Maternal critical care guideline

Summary

The speaker, an obstetric fellow, introduces a maternal Critical Care guideline developed with a multidisciplinary team. The guideline addresses the care of critically ill women from 20 weeks gestation to 14 days postpartum, covering antenatal, postnatal, and non-obstetric-related conditions. It includes practical advice for anesthetists and critical care staff, particularly around topics like consent for breast milk expression in sedated patients and maintaining maternal-infant contact. Key resources, such as emergency guidelines and pharmacological information, aim to improve care and decision-making for critically unwell mothers, with an emphasis on supporting breastfeeding decisions.

Takeaways

• 📚 The speaker is an outgoing obstetric fellow who has contributed to a Maternal Critical Care guideline, highlighting its relevance to anesthesiologists for both antenatal and postnatal care.
• 🤰 The guideline covers a broad range of women from 20 weeks gestation to 14 days postpartum, including those with non-obstetric critical illnesses.
• 🏥 It was developed in response to the need for specific guidelines for critically unwell maternal patients, as identified in various best practice standards and the GPIX2.
• 🍼 A key consideration is the importance of breastfeeding or breast milk expression for women who are critically unwell or require surgery, and the need for consent in such situations.
• 👩‍⚕️ The guideline is a collaborative effort involving a large group of contributors from various specialties, aiming to provide comprehensive care for critically ill pregnant women.
• 📈 It includes detailed information on drug pharmacokinetics and pharmacodynamics in pregnancy and breastfeeding, which is crucial for anesthesiologists when prescribing medications.
• 👶 There's an emphasis on maintaining contact between mother and baby, with procedures in place for facilitating this, even when the mother is sedated and on intensive care.
• 📊 The guideline is designed for easy access to information, with key points and emergency contacts readily available, and it's structured to allow quick reference in critical situations.
• 💊 The document provides a comprehensive review of the top 50 drugs used in critical care, with specific advice on their use during pregnancy and breastfeeding.
• 🔄 The guideline is a living document, with plans for continuous improvement based on feedback and experience, emphasizing the importance of keeping it up-to-date and practical.

Q & A

What is the main purpose of the guideline discussed in the transcript?

The main purpose of the guideline is to provide specific recommendations for the care of critically unwell maternal patients, from 20 weeks gestation to 14 days postpartum, covering a wide range of women who may present with critical illnesses that are not obstetric-related.

Who are the key contributors to the guideline mentioned in the transcript?

The guideline was written by Dr. Cantelo, Claire Llewellyn, a senior matron on ITU, and the speaker, who is an outgoing obstetric fellow. It was also contributed to by a large group of people from various specialties.

Why is the guideline relevant to anesthesiologists?

The guideline is relevant to anesthesiologists because it contains information that can be useful for managing antenatal and postnatal women who are critically unwell, as well as those presenting for surgery during their second or third trimester.

What is the significance of the guideline's coverage from 20 weeks gestation to 14 days postpartum?

The guideline's coverage is significant because it encompasses a broad range of women who may present with critical illnesses, including those not related to obstetrics, ensuring comprehensive care for women during the perinatal period.

What are some unique challenges faced when caring for critically unwell pregnant or postnatal women?

Unique challenges include considerations for breastfeeding or breast milk expression, obtaining consent for medical procedures in sedated patients, and maintaining contact between the mother and baby while the mother is in intensive care.

Why is it important to discuss breastfeeding or breast milk expression with critically unwell women?

It is important to discuss breastfeeding or breast milk expression because some women may need or want to have their breast milk expressed if their baby is delivered, and obtaining consent for this in a sedated patient is a specific and complex issue.

What does the guideline suggest regarding maintaining contact between a mother and her baby while she is in intensive care?

The guideline suggests that there are systems in place to maintain contact, such as bringing neonates to intensive care when appropriate and taking videos for the mother to see, even if she is sedated and ventilated.

What is included in the appendices of the guideline that could be useful for anesthesiologists?

The appendices include safety alert posters, a list of emergency obstetric drugs available in the Omnicell, phone numbers for key personnel, and a comprehensive document on the pharmacodynamics and pharmacokinetics of the top 50 drugs used in critical care during pregnancy and breastfeeding.

How does the guideline address the use of drugs in critical care for pregnant and breastfeeding women?

