Dr Arlene Wise, Chair of the Scottish Maternal Critical Care Network, will join us for a clinical update on the clinical care of the critically ill pregnant patient.
SICS Evening Education Updates - Maternal Critical Care - Dr Arlene Wise
Summary
In this medical educational session, the focus is on maternal critical care and patient treatment, provided by a specialist in obstetric anesthesia, Dr. Arlene Wise. The session will provide insight into the trends and lapses in maternal care highlighted in annual reports like Embrace’s Confidential Enquiry into Maternal Deaths. The talk will look into direct and indirect causes of maternal deaths and changes in these patterns over time. It will explore the necessary knowledge required for a medical professional dealing with pregnant patients, including ventilating patients and deciding on the right time for delivery in a critical condition. This eye-opening session promises to offer practical advice and will encourage improvements in maternal critical patient care. It’s an enlightening session for all medical professionals, irrespective of their field.
Description
Learning objectives
- Understand the role of the Scottish Intensive Care Society and the importance of interventional research, education, and auditing in medical practice.
- Familiarize with the terms 'direct deaths' and 'indirect deaths' in the context of maternal deaths and learn how to differentiate between the two.
- Recognize the epidemiology of maternal mortality rates worldwide, with specificity to the UK and Scotland.
- Gain knowledge about the Embrace Confidential Inquiry into Maternal Deaths and the subsequent reports, their role in understanding maternal mortality causes, trends, and mitigation measures.
- Develop competence in understanding the implications of maternal deaths in relation to critical care and the steps taken for quality improvement in patient care.
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Hello, good evening everybody and welcome to this um January 2024 up, uh six education evening updates. Um It is Burns night this evening. So uh uh thank you all for joining us er, on this Thursday evening. Um I know that many of you, er, will be familiar with sex as an organization but just um to recap. Um sex is an organization which aims to improve the care delivered to critically ill patients throughout Scotland. The focus is on three main areas, education, research and audit. Um and we have a number of membership categories with a number of benefits including reduced delegate rates are meetings, comprehensive travel insurance, travel, and education bursaries. And if you're interested in membership, have a look at the website and now we don't like to, to our own horn, but we're very pleased to have been shortlisted for the Intensive Care Society Best New Education Program this year for these evening education updates. And I think that really reflects the quality of the speakers that we've had along with the last um year or so. And I know that I will continue tonight. A couple of other things to shamelessly flog. The Scottish Intensive Care Society Annual Scientific Meeting is in Saint Andrews on the 7th and 8th of March this year. Um And er, the, er, abstract deadline has actually been extended until the 28th of January. So if you have any uh projects that are um worth, you know, quality improvement projects, interesting cases that you've seen and then please have a think about submitting those we always want to hear um from the work that's going on throughout Scotland and there's some practical sessions there as well um on uh per track, major incident tabletops. So trauma team simulation escape room, they're all available for booking from the 26th of January. Um In addition, one more thing to talk about and that's the Faculty of Intensive Care Medicine and the Scottish Intensive Care Society are collaborating to um bring the UK consultant intensivist transition course. Um This is an Australian course um that is aimed at senior registrars seizure candidates. Um And those within the first two years of, of a consultant in medicine and that explores the rewards and challenges of consultant life. Um and it will be held on the 21st and 22nd of May. This year, there are only a couple of spaces left. So if you're interested in attending, then please drop us an email. So our speaker for this evening, I'm uh is Doctor Arlene Wise. Doctor Arlene. Uh Doctor Wise is a consultant, the test with a specialist interest in obstetric anesthesia, uh in particular maternal critical care provision in the Royal in for me of Edinburgh. She established and until very recently chaired the Scottish Maternal Critical Care Network that was founded to raise awareness of maternal critical care through local advocacy and education of the entire multidisciplinary team. They have forged close links with the sex I group leading to the introduction of Ward Watcher into Scotland's maternity Units to capture obstetric HD data, which is published in our annual report alongside obstetric critical care data. She also developed and runs a very successful maternal critical care module within the online critical care MSC run by the University of Edinburgh. And she's an anesthetic assessor for the embrace confidential inquiry into maternal deaths. So we are delighted to have doctor wise here for a clinical update about care of the pregnant patient. And I'll hand over to you. Thanks Jelly and thank you very much for the invite to speak to this evening. I'm probably very pertinent to be on burns night because I'm not sure how many Children he had, but he was a well known um lover of women, shall we say? So, there may well have been lots of babies as part of that. So I'm gonna talk to you about maternal critical care. Um And as Julie said, I am part and have just recently given up the chair of Scottish maternal critical care work who are aiming to do this in all your different hospitals as well. There will be a phone, a friend person there, which will come on to later. So, what are we going to do this evening? Well, we're gonna chat about what you're going to see in terms of obstetric critical care in your intensive care units. I'm going to talk about what I would like you to know and what you do need to know about that obstetric or recently pregnant patient. Um I'm going to try my mummy's acronym. Um and there'll be more about mummy's coming later on and we're gonna have a quick discussion about how to ventilate your patients. Although there isn't really an awful lot of evidence about that. And then I think what has really um challenged us all over the last couple of years with COVID is when are we going to deliver? And what are the parameters for thinking that we need to deliver this pregnant patient who is critically unwell? And then the million dollar question about how you're going to improve your service tomorrow next week, next month, what can we all do to make things better? So, no talking maternal critical care, to be honest, obstetrics, you can't, you can't not mention embrace in the confidential inquiry into maternal death. So the an intensive among us amongst you will probably be familiar with this. But if there's allied health professionals, you might not be. So the confidential inquiry into maternal deaths was set up 70 odd years ago. Um Just almost after the inception of the NHS itself and what it did and what it still does is look at every maternal death. So every death of a woman who is pregnant, recently pregnant and up to one year after that pregnancy, to look for lessons, to look for themes. Can we improve in any way? And certainly the UK confidential inquiry is held up to be, to be the mother, the, the God, the godmother of all confidential inquiries across the world. Um It's gold standard which other countries try to adhere to um and emulate. So this comes out every year. Um It has traditionally been run as a triennial report. So it used to come out every three years, but in recent decade, it's come out every year, but they still look in that three year rolling circuit and as you can see here, um the rates aren't great. So we had a steady fall all through the nineties, the na and to be honest, well into the 20 tens as well with a decreasing maternal mortality rate. But over the last few years that has, has gone up and to be honest, it's rocketed up as well. Now you can all guess the cause of that. Um COVID is part of that, but it is going up even when you take COVID out of the equation again, for those of you not familiar with embrace, um we talk about direct and indirect death. So, direct death is directly attributable to the pregnancy. So, obstetric hemorrhage, preeclampsia, um clots, thrombosis that you wouldn't have if you weren't pregnant. Um direct indirect causes are other things that happen, other medical conditions that happen and you just happen to be pregnant. So things like cardiac disease, neurological disease, malignancy, um psychiatry has been traditionally thought of as an indirect cause, but a few years ago that got changed to really reflect the changes that happen in a woman's um psychological profile and Purpur um Purpur psychosis, postnatal depression as well. So that is a mixture of indirect and direct as well. Ok. And you can see here that COVID is the leading cause of indirect causes over the last of these last three years, cardiacs up there as well. And in actual fact, having we thought we had sorted out clots, um but actually thrombosis has rocketed up again as the leading cause of death. What it also does is divide that into whether you're pregnant or recently pregnant. And that is up to the 1st 4242 days, the first six weeks and then that six week period up to a year is, is considered to be separately. And we'll see with this slide and the next slide how things change with that. So when we're talking about maternal mortality rate, which is mmr that's the real headline figure that you'll see in the papers and then the press and in government um, releases. So that has gone up to 13 per 100,000 maternity um, in the UK for the, for the years, 2019 to 2021. It, at its best about five years ago, it was 8.4 scan countries can manage to get it at much to much lower, um, single figures. So they're in