Management Of Obstetric Patients Research Articles

Caesarean delivery and the attendant FETO-maternal aftermath at a rural hospital in South Southern Nigeria

Background: Caesarean delivery is a necessary tool in the management of obstetric patients when indicated. However, there is general apprehension about the increasing proportion of births by caesarean section (CS) across the globe. Objectives: To ascertain the CS rate (CSR), the indications and the outcomes of caesarean delivery in the hospital. Methodology: The obstetric and theatre records of all caesarean deliveries at Federal Medical Centre Yenagoa, Otuoke outreach, South-South Nigeria, between January 2017 and December 2021 were assessed retrospectively. Generated data were analyzed using SPSS version 23. Results:There were 770 deliveries, out of which 104 were caesarean deliveries, giving a CSR of 13.5%. The majority, 71 (68.3%) of the patients had emergency caesarean delivery while 33 (31.7%) had an elective caesarean delivery. The commonest indication for caesarean delivery was cephalopelvic disproportion (CPD) (27.9%) followed by previous CS and breech in primigravida (17.3% and 7.7% respectively). The majority of the patients, 58 (55.8%) were booked while 46 (44.2%) were unbooked. The commonest morbidity encountered was anaemia which complicated 21.1% of cases. There was one maternal death and six perinatal deaths giving maternal and perinatal mortality rates of 960/100,000 and 49/1000 respectively. Conclusion: The caesarean section rate was within the limits laid down by the World Health Organization. CPD was the chief indication for CS followed by repeat CS and breech in primigravida. Efforts to maintain the CS rate, within acceptable limits, as noted in this study, should be continued.

What's new on the management of obstetric patients who tested positive for COVID-19?

To date, there is still partial data on the effects of COVID-19 on pregnant women. The constant collection of information results in a continuous updating of the knowledge about the best management of pregnant patients affected by COVID-19. This work aimed to summarize the state of the art on prevention and management of SARS-CoV-2 infection in obstetric patients. This was enabled by a comprehensive literature search for the most recent and relevant publications on the subject, including guidelines and recommendations. Management of these women by a multidisciplinary team is of crucial importance, given the extreme clinical complexity of this condition. Every health worker involved must put in place all possible procedures to protect themselves from contagion. Neuraxial anesthesia should be favored in the management of labor and caesarean section over other modalities, unless there are contraindications based on the patient's status. There is still no standardized drug treatment in pregnant women with COVID-19 due to their exclusion from studies conducted to evaluate pharmacological therapies. Nevertheless, various drugs have been used to treat this disease in pregnancy, although the data at our disposal are still few. As regards mRNA vaccines, it seems that their immunogenicity, safety and tolerability in pregnant women are comparable to those of non-pregnant women of the same age. More studies are certainly needed in infected pregnant women to establish treatment and prevention protocols for this special category of patients.

Improving assessment of acute obstetric patients \u2013 introducing a Swedish obstetric triage system

BackgroundFailure to identify severely ill obstetric patients seeking acute care, and hence delaying treatment, can lead to maternal morbidity and mortality. Triage is the prioritization of patients seeking emergency care, based on clinical decision-making tools assessing medical urgency. While triage has been applied in general emergency medicine for 30 years, there are only a few obstetric triage systems (OTS) and obstetric triage has hitherto been unknown in Sweden. Obstetric triage is more complex than general triage since both mother and fetus require assessment, and pregnancy-related physiological changes must be taken into account. This paper aims to describe the development and an initial evaluation of the first OTS in Sweden.MethodsA multidisciplinary team surveyed reasons to seek acute obstetric care and the current patient flow at the largest obstetric unit in Scandinavia, Sahlgrenska University Hospital, Gothenburg, Sweden, with about 10,000 deliveries/year. A semi-structured literature review on obstetric triage was undertaken. Based on the survey and the literature review the first Swedish OTS was developed and implemented. Patient satisfaction was followed by electronical questionnaires. Initial validity evaluation was performed, defined by the system’s ability to identify patients with need for hospital admission, stratified by acuity level.ResultsThe Gothenburg Obstetrical Triage System (GOTS) addresses the patient to one of five acuity levels based on both vital signs and 14 chief complaint algorithms. It entails recommendations for initial procedures of care as well as an acuity form for documentation. Initial evaluation of the system indicates good correlation between need for admission and acuity level. The implementation has provided the staff with an improved medical overview of the patients and patient flow and enabled the unit to monitor emergency care in a structured way. Implementation came along with increased patient and staff satisfaction.ConclusionThe GOTS is the first OTS developed in and for Sweden and implementation has improved management of obstetric patients seeking acute care. Patients are now prioritized according to level of acuity and the time to assessment and treatment of severely ill patients can be structurally evaluated. Both patients and staff express improved satisfaction with obstetric triage.

