High-risk Obstetric Patients Research Articles

Admission cardiotocography: Its role in predicting foetal outcome in high-risk obstetric patients.

Routine and continuous electronic monitoring of foetal heart rate (FHR) in labour has become an established obstetric practice in high-risk pregnancies in industrialised countries. However, the same may not be possible in non-industrialised countries where antenatal care is inadequate with a large number of high-risk pregnancies being delivered in crowded settings and inadequate health care provider to patient ratios. The objective of this study was to evaluate the predictive value of the admission cardiotocogram (CTG) in detecting foetal hypoxia at the time of admission in labour and to correlate the results of the admission CTG with the perinatal outcome in high-risk obstetric cases. This was a prospective observational study conducted in the labour and maternity ward of a hospital in Gangtok, India, during the period 2008 to 2010. The study included high-risk pregnant women, admitted via the emergency or outpatient department with a period of gestation ≥36 weeks, in first stage of labour with foetus in the cephalic presentation. All women were subjected to an admission CTG, which included a 20 minute recording of FHR and uterine contractions. One hundred and sixty patients were recruited. The majority of women were primigravida in the 21-30 years age group. About 42% patients were postdated pregnancy followed by pregnancy-induced hypertension (PIH) (15.6%) and premature rupture of membranes (PROM) (11.3%) as the major risk factors. The admission CTG were 'reactive' in 77%, 'equivocal' in 14.4% and 'ominous' in 8.7% women. Incidence of foetal distress, moderate-thick meconium stained liquor and neonatal intensive care unit (NICU) admission was significantly more frequent among patients with ominous test results compared with equivocal or reactive test results on admission. Incidence of vaginal delivery was more common when the test was reactive. The admission CTG appears to be a simple non-invasive test that can serve as a screening tool in 'triaging' foetuses of high-risk obstetric patients in non-industrialised countries with a heavy workload and limited resources.

Implementing a Nurse Navigation Program for High Risk Obstetric Patients: An Evidence-Based Practice Approach

Implementing a Nurse Navigation Program for High Risk Obstetric Patients: An Evidence-Based Practice Approach

The role of the post-anaesthesia care unit in the management of high-risk obstetric patients

IntroductionHigh-risk obstetric patients in the immediate postpartum period are frequently admitted to the intensive care unit, but the necessity of this practice has recently been doubted. Herein we describe the efficiency of utilizing the post-anaesthesia care unit (PACU) as an intermediate intensive care facility for those patients.Material and methodsWe retrospectively described the reasons for admission, duration of stay, the anaesthetic used, main interventions and outcome for all obstetric admissions in the PACU during a period of 4 years in a university hospital.ResultsDuring the 4-year period 47 women were admitted to the PACU after delivery. The frequency of admission to the PACU was 15.3 per 1000 deliveries, while obstetric cases represented 4.4 per 1000 admissions to the PACU. The majority represented caesarean sections (81%). The main reasons for admission to the PACU were haemorrhage (49%), cardiovascular problems (19%) and preeclampsia/eclampsia (17%). Mean length of stay in the PACU was 14.5 ±11.6 h, being significantly less in women having received epidural anaesthesia (8.2 ±5.6 h) compared to those who delivered with general anaesthesia (19.0 ±13.6 h, p < 0.05). General anaesthesia was used in 85% of cases in which emergency delivery was indicated, but only in 27% of cases without emergency indications for delivery (p < 0.01). No death or admission to the intensive care unit occurred during the study period.ConclusionsThe PACU can offer an intermediate intensive care facility for high-risk obstetric patients, thus reducing unnecessary admissions to the intensive care unit.

Grandmultiparity: experience at Awka, Nigeria.

