High Dependency Care for Obstetric Patients
Content
Section
1.0
2.0
3.0
3.1
3.2
3.3
3.4
3.5
4.0
5.0
Content
Introduction
Aims and objectives
Management
Admission criteria
Responsibility of different staff groups
Equipment requirements
When to involve clinicians from outside
the maternity service
Criteria for transfer
Audit and Monitoring compliance
References
Page
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1.0 INTRODUCTION
Whilst most pregnancies and births are normal and without complications, there
are some occasions when women will require a higher level of care than that
normally provided in a general care setting. In these instances the women should
be cared for in a suitable environment by staff able to provide the necessary level
of care.
Determining what type of care a woman should receive is based on clinical
judgement utilising the criteria outlined in the Intensive Care Society’s Standards
and Guidelines for the Levels of Critical Care in Adult Patients1.
High dependency Care (ICS Level 2 care)
High dependency care is required for women needing more detailed observation or
intervention including basic support for a single failing organ system, extended
post-operative care and those stepping down from higher levels of care.
Intensive Care (ICS Level 3 care)
Patients requiring a higher level of care than outlined above will need to be
stabilised and transferred to an Intensive Care Unit. For example, women requiring
support for 2 or more organ systems, artificial ventilation, renal replacement
therapy, risk of sudden catastrophic deterioration.
Although it is acknowledged that the location of the woman should not determine
their level of care - it is expected that within the maternity service women requiring
high dependency care will usually be cared for on the Delivery Suite. The LGI site
has a designated area within the Delivery Suite for providing HDU care, the SJUH
site use a fully equipped delivery room to provide the same level of care as in an
HDU unit. If a woman needs ICU care she is transferred to general ICU unit at the
respective sites providing that a bed is available. In some circumstances it may be
necessary to transfer the woman to another unit providing intensive care services.
2.0 AIMS AND OBJECTIVES
The aims and objectives of this protocol are to outline the processes for ensuring
that women receive high dependency care / intensive care in a suitable
environment. In particular it specifies:
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Admission criteria
The responsibilities for the different staff groups
The process for ensuring the availability of equipment in line with national
guidance
Guidance on when to involve clinicians outside the maternity unit
Agreed criteria for transfer to HDU / ICU outside the maternity unit
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3.0 MANAGEMENT
3.1 CRITERIA FOR TRANSFER
3.1.1 Criteria for transfer to high dependency care
These may be met either before or after delivery. The indication for the woman to
receive HDU care should be documented in the hospital records or birth record.
All women receiving high dependency care should have observations recorded on
a modified obstetric early warning chart (MOEWs) in order that deteriorating
condition can be identified.
Patients who are receiving continuous oxygen therapy are not suitable to step
down to level 1 care (ward based) and so will need to remain on delivery suite
even if otherwise well.
Table 1: Examples of indications
Obstetric Indications
Non-obstetric Indications
Eclampsia
Transfer from ICU
Sepsis
Other surgical procedures or complications related
Severe pre-eclampsia
to surgical condition
Severe asthma
Pneumonia/respiratory embarrassment
Major haemorrhage (over
Hypertension
1500mls)
Renal impairment
Diabetic ketoacidosis
Thyrotoxicosis
Thromboembolism
Cardiac or neurological co-morbidity
HELLP syndrome
Morbid obesity (BMI over 40kg/m2) with coPuerperal sepsis
morbidities
This list is not exhaustive and the need for HDU care should be assessed on an
individual basis. When HDU care is required, the midwife/nurse to patient ratio
must be no more than one midwife /nurse to two patients.
3.1.2 Discharge Criteria from HDU to Ward
This will be when care can be managed on a maternity ward and must take into
account staffing levels, skill-mix and workload on the ward to which the patient is
being discharged. A written treatment plan, including clear instructions about the
continued level of observation and when to call medical staff, must be documented
at the time of transfer. Continued support from the obstetric and anaesthetic staff
based on the delivery suite may be required and must be provided. Transfer out of
HDU should be a joint obstetric and anaesthetic decision made at consultant level
unless exceptional circumstances apply and fulfill the following:
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Patient haemodynamically stable, no further continuous intravenous medication
or frequent blood tests required
No invasive monitoring required
No active bleeding
No supplementary Oxygen required
Patient mobilized.