Rapid Cycle Implementation and Retrospective Evaluation of a SARS-CoV-2 Checklist in Labor and Delivery

BackgroundPreparedness efforts for a COVID-19 outbreak required redesign and implementation of a perioperative workflow for the management of obstetric patients. In this report we describe factors which influenced rapid cycle implementation of a novel comprehensive checklist for the perioperative care of the COVID-19 parturient.MethodsWithin our labour and delivery unit, implementation of a novel checklist for the COVID-19 parturient requiring perioperative care was accomplished through rapid cycling, debriefing and on-site walkthroughs. Post-implementation, consistent use of the checklist was reported for all obstetric COVID-19 perioperative cases (100% workflow checklist utilization). Retrospective analysis of the factors influencing implementation was performed using a group deliberation approach, mapped against the Consolidated Framework for Implementation Research (CFIR).ResultsAnalysis of factors influencing implementation using CFIR revealed domains of process implementation and innovation characteristics as overwhelming facilitators for success. Constructs within the outer setting, inner setting, and characteristic of individuals (external pressures, baseline culture, and personal attributes) were perceived to act as early barriers. Constructs such as communication culture and learning climate, shifted in influence over time.ConclusionWe describe the influential factors of implementing a novel comprehensive obstetric workflow for care of the COVID-19 perioperative parturient during the first surge of the pandemic using the CFIR framework. Early workflow adoption was facilitated primarily by two domains, namely thoughtful innovation design and careful implementation planning in the setting of a long-standing culture of improvement. Factors initially assessed as barriers such as communication, culture and learning climate, transitioned into facilitators once a perceived benefit was experienced by healthcare teams. These results provide important information for the implementation of rapid change during a time of crisis.

P.99 Empowering midwives with arterial-line management

Introduction: Arterial pulse waveform analysis provides beat- to-beat monitoring of maternal cardiac output and is increasingly utilised in the management of obstetric patients. Common indications include preeclampsia, haemorrhage, obesity or cardiac disease. Such patients would ordinarily be managed in a high dependence or critical care area and 18% of women cared for in our obstetric high dependency unit required invasive arterial monitoring. We observed varying degrees of comfort amongst midwifery staff on managing arterial lines and sought to formally assess this.

Role of Critical Care Units in the management of obstetric patients (Review).

Pregnancy is considered a natural process for the majority of women. However, a limited proportion of pregnancies and deliveries can present with a broad variety of complications that may require admission to a Critical Care Unit (CCU). In the present review, the indications of admission of obstetrical and postpartum patients to CCUs were critically evaluated with a particular focus on the management of their complications. The management of critically ill obstetric patients remains challenging due to the physiological changes that occur during pregnancy, pregnancy-related diseases and the need to carefully consider the well-being of the fetus before any intervention can be recommended/performed. Indications for admission to CCUs include both obstetric and non-obstetric conditions that may require continuous monitoring and further interventions. Hypertensive disorders of pregnancy and mass hemorrhage are amongst the most common causes of admission to CCUs in pregnant and postpartum women. The establishment of a diagnostic and care algorithm based on the contribution of a multidisciplinary team is of critical importance to aid in the determination of which patients will require intensive care, and to assist in deciding what type of critical care each critically ill patients receives.

Advances in anesthetic and obstetric management of patients with placenta accreta spectrum.

The incidence of placenta accreta spectrum is increasing and it is a leading cause of peripartum hysterectomy and massive postpartum hemorrhage. The purpose of the present article is to provide a contemporary overview of placenta accreta spectrum pertinent to the obstetric anesthesiologist. Recent changes in the terminology used to report invasive placentation were proposed to clarify diagnostic criteria and guidelines for use in clinical practice. Reduced morbidity is associated with scheduled preterm delivery in a center of excellence using a multidisciplinary team approach. Neuraxial anesthesia as a primary technique is increasingly being used despite the known risk of major bleeding. The use of viscoelastic testing and endovascular interventions may aid hemostatic resuscitation and improve outcomes. Accurate diagnosis and early antenatal planning among team members are essential. Obstetric anesthesiologists should be prepared to manage a massive hemorrhage, transfusion, and associated coagulopathy. Increasingly, viscoelastic tests are being used to assess coagulation status and the ability to interpret these results is required to guide the transfusion regimen. Balloon occlusion of the abdominal aorta has been proposed as an intervention that could improve outcomes in women with placenta accreta spectrum, but high-quality safety and efficacy data are lacking.