The grandmultiparae have basically been regarded as high risk obstetric patients. This study was undertaken to estimate the prevalence in this area as well as evaluate the problems, associated factors and ways of reducing the burden. This was a retrospective study of the problems of grandmultiparity (five or more previous viable babies) at Amaku General Hospital, Awka over a three year period, January 2006 to December 2008. One hundred and thirty five (135) grandmultiparous women (study group) were matched with a similar number of women of lower parity (Para 2 and 3), who attended and delivered in the hospital during the same period. The problems seen in both groups during pregnancy and labour, mode of delivery, birth weight, perinatal and maternal mortalities were compared. The soccio-demographic characteristics were also compared. The incidence of grandmultiparae was 7.53%. Twenty nine (21.5%) of the grandmultiparae were unbooked compared to 6 (4.4%) of the control group. Ninety four (69.7%) of the study group belonged to the low social class IV and V compared to 27 (20%) of the control. Anaemia in pregnancy was commoner in study than in the control group (49 (36.3%) versus 12 (8.9%). There was a high caesarean section rate in the study group compared to the control (31 (23.0%) versus 6 (4.4%). The maternal mortality rate in the study group was 22.2/1000. There was no maternal death in the control. Improving the socio-economic standard of our women and increased awareness in the importance of family planning will reduce the incidence and complications of grandmultiparity.

Pregnancy Outcomes After Orthopedic Trauma

This study was performed to determine the effects of orthopedic trauma on pregnancy outcomes in pregnant trauma patients. This was an observational study completed after electronically linking databases for the obstetric service and the trauma service at our Level I trauma center. All pregnant women who presented during the years 1995 to 2007 were eligible for inclusion. Selected pregnancy outcomes in women who delivered at our trauma center during or after their trauma admission were evaluated according to the presence of orthopedic injuries. Statistical analyses were performed using χ, Student's t test, and Wilcoxon rank-sum test; and p < 0.05 are considered statistically significant. There were 65 pregnant women with orthopedic injuries (6%) and 990 without orthopedic injuries. Women with orthopedic trauma had an average gestational age of 28 weeks versus 31 weeks for women without orthopedic trauma. Compared with the patients without orthopedic injuries, patients with orthopedic injuries had a significant increased risk of preterm birth before 37 weeks of gestation (31% vs. 3%; p < 0.001), an increased risk of placental abruption (8% vs. 1%; p < 0.001), and an increased risk of perinatal mortality (8% vs. 1%; p < 0.001). Our findings indicate that traumatized pregnant women with orthopedic injuries are high-risk obstetrical patients and may benefit from referral to a medical center capable of handling both the primary injury and the potential preterm birth associated with the injury.

Inflammatory bowel disease and pregnancy: an update

Women with inflammatory bowel disease have similar rates of conception to the general population unless they have had pelvic surgery. Once pregnant, regardless of disease activity, they have an increased risk of adverse pregnancy outcome and should be followed as high-risk obstetric patients. Most medications are compatible with pregnancy and lactation, as described in this article. Ideally, women should discuss their plans for pregnancy with their physician prior to conception so that risks and benefits can be reviewed, medications adjusted and healthcare maintenance updated. Once pregnant, a multidisciplinary team of gastroenterologists, obstetricians and pediatricians should help to ensure the best care for the mother and child.

The role of the post-anesthetic care unit in the postoperative management of high-risk obstetric patients

Kalimeris, K.; Matsota, P.; Salamalekis, G.; Pandazi, A.; Kostopanagiotou, G. Author Information

Air Medical Transport of a Patient with Placenta Accreta

Air medical transport of high-risk obstetric and postpartum patients accounts for a low number of flights nationwide. Although reflecting a low percentage, they pose potential for increased challenge because of high acuity and increased liability. High-risk obstetrical flight crew education is typically focused on care of the gestational mother and newborn infant, with less time spent on postpartum complications. While uncommon, placenta accreta is one complication that poses a significant mortality risk for postpartum patients.

