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ALTHOUGH evidence-based nursingguidelines exist to direct the care ofacute and chronic conditions in obstetric(OB) patients while they’re in OB set-tings, few if any such guidelines existfor providing care to these same pa-tients in emergency departments and in-tensive care units (ICUs). However, OBpatients can be admitted to critical caresettings with severe conditions—pre -eclampsia/eclampsia, postpartum hemor-rhage (PPH), hemolysis/elevated liverenzymes/low platelet count (HELLP)syndrome, diabetes, cardiomyopathy,complications from anesthesia, renalfailure, sepsis, stroke, amniotic or bloodclot embolism, placental abruption/pre-via/accreta, or trauma—that require rig-orous management.

Some critical care nurses have report-ed that they don’t feel prepared to carefor pregnant and postpartum patients

with serious conditions. Understandingthe unique challenges you might facewith these patients can help you confi-dently care for them. In this article, we’llfocus on two of the most common typesof conditions seen in OB patients: hy-pertensive disorders and hemorrhagicdisorders.

Hypertensive disordersHypertensive disorders—preeclampsiaand eclampsia—are the most commonmedical complications of pregnancy andthe leading cause of ICU admissionsduring pregnancy and after birth.

OverviewPreeclampsia, defined as the onset ofhypertension after the 20th week ofpregnancy with or without proteinuria,is a leading cause of maternal morbidityand mortality. Although the exact cause

Critically ill obstetric patients

Be prepared to care for pregnant and postpartum patients in critical care settings.

By Debra A. Hrelic, PhD, RNC, and Kellie M. Griggs, DNP, MSN-Ed, RNC-OB

AmericanNurseToday.com November 2018 American Nurse Today 21

of preeclampsia is unknown, it’s aresult of generalized vasoconstric-tion and vasospasm that ultimatelyculminates in multisystem failure.It’s primarily related to uteropla-cental insufficiency and prematurebirth. Preeclampsia can developand progress rapidly, and the earli-est signs often go unnoticed by thepatient. The disorder won’t beginto resolve until after the baby isborn and the placenta is delivered.

Signs and symptomsSigns of preeclampsia include bloodpressures (BPs) with systolic read-ings ≥ 160 mmHg or diastolic read-ings ≥ 110 mmHg on two or moreoccasions at least 4 to 6 hours apartwhile the patient is on bed rest.Other signs include lab results in-dicating thrombocytopenia (withplatelets < 100,000/microliter) andimpaired liver function presentingas persistent right upper quadrantor epigastric pain that doesn’t re-spond to medication and/or abnor-mally elevated liver enzymes (up to two times the normal concentra-tion). Renal insufficiency can beprogressive evidence of preeclamp-sia; serum creatinine concentrations> 1.1 mg/dL or a doubling of theserum creatinine concentration inthe absence of renal disease maybe present. Cerebral edema mayoccur with accompanying visualdisturbances, such as blurred vison,dim or dark spots, and even blind-ness. In addition, patients with pre -eclampsia may present with olig-uria evidenced by < 500 mL ofurine in 24 hours.

Without immediate care, thismultiorgan, multisystem disordercan lead to increased morbidity andmortality for both mother and baby.

ManagementNursing management goals for pa-tients with severe preeclampsia include improved placental bloodflow and fetal oxygenation andprevention of seizures and othermaternal complications (stroke,

heart failure, and multiorgan/multi-system failure).

Antepartum patients are kept inbed, preferably in the lateral posi-tion to optimize fetal circulation.Keep the environment quiet, andlimit external stimuli (lights, mon -itors, visitors). The frequency of fetal monitoring should be individ-ualized but may depend on gesta-tional age, the provider’s orders,and maternal status. Fetal monitor-ing is a specialized skill requiringcollaboration with an experiencedOB nurse.

Labetalol, hydralazine, and ni fed i -pine are the firstline drugs of choiceto control severe hypertension be-cause of their efficacy and preserva-tion of uteroplacental blood flow.

Medication side effects may includesubtle physiological changes such asweight gain, edema, headache, olig-uria, epigastric and/or right-sidedpain, and fetal distress.

To control seizures, the providermay order magnesium sulfate. Thisdrug acts to relax smooth muscles(such as the uterus) and reduce vaso -constriction, which promotes circula-tion to the patient’s vital organs andthrough the placenta to the fetus.Increased circulation to the kidneysmay cause diuresis. Closely monitorthe patient’s BP, pulse, and respira-tions every 15 to 30 minutes, andcheck urinary output and presenceof deep tendon reflexes.