The Use of In Situ Simulation to Enhance COVID-19 Pandemic Preparedness in Obstetrics.

Simulation’s benefits in medical education are well established. However, its use for pandemic preparedness in obstetrics is lacking. Management of obstetrical patients with suspected COVID-19 infection is a complex task with safety considerations for mother, fetus and healthcare workers. Implementation of new workflow algorithms to ensure safety is critical but is challenging to implement in real-time. We sought to improve pandemic preparedness by designing and deploying a high-fidelity simulation exercise involving the admission of a labouring obstetrical patient with suspected COVID-19 into a labour room, urgent transfer to the operating room and neonatal resuscitation. The creation of the simulation scenario was a multi-disciplinary effort with input from a focus group of key clinical stakeholders from within and outside of our centre to ensure clinical validity. Simulations were performed on the clinical unit during regular work hours so workflow could be observed in real-time with access to the equipment and personnel in which this clinical scenario would occur. We completed a total of 11 simulation sessions involving 42 participants. Feedback, obtained from debrief sessions and anonymous surveys, was categorized based on the human factors framework, and used as part of an iterative process to adapt, revise and improve the simulation scenario. The result of this iterative process was the creation of validated departmental infection control protocols that continue to be implemented through the second wave of the COVID-19 pandemic.

VP45.09: Lung ultrasound in the management of obstetric patients with COVID‐19 infection

Repeated x-rays diagnostic examinations in obstetric patients are discouraged. The aim of this study was to assess the correlation between lung ultrasound (LUS) patterns, clinical presentation and chest x-Ray (CXR) imaging as well as the role of LUS in the management of obstetric patients with symptomatic COVID-19 infection. Consecutive hospitalised infected patients were included. Clinical and imaging data were prospectively recorded. CXR and LUS were performed in double blind at admission. LUS was repeated in case of worsening respiratory symptoms and at discharge. LUS was performed by two experts in obstetric ultrasound imaging, using a wide-band 4-8 MHz convex probe, with B-mode evaluation according to standardised protocols. Bilateral peribronchial hazy increased opacity at CXR and irregular and thickened pleural line with multiple B-lines at LUS were considered a positive finding for COVID-19 pneumonia. Descriptive analysis and correlation between LUS and CXR patterns were performed. 33 patients were included. 22 were pregnant and eleven on postpartum. At admission, 20 patients presented mild symptoms and thirteen moderate symptoms, according to NIH classification. In 31 patients LUS correlated with CXR (Cohen's K 0.90). LUS patterns was negative and positive in twenty and eleven cases, respectively. Two false-negative LUS findings occurred. During hospitalisation, all patients with positive LUS at admission showed negative LUS findings at discharge, in agreement with symptoms resolution. Two patients with negative LUS at admission reported worsening respiratory symptoms, with LUS at time of symptoms showing bilateral basal abnormal findings. This series supports the use of LUS in the management of obstetric patients with COVID-19 infection. Future studies may clarify if LUS can replace CXR in this population, potentially relevant, efficacious and efficient in developing countries.

Pregnancy in systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) is a chronic illness that often affects women of reproductive age. The objectives of this article are to review the impact of SLE on pregnancy and current management strategies, including commonly used therapies. We conducted a review of available literature on the clinical course of SLE, diagnosis, management and pregnancy complications. SLE has a variable clinical course characterized by flares and periods of remission and can present unique challenges in the management of obstetric patients. Pregnancy in patients with SLE is associated with multiple risks, including fetal loss, preterm birth, fetal growth restriction, and hypertensive disease. With advancements in disease treatment, many women have favorable pregnancy outcomes, but appropriate preconception counseling and disease management remain important tools in reducing complications. Given the implications SLE can have on women of reproductive age and in pregnancy, understanding the disease course and management is important in order to optimize pregnancy outcomes.