The Development and Implementation of an Obstetric Cell Salvage Service

Cell salvage in obstetric haemorrhage is now endorsed by a number of organisations. Most of the literature has focused on isolated case series and safety. We describe how cell salvage, including a quality assurance process conducted prior to clinical implementation, was introduced to our stand-alone obstetric hospital which had no previous experience of this technique. An implementation committee was established and 25 quality assurance and familiarisation cases were initially conducted. As part of this process the alpha fetoprotein, haematocrit, free plasma haemoglobin, potassium and Kleihauer tests were performed when enough blood was available for processing. Our guidelines for clinical use included women at greatly increased risk of obstetric haemorrhage and women at increased risk of haemorrhage who refused traditional transfusion. After the successful completion of this process, cell salvage was signed off for clinical use in March 2007 and was used on 51 occasions between March 2007 and July 2009. Twenty-one patients had salvaged blood re-transfused and for seven patients this was their only red blood cell replacement. The median blood loss in patients re-transfused was 3000 ml (range <500 to 8500 ml), with the median volume re-transfused 359 mi (range 60 to 1300 ml). There was one episode of unexplained hypotension associated with administration of salvaged blood. We have successfully introduced obstetric cell salvage into clinical practice. A quality assurance process prior to implementation was beneficial for the staff involved. Despite targeting a high-risk obstetric population, our re-transfusion rates are approximately 40%. No serious adverse events have been recorded. We recommend that in units that already provide intraoperative cell salvage in a non-obstetric setting, extending the service into obstetric situations should be considered. Units that routinely care for high-risk obstetric patients should also consider the introduction of such a service. Post transfusion Kleihauer testing should be performed as soon as possible in Rhesus-negative mothers who deliver a Rhesus-positive foetus, so that appropriate anti-D prophylaxis can be administered.

Epidural morphine injections for prevention of post dural puncture headache

A prospective, randomised, double-blind trial was conducted to study the effect of epidural morphine in prevention of post dural puncture headache in 25 parturients after inadvertent dural puncture. Women were randomly allocated to receive two epidural injections, 24 h apart, of either 3 mg morphine in 10 ml saline (morphine group) or 10 ml saline (saline group). The incidence of headache and need for therapeutic epidural blood patch were reported. There was a significant difference in the incidence of headache between the two groups: 3/25 (12%) in the morphine group and 12/25 (48%) in the saline group (p = 0.014). Therapeutic epidural blood patches were required in six patients in the saline group and none of the patient in the morphine group (p = 0.022). It was concluded that epidural morphine appears to be a simple and effective technique for prevention of post dural puncture headache after accidental dural puncture in high risk obstetric patients.

Pregnancy outcomes in unicornuate uteri: a review

To elucidate the impact of unicornuate uteri on pregnancy outcomes as evidenced by historical and contemporary studies. Publications related to unicornuate uterus were identified through MEDLINE and other bibliographic databases. Literature review in an academic research environment. Premenopausal women with confirmed unicornuate uterus based on surgical or radiological evidence who were undergoing gynecologic and obstetrical care. None. Rates of ectopic pregnancy, miscarriage, preterm delivery, intrauterine fetal demise, and live birth. Our review revealed 20 studies of varying size and design that had commented on pregnancy outcomes in unicornuate uteri. These studies ranged in date from 1953 to 2006 and from a sample size of one to 55 patients. In total, we examined 290 women with unicornuate uterus reported in the literature. Of those patients, 175 conceived, to carry a total of 468 pregnancies. Incidence data in the literature reveal that unicornuate uterus occurs in 1:4020 women in the general population; the anomaly, however, is significantly more common in infertile women, as in women with repeated poor outcomes. Our review revealed rates of 2.7% ectopic pregnancy, 24.3% first trimester abortion,9.7% second trimester abortion, 20.1% preterm delivery, 3.8% intrauterine fetal demise, and 51.5%live birth [corrected]. Unicornuate uterus is a Mullerian anomaly with prognostic implications for poorer outcomes during pregnancy. The rates of adverse outcomes have likely been historically overestimated. Although it is unclear whether interventions before conception or early in pregnancy such as resection of the rudimentary horn and prophylactic cervical cerclage decidedly improve obstetrical outcomes, current practice suggests that such interventions may be helpful. Women presenting with a history of this anomaly should be considered high-risk obstetrical patients.

