A second type is the obstetrical intermediate care unit, sometimes referred to as a high-dependency care unit (HDU). One example is found at Parkland Hospital. Located within the labor and delivery unit, it has designated rooms stafed by experienced personnel. The two-tiered system incorporates the guidelines for intermediate and intensive care. Care is provided by maternal-fetal medicine specialists and nurses with experience in critical care obstetrics. As needed, this team is expanded to include other obstetricians and anesthesiologists, hospitalists, gynecological oncologists, pulmonologists, cardiologists, surgeons, and other medical and surgical subspecialists (Stevens, 2015). Many tertiary-care centers have developed similar intermediate care units and use selected triage to ICUs. Guidelines
Last, obstetrical ICUs are full-care ICUs but are operated by obstetrical and anesthesia personnel in the labor and delivery unit. Only a few obstetrical sevices have these capabilities (Zeeman, 2003, 2006).
For smaller hospitls, transfer to a medical or surgical ICU is usually preferable, and sometimes transfer to another hospital is necessary. s discussed, indications for admission to these types of critical care units vary, however, patient mix for these units is similar (Table 47-2). he American College of Obstetricians and Gynecologists (2017b) has summarized criticl obstetrical care implementation depending on hospital size and technical facilities.
Data obtained during pregnancy with pulmonary artery catheterization (PAC) have contributed immensely to the understanding of normal pregnancy hemodynamics and pathophysiology of common obstetrical conditions. These include preeclampsia-eclampsia, acute respiratory distress syndrome,
TABLE 47-2. Comparison of Acuity of Patient Mix for Obstetrical Critical Care Shown in Percent
Care Unit Surgical.lCU
Factor {n = 483)a {n = 81.3)b for such transfers must follow the federal Emergency Medical Hypertension
Treatment and Labor Act (EMTALA) guidelines. According to the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017), the minimal monitoring required for a critically ill patient during transport includes continuous pulse oximetry, electrocardiography, and regular assessment of vital signs. They must have secure venous access, and those who are mechanically ventilated must have endotracheal tube position confirmed and secured. Left uterine displacement and supplemental oxygen is applied routinely during transport of antepartum patients. Continuous fetal heart rate or tocodynamic monitoring is individualized.
Preg na ncy-Related 0.2 2 aData from Zeeman, 2003.
bData from Baskett, 2009; Keizer, 2006; Paxton, 2014; Small, 201n2; Stevens, 2006; Vasquez, 2007.
(Columns of indications do not total 100 percent because some diagnoses are not listed.
and amnionic-fluid embolism (Clark, 1988, 1995, 1997; Cunningham, 1986, 1987; Hankins, 1984, 1985). Also, because of these studies, most have concluded that such monitoring is seldom necessary (American College of Obstetricians and Gynecologists, 2013; Gidwani, 2013; Magder, 2015).
In nonobstetrical patients, randomized trials of nearly 5000 subjects have shown no benefits with PAC (Harvey, 2005; National Heart, Lung, and Blood Institute, 2006; Sandham, 2003). According to a Cochrane Database review, no randomized trials have used PAC for preeclampsia management (Li, 2012). he overall mechanisms, benefits, and risks were recently reviewed by Magder (2015).