Goals for Collaborative Management of Obstetric Hemorrhage.

Hemorrhage remains a leading cause of preventable maternal morbidity and mortality worldwide and in the United States. Postpartum hemorrhage is the number one cause of severe morbidity during hospitalization for birth, despite hospital, state, and national initiatives. In addition, studies show that more than 90% of maternal deaths related to obstetric hemorrhage are preventable. This article reviews relevant physiologic changes of pregnancy that may have an impact on hemorrhage management and describes collaborative approaches for management of hemorrhage in this unique population.

Framework for Critical Care in Obstetrics.

In 2015, The American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine issued a joint care consensus document intended to develop standards for designations of levels of maternal care that are complimentary to, but distinct from, neonatal levels of care. Level III and Level IV centers must be prepared to provide obstetric intensive care services. Developing a critical care obstetric program is a resource-intensive process that requires a carefully planned strategic effort essential for successful program implementation and sustainability. In this article, a framework utilizing key components of program development is discussed including environment, scope, model, education and training, maternal transport, and unique aspects of care for women who become critically ill during pregnancy or the postpartum period.

Morbidly Adherent Placenta: Interprofessional Management Strategies for the Intrapartum Period.

"Morbidly adherent placenta" is a term that describes the continuum of placenta accreta, increta, and percreta. The incidence of this type of abnormal placentation has increased significantly over recent decades. The reason is probably multifactorial but, partly, because of factors such as the increasing number of cesarean births. Women at greatest risk are those who have myometrial damage caused by a previous cesarean birth, with either anterior or posterior placenta previa overlying the uterine scar. This condition poses significant risks of morbidity and/or mortality to the pregnant woman and her fetus. A multidisciplinary approach to care throughout pregnancy is essential. This article describes the classification of morbidly adherent placenta, risk factors, methods of diagnosis, potential maternal and fetal complications, and intrapartum clinical management strategies to optimize outcomes.

Acute Myocardial Infarction in Pregnancy: An Update.

Despite current trends that indicate increasing incidence, acute myocardial infarction remains an uncommon event in pregnant women, yet an important contributor to perinatal morbidity and mortality. Diagnosis and treatments represent a complex challenge during pregnancy, and timeliness and coordination of both are critical. This article reviews the comprehensive, collaborative approach necessary for management of acute myocardial infarction during pregnancy to optimize outcomes for the woman, neonate, and family.

Multisystem Effects of Hypertensive Disorders of Pregnancy: A Comprehensive Review.

Hypertension predisposes the woman and fetus to adverse outcomes during the pregnancy and postpartum. The risk for maternal complications and neonatal morbidity associated with the necessity of preterm birth extends beyond the postpartum and postnatal period. A comprehensive review of the multisystem effects of hypertensive disorders and underlying pathophysiology is provided to support the role of prompt identification of and management of acute complications of hypertension.

REACT: An Interprofessional Education and Safety Program to Recognize and Manage the Compromised Obstetric Patient.

In recent years, there has been an increase in the number of pregnancies complicated by preexisting medical conditions as well as an increase in maternal morbidity and mortality in the United States. The goal of the REACT quality and safety initiative was to reduce maternal morbidity and mortality by providing an interprofessional education program for recognizing and managing the woman who becomes compromised during pregnancy, childbirth, or the puerperium. REACT is an acronym for Recognize, Educate, Activate, Communicate, and Treat early signs and symptoms of maternal compromise. Early signs and symptoms of maternal compromise outlined in the REACT program are similar to recently published recommendations by the American College of Obstetricians and Gynecologists, the Centers for Disease Control and Prevention, the Society for Maternal-Fetal Medicine, the Health Resources and Services Administration, the Association of Women's Health, Obstetric and Neonatal Nurses, and the American College of Nurse-Midwives.

Multiple sclerosis in pregnancy.

Multiple sclerosis is the most common chronic neurologic disability in young adults in their childbearing ages of 20 to 45. The disease affects more women than men, which prompts discussion of pregnancy-related issues in a woman with multiple sclerosis. Preconceptual counseling to discuss the safety of medications in pregnancy, the antepartum period along with what the patient can expect during birth, and the postpartum period will be discussed.