In addition, monitor the patientfor headache, level of conscious-

After a critically ill postpartum patient’s condition has stabilized, you need to per-form postpartum assessments. These acronyms will help guide you.

BUBBLE (postpartum assessment)

Breasts: Size, shape, and engorgement. Are nipples inverted or cracked?

Uterus: Firm? Boggy? What is the height in relation to the umbilicus?

Bladder: Tender? Distended?

Bowel: Bowel movement? Bowel sounds?

Lochia: Amount? Odor? Color? Clots?

Episiotomy: Location? Stitches? Edema and redness?

REEDA (episiotomy assessment)

Redness

Edema

Ecchymosis

Discharge, drainage

Approximation

Postpartum assessment

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ness, visual disturbances, and epi-gastric pain. Lab values to watchinclude magnesium level, plateletcount, creatinine clearance, uricacid, aspartate and alanine amino-transferase, prothrombin and par-tial thromboplastin time, fibrino-gen, and fibrin split products.Keep the antidote calcium glu-conate at the bedside when treat-ing patients with magnesium.

If the patient’s condition wors-ens, check for evidence of fetaldistress or fetal demise; implementseizure precautions and care; as-sess for eclampsia, pulmonary ede-ma, placental abruption, and dis-seminated intravascular coagulation(DIC); and monitor lab values formultisystem involvement. Imminentdelivery is indicated if fetal or ma-ternal assessment reveals these crit-ical changes.

Hemorrhagic disorders The second most common diagno-

sis for admitting OB patients to theICU is PPH. Patients are admittedto treat hemodynamic instability andcoagulopathy.

OverviewDiagnosing and treating PPH canbe complicated because blood lossand fluid replacement related tobirth are often inaccurately reportedand underestimated. The diagnosisis made even more difficult becausemost women of childbearing ageare young and healthy and can eas-ily maintain normal BP, even withlarge amounts of blood loss, beforeserious physiological decompensa-tion occurs. Most women with se-vere PPH in an ICU will developDIC, a pathologic form of clottingthat causes widespread externaland internal bleeding.

Signs and symptomsCritical care nurses are skilled atrecognizing the signs and symp-toms of hypovolemic shock, butthey rarely encounter patients withPPH and OB patients with DIC. Be-fore and after the patient with PPHgives birth, assess for signs of ab-

An average of 80,000 adverse ob-stetric (OB) events occur each yearin the United States. A systematicreview by Bayes and Ewens of criti-cal care nurses’ experiences whencaring for pregnant and postpar-tum women found that the nursesfeel “not trained, incompetent, andneeding further education.”

Collaborative education with OBnurses can help address that criticalcare nursing skill gap. It should fo-cus on clear standards of practice,including fetal monitoring, postpar-tum assessment, maternal and neo -natal changes in physiology, andearly warning signs of danger. In ad-dition, evidence-based care guide-lines that incorporate knowledgefrom both OB and critical care nurs-ing can enhance patient outcomes.

Teamwork

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normal or uncontrolled bleedingfrom the vagina, surgical sites (suchas the cesarean delivery incision),and puncture wounds (I.V., injec-tion, and epi dural sites). Bleedingmay indicate DIC and require im-mediate medical intervention.

Signs of hypovolemic shock in-clude increased pulse rate, fallingBP, and increased respirations. Pe-ripheral pulses will become weakor thready, and the skin will be-come cool, moist, pale, and eventu-ally cyanotic. Urinary output willdecrease to ≤ 30 mL/hour until it’sabsent. In addition, hemoglobin andhematocrit levels will decrease. Thepatient’s mental status will change;she’ll become restless, agitated,and have difficulty concentrating.Patients with PPH require an astutenurse to identify the early signs ofhypovolemic shock and DIC.

ManagementMedical management involves cor-

recting the primary or underlyingcause of DIC. Nursing managementof PPH and DIC relies on a sys-tematic and consistent approach tonursing assessment. This allows thenurse to immediately identify andprioritize care in response to subtlechanges in the patient’s condition.Based on the ongoing assessment,the nurse is in a position to chooseinterventions that are appropriateto the clinical manifestations ob-served.

Beyond critical careWhen caring for postpartum pa-tients in the ICU, your first priorityis stabilizing the physiologic con-dition that required intensive carein the first place. After that, you’llneed to address postpartum as-sessments and possibly supportbreastfeeding and mother-childbonding. (See Postpartum assess-ment.) OB nurses routinely con-duct these assessments and pro-

vide this care to their patients, butthis may be new territory for somecritical care nurses. Your expertOB nurse colleagues can be yourpartners in caring for critically illpostpartum patients and their in-fants. (See Teamwork.)

