Critical Care Assessment by Midwives

Maureen Boyle, Judy Bothamley

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781138740204
• eBook ISBN: 9781351728782
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Over the last ten years, pregnancy has not only become more complicated for many women, but the traditional provision of general intensive care units has been reduced. To bridge this gap, critical care units, usually staffed by midwives, have been set up in many maternity units. This textbook is an accessible and comprehensive introduction to this emerging area of practice.

Critical Care Assessment by Midwives also notably sets out a template for assessment of women that will enable early identification of deteriorating health. Serious illness can arise subsequent to an emergency, a pre-existing illness or a complication of pregnancy but can also occur in the context of what appears to be a low risk pregnancy. For this reason, all midwives need to be skilled in assessment that facilitates timely, appropriate referrals and saves lives.

It covers:

• ABCDE assessment tailored for midwives;

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• assessment of cardiac conditions;

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• aassessment of respiratory conditions;

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• assessment of neurological conditions;

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• pre-eclampsia;

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• haemorrhage;

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• shock, including hypovolaemia, sepsis and anaphylaxis;

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• haemodynamic monitoring;

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• fluid replacement and balance;

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• ketoacidosis, hypoglycaemia and sickle cell crisis.

Covering the context of care, relevant pathophysiology, signs and symptoms, specific assessment in detail, relevant drugs, assessment of the fetus, summaries of management, psychosocial support and the specific professional responsibilities of the midwife, this is an essential guide for all midwives and midwifery students.

Chapter 1
Structured assessment to identify deteriorating health

Introduction

Physiology

Structured assessment by the midwife

Summoning help and ongoing assessment

Introduction

A number of reports,^1,2,3 including the ‘Confidential enquiry into maternal deaths’,^4,5 have noted the need for earlier identification of women who are becoming unwell and for seamless care to support their recovery. While there has been considerable improvement in dealing with obstetric emergencies,⁶ other complications can occur, even in the context of what appears to be an uncomplicated birth. There remains a need for midwives to recognise signs of deteriorating illness and refer appropriately.

It has been noted that it is more difficult to detect if a pregnant woman is becoming unwell. They are generally young and healthy with good physiological reserve, enabling them to compensate well. Some of the symptoms of ill health, such as breath lessness, may be normal for pregnancy. The progression of illness can be quicker, such as the extent of blood loss in postpartum haemorrhage. The expectation of normality in maternity settings may be a factor towards delays in initiating referral.⁷ Midwives are not responsible for making the diagnosis but for performing the right observations at suitably frequent intervals, recording them accurately, giving some initial care and ensuring that the right medical staff respond to review the woman. These actions by the midwife will be life-saving.

Physiology

Understanding the signs of compensatory mechanisms indicative of deteriorating health is required to address health problems early and avert serious morbidity and mortality (see Chapter 4 for more details of the physiology of compensatory mechanisms). Table 1.1 summarises the physiological changes in pregnancy that need to be considered when assessing the critically ill woman who is pregnant or has recently given birth.

Table 1.1 Physiological changes to be considered when assessing the critically ill woman who is pregnant or has recently given birth^1,8,9

	Changes in pregnancy	Factors to consider with regard to assessment of critical ill health
Cardiovascular system
Plasma volume	Up to 50% plasma volume expansion	Physiological anaemia; reduced oxygen-carrying capacity; check haemoglobin levels.
Heart rate	Increased by 15-20 bpm	Check against baseline for individual woman; note trends.
Cardiac output and venous return	Increased by 40-50% by term	Women can tolerate quite large amounts of blood loss postnatally without change to blood pressure but this will vary; check vital signs to identify compensatory changes.
	Supine hypotension syndrome occurs when the gravid uterus impedes inferior vena cava and venous return
		Women should be cared for lying on their side or with left lateral tilt to optimise cardiac output.
Uterine blood flow	Significant increase during pregnancy of up to 10% of cardiac output	Potential for large volumes of blood loss quickly, particularly around the time of delivery of the placenta; concealed blood loss both antenatally and following surgery can occur; inaccuracies of estimated blood loss may lead to underestimation of the severity of blood loss.
Systemic vascular resistance	Decreased in pregnancy due to effects of progesterone, resulting in general vasodilation	The response of peripheral vasoconstriction and other features of compensatory mechanisms will mask features of shock until the woman is significantly unwell.
		Perform observations and piot on MEOWS chart.
Coagulation	Pregnancy is a pro-coagulant state	Concentration of clotting factors after delivery and reduced venous return increases risk of venous thromboembolism (VTE).
		Risk assessment for VTE and prophylaxis is required.
Tendency for anaemia	Haemodilution results in physiological anaemia	Women may have poor iron stores and this combined with physiological changes may leave women with iron deficiency anaemia. Haemorrhage may exacerbate this, reducing oxygen-carrying capacity.
	Increased fetal requirements for iron
		Check oxygen saturations and haemoglobin levels.
Respiratory system
Airway changes	Fluid shift and generalised vasodilation	Increased mucosal oedema
Laryngeal oedema		Laryngeal oedema can make intubation more difficult.
		Airway assessment
Oxygen consumption	Increased by 20% due to metabolic demand of fetus and increased requirements of pregnancy	Increased oxygen requirements and changes in lung function make the pregnant woman become hypoxic more readily.
		Check oxygen saturations
Respiratory rate and ventilation	Increased respiratory rate	Breathlessness is a common sign in a healthy pregnancy and this may mean that breathlessness as a sign of critical ill health is ‘explained away’ as normal (see Chapter 7 for assessment of breathlessness).
	Gravid uterus causes displacement of the diaphragm
	Changes in lung function -residual capacity reduced
		Ventilation more difficult
Arterial pC02	Decreased buffering capacity, making acidosis more likely	Note any increase in respiratory rate.
Other changes
Reduced gastric motility and relaxation of lower oesophageal sphincter	Due to effects of progesterone	Minor disorder symptoms of pregnancy, including heartburn and nausea, may be confused with more serious presentation of illness such as chest pain and liver disease.
	Increased risk of aspiration of stomach contents
		Intubation with effective cricoid pressure and the use of H2 antagonists and antacids prophylactically is...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of illustrations
• List of abbreviations
• Introduction
• 1 Structured assessment to identify deteriorating health
• 2 Haemodynamic monitoring
• 3 Fluid balance, electrolytes and fluid replacement
• 4 Shock
• 5 Haemorrhage
• 6 Pre-eclampsia (PET)
• 7 Assessment of the respiratory system
• 8 Assessment of the cardiac system
• 9 Assessment of the neurological system
• Glossary
• Index