the kind of twos and threes, um developing world a at its worst. You're talking about 6, 700 per 100,000 maternity or of cases of death of those 241 deaths, 62 were still pregnant. So I think our, our fear within maternity and I think the fear within the rest of the hospital is that we're going to be faced with a pregnant woman who is peri arrest are critically unwell. Um And that might happen, but it's not that common. Um And certainly with, in terms of embry reporting only 26%. So a a quarter were still pregnant um when they died and the majority of them were actually less than, than, than the magical 20 weeks. So this is the point where we would start thinking that the, that the baby was impacting on the resuscitation of the mom or the ventilation of the mom. So if you were 20 weeks pregnant, you probably have a uterus, a bump to about your umbilicus. If it's less than that, we don't advocate um perimortem cesarean sections um you can do tilt, but there probably won't be that much benefit from tilting them as well. So only 21 out of that 62. So a third of the 26% were greater than, than 20 weeks. And therefore, you've got to really think about what we're doing with them in terms of those that were delivered. A, a proportion were peri delivery, peri partum. And again, they will be probably the obstetric related things, obstetric related hemorrhage, um, or has the mom become critically unwell and we have delivered her, which often happens as well. And the vast majority, the mu isn't pregnant and indeed she isn't petty delivery. It's the day after and beyond up to about 4242 weeks. And you can see here if the pie chart has come out reasonably well, actually, it's, uh, half of it is obstetric related causes that are causing this and the other half are these indirect causes. Um, so you get run down by a car, you, um, have something catastrophic because you've got cardiac disease. These are the other things that it could be. But half of those deaths are direct, directly attributable to obstetric reasons whilst you're pregnant or recently pregnant. Once you get, once you push out from the six weeks to a year, then actually the obstetric causes become much less. Um, and quite often if these patients are admitted to hospital, maternity services don't know. So as part of the embrace report you read through, you can be looking at a pregnancy that was 11 months before, but actually the death is now 11 months on and actually the pregnancy had nothing to do with that death. But those, those deaths still get looked at in detail. So what you're looking at is a slightly higher number. So her mmr is now 15 per 100,000 maternity, so increased levels. But what you're now looking at is psychiatric causes. You're looking at drugs, you're looking at alcohol problems, excuse me, you're looking at domestic violence, you're looking at malignancy, you're looking at a a wider variation of those indirect causes. Um And to be honest, a lot of them at this stage are psychiatric related, um are the most vulnerable patients, um, who we know they're vulnerable going through their pregnancy and they get a lot of attention through their pregnancy and a lot of help and a lot of support, but a lot of that support just disappears once they are not pregnant or if they're not recently pregnant as well. So it's about making sure that other services, other third sector organizations kick in at that point to support them. Why am I talking to you guys? Well, you are looking after critically unwell patients, but in actual fact, um embrace also grades the level of care that these patients were given. So bear in mind that all the case notes are being looked at by an obstetrician and an an obstetric kinesthetic and a midwife. So every single case, all those 600 cases and if we feel that those cases need extra expert opinion, then we will get that. So there are also critical care physicians that are cardiologists that are acute medics, there are surgeons that are pathologists that are psychiatric um experts as well. And in actual fact, if you look there good care was only present in 14% which is a bit of a damning indictment. Um Improvements to cure, you can see this is not ideal but actually nothing would have changed. So that's 35%. But over 50% of cases, different care would have led to a different outcome and maybe not a death. There are no critical care chapters within bra so this was chapter eight from the 2022 report which was reporting on 2018 to 2021. Um And you can see there, it includes cardiac disease, which is obviously one of the big causes of maternal death, malignancy as we've just been seeing in that pushed out period up to a year, sepsis, infections also preeclampsia, um and thrombosis. So not an awful lot of deaths happening in critical care. Um But again, care that could have been better and care that would have made a difference, but that's probably not what you actually see in critical care in terms of your obstetric patients. Those are the patients that die. So where do we look for a little bit more information about what types of patients you are going to get and therefore what should you know about or what should you be really good at C A did a case series um in conjunction with the only probably about 15 years ago now, it was published in 20 in the mid kind of 20 tens. And they looked at all obstetric critical care admissions into England Wales and Northern Ireland intensive care units. So in, in Scotland, we have zigzag elsewhere in the UK, they have now it doesn't cover everyone because you have to pay to be part of a. Um but it was a good representation of, of what there was and what they found was that actually admissions were, were low, which is what you know about very few people going in currently pregnant. And if you were currently pregnant, you were probably going in for a not a non obstetric reason. Um And if you were going in and you were recently pregnant, so you've been delivered, you were probably going into ICU for an obstetric related um condition, hemorrhage, preeclampsia, O PTE. Um And the actual part that was quite reassuring because that was backing up what we were all seeing. Um Most admissions were post delivery. So therefore, you've not got the bump to worry about. Most deliveries were by C section because probably we know that C section increases your risk of morbidity. But also if we are worried about a woman's health, if she is unwell or critically unwell, we will. And if she's term or a reasonable stage, we will, we will probably deliver her in order to further that beneficial care for her. Reassuringly, most babies were live births, they might have been premature, but they were born alive. Um And as I've said, most reasons were obstetric reasons for admission. There was a peak of antenatal admissions in the second trimester. So um I'm presuming everybody knows the trimesters of a pregnancy, but the first trimester is about 12 weeks, second trimester, there's a little bit of a fudge. So it's kind of 12 weeks, probably up to mid twenties and then mid twenties to to term is it's third trimester. So I think this antenatal admission is because they're, they're early enough that we don't want to deliver them if they're critically unwell. So therefore we've, we, we kept them pregnant, we've put them into critical care more up to date. Data is available through the NMP, which is um a branch of equip from the Royal College of Obstetricians and gynecologists. So again, a slight change in um the data that we were getting out England and Wales. So kind of the data, but we were part of it as well in terms of the Scottish Zigzag data. Um So what they looked at was all patients admitted and it's 2015 to 2016. So an update in terms of what data was. Um and as you can see there two women pretty much across all the whole nations per 1000 women were being admitted into, into ICU. That number quite rightly goes up once you push out to a year. Um but you can see the rates are relatively low. So 0.2% of all women are going into critical care. So giving birth is, is a very safe thing to do. Um when you actually look at critical care data and just like that I nar data, it shows that there's a peak around delivery. So if you look at the day of birth here, um that's from hemorrhage, the dark blue bar is from hemorrhage. Um infection is, is the lighter blue and other direct pregnancy causes is the is the even lighter blue. So a big surge of of critical care admissions usually from hemorrhage, heavy delivery. And that's just that's postpartum hemorrhage. So that will be your bread and butter of what you see smaller units. Um amongst you may well, actually see more obstetric hemorrhage patients being admitted than the larger units because of the advent of obstetric HD U. So in the larger units where you can sustain training of midwives, you have a bigger pool of midwives. Um And in actual fact, your ICU can cope with all your numbers that you needed. Actually, you might keep someone who has bled 4 L in your obstetric unit, whereas in a smaller, smaller district general, you just don't have the staff here to look after those patients safely. And so they may well go to intensive care as a level two facility, but essentially just for bed and breakfast to make sure that they're ok. As you can see that, that, that pattern changes as you push out from, from peri delivery. Um and the other causes, the non obstetric causes them prevail up to a year and in the antenatal period as well. And in terms of infection, I think before this, um, study came out, certainly everybody in maternity thought of we're sending, if we're sending patients to you, then it's gonna be your sepsis. It's gonna be your degen sepsis because that's, again, that is our bread and butter. But in actual fact, we keep those patients because we're good at looking after those patients. Um And in actual fact, what, what the majority of what is going into critical care is antenatal pneumonias and in actual fact, postnatal pneumonias as well. Ok. So your bread and butter. So that's what's going into itu we also know a little bit more in the last few years about what types of patients are going in. So we know, we know it's, we know it's hemorrhage, we know it's preeclampsia, we know it's a little