What are the key components of an ICU admission checklist in obstetrics?

ICU Admission Checklist in Obstetrics

Obstetric ICU admissions should follow a structured checklist approach focusing on immediate stabilization, multidisciplinary coordination, and pregnancy-specific modifications to standard critical care protocols. 1, 2

Immediate Assessment and Stabilization (First Hour)

Primary Survey - ABC Priority

• Airway management takes absolute priority, with recognition that pregnant patients have increased aspiration risk and higher rates of difficult intubation 3, 4
• Assess airway patency, breathing adequacy (SpO₂ target >95%), and circulatory status (MAP ≥65 mmHg) 2, 3
• Position patient in left lateral tilt or manual uterine displacement if >20 weeks gestation to prevent aortocaval compression 1, 2
• Designate a timekeeper to call out intervals at 1-minute increments for time-critical interventions 1

Cardiovascular Collapse Protocol

• If no pulse present, initiate CPR with backboard and manual uterine displacement 1
• If no pulse at 4 minutes, START perimortem cesarean delivery (resuscitative hysterotomy) 1
• Establish large-bore IV access or intraosseous line if needed 1, 3

Sepsis Recognition and Management (if applicable)

• Obtain blood cultures before antibiotics but never delay antibiotics for cultures 2
• Administer broad-spectrum antibiotics within 1 hour for septic shock (piperacillin-tazobactam first-line) 2
• Initiate 1-2 L crystalloid bolus within first 3 hours 2
• Measure lactate (normal <2 mmol/L outside labor; interpret cautiously during active labor) 2
• Start norepinephrine at 0.02 µg/kg/min if persistent hypotension after fluids, targeting MAP ≥65 mmHg 1, 2

Obstetric-Specific Interventions

Hemorrhage Anticipation

• Initiate massive transfusion protocol early for hemorrhage or DIC 1
• Administer oxytocin prophylaxis plus additional uterotonics as needed for uterine atony 1
• Give tranexamic acid 1 g IV over 10 minutes if DIC or hemorrhage occurs 1
• Prefer cryoprecipitate over FFP to reduce volume overload 1

Fetal Monitoring

• Implement continuous fetal heart rate monitoring for dual purposes: assessing fetal well-being and providing real-time measure of maternal end-organ perfusion 1, 2
• Recognize that stabilizing the mother typically stabilizes the fetus 1, 2
• Non-reassuring fetal tracings may improve with maternal hemodynamic optimization 1

Hypertensive Disorders Management

• Anticipate pulmonary hypertension and right ventricular failure in severe preeclampsia/eclampsia 1
• Consider echocardiography (transthoracic or transesophageal) 1
• Avoid fluid overload - use 500 mL boluses and reassess frequently 1

Transfer and Escalation Criteria

Indications for ICU Admission

The most common reasons requiring ICU admission are: obstetric hemorrhage (37.8%), hypertensive disorders (28-37%), and sepsis/infection (17-27%) 5, 6

Transfer Decision Criteria

Transfer to Level III or IV facility when patient has: 1, 2

• Persistent hypotension (MAP <65 mmHg)
• Need for vasopressors
• Persistent hypoxia (SpO₂ <92% on room air)
• Altered mental status
• Lactate ≥4 mmol/L

Pre-Transfer Stabilization

• Stabilize patient before transport 1
• Do not delay transport due to inability to monitor fetus - maternal stabilization is priority 1, 2
• If delivery is imminent, may be safer to postpone transfer until after childbirth 1

ICU Management Protocols

Ventilation Management

• Maintain head of bed elevated at 45° for all ventilated patients 3
• Avoid hypoxemia and permissive hypercapnia due to negative fetal impact 4
• Use continuous waveform capnography for all intubated patients 3
• Maintain endotracheal tube cuff pressure at 20-30 cm H₂O 3

Metabolic Management

• Control maternal fever to reduce fetal oxygen consumption and prevent fetal tachycardia 2
• Initiate insulin for persistent hyperglycemia >180 mg/dL, targeting 140-180 mg/dL 2
• Maternal hyperglycemia causes fetal hyperglycemia, acidosis, and decreased uterine blood flow 2

Thromboprophylaxis

• Administer pharmacologic VTE prophylaxis unless contraindicated 1
• Prefer low-molecular-weight heparin over unfractionated heparin for better safety profile 1
• Consider unfractionated heparin if imminent delivery or allergy to LMWH 1

Multidisciplinary Team Coordination

Required Personnel

• Obstetrician or Maternal-Fetal Medicine specialist available at all times 1
• Board-certified anesthesiologist with obstetric experience 1
• Critical care intensivist 1
• Neonatology team for fetal/neonatal concerns 1
• Full complement of subspecialists (cardiology, nephrology, infectious disease, hematology) 1

Nursing Requirements

• 1:1 nurse-to-patient ratio for highest acuity patients 3
• Nurses with competence in managing complex maternal illnesses and obstetric complications 1
• Pod-based model with critical care nurse overseeing and mentoring non-critical care nurses 3

Daily Rounds Checklist

• Include relevant clinicians, nurse in charge, bedside nurse, and physiotherapist 1, 3
• Document airway management details, tube depth, and patient-specific strategies on bedside charts 3
• Evaluate daily the need to maintain ICU care versus prompt delivery 4

Common Pitfalls to Avoid

• Never position supine if >20 weeks gestation - always maintain left lateral tilt 1, 2
• Do not delay perimortem cesarean beyond 4 minutes of pulselessness 1
• Avoid interpreting elevated lactate as sepsis during active labor 2
• Do not withhold necessary imaging or medications due to pregnancy - analyze benefit-risk ratio carefully 4
• Higher antibiotic doses may be needed due to pregnancy-induced pharmacokinetic changes 2
• Maintain high suspicion for streptococcal toxic shock syndrome and perineal fasciitis 4

Documentation Requirements

• Document all interventions with timestamps 1
• Record tube depth and cuff pressures every shift 3
• Maintain bedhead signage for identified airway difficulties 3
• Keep re-intubation and extubation strategies visible at bedside 3
• Track ICU length of stay (median 5-7 days for obstetric patients) 6