Obstetric Management of Patients with Spinal Cord Injuries: ACOG Committee Opinion, Number 808.

Approximately 17,730 new spinal cord injuries (SCIs) occur per year in the United States. Effective rehabilitation and modern reproductive technology may increase the number of these patients considering pregnancy. Obstetrician-gynecologists and other obstetric care professionals who care for such patients should be familiar with problems related to SCIs that may occur throughout pregnancy and during the postpartum period. Autonomic dysreflexia (sometimes called autonomic hyperreflexia) is the most serious medical complication that occurs in women with SCIs and is found in 85% of patients with lesions at or above T6 level. It is important to avoid stimuli that can lead to autonomic dysreflexia, such as distension or manipulation of the vagina, bladder, urethra, or bowel. Women with SCIs may give birth vaginally. Although pain perception is impaired in women with SCIs at or above T10, neuraxial anesthesia is the treatment of choice to reduce the risk of autonomic dysreflexia because it blocks neurologic stimuli arising from the pelvic organs. Adequate anesthesia, spinal or epidural if possible, is needed for cesarean births in all patients with SCIs. In addition to routine postpartum care, obstetrician-gynecologists and other obstetric care professionals should ensure that perineal and cesarean wounds are examined appropriately because of concerns for delayed wound healing in patients with SCI. Depression, suicide, alcoholism, and a wide variety of other mental health problems all occur at higher rates in women with SCIs. Therefore, screening and treatment for postpartum depression and other maternal mental health disorders are especially important in this population.

Obstetric Management of Patients with Spinal Cord Injuries: ACOG Committee Opinion Summary, Number 808.

Approximately 17,730 new spinal cord injuries (SCIs) occur per year in the United States. Effective rehabilitation and modern reproductive technology may increase the number of these patients considering pregnancy. Obstetrician-gynecologists and other obstetric care professionals who care for such patients should be familiar with problems related to SCIs that may occur throughout pregnancy and during the postpartum period. Autonomic dysreflexia (sometimes called autonomic hyperreflexia) is the most serious medical complication that occurs in women with SCIs and is found in 85% of patients with lesions at or above T6 level. It is important to avoid stimuli that can lead to autonomic dysreflexia, such as distension or manipulation of the vagina, bladder, urethra, or bowel. Women with SCIs may give birth vaginally. Although pain perception is impaired in women with SCIs at or above T10, neuraxial anesthesia is the treatment of choice to reduce the risk of autonomic dysreflexia because it blocks neurologic stimuli arising from the pelvic organs. Adequate anesthesia, spinal or epidural if possible, is needed for cesarean births in all patients with SCIs. In addition to routine postpartum care, obstetrician-gynecologists and other obstetric care professionals should ensure that perineal and cesarean wounds are examined appropriately because of concerns for delayed wound healing in patients with SCI. Depression, suicide, alcoholism, and a wide variety of other mental health problems all occur at higher rates in women with SCIs. Therefore, screening and treatment for postpartum depression and other maternal mental health disorders are especially important in this population.

Obstetric Anesthesia During the COVID-19 Pandemic.

With increasing numbers of Coronavirus Disease 2019 (COVID19) cases due to efficient human-to-human transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the United States, preparation for the unpredictable setting of labor and delivery is paramount. The priorities are 2-fold in the management of obstetric patients with COVID-19 infection or persons under investigation (PUI): (1) caring for the range of asymptomatic to critically ill pregnant and postpartum women; (2) protecting health care workers and beyond from exposure during the delivery hospitalization (health care providers, personnel, family members). The goal of this review is to provide evidence-based recommendations or, when evidence is limited, expert opinion for anesthesiologists caring for pregnant women during the COVID19 pandemic with a focus on preparedness and best clinical obstetric anesthesia practice.