bit of cardiac. We know that it's a mix of stuff. Um, this study, um, led by NAS who I'm sure you all know. Um A Monica and Judith intensivist um looked at all that zag data of obstetric patients going into Scottish intensive cares for a long period of time. Um And, and we decided what severe maternal morbidity was so intensive care admission, um seizures, massive blood loss, renal replacement therapy, serious life threatening events. Um and look at them in detail, what needs to be remembered for this paper is the PPH was excluded. So that is the huge number of patients going into critical care. This is the everything else. And from this um there were just short of 1500 critical care admissions of which just over 800 were were two level three. So mechanical ventilation or organ support. Um and a severe ma maternal morta morbidity rate of about 1%. So 10 per 1000 maternity and about a third of that was sepsis. So remember the PPH S have been taken away and within that there were 41 deaths. Um and looking, so this is this is benchmarked against all deliveries in Scotland over that time period. And I think what is striking is the risk of death if you have severe maternal mortality and morbidity is that your, your risk of death, your rate of death is much, much higher. Now, that's not rocket science, that's what you expect. But actually, it's a very stark um difference there for some women who just fly through labor and have a baby and other ones who, who suffer PPH, who suffer other, um, problems as well. What the study also began to tease out was who were these women going in? What were the defining characteristics of these women suffering? The maternal mor morbidity. And again, a lot of this ties in with what we know from embrace those women who are dying. It's are older women who are more likely to have comorbid disease. Um And as you know, we just need to pick up a paper to realize that actually reproductive age isn't necessarily 18 to 48. It's whenever you start having periods to mid fifties these days with, with assisted conception techniques and bear in mind that um patients can travel all over the place. So you may not be eligible for IVF in Britain, but you can be eligible for IVF in lots of places around the world. Eastern Europe is very popular. Spain's very popular. Um Ube, Ube and Kazakhstan, I've heard as well in in passing what we also know is where the mothers were born is important as well. Now this isn't ethnicity because the ethnicity data was too badly filled in. Um and, and NHS Scotland now does try to do ethnicity better. But again, there is a positive factor for people not born in Britain. We also have BM I featuring, we have um diabetes and other look how far comorbid diseases as as well. So our patient population has been changing over the years as well. Um And aren't us are bigger or older and have got lots of things going on with them, lots of other medical conditions and again, multiple gestations are out here. Previous Cesarean sections are also out here as well. So we now know that the typical patient who is likely to go into intensive care and we know these patients have longer stays in hospitals. We know that intensive care admission is associated with poorer fetal outcomes. So, stillbirth is more common and there's an increased mortality rate. As I've already explained to you, this is in prepublication and has been presented as posters at the European Society um meeting in Milan uh in the autumn, further interrogation of that same database. So of the nearly 1500 critical care admissions, we know that within that group, they have more short term readmissions than people who weren't admitted to critical care. We know that they have more longer term readmissions and this isn't coming back to have the baby. This is coming back in because you're medically unwell and it's not related to psychiatric admissions as well. So again, you might think, well, people have been through a horrible period in not per delivery period, then that might be the most obvious thing. But it wasn't that. So we, but we know that there's psychological morbidity, we know they're using health healthcare resource and there's increased mortality. So there's lots of work being done at Scottish government and S PSP maternity level to try and stop that morbidity happening in the first place quality improvement work. And NAS as part of the team are working on a risk prediction model to work out who we think is most at risk and we can try and put mitigating factors in place. So prior to this coming along, it was probably postnatal patients with a bleed and actually not that often you had an antenatal patient and probably the antenatal patients were so few and far between that even although maybe your staff, maybe you got the feed a little bit. Actually, it was probably several months or a year until you had the next one that you could think. Oh no, that's fine. We don't actually need to do nothing, but then the guy came along and then the whole landscape changed. So again, we're back to ecor figures in terms of the pregnant population. We spent a lot of early 2020 when you guys were being absolutely hammered body, but probably nothing actually came of it, especially in Scotland. I think our Scottish pregnant population just had away in that spring of 2020. Um We were scared it was going to become another H1N1 which from a decade before had and disproportionately affected pregnant patients. Those of you who remember that will remember um pregnant women being in your itu and by the time 2020 was going out, we thought we got away with it. There still was no vaccine at this point. And remember the furor about vaccinating pregnant women or recently pregnant women or breastfeeding women. And again, we'll come on to that at the end. But then the alpha variant hit and then again, we were just getting off that and then the delta variant hit and it was the delta variant that was nearly broke the maternity units in the, in the summer of 2021. And we saw influxes waves of pregnant women going into our ICU S. And I think that has very much changed the whole narrative around maternal critical care because suddenly this isn't just a woman who has had a baby. You might have had a worst. We had four on the royal itu at one time being ventilated and I three of them were admitted on the same day. So this was a huge problem for intensive care units all around Scotland, all around Britain, all around the world. To be perfectly honest, because again, by this point, they still weren't vaccinated because they've had the visa scared out of them earlier on in the time because nobody thought of them when they were making up the rules. This just reflects the um Scottish data. So you can see there that in terms of critical care admissions in the obstetric population in Scotland, it's fairly steady, about 100 and 20 the majority of them are are, are postnatal recently pregnant, which is the green and the dark blue is the, the still pregnant ones. And you can see for 2021 that summer, but it's all of 2021. There was, there was a big peak in the summer. Um, almost doubling of our antenatal patients and, and they were ill antenatal patients. It wasn't just, we were worried about them. We were, they were level three patients at that. Um Luckily for Scotland and II have my own um thinking about this and we only had one Scottish death from COVID in, in, in that, in the maternity population. Um where as you can see, there was considerable deaths from the rest of, of Britain as well. So thank you from me. Um for all the work that you did over that COVID period, looking after our pregnant women, we know that pregnant women were, were, were being disproportionately affected by the Delta variant. Um But I think primarily this was a disease that affected the unvaccinated populations. And the problem was that our majority of our population was unvaccinated um that we will discuss um later on as well. And therefore the new um COVID, the new embry support, we, we all knew the mmr was going to be going up because of all the COVID deaths. Um But as you can see here, hopefully, next year, it will be better again because again, people have got people who, who were pregnant and subsequent COVID waves, um, had probably been vaccinated before they even thought they were going to get pregnant or have been vaccinated after they've been pregnant. But those, that probably year 18 months really sparked um, a big conversation in terms of what do we do with all these antenatal patients, where do we put them? Where is the best place to look after them? So, is that a delivery suite where if they're going to go into labor or there's a baby, we can look after the baby properly or we're very good at looking after them if, if they're in labor or there's obstetric concerns, but we're not very good at looking after the critical care needs. Do we put them into critical care where you guys are excellent and the experts are critical illness, but you're not very familiar with obstetric patients or do we put them into a medical ward where actually we don't really tick any of those boxes? So certainly when I work, um hardly anybody went into a medical ward because a, the nurses weren't familiar b the medics aren't familiar and c critical care and us maternity were very, um what's the right word concerned about our pregnant patients being in a medical ward. So we had uh it was either labor ward or it was itu looking after anybody who was unwell and that leads to its own problems. But that's partly why I'm here this evening as well. And with all the other work that I do in terms of kind of education, you not skilling your midwives. So what does the embrace tell you guys in that chapter eight of of two years report to, to, to optimize. So what the COVID pandemic really did was highlighted the inequity of medical care experienced by pregnant women compared to nonpregnant women. So um pregnant women admitted to ICU didn't have the same access to all the life saving therapies and medications that your non pregnant patients were. They didn't get steroids, they didn't get toxoi, some didn't get x-rays, some didn't get itu some didn't get proper care. Um And again, it's just about familiarizing all of ourselves with