Evaluation of Neonatal Mortality Rate and the Impact on Transparency

The purpose of this study was to determine potential causes of an unusually high neonatal mortality rate in a large Midwestern university hospital compared with its peer groups within the University HealthSystem Consortium (UHC). The data evaluated in this study were a combination of chart reviews and clinical data reports received from the UHC. Historically, this hospital has a referral basis of extremely high-risk obstetrical patients, and many of the neonates born are not expected to survive. On close examination of our data and the UHC reports, we identified two issues: (a) documentation of viability and nonviability of the neonates born and (b) the process used by UHC to categorize observed versus expected mortalities. Our results following review of 35 charts revealed 77%of the neonateswere born at less than 24 weeks' gestation, 80% weighed less than 1,000 g (with 37% weighing less than 500 g), and 60% had some form of anomaly. We discovered discrepancies related to the documentation, and coding of the neonate from current practices revolved around the maintenance of a neonatal chart. Implications of this study are specific to pediatric nursing practice related to end-oflife care and improved documentation about the nonviable neonate. Results are of interest to multiple audiences including bedside nurses caring for newborn neonates and their mothers, advanced practice nurses, physicians, and individuals from quality and coding. Patient care quality is focused on specific quality indicators, accuracy of documentation of care, reporting of data, and transparency to the public and payor sources.

Admission cardiotocography screening of high risk obstetric patients

Background: To predict the neonatal outcome in high risk obstetric cases by admission cardiotocography (CTG) testing. Methods: A total of 150 consecutive high risk obstetric patients meeting the inclusion criteria were subjected to admission CTG testing in this prospective study. The CTG tracing was categorized based on Royal College of Obstetricians and Gynaecologists (RCOG) criteria. Specific foetal and neonatal outcome measures were studied and correlated with the admission CTG testing. Result: Foetal distress during labour developed in 15% of patients with a normal test and in 73% of patients with an abnormal test. The admission test had a sensitivity of 66.7%, specificity of 93.3% and a positive predictive value of 53.3% for predicting an Apgar score < 5 at birth. Neonatal admission to neonatal intensive care unit was required in 1% of patients with a normal test and 33% of patients with an abnormal test (p < 0.01). Conclusion: The result of admission cardiotocography testing could be used to identify patients likely to develop adverse foetal outcomes and help in optimal utilization of labour room resources.

Chances of Adverse Neonatal Outcome in High-Risk and Low-Risk Obstetrical Patients

Objective To analyze and compare occurrence of adverse immediate neonatal outcomes in high and low-risk obstetrical population. Methods Retrospective cohort study of 2370 pregnant women. The odds of adverse outcomes (i.e. low Apgar score (1–4 points) and intermediate Apgar score (5–8 points) at 1 and 5 minutes of life, birth to a small-for-gestational-age neonate (below 90th percentile of birth weight), and requirement for advanced level II-III nursery care) as well as odds of primary cesarean delivery–-were analyzed using logistic regression analysis. Results All of the studied outcomes were seen more often among the high-risk patients. When the outcomes were analyzed within a given group some interesting observations were made. The highest odds of abnormal Apgar scores (when compared to the low risk population) were seen in patients with preeclampsia–-6.06 (95% CI 3.28; 11.22) and twin pregnancies–-odds ratio of 6.63 (95% CI 2.24; 19.67). Among Small-for-Gestational-Age newborns the most frequently identified maternal condition was preeclampsia (21.57%), out of all fetal conditions twin gestation (26.67%) was number one identified scenario. The highest proportion of patients requiring advanced level nursery care (level II and III) was observed in those with twin gestation, pregnancies complicated by hypertension with and without diabetes. The highest odds of having primary cesarean delivery in laboring patients (when compared to the low risk population) were seen in the patients with IUGR fetus–-odds ratio of 26.78 [95% CI 7.65; 93.75], followed by macrosomia–-odds ratio 5.74 [95% CI 2.14; 15.41], preeclampsia–-odds ratio 5.52 [95% CI 3.14; 9.69]. For additional findings and more information on select conditions, please, refer to the full-text article. Conclusion The studied outcomes are useful markers of fetal/neonatal status and can be used to compare perinatal outcomes between different medical conditions, different locales and to assess the dynamics of fetal/neonatal well-being over the course of time. Level of Evidence II Detailed information on the studied adverse neonatal outcomes can be found in the full-text version of this document.

