cardiac arrhythmias, status asthmaticus, status epilepticus, stroke, pulmonary embolus, diabetic ketoacidosis, and thyroid storm. Training to manage the above must be given if an intensive care unit is to exist. Training can be obtained in several ways: a critical care fellowship , a medicine residency, or a maternal-fetal medicine fellowship interacting with the subspecialists.
Benefits of an obstetric Intensive care unit Improved patient care. An obstetric intensive care unit offers the opportunity to improve patient care. Two of the main benefits are observation and organization. Close observation in the intensive care unit allows problems to be detected earlier and complications to be prevented, enabling the patient to recover more quickly. For example, atelectasis and pneumonia can be prevented or ameliorated by early ambulation, coughing, aerosol treatment, and use of an incentive spirometer. Complex patient care can be more easily organized in the intensive care unit. Laboratory data accumulate so rapidly on sick patients that sometimes an important abnormality may go undetected. We use a bedside blackboard to facilitate organization. Each board contains the patient'S name, diagnosis, medications , treatment, and pending diagnostic studies. Nurses maintain a laboratory flow sheet at the bedside, recording laboratory results in chronologic order so that trends can be identified and missing results recalled. Locating the intensive care unit in the labor and delivery area further assures that an obstetrician, as well as a nurse, will be at the bedside. The obstetrician who
Obstetric intensive care
3
initiated care has the opportunity to provide continuity of care. For example, in massive hemorrhage, the obstetrician who operated on the patient knows best when the patient needs to undergo reexploration. He knows the technical problems that occurred during previous surgery and has the continuing duty to watch the patient closely at the bedside. He/she cannot do this adequately if the patient is transferred to another service or to another part of the hospital for intensive care. Gaining facility in invasive hemodynamic monitoring. Using the Swan-Ganz pulmonary artery catheter in obstetric patients allows the obstetrician to recognize patterns of disease, to understand pathophysiology, to make corrections when abnormalities are subtle, to evaluate the hemodynamic effects of drugs and other interventions, and to study the rare case. We prefer the Swan-Ganz catheter but recognize that it is only a monitoring device . The decision to use the catheter is based on the likelihood that one will find a hemodynamic abnormality that can be treated. Indications include pulmonary edema, oliguria, massive hemorrhage, septic shock, adult respiratory distress syndrome, class 3 and 4 cardiac disease, or pulmonary infiltrates when the diagnosis is unclear. If the intensive care unit equipment is not used frequently, it will be "borrowed" by other services and the skills of trained personnel will atrophy. We believe that the Swan-Ganz catheter is safe in experienced hands and that complications such as intracardiac knotting, pneumothorax, pulmonary artc~ry rupture, and endocarditis are quite rare. Incidentally, we believe that our own lack of serious complications is attributable not only to experience but to the following: (1) We do not persist with multiple punctures at various sites if difficulty is encountered inserting the catheter; (2) we position the catheter tip in the main pulmonary artery so that the balloon' does not float peripherally and cause pulmonary infarction; (3) we remove the catheter as soon as possible, usually within 24 hours of insertion . One problem that must be guarded against is mesmerization by the monitoring equipment. The physician may unwittingly spend excessive time calibrating, "debugging," and "troubleshooting" yet ignoring such equally important aspects as the fetal heart rate tracing or the progress of labor. A related problem is information "overload." One cannot see the forest for the trees! In addition to the history, physical examination, laboratory data, x-ray film, and ultrasonographic data, one must integrate complex hemodynamic data. What is important? What does one follow ? What are the priorities? Training and maintaining intensive care nurses. It is relatively easy to obtain equipment for an intensive
4 Mabie and Sibai
care unit, but quite another issue to recruit experienced, well-trained nurses. We find that regular obstetric nurses can function well in the intensive care unit setting. Indeed, the intensive care unit attracts some of the best nurses, but they are often so highly motivated that they "move up" into nursing administration. Therefore one constantly trains new nurses. We believe the ideal intensive care unit nurse is one who has a few years of labor floor experience, has seen most of the major obstetric complications, and wants to learn something new. Some centers use a labor and delivery nurse for the obstetric care and a medical intensive care unit nurse for managing the hemodynamic monitoring. This is not only expensive but less than ideal in terms of merging the two disciplines for optimal patient management, i.e., one nurse who can put the whole picture together. In our system the obstetric intensive care unit nurse also must work in the normal labor and delivery area when there are no patients in the intensive care unit. Such variety prevents "burnout." The intensive care unit thus raises the general level of nursing care in the labor and delivery area. Because our nurses do not receive extra pay for working in the intensive care unit, the advantages are restricted to intellectual stimulation, variation from routine obstetrics, and the satisfaction of helping a critically ill patient recover. Improved resident and fellow education. Another benefit of the obstetric intensive care unit is that residents and fellows learn critical care medicine. It sparks continuing interest by the faculty to teach and to keep up with new advances in the field. One learns more and remembers the experience better when he/she has responsibility for the patient and writes orders for dayto-day management. The resident or fellow's self-image is improved when he/she not only learns the principles of cardiopulmonary support but actually uses invasive hemodynamic monitoring and powerful pharmacologic agents." Having access to these patients and seeing the type of care available in an obstetric intensive care unit, residents are more likely to refer patients to it when they are in practice. Does an obstetric service need an IntenSive care unit?