what is the appropriate way of treating these patients. And again, it's what you guys do day in, day out. It's about MDT working. You're used to working in teams. You're, you work in teams beautifully. But so do we in maternity, it's just a different team and we need to bring those teams together. We also use news. So maternal e early warning scores because of the different physiology, malnutrition was specifically highlighted um in some of these women as well and we'll come on to research and we'll come on to emo concerns as well. So what do I want you to know? So, um this was me trying to work out what the key things were and it's a bit, it's a bit t but I think it works quite well. So I want you to know about the MDT multidisciplinary team who's on that and who do we need on that? And how often do we need to convene? I want you to understand a little bit more about physiology and therefore you can understand the path of physiology of obstetric related problems. You need to know about news. And even although I am probably not going to persuade you to use a news chart in terms of your primary um way of noting down observations because that may well, actually all be on a computer these days. What I want is you to know news exist and to have it on your bedside. So you can do a double check every time you're putting in a BP, a heart rate, a respiratory rate. I want you to know a little bit about medication and imaging and then we'll chat about ECMO and then we'll talk about the SS as well. Um And in actual fact, when I was looking for a picture on mummies, um I came across this one and this is the Warsaw mummy project where they have CT scanned the mummies that are in Poland. And in actual fact, they found one, probably the only one that they, they think in the world of a mummy who was actually going to be a mummy. So this is a fetus in the pelvis um of €1000 money. So who is in the MGT. Well, if you think you're going to be looking after a pregnant woman or seeing a pregnant woman on a critical care, then you're in the MDT. And in actual fact, it fits in really nicely with this um infographic from uh embrace report a good few years ago, which just repeats the mantra of treat women who may become pregnant or pregnant or who are recently pregnant the same way as you would treat a non pregnant woman unless there's a very, very, very good reason not to. And in actual fact, sometimes when we're teaching, in actual fact, I take that a little bit further, in actual fact, treat her as if she was a man because then you won't miss anything. And what we're trying to do is to get you not to freeze, to not be scared about, about looking after them because you know how to do this. You look after pneumonias all the time, you look after sepsis is all the time. You look after hemorrhages all the time. And therefore there's just little nuance things about the pregnant or recently pregnant women that you need to know. And in actual fact, most of us work in hospitals where there's somebody else who is part of that MDT team and will come and help you. They're in critical care because their, their primary caregiver can't look after them. They don't have the skills to look after them. And therefore we all just need to come together. So it's a anesthetist. It's obstetricians, it's midwifery, it's nursing, it's intensivist, but it's also critical care nurses. It's, it's your physios. It's your pharmacist. It's the Peds as well because they've got a big part to play in this as well in England. They have something called obstetric physicians. So, these are physicians and see whether you got a gi physician or cardiologist or doctor, um, who have specialized in, in obstetrics. And that's all they do. They might do a diabetes clinic or whatever, but that's their main focus. And they are really part of the team for women with comorbid other conditions. So, thyroid, um diabetes, cardiac disease, epilepsy, rheumatology problems. They are the experts and can bridge that gap between obstetrics and medicine to try and make sure that patients are treated properly as well. And you can see in this jigsaw, it's, it's everything and which is the key one work as a multidisciplinary team remem remember the benefits of treatment and not just excluding treatment. Um Now we're going on to the uh of the mummies. So understanding the, the physiology. So you can pick up a textbook, you can read an article in terms of this and learn lots of numbers. Um But the reality is that from not pregnant to just pregnant, there is a change from first trimester to second trimester, there's a change from, there's a change from second trimester to third trimester and then in the early postpartum period there is also a change and we know a lot more about that now. Um So in actual fact, the books that probably are more than 10 years old probably aren't actually that accurate. But what you need to know is that things change and luckily all those changes are mapped out in AM chart. So that's why I want you to have a muse chart. The main things, the headline figures are cardiovascular changes. So the circulating blood volume increases from 70 mils per kilo to about 100 mils per kilo. Now we cap that if you're over 100 kg cause you, it becomes ridiculous, but there's an increased circulating blood volume, there's an increased cardiac output, BP changes, heart rate changes your S VR changes. There's an a cable compression effect as well that if a pregnant woman is lying supine, um then the baby will probably be squishing her inferior vena cava and therefore decreasing her venous return. So that's why we encourage people to sit up. And if they're, they have to be supine, then we have them tilted onto their left, so left lateral tilt. Um We can do that in theater with our anest, with the anesthetic trolleys. Um But if you're not on that, then we would need to do manual try and displacement as well, which is basically just pulling or pushing. There isn't, there isn't a right way or a wrong way to do it, what these cardiovascular changes mean is that pregnant women handle hemorrhage differently. They, they handle critical illness differently as well. They, presently they'll look fine, they'll look fine, they'll look fine. Oh, my Gide a they're looking awful. Um, so very, like the very fit squatted person comes in with hemorrhage, hypertension is a very, very late sign preeclampsia interferes with all these cardiovascular problems as well in terms of their spiry centers, um, tidal volume changes, respiratory changes, but not as much as you think you lose your FRC you functional residual capacity. So they're more difficult to preoxygen oxygenation can be a problem as well. Um I'm not even going to touch on difficult intubation. You can look at the, the um airway Society guidelines and the OA guidelines for that, but bear in mind that they will be more difficult to intubate because of weight gains in different places. They're more likely to um regurgitate aspirate with the gi changes that you can see there as well. Um And with the the respiratory parameters changing, then there are slightly different gasses that we would expect as well. And you've got to think that there's still the oxygenation of the baby if she's pregnant hematologically, um you get dilutional anemia or you naturally you can get profound anemia with that as well. Thrombocytopenia. Um You can get with preeclampsia, you can get that with help. You can get gestational thrombocytopenia as well. It's just, it's just the dilution effect patients are hypercoagulable. So, fibrins of five or six are fairly normal, but that's protective because of the potential obstetric hemorrhage when they're delivering. But that does mean that they're more likely to have P ES DVTs, CB SDC V, ST. So if people are coming in with headache, neurological changes, you've got to think of CV ST they're also slightly immunosuppressed as they've got this baby. That isn't 100% them growing inside of them. Um And D diers are raised as part of all those changes. So we do not use D Diers to risk stratifying. So if someone is coming in through Ed or you see somebody that you're thinking of a pe, you cannot use D Diers in terms of stratifying that risk, whether it's a pe or not endocrine systems change as well. And we'll see that when we're talking about pharmacology and the renal system changes because of all that increased blood that you've got in your body as well, there's an increased G fr and in actual fact, if you look at the renal function tests of a pregnant woman, then in actual fact, and creatinine are, are really, really low. It's not abnormal for, to see ure of one or two. And in actual fact, we will trigger, trigger delivery if we have urea potentially of seven or eight or it's climbing up to those levels because that means that the kidneys are taking a hit because that's not what they should be. Whereas in intensive care, patient, you'll be happy days of it. So urea of seven, um just see that um lycia is also common because you can get gestational diabetes as well because of that different handling of the metabolic load. And finally, with the physiology, we spoke about pharmacology. So the distribution of drugs is different, blood concentrations are different. And the main ones that this affects is antiepileptics and thyroxine. Um insulin gets antagonized by um H BL which is produced by the placenta. So all these drugs need different um need titration by obstetricians by medics as well. There are safety concerns over some of the, the drugs that patients might be on as well. Now, some of these are real, some are perceived risks, but actually in obstetrics we use them all the time and some are just nonsense. Um And again, it's, it's trying to reinforce the point of phoning a friend phone a pharmacist, don't just stop it. Make sure that, that we're having a conversation about it. And it's about knowing when are you trying to give these drugs? Some drugs will affect the first trimester, some drugs will be effective or you really don't want to give them in the third trimester. So that changes as well. So remember what I said about all the books about obstetric physiology will probably be wrong from anything up to probably five years ago. And this is a study that has probably proved them all wrong. So the four p studies was done in three sites throughout Britain and basically, they just looked at pregnant women and um charted them and then they put it all into a nice paper. And in actual fact, all the heart rate changes, all the respiratory changes, all the BP changes weren't as big as we thought they were going to be. So, in actual fact, if you've got somebody coming in with a heart rate of 120 it's not just because they're pregnant. A respiratory of 20 is not because she's pregnant and trust me, I see a lot of these respiratory at 30. 