Maternal cardiac arrest: an overview.

Cardiac arrest in pregnancy is a rare event, and the speed of resuscitation response is critical to the outcome of both the mother and the fetus. The management of the unresponsive pregnant woman differs from that of the traditional adult resuscitation. In this article, causes of maternal arrest, management of proper cardiopulmonary arrest in pregnancy, and implementation of perimortem cesarean delivery are discussed.

Electronic fetal heart rate monitoring: where are we now?

Electronic fetal heart rate monitoring (EFM) continues to be the primary method utilized for fetal assessment in the United States. Standardization of nomenclature associated with this perinatal technology has evolved over the past 40 years such that the current nomenclature recommended by the National Institute of Child Health and Human Development (NICHD) has been adopted by professional perinatal organizations as the agreed-upon method for professional communication and documentation. Current research continues to focus on the optimal management of intrapartum fetal heart rate tracings. The clinical controversies and challenges related to electronic fetal heart rate monitoring continue to evolve.

Burn injuries and pregnancy.

Although burn injuries during pregnancy are considered relatively rare, the exact incidence is not known. Multiple factors influence morbidity and mortality resulting from burn injuries during pregnancy. These factors include the depth and size of the burn, the woman's underlying health and age, and the estimated gestational age of the fetus. Associated inhalation injury and development of other significant secondary complications also influence maternal and fetal outcomes. Successful burn care requires a team approach in which almost every healthcare discipline is represented. Initial care is almost always provided by a specially trained emergency medical team in an out-of-hospital setting. During this phase, the ability of the team to communicate with emergency hospital personnel facilitates appropriate clinical management at the scene. In addition, continued communication regarding the woman's status and responses to treatment allows critical care specialists within the hospital to ensure that necessary personnel and resources are available when the patient arrives. From the time the pregnant woman is admitted to a hospital for additional acute and critical care through the extensive process of rehabilitation from burn injuries, providing care often evokes strong emotions and requires specialized skills to achieve the most positive outcomes.

Cardiac disease in pregnancy.

Cardiac disease complicates approximately 1% to 3% of pregnancies and is responsible for 10% to 15% of maternal mortality. The number of women of childbearing age with congenital disease is increasing as advances in diagnosis and treatment improve survival rates and overall health, allowing successful pregnancy. Pregnant women with severe cardiac disease or women who experience a cardiac event during pregnancy will require admission and stabilization in an adult critical care unit. This group of patients can prove challenging for the obstetrical staff and the critical care staff because they require blending of the knowledge and skills of 2 highly specialized areas of healthcare. The key component to a comprehensive and organized approach to management that ensures the best possible outcome for the woman is a multidisciplinary team that devises a plan on the basis of the most current information, communicates with each other and the patient effectively, and assumes responsibility for implementation of the plan. The purpose of this article is to review management of the woman with cardiac disease throughout pregnancy.

Myocardial infarction in pregnancy.

UNLABELLED: The number of women experiencing myocardial infarction (MI) in pregnancy is relatively negligible. However, the incidence of MI in pregnancy may be on the rise, and maternal and neonatal morbidity and mortality is significant. While diagnosis may be difficult, perinatal nurses must be knowledgeable about the risk factors and various means of treatment for the woman and family experiencing this acute complication of pregnancy. PRECIS: MI in pregnancy is rare, but can produce significant maternal and fetal morbidity and mortality. Challenges in diagnosis and treatment of MI in pregnancy are discussed.

Electronic fetal monitoring of the preterm fetus.

Following an analysis of the literature, this article reviews the current practices, guidelines, and recommendations for electronic fetal monitoring of the preterm fetus. The physiologic aspects of fetal heart rate control, electronic fetal monitor parameters, and differences between the preterm and term fetus are discussed. Clearly identified is the need for clinical research regarding electronic fetal monitoring of the preterm fetus to establish evidence-based practice guidelines.