What is the optimal way to manage sick obstetric patients? Should one transfer the patient to a medical or surgical intensive care unit or retain the patient in an obstetric intensive care unit? The answer depends on many factors, some unique to a given health care institution. The argument for transfer is that the critical care specialist deals with life-threatening situations daily. Most obstetrician-gynecologists do not see a sufficient number of these cases to maintain their skills.
January 1990 Am J Obstet Gynecol
The explosion of knowledge in critical care allows only the critical care specialist to keep up with this fast-paced field. By contrast, the argument for the obstetric intensive care unit is that critical care is not just the province of surgeons or internists. Several specialty boards are now certifying their members in critical care medicine, including internal medicine, pediatrics, surgery, and anesthesiology." In fact, the obstetrician has a background and experience that makes him/her ideal for treating critically ill obstetric patients. He/she knows the natural history of the disease process and its complications, understands the maternal physiologic adaptations to pregnancy and the changes in normal laboratory values in pregnancy, and appreciates the remarkable physiologic reserve of young, previously healthy women and the rapidity with which they improve with appropriate treatment. He / she also expertly reads the fetal monitor tracing, which is integral for antepartum management. Furthermore, continuity of care and the doctor-patient relationship can be preserved. Many subtle changes in the patient's condition are not reflected in the progress notes or laboratory data and can be detected only by serial observation at the bedside. Nonobstetricians and nonobstetric nurses are not familiar with some essential drugs. A prime example is intravenous magnesium sulfate. They may stop magnesium sulfate and allow seizures to occur or they may not know how to adjust the dosage for renal insufficiency and cause an overdose. In conclusion, we have found that an obstetric intensive care unit improves patient care, understanding of pathophysiology, and education of residents and fellows. Given the resources needed, the cost, and the utilization rate (1 % of deliveries), an obstetric intensive care unit is practical in those centers having a large obstetric service or a large maternal transport service. We acknowledge the commitment and hard work of the faculty, residents, and nurses who made the obstetric intensive care unit possible. REFERENCES 1. Zuspan FP, Sachs L. The impact of subspecialties on obstetrics and gynecology. AMJ OBSTET GYNECOL 1988;158: 747-53. 2. MerrillJA. SubspeciaJization in obstetrics and gynecology: results of a survey by the American Board of Obstetrics and Gynecology. AMJ OBSTET GYNECOL 1987;156:550-7. 3. Randall CL. The current practices of board-certified obstetricians and gynecologists in the United States. AM J OBSTET GYNECOL 1974;119:156-64. 4. Bryan-Brown CWo Pathway to the present: a personal view of critical care. In: Civetta JM, Taylor RW, Kirby RR, eds. Critical care. Philadelphia: JB Lippincott, 1988: 1641-8. 5. Day HW. An intensive coronary care area. Dis Chest 1963;44:423-7. 6. Walt AJ. The training and role of the surgeon in the intensive care unit. Surg Clin North Am 1985;65:753-62.