0, she's pregnant or she's obviously anxious. So I think the, I think this study will actually be a, an amazing benchmark in terms of we now know what normal is for pregnancy and it's not as much as we previously thought it was what they have put, put all these figures into is a, is a national English news chart that actually I think we will probably adopt in Scotland once it has gone through all its, its testing as well. And you can see here the difference if you look at systolic BP, this is the top one is your news. So green up to 180 the news will trigger at 140 because we don't like hypertension in pregnant women because they can stroke. You can get lots of bad things happening with that. So we are really tight on, on systolic BP and diastolic BP. But you can see the difference of what you would miss. And certainly in my hospital, there's been cases of this a few years ago where a pregnant patient had an absolute off the scale BP, but wasn't triggering for critical care concerns. And it was only because an et kinesis, what happened to what passed to see someone else that actually that was, that was discovered and dealt with what you can also see with these charts is how much it changes um postnatally. So you can see that it changes subtly between being pregnant and being not pregnant as well and the different stages of pregnancy. So I think this is, that's currently being tested in England um in real life hospitals with real life patients. And then I think it'll probably be coming to the rest of the UK in Scotland. We have the news chart. So we, we were the forerunner of, of this um in the UK and this is what we use and this is what I would advocate you have at every bedside um as it is just now or get that uploaded onto your electronic systems. So we're on to medication now. So this is probably what we get the most concern from, from critical care of people. It's about, can I give this? Is this ok if she's pregnant? Is this ok? If she's breastfeeding and, and most of the time people working in maternity, the obstetricians, obstetric anesthetist. If you're, if you're in England, the obstetric physicians will be able to say, yeah, it's fine. We use that all the time. So, so chill, it's ok. Um But sometimes we do need to go to the experts. So these are two services that exist. I've used both of them. Um They're amazing. They're very quick, quick turnaround. So specifically for pregnancy, specifically for pe people who are breastfeeding as well. So I would advise you to take screenshots of this if you, you get the slides afterwards and it's all off the back of thalidomide. It's all off the back of concerns about people about harming the unborn child or something going through to the baby. And a lot of that concern has, you know, dear God, thalidomide. You wouldn't wish that on anybody. It's awful. And currently we're going through, you don't, you just need to pick up um a newspaper to see what's happening with sodium. Evaluate at the moment. Um Not just does it affect moms who are, who are getting pregnant, affects the dads who are, who are the fathers of those Children as well. Um But a lot of the time the problems come because the woman has been taken off all her medication by the GPS or the woman herself or medics who actually, I just presumed that that they can't be on any of these medications. So actually someone who was really psychiatrically stable on two antipsychotics probably needs those two antipsychotics. Or maybe she definitely needs one or lower doses, but she doesn't need to come off all of them. If you're very stable with your, um, inflammatory bowel disease on your biologics. Should you come off that? What is the best thing for you? And what is the best thing for this baby? So, our mantra is definitely not to come off all medication. There needs to be a discussion and there are certain medications where we don't want you on, but that ideally should be done preconceptually as well. Um But in actual fact, there's always guidelines, there's always an an amazing pharmacist in the building. There's bumps, there's, there's the UK Dill Service. Um And in actual fact, there are lots of guidelines out there. So the Rheumatology law have got stuff about biologics. I pulled this up a couple of weeks ago for to see somebody in the clinic about breastfeeding on a particular biologic. Um UCO is the UK Obstetric Surveillance Service service. So they look at that's a big national audit. Um And again, they look into these things as well. So there's always a guideline, there's always someone that you can ask, likewise, cardiovascular problems, likewise, anticoagulation. Um Everyone has usually thought about this and, and if we don't know, then we can, we can phone our friends, you know, the obstetric, this is where the obstetric physicians come into their own. So that's medication imaging. It's OK to image pregnant women. Ok. Again, through COVID, we, we saw they can't get an X ray. Well, if she wasn't pregnant, would she be getting an X ray or if she was a man, would she be getting an X ray? So x-ray her please, if she needs a CT, don't do these things. Willy nilly. But if she needs it, then please do it um or ask us and we will say that it's ok. And again, it comes back to this embrace, treat them as if they weren't pregnant or indeed if they were a man, think about what you are actually doing by not treating them, think about what you're doing by not imaging them. Um And again, there are guidelines, this was just one that I found yesterday, there will be UK guidelines as well. Ok. Gadolinium does have its issues. But again, if she really needs gadolinium scan, then she should probably get it. Um But again, that's not for you to that make decision on your own. That's an entity decision. There's a lot of chat about CT P and VQ if you think she's got a pe um a lot of the time it actually comes down to what's available. Um and what's not available in your hospital, whether it's four o'clock in the morning, CT P will irradiate the breasts more um which increases tiny amount, increases your risk. Um But there's less radiation to the fetus BQ is more radiation to the fetus, increasing risk of childhood cancers. Um I think as well. A CTP cannot be underestimated because it actually gives you lots more information about what else is going on. Echo. So, embrace hasn't been terribly flattering about access to echo for pregnant patients and recently pregnant women. Um, and, and it feels a little bit like goldilocks. It's either been too early. So you read about phone, the Emo center, too early, phone, the EMA Center too late and there's not a huge amount of change. There's not a huge amount of um, time in between those referrals. Um We know that there are and I'm just about to come on to this um, registries with pregnant patients going through em. Um And those registries would suggest that pregnant women do particularly well with EO as well. So there's been a call for specific guidance on um EC O in the pregnant women. Um So that's an ongoing um quality improvement process that that's kind of been done on a national level. So again, the Echo, you guys are the experts in echo. I am not. Um But in actual fact, the big registries that you, that have been published would suggest that mums do reasonably ok, and actually do better than, than other people would do an echo and you can deliver an echo you can deliver while you're fully anticoagulated as well. And in actual fact, the babies do reasonably well as well. Bear in mind that it, it's an indication of how mom does, how well the fetus does. So if you can optimize mom as best you can, you're optimizing the fetus as well. And this is a slightly more up to date one good maternal survival. Um And this was a good paper um actually gave you a good um comparison about things to aim for as well in terms of, of your echo and parameters. So consider early phone, early guidance is coming. What has also come out of, of COVID is that we all thought probably pruning wasn't for the pregnant women. And I'm, I'm not sure at 34 weeks, I would be pruning someone. I think I might be delivering and therefore the kid prone immediately after a section. But in actual thought in those late second trimesters, early third trimester, um women the to people and obstetric and gynecology. Um from the start of COVID, um talks about an extreme lateral decubitus position supported by um pillows all around them as well. Um What you'd need to be careful of is about fetal monitoring. It's not going to be easy. And, and how do you then what do you do if there's a problem with that? But it is possible to do some of it. And we've certainly done a little bit of, of attempted a week pruning and in some of our patients who were still pregnant So now we're on to staffing, we're onto the SS. I don't work in ICU but what you hear about is awful staffing conditions in intensive care. Um especially with the nurses. What I would say is that we have an equally big problem in maternity. Um And again, you don't, you, you probably need to be living under a rock to not see this all over our social media, all over our papers, all over everywhere. Um There are no midwives um and the midwives that we do have are leaving in droves because the work is so miserable. Um And the patients are being damaged by that as well. So we're, we're in a very difficult situation in terms of maternity at the moment because there are no midwives and standards aren't being kept up. Um And we're having to fudge things all the time. And I think the crucial thing here up in Italic is that midwives aren't nurses. So I don't even know probably 15 years ago, 20 years ago, definitely all midwives