Recent advances in the diagnosis and management of sepsis in pregnancy

Background: Maternal sepsis accounts for 11% of all maternal deaths worldwide. It is the third most common direct cause of maternal death and is a major contributor to other common causes of maternal death, such as haemorrhage and thromboembolism. Methods: This review addresses important topics, including the epidemiology, risk factors, prevention, diagnosis, care bundles and management of maternal sepsis, including antibiotic treatment, and critical care interventions such as extracorporeal membrane oxygenation. Preventative measures that have had an impact on maternal sepsis as well as future research directions are also covered in this review. Case studies of maternal sepsis which highlight key learning points relevant to all clinicians involved in the management of obstetric patients will also be presented. Results: Although, historically, maternal death from sepsis was considered to be a problem for low-income countries, severe obstetric morbidity and maternal death from sepsis are increasing in high-income countries. The global burden of maternal sepsis and the obstetric-related and patient-related risk factors and the likely sources are presented. Recent changes in definition and nomenclature are outlined, and challenges in diagnosis and identification are discussed. Conclusions : Following maternal sepsis, early diagnosis and early intervention are critical to save lives and prevent long-term adverse sequelae. Dogma surrounding critical care interventions in pregnancy is being challenged, and future research is warranted to maximise therapeutic options available for maternal septic shock.

Sonographic estimation of gestational age from 20 to 40 weeks by fetal kidney lengths\u2019 measurements among pregnant women in Portharcourt, Nigeria

BackgroundUltrasonography has become an indispensible tool in the management of obstetric patients. Accurate determination of fetal gestational age (FGA) has posed great challenge to patient management as the accuracy of traditional biometric parameters decreases with advance in gestation age. Accuracy of fetal kidney length (FKL) in the determination of FGA at third trimester has been documented in other population. This study is aimed to create baseline reference values of fetal kidney lengths in a Nigerian population as previous studies show population specific variations.MethodsThis prospective cross sectional study was carried out on 534 pregnant women between 20 and 40 weeks of gestation who met the inclusion criteria at Diamond Biomedical Services Ltd. A pilot study was conducted on 20 patients to determine the reproducibility and reliability of ultrasound measurement of FKL. Fetal kidney lengths were calculated as mean of three separate measurements. The 5th, 50th and 95th percentiles were calculated using least squared regression analysis. Third polynomial regression models were used to establish the relationship between right and left FKL and FGA.ResultsBoth FKL measurements are highly reproducible with excellent correlation and agreement within and between sonographers. It correlates strongly with gestational age while the relationships between right and left kidney lengths with gestational age were established using the following regression equations: RKL = − 11.18 + 1.193 × FGA − 0.0350 × FGA2 + 0.00037 × FGA3 and LKL = − 12.57 + 1.332 × FGA − 0.0390 × FGA2 + 0.00040 × FGA3 for right and left kidneys respectively.ConclusionNigerian population specific baseline reference values of FKLs for the estimation of FGA should be adopted rather than relying on the Caucasians values as universal patterns.

Complications of pregnancy and labour in women with Klippel-Trénaunay syndrome: a nationwide cross-sectional study.

To evaluate complications of pregnancy, including thromboembolism, in women with extensive vascular malformations associated with Klippel-Trénaunay syndrome (KTS). Nationwide cross-sectional study. Two tertiary expert centres and the Dutch Klippel-Trénaunay patient organisation. Adult women with KTS. Patients with KTS were invited to participate in a comprehensive online survey about their obstetric history. Reference data on pregnancy outcomes and complications of non-diseased women were collected from population-based cohorts from the literature. Prevalence of complications, specifically venous thromboembolism and postpartum haemorrhage. Sixty women completed the survey. Seventeen patients did not conceive, of whom three refrained from pregnancy because of KTS. A total of 97 pregnancies and 86 deliveries were reported in 43 patients. KTS-related symptoms were aggravated during pregnancy in 43% of patients. Deep vein thrombosis was present in 5.8% and pulmonary embolism was present in 2.3% of pregnancies, which was extremely high compared with the reference population (P < 0.0001), with a relative risk of 108.9 (95% confidence interval, 95% CI 46.48-255.03) and 106.2 (95% CI 26.97-418.10), respectively. Severe postpartum haemorrhage (PPH) occurred in 11% of KTS pregnancies, compared with 5.8% of pregnancies in the reference population (relative risk, RR 1.81, 95% CI 0.97-3.37, P = 0.06). Our data suggest that women with KTS have a significant risk of venous thromboembolic events, severe postpartum haemorrhage, and aggravation of KTS symptoms during pregnancy, and in early postpartum period. Obstetricians should counsel patients about these risks in the preconception phase. Antithrombotic prophylaxis should be considered in the obstetric management of patients with KTS. High risk of complications during pregnancy and labour in women with Klippel-Trénaunay syndrome.

Impact of Xpert MRSA/SA blood culture PCR assay on management of positive blood cultures in obstetric patients: a retrospective audit.