and Gynecology Founded in J920
volume 162
number 1 JANUARY 1990
CLINICAL SECTION Clinical Opinion Treatment in an obstetric intensive care unit William C. Mabie, MD, and Baba M. Sibai, MD Memphis, Tennessee A three·bed intensive care unit was opened in the labor and delivery area of a city-county hospital having approximately 7500 deliveries annually. The utilization rate of 0.9% and the severity of illness were sufficient to justify such a unit. Main indications for admission were hypertensive disorders (46%), massive hemorrhage (10%), and medical problems of pregnancy (44%). Identifiable benefits of the unit were as follows: (1) Intensive observation and organization allowed for prevention or early recognition and treatment of complications; (2) familiarity with invasive monitoring permitted personnel to exert prompt, rational treatment of hemodynamically unstable patients; (3) continuity of care was improved before and after delivery; (4) residents and fellows learned a great deal about intensive care and the management of rare medical complications of pregnancy. We conclude not only that critically ill pregnant women can be managed successfully in an obstetric intensive care unit but also that critical care is a bona fide part of obstetric practice and has been incorporated into our training program. (AM J OesTET GVNECOL 1990;162:1-4.)
Key words: Intensive care, Swan-Ganz catheter, medical complications of pregnancy
Maternal-fetal medicine, along with reproductive endocrinology and gynecologic oncology, was recognized as a subspecialty by the American Board of Obstetrics and Gynecology in 1972. I The first examinations were given and the first certificates of special competence were issued in 1974 .. These developments were in response to practice patterns already well established at the time. A 1972 survey of 11,689 diplomates of the board revealed that 14.1 % of the respondents limited their practice to an area of special interest such as obstetrics, reproductive endocrinology, or gynecologic oncology.' Although in utero diagnosis and fetal therapy are the primary focus of current research in maternalfetal medicine, a major clinical role of the sub specialist in maternal-fetal medicine continues to be that of an "internist for pregnant women." The obstetric intensive From the Department of Obstetrics and Gynecology, UnzveTSlty of Tennessee, MemphIS. Repnnt requests: William C. Mable, MD, Department of Obstetncs and Gynecology, Unzvemty of Tennessee, 853 Jefferson Ave., Room E-102, Memphis, TN 38163 .
6/1/14580
care unit can thus be seen as a product of the evolution of maternal-fetal medicine. The intensive care unit had its origin in the postoperative recovery room. In 1863, Florence Nightingale wrote that it was not uncommon in community hospitals to have a small area set aside near the operating rooms for patients recovering from the immediate effects of surgery. Walter Dandy started a postoperative neurosurgical unit at Johns Hopkins in 1923. Dwight Harkin established a cardiac surgical unit in Boston in 1951. During the Scandinavian polio epidemic of 1952, a special lOS-bed respiratory care unit was set up at Blegdam Hospital in Copenhagen for endotracheal intubation and intermittent positivepressure ventilation in patients with polio .. The first coronary care unit was established by Hughes Day 5 in Kansas City in 1962. There were many other pioneers in the development of adult, pediatric, and neonatal intensive care units , but the philosophy was the same: Put the sickest patients in a room with the best nurses in a 1: 1 or 2: 1 patient-to-nurse ratio. The purpose ofthis communication is to describe the
2
Mabie and Sibai
January 1990 Am J Obstet Gynecol
Table I. Main indications for intensive care unit admission Hypertensive disorders (eclampsia, n = 21; pulmonary edema, n = 10) Massive hemorrhage (abruptio placentae; n = 9, placenta accreta, n = 3) Medical problems of pregnancy Cardiac Pulmonary Renal Sepsis Gastrointestinal Endocrine Central nervous system Other
92 21
87 19
14
12 9 8
7 7
11
development of and initial experience with an obstetric intensive care unit detailing equipment, staffing, types of patients treated, and lessons learned. Population served
In January 1986 a three-bed obstetric intensive care unit was opened in the labor and delivery area of E. H. Crump Women's Hospital and Perinatal Center, a tertiary care, city-county hospital that serves as the main obstetric and gynecologic teaching hosp'ital at the University of Tennessee, Memphis. The hospital has approximately 7500 deliveries annually and receives maternal transfers from a five-state area including Tennessee, Arkansas, Mississippi, Missouri, and Kentucky. The referral area has approximately 40,000 deliveries per year, and there are no towns with a population > 100,000 within a 100-mile radius of Memphis. Facilities