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There is a named consultant anaesthetist responsible for all HDU patients 24
hours per day.
When transferring a woman from HDU to the postnatal ward a personal handover
of care should be given from the midwife handing over care to the receiving
midwife utilising the SBAR principle for communication. This should be person to
person the woman should be accompanied to the postnatal ward as there may be
significant complications that require a more detailed handover and should always
be done face to face to the receiving midwife by either a midwife , nurse or doctor.
3.1.3 Criteria for transfer to ICU Care
Women requiring ICU care are generally transferred to an ICU within the Trust.
Following assessment of the woman’s condition, the decision for transfer will be
made by the Consultant Obstetrician and the Consultant Anaesthetist in liaison
with other specialties as required. The reason for transfer should be clearly
documented in the Hospital records and/or birth record
Women who may require ICU care have usually more than one organ failure
including:
 Women requiring advanced respiratory support (ventilation)
 Women requiring invasive renal support
 Women requiring inotropic support would be considered
 Exacerbation of pre-existing medical problem.
Plans would be made between the Consultant Obstetric anaesthetist, Consultant
Obstetricians and the Intensive Care Consultant again using the SBAR principle for
communication. On going care for these women must include daily conference
between these key personnel.
Discharge from ICU is a consultant level decision and should be back to an
obstetric HDU in the first instance unless otherwise directed. The outreach team
may need to provide advice and support following discharge from ICU but this will
be at the discretion of the Consultant Anaesthetist and Consultant Obstetrician and
will depend on the original indication for admission to ICU. Again the transfer
should be made person to person the woman should be accompanied to the HDU
area as there may be significant complications that require a more detailed
handover and should always be done face to face to the receiving midwife by
either a midwife, nurse or doctor.
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3.2 Responsibilities of the different staff groups
The table below outlines the key roles and responsibilities of staff involved in the
care of women requiring level 2 care or above.
ROLE
Obstetricians
RESPONSIBILITIES
Attend & review woman at least 3
times/24hours (as a minimum on
ward rounds at change of shift)
review of investigations and actions
as appropriate
communicate with other staff about
plan of care and escalate if more
senior review required
Respond to an abnormal MOEWs
score
Documentation
Individual plan of care
in hospital records
Discussing care with woman and/or
partner
Document discussions
in records
Liaise with MDT regularly regarding
appropriate level and place of care
Document discussions
in hospital records
Be aware of transfer criteria as
stated in guidance and arrange
transfer as appropriate
Anaesthetists
Ensure patient is physiologically
stable and that appropriate
monitoring is in place
Be immediately available to review
woman if her condition deteriorates
Document reason for
change in level of care
and personnel required
to undertake transfer
Document plan of care
(may be part of ward
round documentation
from obstetric team as
above)
Liaise with ICU/outreach team if
woman requires level 3 care
Accompany woman to ICU and
handover care to receiving team
Midwifery Staff
Document discussions
in hospital records
Document handover of
care including name of
person taking over
care
To undertake physical observations Documentation on the
for women and report any change in MOEWs chart
score to medical staff
To provide support for women and
their partners/family
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photocopy birth records and
hospital records if transferring
outside the Trust
Accompany woman to ICU and
handover care to receiving team
Document handover of
care including name of
person taking over
care using SBAR
sticker or SBAR
headings
3.3 Equipment requirements
HDU care should be conducted in the appropriate care setting with staff skilled and
trained in this area. The basic equipment available in both the HDU and in delivery
suite rooms to provide HDU care is:
 equipment available to monitor vital signs including, pulse, blood pressure, and
oxygen saturation (eg SPACELAB / Dynamap)
 Oxygen supply with masks and tubing
 Suction with Yankauer catheter and tubing with various size suction catheters
 Ambubag and masks of different sizes.
 Emergency intubation equipment and drugs (on Crash trolley)
 Minitrach tracheostomy set (on crash trolley)
 Assorted cannula for intravenous access / drip stands
 Wound dressings , tape
 Gloves (Sterile / unsterile in various sizes) / Aprons
In addition there is daily stock check of drugs and fluids.