would have been a nurse. You would have done your nurse training, you would have been gone off and did a bit of maternity. And if you like that, you would have become a midwife, direct entry is now the commonest way to become a midwife. So you do not need to have done a nursing degree. You do not need to have seen anybody ill on a ward. What it is is is direct entry midwifery where you look after women who are pregnant, who are recently pregnant. Now, that's a huge job because it's from community all in with that community portfolio intrapartum and then into the postnatal period as well. So we're asking the midwives to do a lot. Um But what they aren't, are midwives are, they aren't nurses? Ok. And again, we are, um being hammered by, certainly in England, by the CTC. We don't have that in Scotland. Um, but maternity is not a happy place. And, and if you read all of this, you, we think it wasn't a very safe place either. And I think that probably has its place um probably as a, as a result of acuity and capacity and staffing probably similar to the same problems that you guys are having. Um But that's the background. So sometimes we will need a patient admitted to ICU, not because they are a level three patient, but, but just because the acuity in our labor ward, there are still three people who need a category one section or there's, there's other things that need to be done as well and we just need that woman in a safe place. We've also got societal context of women having babies. Um The majority of women having ba well, all women have a baby except that it's a life changing event. Your life is going to change. You know, you're not expecting it to stay the same but it's not meant to be a life threatening event. We have thought if you ask any of your, your grandparents, your great grandparents about pregnancy, they probably had a, a healthy fear of it. Um because people died in childbirth 50 years ago in Britain. Um from things that we see in low and middle income countries now. So health maternity care has got much, much better over the last 50 100 years. Um And people used to know that, that it was dangerous to have a baby and it, it affected everyone. You can go back into history and see Queens dying. Princess is dying, wealthy people, poor people. But I think we've forgotten that night. We've forgotten what can happen. As you've probably realized during the talk, we've got unprecedented precedented levels of morbidity. Um, age is going up. Sometimes I do this talk and I've got pictures of the 6060 something year old woman from somewhere getting I VFB M I is going up, comorbid disease is, is going up. It is unusual to have someone just coming in who is completely fit and well young slim. We do have them, but they are certainly not the majority coming in to have a baby. And I think we've also got um quite rightly levels of expectation about how it's going to be. Now, that can either be, it's all going to be amazing and this is the type of delivery that I want or I've read all those, all that bad press and CTC reports and I've got the fear in me. So it's a little bit of, of, of Yin and Yang going on and then when things don't happen as they're meant to or there's an emergency section or you take four days from induction to actually even get into labor that doesn't go unnoticed. So we have also a wave of people coming through with psychological trauma about what their birth has been, what their birth experience or birth journey has been. Um And in actual fact, maternity services are being debated in the House of Lords this evening. Um There's an MP who is telling her birth story as part of the drive to improve things. But, but she is talking about I was awake for an operation after my um after the delivery of my baby. Now, I think from what I can gather, she sounds like she's had a third degree tear. I was awake with an epidural. Now, that's normal practice that we keep patients awake. I was paralyzed. So it, it's the, it's the, it's the narrative, it's the vocabulary that we're using. Um and we, we do our best, but that actually means that people coming back for their next baby are wanting an elective section to try and control things because they felt things were out of control the last time that then leads to a rising section rate which then puts more pressure in the system which then increases the morbidity, which then increases psychologically. So you can see it's, it's a vicious circle and I'm not quite sure how we get out of it. We need lots more staff, lots more capacity, um and lots more help within the, within the hospitals as well and add to that unprecedented levels of, of scrutiny as well. Again, pretty much every single region in England has got a maternity investigation going on and I'm not sure that Scottish hospitals actually would fare much better. I think it's just the maternity units of what they are just now. So, studies, how are we going to make this better because I am running out of time as well. Um I think the key thing is to include patients in research, you're protecting them, you're not protecting them by excluding them. So all the COVID stuff, actually recovery was great because pregnant women were included in it. Um But lots of other things don't include the pregnant women, don't include the breastfeeding women. Well, can we then extrapolate those results into giving the pregnant women the lifesaving treatment? So, what we need to do is try to work a way to include pregnant women, find a way that it can and recovery manage that. And then this editorial that came out in the BMG um A a little bit after, you know, the first wave of COVID, looking at the patients, the woman who had died from COVID um 90% of them didn't get treated with RT OG guidelines. So that was maternal steroids. Too late. No, to eab or too late MDT too late. And actually it's heartbreaking to be these vignettes in the, in the embrace report, um, deed it ineligible for therapies. Um I misplaced concerns of the pregnancy. We can't do that because of, we can't x-ray because of, we can't give those drugs because of um my, my um what's the right word again? I am very proud of our response in Edinburgh Royal Infirmary because in actual fact, every single patient that was eligible to get Tox Eliz Aab got Toxoi, every patient that was eligible to get steroids for COVID got steroids. And I think that was the majority of, of hospitals in Scotland were, were doing that as well, but that, that didn't come easily. That was a lot of education. That was a lot of writing. That was a lot of support as well. Um This paper looking at studies um from the last little while 50% explicitly excluded pregnancy as part of um admission criteria. So it's, it's about the s the people who runs trials about including pregnant women and trying to work out how we do that. Why does this happen? Now, you're probably see where I'm going with this. I think it's because we're, there's still a little bit of protect the baby at all costs. Um Catherine Nelson Pierce, who is the C MP person up there. Um has got a phrase that says the mother is not just a vessel. Um And I think sometimes how we treat patients or have treated patients in the past is to say, can't do anything. She's pregnant. What about the baby? Um And people still do that and you think they won't, but they do. Um And in actual fact when I was doing digging for this, um I found something about Toyota are now testing. The crash test dummies have now made a pregnant, crash test dummy to test cars to test seatbelts. It's 2024 we've had cars for 100 years. You know, why hasn't that been done before? Why has nobody thought of that? And I suspect it probably is a lot of invisible women. Um You know, for those of you who have read this book about women, not really being considered the, the the world is kind of made for men um around us. And again, I never thought I would be doing a talk with Davina mccall picture of Davina mccall in it. But in actual fact, these are all from the last six months. In actual fact, why are periods only just been looked at at a proper research level? Why is money only just getting the cure for morning sickness? Why are we only just being on a cusp of a breakthrough of endometriosis as long as there have has been life on this earth. There has been women having periods, there has been women with reproductive systems, yet it's not been deemed important to do and childbirth and research and childbirth and research in pregnant women and drugs as part of that. However, I am hopeful in actual fact, um one of the new chief scientific advisors at the Department of Health and Social Security, Social and Health is now Lucy Chappell. She is a consultant obstetrician with a huge background in research. So in actual fact, I think things will be changing. And in fact, they are because Marian Knight who is embraced Marian Knight um has just been appointed in a in NIH R scientific director and she is currently giving out 50 million lbs, which isn't a huge amount, but it's better than nothing for women's health, for things to do with women's health to try and get more research into maternity. So we're on the home run now. This is the how to bit, we don't really know how to ventilate a pregnant woman. So the this is all to do with pregnant women. How low can you let the, the oxygen go? How high can you let the CO2 go? They are the main things that we can get concerned about. How do you actually ventilate when you've got a heavily pregnant when you've got a gravid uterus there? And obviously the the data is limited because patient, pregnant patients are excluded from research. Um So we don't really know what we do know is that we don't give oxygen for fetal braies anymore. If we give oxygen through labors, then actually the babies come out with worse gasses. Um And what you also need to remember is that fetal hemoglobin is different from adult hemoglobin. So it, it, it associates with, with oxygen at different levels. It dissociates with oxygen at different levels. So what you think is going on with the adult isn't necessarily going on with the fetus as well. So we don't know whether low CO2 is bad. High CO2 is bad. It, it affects placental blood flow is it. And then you've got fetal cerebral blood