Our obstetric intensive care unit consists of one large room (700 square feet) located next to the recovery room. Major equipment includes three HewlettPackard three-channel hemodynamic monitors, one Hewlett-Packard cardiac output computer, a strip chart recorder and printer, a Nellcor pulse oximeter, a Wescor colloid oncometer, two electric hospital beds, and one birthing bed that can be used for vaginal delivery of patients in the intensive care unit. Emergency equipment includes a "crash" cart, defibrillator, suction machine, and electrocardiograph machine. Fetal monitors are readily available. Rationale and staffing
The aim of the obstetric intensive care unit is to care for all critically ill pregnant women, except women having major trauma (treated in our institution's trauma
center), neurosurgical disorders, or necessity of mechanical ventilation for >5 days. Maternal-fetal medicine fellows and obstetrics-gynecology residents provide physician staffing for the intensive care unit. The director of the unit is board-certified in internal medicine, obstetrics and gynecology, and maternal-fetal medicine. The unit is staffed by 10 obstetric nurses, who control their own work schedule and assure that at least one is available 24 hours per day, 7 days per week. All nurses have had at least 2 years of labor floor experience; previous medical or surgical intensive care experience is desirable although not essential. All nurses are given a 4-week course in high-risk obstetric nursing, a I-week course in obstetric intensive care, a I-week course in medical intensive care, a 2-day course in hemodynamic monitoring, and a I-day course in mechanical ventilation, and they are encouraged to become certified in advanced cardiac life support. Nurses also gain clinical experience by working in the medical intensive care unit and refresh their knowledge by working there periodically. When there are no patients in the obstetric intensive care unit, those nurses work in the contiguous labor and delivery area. Most common disorders
During the 3-year period from Jan. I, 1986, to Jan. I, 1989, 200 patients were managed in the obstetric intensive care unit. During the same period there were 22,651 deliveries, for an intensive care unit utilization rate of 0.9%. Admission to the intensive care unit was limited to our sickest patients (in some instances because of unavailable nursing). The major categories of problems were hypertensive disorders (46%), massive hemorrhage (10%), and medical problems of pregnancy (44%) (Table I). The average intensive care unit stay was 2.5 ± 2.0 (mean ± SD) days. Only 9 of the 200 patients (4.5%) required transfer to another intensive care unit. The main indication for transfer to the medical intensive care unit was requirement for prolonged mechanical ventilation of patients having viral pneumonia or adult respiratory distress syndrome (n = 6). One patient was transferred for streptokinase therapy of acute massive pulmonary emboli, one for long-term management of thrombotic thrombocytopenic purpura, and one because of ruptured arteriovenous malformation. Managing the 200 patients required several procedures not conventional to obstetrics and gynecology: radial arterial lines (n = 151), pulmonary artery catheterization (n = 74), mechanical ventilation (n = 24), and hemodialysis (n = 8). An indication of the severity of illness was the occurrence of seven maternal deaths from the following causes: (1) ventricular septal defect
Volume 162 Number 1
with Eisenmenger's syndrome, (2) ruptured arteriovenous malformation, (3) varicella pneumonia, (4) malignant hypertension with renal failure, (5) metastatic breast cancer with evisceration, (6) metastatic pancreatic cancer with lactic acidosis and acute renal failure, and (7) thrombotic thrombocytopenic purpura.
Background of the obstetric Intensive care unit director In addition to routine obstetrics and gynecology, certain specialized clinical skills were frequently needed in our intensive care unit-inserting radial and pulmonary artery catheters, performing endotracheal intubation, managing a ventilator, reading an electrocardiogram, directing cardiopulmonary resuscitation, and performing a cesarean hysterectomy or bilateral hypogastric artery ligation. We observed the following emergencies repeatedly: pulmonary edema, massive hemorrhage, disseminated intravascular coagulation, septic shock, adult respiratory distress syndrome, acute renal failure, hypertensive crisis, cardiac arrhythmias, status asthmaticus, status epilepticus, stroke, pulmonary embolus, diabetic ketoacidosis, and thyroid storm. Training to manage the above must be given if an intensive care unit is to exist. Training can be obtained in several ways: a critical care fellowship , a medicine residency, or a maternal-fetal medicine fellowship interacting with the subspecialists.