The guideline provides detailed information on the appropriate use of drugs in critical care for pregnant and breastfeeding women, including a document created by critical care pharmacists that covers the top 50 drugs used, their safety, and considerations for breastfeeding.

What is the guideline's stance on supporting maternal choice regarding breastfeeding?

The guideline supports maternal choice by providing information on drug safety during breastfeeding, aiming to prevent unnecessary discouragement of breastfeeding and to allow women to make informed decisions based on the best available evidence.

Outlines

00:00

👩‍⚕️ Introduction to Maternal Critical Care Guidelines

The speaker, an outgoing obstetric fellow, introduces a new Maternal Critical Care guideline developed over the past year. The guideline is a collaborative effort with contributions from various medical specialties and is aimed at providing comprehensive care for critically ill pregnant or postpartum women. It covers a wide range of scenarios from 20 weeks gestation to 14 days postpartum, including non-obstetric critical illnesses. The speaker emphasizes the guideline's relevance to anesthesiologists, as it contains valuable information for managing critically ill pregnant or postnatal women. The guideline addresses the unique challenges faced by healthcare providers when dealing with critically ill pregnant women, such as considerations for breastfeeding or breast milk expression in intensive care settings. It also discusses the importance of obtaining consent for breast milk expression from sedated patients and maintaining contact between mothers and babies, even when the mother is on intensive care.

05:01

📚 Overview of the Maternal Critical Care Guideline

The speaker provides an overview of the guideline, which is about 50 pages long and designed for easy access to relevant information. It includes a previous level two and labor guideline and is intended to be a comprehensive resource for healthcare professionals. The guideline contains quick access infographics for critical care situations involving pregnant women, such as intubation, ventilation, and resuscitation. It also includes a detailed renal section written by renal consultants with obstetric interests, providing information on managing women with chronic or acute renal disease during pregnancy. The speaker highlights the usefulness of the guideline for nurses and midwives, particularly for out-of-hours care, and directs attention to the appendices, which contain safety alert posters, emergency contact numbers, and a guide to drugs used in critical care, including their pharmacodynamics and pharmacokinetics during pregnancy and breastfeeding.

10:02

💊 Comprehensive Drug Information for Critical Care in Pregnancy

The speaker discusses an extensive section of the guideline that focuses on the top 50 drugs used in critical care, detailing their pharmacodynamics and pharmacokinetics during pregnancy and breastfeeding. This section is particularly useful for anesthesiologists and other healthcare providers who need to make informed decisions about drug safety and appropriate use in pregnant or breastfeeding women. The document provides practical advice on drug use and breastfeeding, helping to ensure that women can make informed choices about their care. The speaker also mentions resources for further information on specific drugs and encourages feedback for future revisions of the guideline to ensure its ongoing relevance and accuracy.

Keywords

💡Obstetric

Obstetric refers to the medical specialty that focuses on pregnancy, childbirth, and postpartum care. In the context of the video, the speaker discusses guidelines for maternal critical care, which are crucial for obstetricians and other healthcare professionals managing critically ill pregnant women or those who have recently given birth.

💡Maternal Critical Care

Maternal Critical Care is a specialized area of medicine that deals with the care of pregnant women who have severe medical conditions requiring intensive care. The video script emphasizes the importance of these guidelines for managing such critical cases, ensuring the safety of both the mother and the unborn child.

💡Gestational Age

Gestational age is the term used to describe the stage of development of an embryo or fetus. The script mentions that the guidelines apply to women from 20 weeks gestation to 14 days postpartum, highlighting the broad range of patients that these guidelines cover.

💡Intensive Care Unit (ITU)

The ITU, or Intensive Care Unit, is a special department within a hospital that provides care for patients with life-threatening conditions. The video discusses the challenges faced by ITU nurses and the importance of guidelines for the care of critically ill pregnant or postpartum women in such settings.

💡Breast Milk Expression

Breast milk expression refers to the process of manually or mechanically extracting milk from the breasts. The script discusses the importance of considering breast milk expression for women who are critically ill and unable to breastfeed, emphasizing the need for consent and the impact on newborn care.

💡Consent

Consent in a medical context is the voluntary agreement by a patient to receive treatment or undergo a procedure. The video script mentions the complexity of obtaining consent for breast milk expression in sedated patients, which is a critical legal and ethical consideration in maternal critical care.