flow as well. And a lot of the studies are done not in humans because we can't do them in humans, but they're done in sheep, they're done in pigs, they're done in other animals. And in actual fact, they have in important interspecies, differences in placenta flow and function. So we don't really know again, what we've got is is off the back of the COVID is a lot of the cases. A lot of the big units in America were looking at what they were doing. Um So this study um which was presented at soap, which is Society Obstetric and Perinatology, which is a big um It's probably like the I CS for obstetrics um in, in ICU. So this is at Maryland, they looked at all their deliveries um through COVID who were ventilated, some were in EC O and they looked at what the PO two was and what the P CO2 was um in relation to how the baby did and that's engaged by a gars, not gasses. So this is how the, the baby is functioning. Are they breathing? Are they pink? Do they have tone? What are they doing? And what they saw was that what the gasses in the malware around delivery impacted? or there was a, there was a correlation with what the Aars they were seeing as well. But more remote differences in gasses didn't really follow that. So what they've come out with is you should maybe be aiming for po two of about nine and rather than probably eight and eight, I think in our hospital we said aim for AP O2 of 9 CO2 of about seven. Maybe we should be tightening that up a little bit based on this paper. But I think the evidence just isn't there when to deliver or whether to deliver. Um I think we need to make sure that maternal health and wellbeing takes precedent at all times. And that is a, that is easy to say but is much more difficult to actually do. Um because it's very, you're very aware, there's another person in there. I think what is important is that the need for intubation does not equal the need to deliver. So if you need to intubate her, that doesn't mean you need to be getting a delivery set up, um, get her intubated, get her stabilized, then pull the MDT in. And these decisions are complex and nuanced and nobody, no one person has the right answer and there probably isn't a right answer because what you're weighing up is a, a premature baby who might, may well have problems versus a very sick mother. And in actual fact, what some of the studies are showing is actually the delivering the baby does not, it's not your magic cure for making the mu better. Um And in actual fact, people mainly in Canada, Steven Lapinski is a big name in this. He is now advocating for just delivering for fetal reasons. Whereas actually our gut feeling probably in Scotland is so it may be actually better to get the baby out if we're not extre at extremes of prematurity. So probably gestations over 28 weeks, we would probably are in the sight of delivering rather than keeping baby in. But essentially you need to do pre planning. You can't be making these decisions, you can't be making these decisions at four in the morning. You can't be planning this out and coming up with your sop at four in the morning. This needs to be thought about for what I would say as well as categorization of C section. The anesthetist amongst you will know about C 1234 sections that's for a maternity footprint that isn't for this one, no expecting these things to happen that quickly. So again, some of the papers out of COVID would suggest that um delivery improved things. But if you look here in terms of after delivery, it's not immediate, it's not the magic bullet to get for mom's oxygenation. Likewise, um This one showed that it was better at 48 hours, which is AAA little bit earlier than that other paper. Um And in actual fact, you know, they're tiny, tiny numbers and likewise the one they looked at two hours before delivery, two hours after living there 24 hours and, and found there was a, there was a change in the PO two and the F IO two, but nothing really else changed. And I think this is what has driven the, don't think, don't necessarily think you're gonna get, you're not out of the woods. Once the baby's out, actually, things might not change very rapidly. And you've just subjected the mom to a major operation when actually she could bleed, there would be other complications as well. So it's, it's not easy. It's, it's phoning a friend. It's a big MDT discussion. So, how did you improve your service? This is, this is the last couple of slides. Well, it's all there. It's all been there for a decade, but in actual fact, nobody's really done much about it. The providing equity, critical care was out in 2011. And I think about four people read it and nobody really did anything about it. Um Critical care of the women, the 2018 1 is, is a rehash of the providing equity of critical care and the enhanced maternal care units is, is a rehash of the 2018 1. Effectively, they're all seeing the same thing. Um GPIX is essentially a lift from the 2018 1. Um And what they are saying and this is what you can do tomorrow is you need to have thought about this. You need to have made those relationships, you need to have thought about what you're going to do. So you need an ICM lead in your, in your building, in your hospital for critical care, you need a nursing lead as well. Um And as I said, at the start, there are et kinesis in every single maternity unit in Scotland, um who are part of the Scottish maternal critical care network who would be more than happy to act as your lunch pin into maternity services. So it's an obs is an interest, it's critical care is a nurse that's a midwife. That's your base team to start making these, to have these conversations. You also need to think if you're having, if you're admitting women more than 20 weeks gestation into your ICU S, if she has a cardiac arrest, who is going to do that perimortem cesarean section, who, which pediatrician, which neonatologist is going to resuscitate that baby. If you deliver that baby at 24 weeks, at 25 weeks. Do you have your equipment in your ICU to be able to facilitate that? You need to get the upset team to look at, to come and review your patient every 24 hours. But in actual fact, it should probably be every, every 12 hours, every shift. And that's certainly what we would advocate doing. I see you need to have your contact numbers that are immediately available and you need to provide education for your critical care team and the nature of maternity, just like I was saying about some patients will need to come because maternity is too busy to look after a sick patient. Actually, you will have the sickest of sex patient in the building. But actually there are lots of other people needing delivered, taking up, using up the oxygen in the room, taking up the capacity. So our visiting might not reflect that actually, you have the sickest patient and the one that we're most worried about breastfeeding before you get them off to sleep, make sure you ask permission to, to express cause we've forgotten about that and actually nobody else can, can consent for it. So it just makes it easier contact the baby if she's postnatal or if you've had to deliver her. So that's a diary that's photos. Um get the baby along to ICU. Um Obviously, you need to be concerned about, about infection risk and things like that, but actually those are very overdone concerns as well. Um, and in that right, you can't really see it but there's a baby underneath the little, um, arrow EMC talks about super regional centers and about transferring out if, if you, if you've got a critically ill patient who's pregnant for greater than 48 hours, I'm not sure that's actually been done at the moment. I think it's more phone a friend, make sure you, you are pulling all that expertise and, and with teams um with all the technology that we've now got with um with COVID, then, then that is now much easier. And again, as I said, you need to make sure you've got the kit to do a perimortem Cesarean section. So, have you got Tritonic on your unit? Have you got a kit? But that's just essentially scalpel who's going to do that? Perimortem Cesarean section. If the obstetricians are busy or, or even worse, if you don't have obstetrics on site, do you have surgeons? Are they gonna come and do it? Because you probably haven't done a Cesarean section. Who's going to do that, who's going to do that because it's part of the resuscitation algorithm. You, somebody needs to do it and have you got peed on site as well? Have you got the kit for them? Um Council embrace and put out a um a sexual cardiac arrest um algorithm, but essentially it's just the same. Do what you would normally do if she wasn't pregnant. But for the fact, you need to do manual trying displacement um of the fetus to make sure she's not got a aortic cable compression and you're delivering that baby by four minutes for five minutes. And if she's, if she, there's been downtime, you're just delivering the baby as well. But everything else is pretty much the same. This is a really good resource. Um If you just want to go to eight pages done by the Royal College of Physicians and Slightly Acute Medicine, written by a lot of the obstetric physicians. There's a little blurb about physiology, there's stuff about imaging, but it's ok. There's about pharmacology that it's ok and then it looks at specific medical problems, the common uh medical take problems as well. And then there's red flags of what isn't normal for pregnancy. But again, going against with all that four ps, what that physiology study did as well. So that's, that's recommended. And then after they've got out of ICU, it's where you think they would be best placed. Is that a medical ward? Is a surgical ward? Is it, is it back with us a maternity? Is there a baby that needs to be accommodated as well? And certainly in postnatal wards, we have a lot of psychological support now because psychological teams have come in to support all this birth trauma that's happening. But we don't have an occupational therapist. We have physios that are used to dealing with pelvic floors and legs that are a bit not working terribly well, but they, they haven't done chest physical for ages and we certainly don't have speech and language therapy. We don't have dieticians immediately