BreastfeedingAfter critical care issues are re-solved, breastfeeding represents areturn to the expected normalcy of childbirth. You may be asked tosupport or participate in maternal-infant bonding, breast pumping, orbreastfeeding, especially if a lacta-tion consultant isn’t available. (SeeBreastfeeding resources.)

Bleeding disorders may result indifficulty breastfeeding because ofdecreased breast milk production.Studies show that significant post-partum blood loss may result inchallenges initiating and sustainingbreastfeeding, which will requiremore education and support and

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may lead to long-term emotionaleffects for the mother. Interventionrequires time and patience and anunderstanding of breastfeeding phys -iology. Breastfeeding often needs tobe learned by both mother and ba-by, particularly when medical com-plications intervene.

Postpartum patients who are

cared for in the ICU report wantingto be recognized as new mothers.They’ve been separated from theirbabies, and they want nurses to ac-knowledge and act on their plansfor breastfeeding or bottle feedingand address medication safety, milkexpression, baby care, and barriers(such as distance from the baby).

Unique challengesOB patients who are admitted tocritical care settings may present aunique set of challenges. Stabilizingthe patient’s acute condition is yourpriority, but antepartum and post-partum assessment, in collaborationwith your OB nurse colleagues, canhelp ensure good outcomes for bothmother and child.

The authors work at the University of North Caroli-na Wilmington. Debra A. Hrelic is the RN-BSN pro-gram coordinator, and Kellie M. Griggs is an assis-tant professor.

Selected references Bahadur BR, Kodey P, Tanniru J, TirumalaS. Study of outcome of obstetric emergen-cies admitted to intensive care unit. Int JReprod Contracept Obstet Gynecol. 2018;7(7):2909-14.

Bayes S, Ewens B. Registered nurses’ experi-ences of caring for pregnant and postpartumwomen in general hospital settings: A sys-tematic review and meta-synthesis of qualita-tive data. J Clin Nurs. 2017;26(5-6):599-608.

Henry L, Britz SP. Loss of blood = Loss ofbreast milk? The effect of postpartum hemor-rhage on breastfeeding success. Poster pres-entation. J Obstet Gynecol Neonatal Nurs.2013. onlinelibrary.wiley.com/doi/full/10.1111/1552-6909.12198

Hinton L, Locock L, Knight M. Maternal criti-cal care: What can we learn from patient ex-perience? A qualitative study. BMJ Open.2015;5(4):e006676.

Kawilarang S, Negara KS. Characteristics ofthe obstetric patients admitted to the In-tensive Care Unit of Sanglah General Hos-pital in 2013-2016. Crit Care Shock. 2017;20(1):4-9.

Lowdermilk DL, Perry SE, Cashion K, AldenKR, Olshansky EF. Hypertensive disorders.In: Maternity & Women’s Health Care. 11thed. St. Louis, MO: Elsevier; 2016:653-68.

Lowe SA. Obstetric medicine and the criticallyill pregnant woman. Obstet Med. 2016;9(4):147.

Murray SS, McKinney ES, Holub K, Jones, R.Complications of pregnancy. In: Foundationsof Maternal-Newborn and Women’s HealthNursing. 7th ed. St. Louis, MO: Elsevier;2019:208-31.

Rippin A. Evidence-based design: Structuringpatient- and family-centered ICU care. AMA JEthics. 2016;18(1):73-76.

Vesel J, Nickasch B. An evidence review andmodel for prevention and treatment of post-partum posttraumatic stress disorder. NursWomens Health. 2015;19(6):504-25.

When caring for postpartum critically ill patients, nurses may need to support newmothers in their breastfeeding efforts. Tap into these resources to learn more.

Breastfeeding supportUse these resources to learn more about breastfeeding.International Lactation Consultant Association (ilca.org). This organization’swebsite includes an online community as well as a lactation consultant finder.

La Leche League USA (lllusa.org). Read blogs, search frequently asked ques-tions, and find out about local events that support breastfeeding.

Breastfeeding in the NICUAccess these resources and share them with your patients whose babies are inintensive care.Feeding your baby in the NICU (marchofdimes.org/baby/feeding-your-baby-in-the-nicu.aspx). This website offers ideas for meeting the challenge ofbreastfeeding in the neonatal intensive care unit (NICU).

Breastfeeding your infant in the intensive care unit (ahc.aurorahealthcare.org/fywb/x18507.pdf ). This patient handout providesinformation about the importance of breastfeeding and tips for motherswhose babies are in the intensive care unit.

Breastfeeding resources