Hurricane Babies: The Experience of a Receiving Hospital after Katrina

Public Administration ReviewVolume 67, Issue s1 p. 143-146 Hurricane Babies: The Experience of a Receiving Hospital after Katrina Jamie L. Haeuser, Jamie L. Haeuser Senior Vice President Woman’s Hospital, Baton Rouge, LouisianaSearch for more papers by this author Jamie L. Haeuser, Jamie L. Haeuser Senior Vice President Woman’s Hospital, Baton Rouge, LouisianaSearch for more papers by this author First published: 07 December 2007 https://doi.org/10.1111/j.1540-6210.2007.00822.xCitations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume67, Issues1December 2007Pages 143-146 RelatedInformation

Can we improve maternal outcome for high-risk obstetric patients?

Despite advances in medical, obstetric and anesthetic care, the maternal mortality rate in the US and UK has remained relatively static over the past few decades. 1–3 One explanation for the minimal progress being made to reduce maternal mortality in the developed world is the increasing number of high-risk patients becoming pregnant. This has been associated with advancing maternal age, obesity and increasing numbers of those with significant co-morbidity surviving to childbearing age. The management of high-risk obstetric patients provides one of the most challenging aspects of clinical practice in obstetric anesthesia. The variable presentation and wide spectrum of obstetric-related complications often necessitate anesthetic intervention in an acute setting. High-risk patients may be referred for anesthetic assessment at any time during the antenatal or peripartum periods, and the late timing of referral can lead to inadequate investigation and treatment before delivery. Meanwhile, anesthetic interventions have become increasingly likely with the exponential increase in labor epidural and cesarean delivery rates in the US. 4 Careful clinical decision-making and management may reduce the likelihood of these high-risk patients developing life-threatening conditions and severe maternal morbidity or mortality. The importance of early identification and management of these cases is emphasized in the Confidential Enquiries into Maternal and Child Health (CEMACH) in the UK. 3 This peer

Compliance with a Fetal Movement Chart by High-Risk Obstetric Patients in a Peruvian Hospital

We sought to determine the degree of compliance with a novel fetal movement chart (FMC) by high-risk patients versus the standard so-called count-to-10 method. This prospective trial included 1400 high-risk patients. Women with singleton gestations were randomly assigned to use either the count-to-10 chart or a FMC proposed by the Latin American Center for Perinatology (CLAP). Advantages and disadvantages were identified by patients. Compliance with regimens was measured and compared between the two groups. Demographic characteristics were similar. Compliance in the CLAP group (448 of 700) was lower than in the count-to-10 group (638 of 700; 64 versus 91%; P < 0.0001). The main advantage of the count-to-10 chart was lack of interference with daily activities. No intrauterine demises occurred in either group. High-risk patients were more compliant with the standard count-to-10 charting method than with the novel FMC. The count-to-10 method is an easy and inexpensive tool for fetal monitoring and should continue to be used in obstetric practice.