The Xpert MRSA/SA blood culture assay (Cepheid, USA) is a rapid PCR test which can be used for positive blood cultures where Gram-positive cocci in clusters are seen. It can detect Staphylococcus aureus and also the mecA gene, which encodes for β-lactam resistance. The assay was introduced into the Rotunda Hospital for positive blood cultures to allow earlier detection of MRSA and methicillin susceptible S. aureus. To assess the impact of the Xpert MRSA/SA blood culture assay on the management of obstetric patients with a positive blood culture where Gram-positive cocci in clusters were seen. The main outcome measures were duration of intravenous antimicrobials and length of admission. Pre-intervention and post-intervention groups were identified relating to whether or not the test was in use at the time. A standardised form was used to retrospectively review the medical notes and laboratory results. There were 35 obstetric patients with positive blood cultures with Gram-positive cocci in clusters in the pre-intervention group and 22 cases in the post-intervention group. All 22 positive blood cultures in the post-intervention period were correctly identified. The antimicrobial duration was reduced from a median of 55.5-43.5h and length of admission reduced from a median of 66.5-56h (Mann-Whitney U value=161, p=0.46 and U value=256, p=0.15, respectively). This study has shown a reduction in the median duration of intravenous antimicrobials and admission; however, larger multi-centre studies are needed to evaluate this potential benefit further.

Intraobserver and Interobserver Agreement Among Obstetric Experts in Court Regarding the Review of Abnormal Fetal Heart Rate Tracings and Obstetrical Management

(Am J Obstet Gynecol. 2015;213:856.e1–e.8) It has been noted that the fear of litigation has an impact on obstetricians and institutions, and obstetricians pay some of the highest premiums among physicians for malpractice insurance. The objective of this study was to evaluate the intraobserver and interobserver agreement among obstetric experts in court (OECs) regarding the retrospective review of abnormal fetal heart rate tracings (AFHRTs) and obstetrical management of patients with AFHRT during labor.

Intra- and interobserver agreement among obstetric experts in court regarding the review of abnormal fetal heart rate tracings and obstetrical management

The objective of the study was to evaluate the intra- and interobserver agreement among obstetric experts in court regarding the retrospective review of abnormal fetal heart rate tracings and obstetrical management of patients with abnormal fetal heart rate during labor. A total of 22 French obstetric experts in court reviewed 30 cases of term deliveries of singleton pregnancies diagnosed with at least 1 hour of abnormal fetal heart rate, including 10 cases with adverse neonatal outcome. The experts reviewed all cases twice within a 3-month interval, with the first review being blinded to neonatal outcome. For each case reviewed, the experts were provided with the obstetric data and copies of the complete fetal heart rate recording and the partogram. The experts were asked to classify the abnormal fetal heart rate tracing and to express whether they agreed with the obstetrical management performed. When they disagreed, the experts were asked whether they concluded that an error had been made and whether they considered the obstetrical management as the cause of cerebral palsy in children if any. Compared with blinded review, the experts were significantly more likely to agree with the obstetric management performed (P < .001) and with the mode of delivery (P < .001) when informed about the neonatal outcome and were less likely to conclude that an error had been made (P < .001) or to establish a link with potential cerebral palsy (P = .003). The experts' intraobserver agreement for the review of abnormal fetal heart rate tracing and obstetrical management were both mediocre (kappa = 0.46-0.51 and kappa = 0.48-0.53, respectively). The interobserver agreement for the review of abnormal fetal heart rate tracing was low and was not improved by knowledge of the neonatal outcome (kappa = 0.11-0.18). The interobserver agreement for the interpretation of obstetrical management was also low (kappa = 0.08-0.19) but appeared to be improved by knowledge of the neonatal outcome (kappa = 0.15-0.32). The intra- and interobserver agreement among obstetric experts in court for the review of abnormal fetal heart rate tracing and the appropriateness of obstetrical care is poor, suggesting a lack of objectivity of obstetrical expertise as currently performed in court.

Applications of Focused Cardiac Ultrasound (FoCUS) in Obstetrics

Focused cardiac ultrasound (FoCUS) is emerging as a safe, convenient, and cost-effective method to non-invasively assess complex hemodynamics. This technique has particular promise in the obstetric population, with important applications such as assessment of preload and contractility, in a range of clinical circumstances. Although outcome data remain sparse, anesthesiologists should consider incorporating FoCUS into the management of obstetric patients.