Critical care in obstetrics: a strategy for addressing maternal mortality.

The acute rise in maternal morbidity and mortality in the United States is in part because of an increasingly medically complex obstetrical population. An estimated 1% to 3% of all obstetrical patients require intensive care, making timely delivery and availability of critical care imperative. The shifting landscape in obstetrical acuity places a burden on obstetrical providers, many of whom have limited experience in identifying and responding to critical illness. The levels of maternal care definitions by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine designate hospitals based on the availability of obstetrical resources and highlight the need for critical care resources and expertise. The growing need for critical care skills in the evolving contemporary obstetrical landscape serves as an opportunity to redefine the concept of delivery of care for high-risk obstetrical patients. We summarized the key tenets in the prevention of maternal morbidity and mortality, including the use of evidence-based tools for risk stratification and timely referral of patients to facilities with appropriate resources; innovative pathways for hospitals to provide critical care consultations on labor and delivery; and training of obstetrical providers in high-yield critical care skills, such as point-of-care ultrasonography. These critical care-focused interventions are key in addressing an increasingly complex obstetrical patient population while providing an educational foundation for the training of future obstetrical providers.

Risk Assessment of the Cardiac Pregnant Patient.

Women with heart disease are at increased risk for maternal and fetal complications in pregnancy. Therefore, all women with heart disease should undergo evaluation and counseling, ideally before conception, or as early in pregnancy as possible. In this article we will review the role of risk assessment, the history of development of the cardiac risk prediction tools, and the role of current cardiac risk prediction tools.

Putting the "M" back in maternal-fetal medicine: A 5-year report card on a collaborative effort to address maternal morbidity and mortality in the United States.

The Centers for Disease Control and Prevention have demonstrated continuous increased risk for maternal mortality and severe morbidity with racial disparities among non-Hispanic black women an important contributing factor. More than 50,000 women experienced severe maternal morbidity in 2014, with a mortality rate of 18.0 per 100,000, higher than in many other developed countries. In 2012, the first "Putting the 'M' back in Maternal-Fetal Medicine" session was held at the Society for Maternal-Fetal Medicine's (SMFM) Annual Meeting. With the realization that rising risk for severe maternal morbidity and mortality required action, the "M in MFM" meeting identified the following urgent needs: (i) to enhance education and training in maternal care for maternal-fetal medicine (MFM) fellows; (ii) to improve the medical care and management of pregnant women across the country; and (iii) to address critical research gaps in maternal medicine. Since that first meeting, a broad collaborative effort has made a number of major steps forward, including the proliferation of maternal mortality review committees, advances in research, increasing educational focus on maternal critical care, and development of comprehensive clinical strategies to reduce maternal risk. Five years later, the 2017 M in MFM meeting served as a "report card" looking back at progress made but also looking forward to what needs to be done over the next 5 years, given that too many mothers still experience preventable harm and adverse outcomes.

The "virtual" obstetrical intensive care unit: providing critical care for contemporary obstetrics in nontraditional locations.

Management of the critically ill pregnant patient presents a clinical dilemma in which there are sparse objective data to determine the optimal setting for provision of high-quality care to these patients. This clinical scenario will continue to present a challenge for providers as the chronic illness and comorbid conditions continue to become more commonly encountered in the obstetric population. Various care models exist across a broad spectrum of facilities that are characterized by differing levels of resources; however, no studies have identified which model provides the highest level of care and patient safety while maintaining a reasonable degree of cost-effectiveness. The health care needs of the critically ill obstetric patient calls for clinicians to move beyond the traditional definition of the intensive care unit and develop a well-rounded, quickly responsive, and communicative interdisciplinary team that can provide high-quality, unique, and versatile care that best meets the needs of each particular patient. We propose a model in which a virtual intensive care unit team composed of preselected specialists from multiple disciplines (maternal-fetal medicine, neonatology, obstetric anesthesiology, cardiology, pulmonology, etc) participate in the provision of individualized, precontemplated care that is readily adapted to the specific patient's clinical needs, regardless of setting. With this team-based approach, an environment of trust and familiarity is fostered among team members and well thought-out patient care plans are developed through routine prebrief discussions regarding individual clinical care for parturients anticipated to required critical care services. Incorporating debriefings between team members following these intricate cases will allow for the continued evolution of care as the medical needs of this patient population change as well.

Postpartum Hemorrhage Management and Blood Component Therapy.

This article serves to highlight both the common nature and severity of postpartum hemorrhage (PPH). Identification of etiologies and management of each is reviewed. In addition, the evaluation and administration of proper blood component therapies and massive transfusion are also explained to help providers become comfortable with early administration and delivery of blood component therapies.

Correlation between medical management and teamwork in multidisciplinary high-fidelity obstetrics simulations.

BACKGROUND: Teamwork and communication gaps are consistently cited as contributors to adverse outcomes in obstetrics. The Critical Care in Obstetrics Course provides an innovative experience by combining brief interactive didactics with the opportunity to practice and implement the knowledge gained with hands-on simulation. Most participants have never worked together, which creates a unique environment to evaluate the importance of teamwork and communication. OBJECTIVE: This study aimed to evaluate the association between teamwork and medical management in high-fidelity critical care simulations. STUDY DESIGN: The participants were separated into multidisciplinary teams and taken through simulations, including placental abruption, hypertensive emergency, eclampsia, sepsis, cardiac arrest, venous thromboembolism, diabetic ketoacidosis, and thyroid storm. Facilitators completed a validated checklist assessment for each group's performance in medical care and teamwork. Each element was rated on a scale from 1 to 5, with 1 being unacceptable and 5 being perfect. We evaluated 5 communication measures, including the use of closed-loop communication and orientation of new team members. A Spearman correlation was used to evaluate the relationship between total medical management and total teamwork scores and specific measures of team communication. Receiver operating characteristic curves were created for total teamwork score as a predictor of good or perfect medical management. RESULTS: A total of 354 multidisciplinary teams participated in 1564 high-fidelity simulations. There was a significant correlation between medical management and teamwork and communication scores for all scenarios. The strongest correlation was for the total teamwork score for all simulations (ρ=0.84). Teamwork scores were highly predictive of medical management scores with an area under the curve of at least 0.88 for all simulations, although this was not significant for diabetic ketoacidosis. CONCLUSION: The quality of teamwork and communication correlated with the quality of clinical performance in newly formed multidisciplinary teams. This demonstrates the importance of teamwork training, with a focus on key communication tools and strategies, among medical providers to optimize the management of complex and emergent obstetrical conditions.