Benefits of an obstetric Intensive care unit Improved patient care. An obstetric intensive care unit offers the opportunity to improve patient care. Two of the main benefits are observation and organization. Close observation in the intensive care unit allows problems to be detected earlier and complications to be prevented, enabling the patient to recover more quickly. For example, atelectasis and pneumonia can be prevented or ameliorated by early ambulation, coughing, aerosol treatment, and use of an incentive spirometer. Complex patient care can be more easily organized in the intensive care unit. Laboratory data accumulate so rapidly on sick patients that sometimes an important abnormality may go undetected. We use a bedside blackboard to facilitate organization. Each board contains the patient'S name, diagnosis, medications , treatment, and pending diagnostic studies. Nurses maintain a laboratory flow sheet at the bedside, recording laboratory results in chronologic order so that trends can be identified and missing results recalled. Locating the intensive care unit in the labor and delivery area further assures that an obstetrician, as well as a nurse, will be at the bedside. The obstetrician who
Obstetric intensive care
3
initiated care has the opportunity to provide continuity of care. For example, in massive hemorrhage, the obstetrician who operated on the patient knows best when the patient needs to undergo reexploration. He knows the technical problems that occurred during previous surgery and has the continuing duty to watch the patient closely at the bedside. He/she cannot do this adequately if the patient is transferred to another service or to another part of the hospital for intensive care. Gaining facility in invasive hemodynamic monitoring. Using the Swan-Ganz pulmonary artery catheter in obstetric patients allows the obstetrician to recognize patterns of disease, to understand pathophysiology, to make corrections when abnormalities are subtle, to evaluate the hemodynamic effects of drugs and other interventions, and to study the rare case. We prefer the Swan-Ganz catheter but recognize that it is only a monitoring device . The decision to use the catheter is based on the likelihood that one will find a hemodynamic abnormality that can be treated. Indications include pulmonary edema, oliguria, massive hemorrhage, septic shock, adult respiratory distress syndrome, class 3 and 4 cardiac disease, or pulmonary infiltrates when the diagnosis is unclear. If the intensive care unit equipment is not used frequently, it will be "borrowed" by other services and the skills of trained personnel will atrophy. We believe that the Swan-Ganz catheter is safe in experienced hands and that complications such as intracardiac knotting, pneumothorax, pulmonary artc~ry rupture, and endocarditis are quite rare. Incidentally, we believe that our own lack of serious complications is attributable not only to experience but to the following: (1) We do not persist with multiple punctures at various sites if difficulty is encountered inserting the catheter; (2) we position the catheter tip in the main pulmonary artery so that the balloon' does not float peripherally and cause pulmonary infarction; (3) we remove the catheter as soon as possible, usually within 24 hours of insertion . One problem that must be guarded against is mesmerization by the monitoring equipment. The physician may unwittingly spend excessive time calibrating, "debugging," and "troubleshooting" yet ignoring such equally important aspects as the fetal heart rate tracing or the progress of labor. A related problem is information "overload." One cannot see the forest for the trees! In addition to the history, physical examination, laboratory data, x-ray film, and ultrasonographic data, one must integrate complex hemodynamic data. What is important? What does one follow ? What are the priorities? Training and maintaining intensive care nurses. It is relatively easy to obtain equipment for an intensive
4 Mabie and Sibai
care unit, but quite another issue to recruit experienced, well-trained nurses. We find that regular obstetric nurses can function well in the intensive care unit setting. Indeed, the intensive care unit attracts some of the best nurses, but they are often so highly motivated that they "move up" into nursing administration. Therefore one constantly trains new nurses. We believe the ideal intensive care unit nurse is one who has a few years of labor floor experience, has seen most of the major obstetric complications, and wants to learn something new. Some centers use a labor and delivery nurse for the obstetric care and a medical intensive care unit nurse for managing the hemodynamic monitoring. This is not only expensive but less than ideal in terms of merging the two disciplines for optimal patient management, i.e., one nurse who can put the whole picture together. In our system the obstetric intensive care unit nurse also must work in the normal labor and delivery area when there are no patients in the intensive care unit. Such variety prevents "burnout." The intensive care unit thus raises the general level of nursing care in the labor and delivery area. Because our nurses do not receive extra pay for working in the intensive care unit, the advantages are restricted to intellectual stimulation, variation from routine obstetrics, and the satisfaction of helping a critically ill patient recover. Improved resident and fellow education. Another benefit of the obstetric intensive care unit is that residents and fellows learn critical care medicine. It sparks continuing interest by the faculty to teach and to keep up with new advances in the field. One learns more and remembers the experience better when he/she has responsibility for the patient and writes orders for dayto-day management. The resident or fellow's self-image is improved when he/she not only learns the principles of cardiopulmonary support but actually uses invasive hemodynamic monitoring and powerful pharmacologic agents." Having access to these patients and seeing the type of care available in an obstetric intensive care unit, residents are more likely to refer patients to it when they are in practice. Does an obstetric service need an IntenSive care unit?