💡Pharmacokinetics

Pharmacokinetics is the study of how drugs are absorbed, distributed, metabolized, and excreted by the body. The script highlights the importance of understanding pharmacokinetics in the context of pregnancy and breastfeeding, as it informs the safe use of medications in critically ill women.

💡Preeclampsia

Preeclampsia is a pregnancy complication characterized by high blood pressure and damage to another organ system, often the liver and kidneys. The video mentions guidelines for treating preeclampsia, which is a condition that can lead to critical care needs for pregnant women.

💡Uterotonics

Uterotonics are medications that stimulate or enhance the contraction of the uterus. The script refers to guidelines for the use of uterotonics in critical care situations, which are essential for managing postpartum hemorrhage and other complications.

💡Renal Disease

Renal disease refers to any condition that affects the function of the kidneys. The video script includes a section on renal disease, emphasizing the need for specialized care and consideration in the management of pregnant women with chronic or acute renal conditions.

💡Critical Care Pharmacist

A Critical Care Pharmacist is a specialist who provides expert advice on the safe and effective use of medications in intensive care settings. The script mentions the role of critical care pharmacists in compiling information on drug use during pregnancy and breastfeeding, which is invaluable for patient care.

Highlights

Introduction of a new Maternal Critical Care guideline developed over the last year.

The guideline is applicable to all women from 20 weeks gestation to 14 days postpartum.

The guideline is not only for obstetric emergencies but also for non-obstetric critical illness during the perinatal period.

Unique challenges in managing critically unwell pregnant or postnatal women are discussed.

Importance of considering breastfeeding or breast milk expression in critically ill women.

Legal considerations for obtaining consent for breast milk expression in sedated patients.

The guideline includes a comprehensive section on drugs used in critical care, including pharmacodynamics and pharmacokinetics during pregnancy and breastfeeding.

Practical advice on maintaining contact between mother and baby while the mother is in intensive care.

The guideline is designed for quick access to information, with key points and links on the first page.

Safety alert posters are included for quick reference in critical care settings.

A detailed section on the management of preeclampsia and the use of uterotonics.

The guideline is a collaborative effort involving multiple specialties and contributors.

The guideline is intended to be a living document, with plans for regular updates and revisions based on feedback.

Encouragement for users to provide feedback for future improvements of the guideline.

The guideline aims to support informed decision-making regarding breastfeeding and medication use post-operatively.

Information on how to handle specific drugs and their safety during pregnancy and breastfeeding.

