oa The critically ill mother: Recognition and management (who, where and how?)

There is an ongoing debate about the management of the critically ill mother, notably with regards to who should manage this group of patients (the intensivist, the obstetric anaesthetist, or the obstetrician?) and where is the ideal place to manage them (labour ward, obstetric high dependency unit or the intensive care unit?). To make the most appropriate choice, an understanding of how to recognise maternal critical illness is paramount. Using the modified early obstetric warning system score (MEOWS) for obstetric patients is a useful tool ¹. MEOWS looks at additional parameters to the standard early warning systems parameters with modified triggers to suit the altered physiology in the pregnant patient. Other predictors like APACHE and SOFA scores may also be used to predict maternal mortality ². Data from several national audit and surveillance programs such as MBRRACE-UK (Mothers and Babies: Reducing Risk Through Audits and Confidential Enquiries across the UK) ³, UKOSS (The UK Obstetric Surveillance System), and ICNARC (Intensive Care National Audit & Research Centre) are used to aid the understanding of why mothers die in childbirth and up to six weeks postpartum and which critically ill mothers are admitted to the intensive care unit and the reason for their admission ⁴. Audit reports show that a significant number of deaths reported in the maternal mortality reports are associated with suboptimal care. There is a great need for an evidence-based triage system for the critically ill obstetric patient in order to help clinicians direct them to the appropriate level of care and avoid situations of suboptimal care. Regionalizing maternal critical care may help develop this triage system by increasing the exposure to such patients. Deciding on who should manage these patients will depend on the level of training and expertise of the team members involved in the management on how to detect an acutely deteriorating mother. The team members should include obstetricians, anaesthetists, intensivists, intensive care nurses and midwives. The training can be achieved using different educational approaches that are competency-based to improve the knowledge and skills in detecting signs of deterioration in order to take the appropriate actions. Multidisciplinary teams should train together using simulation-based learning focusing on human factors and communication skills ⁵. Deciding on where these patients should be managed will depend on the level of organ support and monitoring available as well as the access to support services such as obstetric and neonatal services, regardless of what the terminology of that location is. The different models of delivering care to the critically ill obstetric patient with the different requirements for these areas are highlighted in Table 1. Taking all the previous factors into consideration will help find the answer to the WHO, WHERE and HOW question.