What is the optimal way to manage sick obstetric patients? Should one transfer the patient to a medical or surgical intensive care unit or retain the patient in an obstetric intensive care unit? The answer depends on many factors, some unique to a given health care institution. The argument for transfer is that the critical care specialist deals with life-threatening situations daily. Most obstetrician-gynecologists do not see a sufficient number of these cases to maintain their skills.
January 1990 Am J Obstet Gynecol
The explosion of knowledge in critical care allows only the critical care specialist to keep up with this fast-paced field. By contrast, the argument for the obstetric intensive care unit is that critical care is not just the province of surgeons or internists. Several specialty boards are now certifying their members in critical care medicine, including internal medicine, pediatrics, surgery, and anesthesiology." In fact, the obstetrician has a background and experience that makes him/her ideal for treating critically ill obstetric patients. He/she knows the natural history of the disease process and its complications, understands the maternal physiologic adaptations to pregnancy and the changes in normal laboratory values in pregnancy, and appreciates the remarkable physiologic reserve of young, previously healthy women and the rapidity with which they improve with appropriate treatment. He / she also expertly reads the fetal monitor tracing, which is integral for antepartum management. Furthermore, continuity of care and the doctor-patient relationship can be preserved. Many subtle changes in the patient's condition are not reflected in the progress notes or laboratory data and can be detected only by serial observation at the bedside. Nonobstetricians and nonobstetric nurses are not familiar with some essential drugs. A prime example is intravenous magnesium sulfate. They may stop magnesium sulfate and allow seizures to occur or they may not know how to adjust the dosage for renal insufficiency and cause an overdose. In conclusion, we have found that an obstetric intensive care unit improves patient care, understanding of pathophysiology, and education of residents and fellows. Given the resources needed, the cost, and the utilization rate (1 % of deliveries), an obstetric intensive care unit is practical in those centers having a large obstetric service or a large maternal transport service. We acknowledge the commitment and hard work of the faculty, residents, and nurses who made the obstetric intensive care unit possible. REFERENCES 1. Zuspan FP, Sachs L. The impact of subspecialties on obstetrics and gynecology. AMJ OBSTET GYNECOL 1988;158: 747-53. 2. MerrillJA. SubspeciaJization in obstetrics and gynecology: results of a survey by the American Board of Obstetrics and Gynecology. AMJ OBSTET GYNECOL 1987;156:550-7. 3. Randall CL. The current practices of board-certified obstetricians and gynecologists in the United States. AM J OBSTET GYNECOL 1974;119:156-64. 4. Bryan-Brown CWo Pathway to the present: a personal view of critical care. In: Civetta JM, Taylor RW, Kirby RR, eds. Critical care. Philadelphia: JB Lippincott, 1988: 1641-8. 5. Day HW. An intensive coronary care area. Dis Chest 1963;44:423-7. 6. Walt AJ. The training and role of the surgeon in the intensive care unit. Surg Clin North Am 1985;65:753-62.