Transcripts

foreign

ER I am the recently outgoing obstetric

fellow for nuh and I'm just currently my

st7 year at Derby and what I want to

talk to you about today is a maternal

Critical Care guideline that we've

produced in the last year both myself Dr

cantalo and Claire Llewellyn who's a

senior matron on itu uh wrote This

Together along with a massive group of

people who contributed from all

Specialties now I don't want to lose

people immediately I promise there is

stuff in here that will be really useful

in anesthetics it's not just information

that's helpful for an obstetric woman

who is critically unwell in her

perinatal period there is lots of stuff

in here that will be useful for

antenatal and postnatal women

so a bit of background first of all the

guideline came about because there's

been lots of best practice standards in

various different reviews and documents

that says we need specific guidelines

for critically unwell maternal patients

and and the gpix 2 specifically has lots

of information about what we need to

have for these women

so this guideline that we've made

applies to all women from 20 weeks

gestation to 14 days postpartum so

there's a huge range of women in there

who may be presenting to Edie with

critical illness which is not obstetric

related or he may be presenting for

surgery in their second or third

trimester

or who are presenting again postnatally

with illnesses that are not obstetrics

so it's re it affects a wide range of

women and these are women that you may

encounter both in theater or in recess

so I think there's a lot of stuff in

here that could potentially help you in

these situations

these women create uh present us with a

significant unique challenge that we

don't encounter very often particularly

if you don't do obstetrics there's

potentially an area that you never

really

um work in so there are some key things

to think about which actually a lot of

things even despite doing an objective

Fellowship I hadn't even considered

until I had conversations with the it

nurses about things that present them

with significant challenges with these

women and one of those is actually about

breastfeeding or breast milk expression

so if you have women who present

antenatally for surgery or critically

unwell he needs to go to itu prior to

delivery

actually some of those women may need

delivery or may want to be able to have

their breast milk expressed if their

baby is delivered and getting consent

for breast milk expression in a sedated

patient is a very specific thing that

I've certainly never thought about

before I wrote this guideline and it is

actually something that would be really

is really helpful if we can get verbal

consent for women and document somewhere

in their notes that they would wish to

have breast milk expressed if they were

unconscious and unable to give verbal

consent

then that makes life a lot easier for

the um intensive care midwife intensive

care nurses and the midwives

so um we did run this past legal because

there's a lot of conversation about

whether it was appropriate to do this

and legal have said that this would be a

best interest decision

um as all other medical decisions are

but it's obviously incredibly

complicated and for women who are having

their first baby there may not be a

precedent and the family may not be

clear about exactly what that woman

would want to do because there is a

significant difference between choosing

to breastfeed your baby and having

breast milk expressed from you while you

are unconscious on intensive care

so that's one of the areas that's I

think really useful to think about if

you're looking after a critically unwell

woman in any context

also particularly for families

um for families and mothers potentially

before their anesthetized to know that

there are lots of systems in place to

maintain contact between mother and baby

and once babies delivered or if the

woman is postnatal and while the woman

is on intensive care even if she is

intubated and sedated and ventilated and

that involves bringing

um neonates to intensive care where it's

appropriate and also taking videos and

we've got a standard operating procedure

to facilitate that so that families and

mothers can have access to those

pictures when the mother and baby are on

itu even if the mother is sedated and

that's caused quite a lot of difficulty

for the itu nurses where you know people

want to have pictures of their baby in

that time frame and and there were

difficulties with confidentiality and

taking pictures of somebody who is

sedated and ventilated so knowing that

that is something that we have looked at

and discussed allows you as the

anesthetist caring for these women to

reassure them that we can maintain

contact and just because they are

sedated and ventilated it doesn't mean

they will be separated from their baby

so it is a big guideline it's about 50

pages and it is deliberately designed to

be really useful and to hopefully have

easy access to the bits that you want

and to kind of freeze past the bits you

don't want

um some of you may be aware that there

was a level two and laboratory guideline

which applied to women who were admitted

onto the critical care bed state but

kept on labor Suite so these are women

who are in their perinatal period

although her presenting with an

obstetric issue but needed to be under

critical care that

um guideline is now part of this one so

if you're looking for it you'll find it

in here and there is a separate uh

guideline for enhanced internal care

which is held by maternity because

that's a specific Midwifery and

obstetric-led element of care so this is

the contents of what is in the guideline

I will run you through the bits that I

think are most relevant to anesthesia so

you don't have to kind of trawl through

everything but just to give you an idea

of

um the kind of stuff that's covered

within this

most of the really useful stuff is in

the appendix so if you're looking for

something you probably want to be

heading there

so this is Page Three

um if you're in a scenario where you

need

um quick access to information then

we've tried to put all the key things on

here and all the links on here so this

is kind of the first place to go for

emergency information a lot of this is

specifically for

um critical care but it will tell you

the pages you need to get to to get to

the information independencies which

I'll come to in a minute

um so for most anesthetists um

caring for critically unwell of sexually

patients is perhaps not something you do

on a routine basis so

early on in the guideline there is some

kind of quick

uh infographics I suppose as was shown

here of um things you just might want to

think about if you are intubating or

ventilating or resuscitating a woman who

is critically unwell who is pregnant and

some of this it's not included on these

slides but there's also a significant