Improving obstetric hemorrhage morbidity by a checklist-based management protocol; a quality improvement initiative.

OBJECTIVE: Postpartum hemorrhage is a leading cause of maternal morbidity and mortality worldwide. Institutions are encouraged to have a standardized approach to the management of obstetric hemorrhage. The purpose of this quality improvement project was to investigate postpartum hemorrhage associated morbidity before and after implementing an obstetric hemorrhage checklist-based protocol. STUDY DESIGN: In 2015, a resident-driven initiative for obstetric hemorrhage was initiated at a single institution using a checklist-based protocol for postpartum hemorrhage. The project included development of the obstetric hemorrhage checklist by a multidisciplinary team and implementation using low cost education and training strategies. Following implementation, a pre-and post-protocol retrospective analysis was performed measuring maternal morbidity surrogates and protocol compliance. During the 18 month study period, 422 women were identified for review and 147 met criteria in the pre-protocol group and 150 met criteria in the post-protocol group. RESULTS: There was a significant decrease in severe postpartum hemorrhage rates in the post-protocol group (p = 0.04) and all other surrogates for maternal morbidity decreased in the post-protocol group. Protocol compliance was 62.2% and compliance with screening using an assessment of hemorrhage risk was 75.7%. CONCLUSION: The implementation of a checklist-based management protocol for postpartum hemorrhage has shown a promising trend in improving maternal morbidity, screening, early diagnosis, and healthcare delivery for obstetric hemorrhage at our institution and has been approved for larger scale implementation within our health system.

Multidisciplinary obstetric critical care delivery: The concept of the "virtual" intensive care unit.

With an increasing prevalence of chronic medical conditions and the associated potential for decompensation to critical illness among modern day parturients, we present here the concept of the "virtual" intensive care unit. We challenge the traditional association of the word "unit" to extend beyond a fixed physical setting to portray an individualized, predetermined patient care team capable of managing these complex patients in a variety of settings. In this model, obstetric critical care is provided through a multidisciplinary patient care team, with emphasis on early identification of complicated pregnancies, detailed antepartum planning, anticipation of complications, and retrospective review of clinical outcomes aimed at continued quality improvement. This structured approach in the provision of care to the critically ill pregnant patient will serve as a foundation for future attempts at reduction in rates of maternal morbidity and mortality.

Transforming Clinical Education in Obstetrics and Gynecology: Gone Is the Day of the Sage on the Stage.

Many traditional approaches to clinical education today are outdated and inefficient with disruptive changes on the horizon. Millennials are the new wave of learners in health care and do not learn the same way as their older faculty. Merging health care systems are moving to standardizations of care and reduction of errors, and health care providers are going to be increasingly held more accountable for their clinical outcomes. Computers, digitalization, and connectivity are revolutionizing learning environments, and simulation learning in the form of trainers, mannequins, and team training is already widespread. Newer technologies like virtual and augmented reality are beginning to be used for clinical education and will be a more efficient and standardized way of providing simulation learning. Emerging technologies like holograms and head-mounted displays will follow soon after and be even more disruptive. Faculty and mentors will always be crucial to learning in health care but will be empowered to teach in more focused and comprehensive ways. The educational model of the future will be a hybrid model of experienced faculty, interactive learning, and innovative and emerging technology. It is time we start to train health care providers for their future, not our past.

Is peripartum hysterectomy more common in multiple gestations?

OBJECTIVE: To compare the occurrence of peripartum hysterectomy between singleton and multiple gestations. METHODS: This was a historical cohort study comparing the occurrence of peripartum hysterectomy between singleton and multiple gestations at Banner Good Samaritan Regional Medical Center, Phoenix, Arizona, from January 1, 1996, to December 31, 2001. RESULTS: During the study years, 42,595 singleton, 1,131 twin, 164 triplet, 35 quadruplet, and 2 quintuplet deliveries occurred. A total of 100 peripartum hysterectomies were performed. Of these hysterectomies, 88 occurred in singletons, 5 in twins, 6 in triplets, and 1 in quadruplets. The overall occurrence of peripartum hysterectomy was 2.28 per 1,000, and the occurrence of emergent peripartum hysterectomy was 1.73 per 1,000. Multiple gestations had a significantly greater risk of emergent peripartum hysterectomy than singletons (odds ratio [OR] 6.04, 95% confidence interval [CI] 3.28-11.11; P < .001). This difference was more pronounced among higher-order multiple gestations: twins (OR 2.95, 95% CI 1.22-7.13, P = .03), triplets (OR 25.22, 95% CI 11.02-57.77, P < .001), and quadruplets (OR 19.53, 95% CI 3.34-114.69, P = .04). When compared with singletons, higher-order multiple gestations had nearly a 24-fold increased risk of emergent peripartum hysterectomy (OR 23.97, 95% CI 11.05-51.99, P < .001). CONCLUSION: Multiple gestations have a significantly higher occurrence of emergent peripartum hysterectomy than singletons. This information should be used in counseling and managing patients with these pregnancies.