on hand. So it's about ensuring that that patient is getting equitable care. And then what support is there in the community? Um, I'm not sure you can go to your la your, your local birth group and say actually, I've had a hysterectomy and I've been in ICU and, and, and it, it's about supporting these women afterwards as well. So that's essentially me. There's lots of for going on and on and on and running late. There's lots out there. So Steven Lepinski, who I mentioned in, um Canada has set up a world of critical care society that is just in its, in its infancy um to use a maternity pun. And that's going to be looking at specific research questions for critical care about how do we ventilate prolong sedation and analgesia? When should we be delivering? Mac Care has done a benchmarking exercise. And again, has presented posters at the European Society of Intensive Care Medicine in Milan. Um And the paper is just being published as well in terms of what provision there is for maternal critical care throughout Europe and the Royal College of Anesthetist RCO G Royal College Midwives um actually worked really, really well with intense care society. And as Well, so there is lots out there on a national level kind of organizational level. On a more low key level, there's prompt courses that will be running in your hospital. So that's obstetric um drills and skills. Scottish perinatal network has got guidelines as well. I've, I've obviously mentioned Scottish maternal critical care. We'll be having a meeting later on the year probably in November and there's the managing medical and obstetric emergency. This was kind of the mo course as it was um that you're welcome that that senior medics are welcome to. Come on. And as Julie said, there's the maternal critical care course within um Edinburgh University and that is me slightly over apologies, Shirley. No, no. Thank you so much, Arlene. That was really, really comprehensive and extremely well situated within our kind of Scottish critical care environment as well. We've probably got time for warrant two questions. So if you've got a question for Arlene, if you just type it for me in the chat box and I'm interested, would you mind? So you just at the end there, you touched on follow up for these patients and they seem like a group that have a number of stacked life events. So they are having the life event of having a baby. They then have the life event of often having a difficult or traumatic birth experience and then they have an adverse life. You know, they have the adverse consequences of critical illness So, I think probably relative to other groups, they're probably at higher risk of the kind of morbidity that comes with critical illness than maybe some of our, um, patients are. Uh, and then our follow up services aren't really well designed for these groups of patients. How do you think we can address that or make it better? So, um, I would love to set up. I even got a name. Um, and that's an ICU step. So my, my one is gonna be called ICU baby steps. Um but I haven't got there yet. So certainly with the Edinburgh Royal Infirmary, we have the critical care recovery service that has kind of been B and J awarded and things like that. So I'm really lucky because we have that and in actual fact, in discussions with the people that run that, I think the normal criteria is 48 hours ventilated, whereas our pregnant patients are if you're in it for more than 24 hours. So we've already, as you say, we've already got them as a special case. Um Not everyone that's eligible has been seen, but in actual fact, when you look at the ones that have been seen, you're like, oh my God. Yeah, that's absolutely amazing because it's, as you say, it's comprehensive, it's seeing the critical care nurse. There's an explanation, there's a follow up in community, we've made sure that that the critical care nurses following them up have the midwives have the health visitors to put it all together and it's about speech and language therapy. It's about things we don't have. Um So I am very lucky that, that we have certainly within our maternity services as well. We've got perinatal mental health, which has been, which has had to explode and expand and over the last five years. So in actual fact, the people that the critical care recovery doesn't catch then NMP or the obstetricians and actually obstetricians and obstetric esthesis are well used to debriefing patients about everything else. So II think there's a, there's quite a lot of underpinning. Um I've been across to see what Lucy Hogg is doing in the Inspire Program as well. I know lots of other units have done that as well. Um And again, that was the thought was to try and set up probably an online ICU baby steps, but we haven't got there yet, you know, pulling it up because you, you're probably talking a couple of patients a year. Um But yeah, we watch this space. Um And we've got a question here from Helen French. She's saying, does your unit have protocols or guidelines to support breastfeeding in critically ill uh women who wish to do so. So Helen, we try to make sure we ask them before they go off to sleep whenever that is. Um We don't always manage that, but we're getting better at it um for permission to express because the heart, the husband can't do it. The husband partner can't say well, she was going to breastfeed that just doesn't work. Um And then if we've got permission, then even if they're asleep, the midwives will come along. And in actual fact, some of the critical care nurses in the royal now are happy enough to do it themselves to just start expressing. And I have to say I am, I am constantly amazed and I've been very, very impressed in the last year with our, with our critical care nurses and the Royal infirmary because again, you know, this has been 10 years of work in the Royal infirmary and we did somebody who was desperately desperately unwell premature babies. Um And in fact, by the time those babies had been along with an hour of her being extubated um before, you know, it was amazing, they'd already been gone by the time I had gone to see her. Um So it's about normalizing babies being in the unit. It's about normalizing um ac being there with the, with the family. It's about normalizing breastfeeding. The midwives can come along if the if the nurses aren't happy, but the nurses might be happy doing it. Um So I don't think we do have a proper protocol or guideline, but it's, but it's now embedded in, in what we do. But that's only you knew that we will need, need a global respiratory pandemic to move in terms of the it has, it has helped a little bit because there's just been, there were so many over 2020 2021. Um I cannot see any questions in the chat there. Um So, uh we just have time to hold on. Pam's just said Arlene Pam is, um, saying she's happy to help out baby steps and, and an act, Pam and I spoke about this probably PRE COVID about getting something on to, um getting up something onto critical care recovery website. Pam was happy at that point and then COVID came in and it's been forgotten. So it is on my hit list. Pam, I will maybe email you. Uh I've got a busy couple of weeks but I'll, I'll give you an email going forward. Um Rowan. Now, I apologize if I absolutely butcher. This is asking around critical here nursing CC three N competencies. What's that? Can you expand a little bit more on that ruin and what they are? I'll talk over about Rowan's typing hopefully. And so I think the crucial thing is that this isn't just seen as I'm obviously talking to the critical care community, but this isn't just you needing to up your game. We we, we have spent the last 10 years trying to up our game. So it's everybody trying to see everything from each other's perspective. It's that shared mental model that we talk about. And so we have done lots of work with our midwives about trying to get them, not make them into critical care nurses because we're never gonna do that but try to upskill them to look after a lines to look after um critically ill woman recognition escalation. So the a line doesn't die within 20 minutes of it going into an obstetric HD. Um But what we've also done is do education for the critical care nurses. So as part of that maternal critical care course, um with the Edinburgh University course, we have had local midwives come along and we've had local critical care nurses on each time we have run it. So we are upskilling the knowledge base and, and again, those, those relationships um and that shared mental model of that our, our critical care nurses have come along to our local course, they come along to our prompt course. And it's never as good as you want it to be because of capacity because of a purity because you can't be let off the unit. And that works both ways. But actually we have a really good, I think in the royal, we have a really good relationship, I think. Yeah, Julie. Uh Yeah, I think so. I'm certainly the feedback from um our students on the master's course who were doing the Full Masters was that the, the PD students coming in? It helped really with it like experiential learning for students in terms of people who are working in, you know, in environments with um unwell, you know, maternity patients every day that you find that really valuable. And so I don't know if I completely answers your question, but it goes somewhere about how you might be able to share learning between critical care and, and I guess maternity environment. So, yeah, we are upscaling our, our critical care nurses as well in terms of obstetric stuff. Um I can't see any other questions. So um we, I just want to thank you very much doctor wise for a really fantastic um presentation. Thank you so much for giving up your Thursday evening to come along and share all of that knowledge and experience with us, which really much appreciated. There is um a link to feedback in the chat box there. Please have a click on that, that that will be able to generate your certificate for you as well. And that would be really useful for us in terms of uh making sure that we can make these um these sessions as, as good as we can for you moving forwards. Uh Thank you everybody and I hope everybody has a lovely evening. Right? Thanks Julie.