renal section written by Matt Hall the

renal consultant who has an obstetric

interest and Suzanne Wallace who's our

obstetrician with an obstetric interest

with a renal interest sorry

um and there's some really really useful

information in there about women with

chronic renal disease and acute renal

disease so I'm not going to go through

this in loads of detail this will be

familiar to everybody I'm sure but if

you need a quick reminder or if you're a

trainee who's on critical care looking

after a pregnant woman and you just feel

that you need a refresher and everything

is on here and there's some useful stuff

about a gas exchange and what you'd be

aiming for and things that are normal in

pregnancy or postnatally that might not

be normal for a different critically ill

patient

in terms of nursing information there is

quite a lot of nesting information in

this document and that's not necessarily

relevant um for each and easy test but

particularly out of hours it'd be really

useful if you could sign post nurses and

midwives to this guideline so that they

know it exists most of them should do

but if there's any people who are unsure

because there's a lot of stuff in here

that will help them in terms of

supporting getting these women admitted

and supporting decision making about

breastfeeding about facilitating contact

about admitting people onto the bed

State all those kind of practical things

that the critical care nurses need

access to

so the appendices so this is the stuff

that I think will be the most useful for

people

so there are

uh seven appendices on this the first

two are safety alert posters which look

like this which are uni individual for

City and queens and these should be put

up in the bed space for these women when

they're admitted to critical care so if

you were called to critical care to help

with a woman who for example needed

delivery on intensive care or was

um acutely unwell and needed extra hands

on critical care these posters will be

up and this just gives you rapid

um access to the information that you

might need so in particular where is the

emergency delivery pack where is the

recessive tear where is everything that

you're going to need to get that baby

out if you need to do a crash section on

itu

and who do you need to call and what are

the numbers so that you don't have to go

through switchboard so look for these up

on the wall all of the emergency

obstetric drugs on critical care will be

in the Omni cell and there is a kit with

all the uterotonics and stuff you're

going to need and again the omnicell

numbers are given on these posters and

how to get it

so it's just useful to know that these

exist and to look for them if you end up

in a situation where someone is

critically unwell on itu and needing an

urgent delivery

again if you need any phone numbers for

anybody you need to both sites then

these numbers are all in one place and

these are in the appendices so that you

don't have to go digging around for all

these people's phone numbers they're

easy to get hold of

and then probably the most useful part

of this guideline is it's the incredible

Critical Care pharmacists went through

the top 50 drugs that we use in critical

care and they gathered loads of

information about the pharmaco Dynamics

the pharmacokinetics in pregnancy and

the appropriate use of these drugs in

breastfeeding so you know it's over 10

pages long this document

um and it's got it doesn't just say no

safety data it says useful information

about what when it may be appropriate to

use these drugs for different women and

I think it's important to note that

there is a move to supporting or you

know we are trying to make sure people

understand a bit more about

breastfeeding and when women need to be

told not to breastfeed particularly

after anesthesia or when they actually

might need to

um Express their milk and discard it and

for how long and when actually it's fine

for them to breastfeed and there's

really really Limited

information out there so the critical

care pharmacies have gone through lots

of different resources and come up with

a document that's just practical and

useful so for many women that you care

for even if they're not critically

unwell and they're just presenting for a

routine operation in their second or

third trimester this document can

hopefully give you some advice about

whether drugs are safe or reasonable to

use and also information that you can

share with the woman so that she can

make an informed decision about whether

she wishes to breastfeed her baby

post-operatively

um there is there are resources in the

guideline as well in the main body of

the guideline if you have specific

questions about certain drugs or if

women have specific questions about

certain drugs so that you can contact

the um groups that we spoke to to

produce this guideline who can give you

tailored advice for individual

medications that you might be using

so I think this this is probably the

part of the guideline that can be the

most useful for people and can probably

make the biggest difference for women

because we do have a tendency to say oh

the BNF isn't clear and I'm not sure so

just don't breastfeed but actually for

many women that's not appropriate it's

not something that they want to do

um and there is a tendency to

potentially tell women to discard milk

that they don't need to be discarding

and that might result in that baby

having to have formula that a mother

would prefer not to use so it allows

women to have maternal Choice with all

the information that we can have access

to so um probably if you remember

nothing else in this presentation try

and remember that this exists

if you end up looking after a woman who

needs any uterotonics or any treatment

for preeclampsia

which is slightly out of your remit of

normal practice again there is a summer

sea of guidance here for how to give it

now this is written for the critical

care nurses mainly because these are

drugs they probably have never used so

it's written in the way that they would

give their medications on critical care

but it's useful if you just need a quick

reminder of what to do

um and how to draw things up and how to

give them so I just want to say a huge

thank you to everyone that participated

in making this because it was a massive

team effort and and there are as always

things that need tweaking and changing

and we've kind of already picked up

um by having this guideline in use for a

few months that there are things we need

to change for the next uh revision of

the guideline so if anybody's looking at

it and they come across things that they

think don't quite work or that we need

to change please drop me an email

um because we you know we want to make

it as useful and practical as possible

so that we can take it forwards into the

next into the next edit

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