Opening Our Doors for All Newborns: Caring for Displaced Neonates: Intrastate

Woman’s Hospital in Baton Rouge, Louisiana, one of the first women’s specialty hospitals in the nation, is a 225-bed, private, not-for-profit organization that delivers more than 8000 infants each year. Sick newborns and infants less than 1 year of age are cared for in the 83-bed Center for Newborn and Infant Care, comprised of a level III-C NICU,1 special care nursery (level II), developmental nursery, infant care center, and neonatal surgery center. A private physician group consisting of 9 neonatologists and 2 neonatal nurse practitioners (NNPs) provide in-house coverage on a 24/7 basis. The hospital employs 4 NNPs to serve as transport NNPs. The Louisiana Office of Emergency Preparedness (OEP) designated Woman’s Hospital as the referral center for high-risk obstetrical patients and neonates for both Hurricanes Katrina and Rita. In a period of 5 days, 87 neonates were transferred to Woman’s Hospital during Hurricane Katrina, and transports were arranged for an additional 34 infants to other facilities. Twenty-one neonates were transferred to Woman’s Hospital during Hurricane Rita. ### Peak Census: 61; Midnight Census: 56* Katrina, still in the Gulf of Mexico, became a category 2 hurricane, and by 11 pm, the landfall forecast was for just east of New Orleans, Louisiana.2 We knew Baton Rouge would experience some type of adverse weather. The Hospital Emergency Incident Command System contains 4 increasing states of storm readiness based on the type of tropical storm/hurricane watches and warnings issued for Baton Rouge. Level 2 was implemented, which included fueling of emergency power generator tanks, establishment of alternate communications, updating departmental emergency call lists, stocking of hospital linen, replenishment of emergency food and drinkable water supplies, battery charging on portable equipment, and an evaluation of current medication supplies in the pharmacy, with procurement of additional needed emergency medications. ### Peak Census: 59; Midnight Census: 54 Katrina became a category 3 hurricane. During the day, the … Address correspondence to Steven B. Spedale, MD, FAAP, PO Box 45171, Baton Rouge, LA 70895-4171. E-mail: steve.spedale{at}infamedics.com

Obstetric intensive care admissions: A 12-year review in a tertiary care centre

Objective To review all pregnant women who required admission to an Intensive Care Unit (ICU) during pregnancy, childbirth or puerperium. Study design Retrospective follow-up study in a tertiary care centre in The Netherlands. The files of all obstetric ICU admissions over the period 1990–2001 were reviewed. Results Over these 12 years, 142 women required ICU admission (0.76% of all deliveries, 0.70% of all adult ICU admissions). The most common reasons for ICU admission were (pre)eclampsia (62.0%) and obstetric haemorrhage (18.3%). Twenty-seven out of 142 women (19.0%) were of non-caucasian origin. The most common therapeutic interventions were transfusion of erythrocytes (66.2%), caesarean section (50.7%) and artificial ventilation (44.4%). We observed seven maternal deaths (4.9%). Conclusion We need better information about high-risk obstetric patients in order to prevent severe maternal morbidity and to improve maternal care. The high number of non-caucasian women requiring ICU admission indicates the need for a study into the role of ethnicity. We have initiated a nationwide confidential enquiry into the causes of severe maternal morbidity.

Re-evaluating the role of the MFM specialist: Lead, follow, or get out of the way

Objective. To assess the effect of sub-specialty prenatal care provided to high-risk obstetrical patients in a community perinatal center as a function of whether consultation and referral to a Maternal–Fetal Medicine (MFM) sub-specialist was at the discretion of the generalist, required by the insurance carrier, or by patient choice.Methods. Demographics, management, and perinatal outcomes for high-risk patients managed exclusively by MFM were compared with those managed by generalists who were later referred to MFM after problems arose.Results. Despite similar demographics, high-risk patients managed exclusively by a single MFM had less prematurity, lower cesarean section rates, fewer low 5-minute Apgar scores (1.3% vs. 5.5%, p < 0.001), and lower perinatal mortality rates (8.0/1000 vs. 47.6/1000, p < 0.001) than those referred at a later date.Conclusions. In this setting, earlier MFM care resulted in better outcomes. These data suggest that the ‘gatekeeper’ model of generalist to MFM might be better the other way around.