Intensive Care Considerations in Obstetrics

What Makes a Unit an Intensive Care Unit?

The World Federation of Societies of Intensive and Critical Care Medicine defines an intensive care unit as “an organized system for the provision of care to critically ill patients that provides intensive and specialized medical and nursing care, an enhanced capacity for monitoring, and multiple modalities of physiologic organ support to sustain life during a period of acute organ system insufficiency.” Levels of intensive care range from the simple provision of additional noninvasive monitoring, all the way up to complicated and invasive life-support interventions such as extracorporeal membrane oxygenation. An international federation has defined 3 levels of ICU support: level 1 provides oxygen and noninvasive monitoring; level 2 provides invasive monitoring and basic life support for a short period; and level 3 provides a full spectrum of monitoring and life-support technologies (e.g., invasive mechanical ventilation). Not all units can provide all services.

The intermediate care unit (IMCU), stepdown unit, or high-dependency unit (HDU) represents a level between regular ward care and full intensive care. These exist to address a need for short-term intensified monitoring that cannot be carried out on the general ward but does not require the life-support interventions of a full-on ICU. When an intermediate-care unit is available, it reduces the pressure on ICUs and may decrease costs, since it can be staffed at a lower nurse-to-patient ratio. Labor and delivery (L&D) units sometimes implicitly serve this purpose for obstetric patients, e.g., when women with preeclampsia, on magnesium sulfate, are managed on L&D in the postpartum period. In the US, most maternity services that claim an “OB ICU” would more properly be described as having an HDU.

In 2020 and 2021, with the demands of the SARS-COV-2 (coronavirus) pandemic, hospitals and health authorities scrambled to add ICU capacity. Intensive care needs three major resources: space, “stuff,” and staff. Space is the easiest to come by, because existing spaces can be converted or repurposed. “ Stuff” refers to equipment, such as monitors, ventilators, and the like. Staff is always the most difficult to flex up, because the nurses, physicians, respiratory therapists, pharmacists, etc., take a long time to train and to acquire expertise, and because additional patient demand cannot easily be met; in a level 3 ICU, where the expected nurse-to-patient ratio is 1:1 or 1:2, adding more patients without being able to add more nurses only dilutes the care each one gets.

Tools, Techniques, and Competencies in Critical Care

The critical care specialist must be familiar with an extensive body of knowledge. This includes:

• Recognition of acute crisis or deterioration in patient status

• Knowledge of normal physiology and pathophysiology

• Identification and management of respiratory failure, including ventilator management

• Pharmacology of drugs, including vasoactive drugs, sedative and analgesia drugs, immunotherapy, antimicrobials; nutritional requirements

• Identification and management of shock

• Management of resuscitation

• Management of fluids and electrolytes in a variety of conditions

• Management of trauma and burns, at least after initial stabilization

• Identification of common cardiac disorders, including dysrhythmias, heart failure, hypertensive crisis, pulmonary hypertension

• Recognition and management of neurologic disorders such as coma and delirium

• Management of acute gastrointestinal or hepatic disorders (i.e., acute gastrointestinal bleeding, pancreatitis, hepatic failure)

Technical skills are also needed, such as arterial and central venous cannulation, basic and advanced airway management, and point-of-care ultrasound.

In addition to expertise in monitoring, resuscitation, diagnosis and management of critical illness, and advanced organ support, the intensivist must have expertise in teamwork, communication, end-of-life care, coordination of complex networks of consultants, cultural competence and sensitivity, and support of both patient and family. Box 71.1 gives a series of competencies expected of the intensivist.

Neither training in obstetrics and gynecology nor in subspecialties of maternal-fetal medicine and gynecologic oncology includes much exposure to specific critical care competencies. For those desiring extensive formal training, critical care fellowships in the United States are offered through a number of disciplines: internal medicine, surgery, anesthesiology, and emergency medicine. After residency, the length of training in critical care fellowship ranges from 1 to 3 years. Following completion of training in critical care, it would be difficult to maintain these skills and knowledge through regular practice exclusively in obstetrics and gynecology or any of its subspecialties. Although it is beyond the scope of this chapter to cover all elements of critical care, and although some of the topics (preeclampsia, obstetric hemorrhage) are covered elsewhere in this book, we will address a few conditions important in critical care medicine, specifically sepsis and acute respiratory distress syndrome (ARDS).