Equipment and algorithms required for resuscitation and care of HDU patients are
included in Trust Basic HDU Competencies document.
To ensure the availability of all necessary and functioning equipment, an inspection
is undertaken on a daily basis by the duty Operating Department Practitioner
(ODP) and/or Delivery Suite Midwife. If any defects/ faults are found in the
equipment at inspection then it is removed from service and reported promptly to
Medical Physics (LGI ext: 23492, SJUH ext 66167). A note will be made in the
communication book and the information passed on at each shift change so that all
staff are aware. Extra equipment is available in the theatre store cupboard if
required. This equipment is checked on a regular basis by Medical Physics
3.4 Guidance on when to involve clinicians outside the maternity
unit
Transfer out of Obstetric HDU care requires the woman to be assessed jointly by a
senior anaesthetist and a senior obstetrician and in some cases other disciplines
that have been involved in the woman’s care e.g. renal, cardiac. Senior clinicians
from other specialties will be involved in the care of women where there is:
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1. Failure of more than one system
2. Disease whose management is out-with the expertise of the obstetric or
anaesthetic team
e.g. i renal failure, other than the impairment associated with pre-eclampsia
ii hepatic failure
iii respiratory disease especially that requiring ventilatory support
iv cardiac disease, pre-existing or of recent onset
v neurological conditions
vi endocrine disease including diabetes mellitus
vii non-obstetric surgical problems
The referral will be at Consultant level and ideally such women will be reviewed by
the Consultant from the appropriate specialty. The reason for referral and who the
referral is made to should be documented in the Hospital records and/or Birth
record
The outreach team should be consulted if there is a transition to or from the ICU or
for help with a specialised problem e.g. high flow oxygen therapy.
Once the patient is deemed to have stabilised sufficiently to be nursed on a
postnatal ward, this will be communicated to the midwife responsible for her care
as well as the co-ordinating midwife. There should be a clear plan of on-going care
and observations documented on the MOEWS chart once the HDU chart is no
longer necessary.
4.0 AUDIT AND MONITORING COMPLIANCE
A clinical incident report will be completed for all women admitted to intensive care
or transferred to high dependency care outside the maternity unit. Each case will
be reviewed at the weekly risk management meeting who will decide if any further
action is required including a level 2 investigation.
A multidisciplinary annual audit will be carried out in accordance with the Maternity
Services Audit Plan. Auditable standards include:
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Number of women cared for in HDU
Length of stay
Admission and discharge criteria
involvement of clinicians outside the maternity service
responsibilities of different staff groups
availability of medical equipment
documentation requirements
Audit results will be presented at the Women’s Services Clinical Governance and
Audit meeting and an action plan developed as necessary. A lead will be appointed
for monitoring of the action plan, including re-audit, and the status of the action
plan reported to the Women’s Services Clinical Governance and Risk management
Forum quarterly. Audit results will be included in the Maternity quarterly risk
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management report and any resulting changes disseminated via the Maternity
Services Forum, Team Leaders Forum, Supervisor’s Forum.
5.0 Evidence Base
ICNARC (Obstetric) 2010
The Joint Standing Committee of the RCoA and RCOG, in collaboration with the OAA,
commissioned ICNARC to introduce fields for “currently pregnant” and “recently pregnant” into their
well established Case Mix Programme from February 2006. http://www.oaaanaes.ac.uk/content.asp?ContentID=323
Sabir N, Vaughan DJA, Lucas DN, Chan I, Bhuptani S, Robinson PN. A survey of obstetricians'
knowledge of aspects of acute care in maternity HDU patients. Int J Obstet Anaesth 2009; 16: S21.
Swanton RDJ, Al-Zawi S, Wee MYE. Obstetric Early warning scoring systems- an OAA approved
national postal survey IJOA 2008 O14
Srinivas K, Yadthore S, Collis RE. Obstetric high dependency facilities: a survey of current practice.
Int J Obstet Anaesth 2007;16: S45.
Rathinam S, Khan A, Rupasinghe M. Preparation of midwives for high risk care: viewpoint of the
midwife (Abstract). Int J Obstet Anesth 2007; 16: S50.
Harrison DA, Penny JA, Yentis SM, Fayek S and Brady AR. Case mix, outcome and activity for
obstetric admissions to adult,general critical care units: a secondary analysis of the ICNARC Case
Mix Programme Database Critical Care 2005 Vol 9 No Suppl 3
Gatt S. Pregnancy, delivery and the intensive care unit: need, outcome and management. Curr
Opin Anaesthiol 2003; 16: 263-7in
Ryan M, Hamilton V. The role of high dependency unit in a regional obstetric hospital. Anaesthesia
2000; 55: 1155-8
Cordingley JJ, Rubin AP. A survey of facilities for high risk women in consultant obstetric units. Int J
Obstet Anesth 1997; 6
General, Outreach/MEWS
Department of Health. Comprehensive Critical Care: a review of adult critical care services.
London: DoH, 2000.
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4006
585<http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidanc
e/DH_4006585>
An Acute Problem? A Report of the National Confidential Enquiry into Patient Outcome and Death.
www.ncepod.org.uk<http://www.ncepod.org.uk> 2005.
Out of our reach?: Assessing the Impact of introducing a critical care outreach service. Pittard A.J.
Anaesthesia 2003; 58: 882-885.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985). "APACHE II: a severity of disease
classification system". Critical Care Medicine 13: 818–29. PMID
3928249<http://www.ncbi.nlm.nih.gov/pubmed/3928249>.
Stenhouse C, Coates S, Tivey M, Allsop P, Parker T. Prospective evaluation of a modified Early
Warning Score to aid earlier detection of patients developing critical illness on a surgical ward.
British Journal of Anaesthesia 2000; 84: 663
McQuillan P, Pilkington S, Allan A, et al. Confidential enquiry into quality of care before admission
to intensive care. British Medical Journal 1998; 316: 1853-8.
Goldhill DR, Worthington L, Mulcahy A, Tarling M, Sumner A. The patient-at risk team: identifying
and managing seriously ill ward patients. Anaesthesia 1999; 54: 853-60.
Morgan RJM, Williams F, Wright MM. An early warning scoring system for detecting developing
critical illness. Clinical Intensive Care 1997; 8: 100.
Physiological values and procedures in the 24h before ICU admission from the ward. Goldhill et al.
Anaesthesia 1999; 54: 529-34.
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Protocols relating to care of Obstetric Women requiring High Dependency Care
(HDU) / Intensive Care (ICU)
Author(s)
Audrey Quinn (Consultant Anaesthetist); Katie-Sue Leech (Midwife)
Contact name
Audrey Quinn (Audrey.quinn@leedsth.nhs.uk)
Approval
Maternity Services Forum
process
for
amendments
First Issue
Date
September 2010
Reviewed
July 2012
Version no:
2.0
Review Date:
July 2015
Ratified by Maternity services Clinical
Management forum (27/08/2010)
Amendments approved by MSF 22/06/2012
Ratified by
Governance
and
Risk
Consultation Process
Maternity Services Guideline Group / Maternity Services Forum, Maternity Services
Clinical Governance and Risk Management Forum / Obstetricians / Team Leaders /
Supervisors of Midwives
Scope of guidance
Clinical
condition
High Dependency/Intensive Care for Maternity Patients
Patient Group
All women delivering within LTHT requiring High Dependency/Intensive
Care
All Health Care Professionals involved in the provision of maternity care
within the Leeds Teaching Hospitals NHS Trust
Professional
Group
Distribution
List
Consultant Obstetricians
Obstetric Anaesthetists
Head of Midwifery
Midwifery matrons
Midwifery Team Leaders (for distribution to midwives within their areas)
Supervisors of midwives
Dissemination Via Risk Management Midwife
Audit and
Monitoring
Will be carried out in accordance with Maternity Services Audit Plan
Equity and Diversity
Leeds Teaching Hospitals NHS Trust believes in fairness, equity and above all values
diversity in all dealings, both as providers of health services and employers of people. The
Trust is committed to eliminating discrimination on the basis of gender, age, disability,
race, religion, sexuality or social class. We aim to provide accessible services, delivered
in a way that respects the needs of each individual and does not exclude anyone. By
demonstrating these beliefs the Trust aims to ensure that it develops a healthcare
workforce that is diverse, non discriminatory and appropriate to deliver modern
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healthcare.
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