Just curious what you would consider a "high risk" OB patient? I ask because I am at a small community hospital where resources are limited and staffing is slim. I have had scuffles with some OBs in the past because they make some poor choices in patient selection for this place (congenital dwarfism, BMI>50, severe HELLP syn, preterm labors). We don't have a NICU or inpatient peds and our ICU staff is pretty slim.
What do you consider "high risk" OB?
- Thread starter PainDrain
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deleted171991
I personally would consider "high risk" for OB anesthesia any patient who was a clear undebatable ASA 3 pre-pregnancy, based on pre-existing medical disease, or is an ASA 4 now, due to pregnancy-related complications, or any difficult airway (beyond the usual airway edema - e.g morbid obesity, achondroplasia, cervical fusion etc.) or predictably difficult C-section. This might not be comprehensive, but it's a starting point. I would also add to this the patients the anesthesia staff is just not comfortable anesthetizing, like surgically-repaired and well-compensated congenital heart disease in the mother, but with a special physiology etc.
None of these belong to a limited resource OR or labor floor. It also seems that you have to consider the neonatal risk, since you don't have a NICU or peds, which basically rules out any preterm labor, or predictably complicated labor or delivery (pre-eclampsia or worse, cocaine use, alcoholic mothers, IUGR, placental pathology etc.). I am honestly shocked that they allow you to have deliveries without a few neonatal (ICU) beds and around-the-clock in-house neonatologist. It's a recipe for disaster. Even babies from healthy mothers and uncomplicated pregnancies can get in trouble occasionally.
None of these belong to a limited resource OR or labor floor. It also seems that you have to consider the neonatal risk, since you don't have a NICU or peds, which basically rules out any preterm labor, or predictably complicated labor or delivery (pre-eclampsia or worse, cocaine use, alcoholic mothers, IUGR, placental pathology etc.). I am honestly shocked that they allow you to have deliveries without a few neonatal (ICU) beds and around-the-clock in-house neonatologist. It's a recipe for disaster. Even babies from healthy mothers and uncomplicated pregnancies can get in trouble occasionally.
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In my remote location we only take care of low-risk OB patients. So no ASA3+, no VBACS, Morbid obesity, HELLP, Pre-E or Eclampsia, HELP syndrome. We always have to be ready for pre-term laborers because we are the only shop in our location. The problem arises when these patients are diagnosed during laboring with pre-eclampsia or eclampsia, we cannot get them out of the hospital until baby is born. We can however bring resources in, we cannot get a laboring mom out. We have a one pediatrician and one ICU room that can be converted to a NICU bed until the medevac team arrives. I am interested in knowing at what point can you transport your morbidly obese patient that shows up in the ER with ROM. Do you transport mom out laboring or do you proceed with the labor process?
The reason I am asking about this is because how many really dumb decisions I see these OBs make. I had a patient come in for induction with a HCT of 23 and hx of severe iron def anemia. They called a section for failure to progress and she had only gotten half a unit. Another was a clear HELLP syn who they kept in house for two days before deciding she needed a section on her third hospital day. If I sat and told you the stories your jaw would drop. The culture seems to be "we have been doing things this way forever" and no one cares. I have even been written up for arguing about this stuff.
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deleted171991
Time for your group to fix it, or for you to look for a new job, before the **** hits the fan.
If you are not being listened to about stuff that are serious safety issues for you, you are making a mistake by staying. There is just so many times you/they can get away with it. Bad surgeons = recipe for malpractice suit.
Yah. That is definitely something I am considering when evaluating my current situation. Sometimes I think others in my group think it's because I am on the younger side but I look at the whole picture and some people are playing with fire.
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deleted126335
We have had this fight at one of the smaller hospitals that we provide service to. Unfortunately there isn't much you can hang your hat on in the literature other than estimated gestational age and fetal size. "High risk" just isn't defined in the literature other than that. The best you can do is a "high risk" strategy for you- document your recommendations in the record that the patient should deliver somewhere else and that you recommend transfer to a tertiary center. Have seen similar crap to Pain Drain.
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you and your group need to define the rules of engagement - produce a written set of guidelines/restrictions - give your protocol to the hospital and your OB groups.
you can avoid "scuffles", contention, confusion, danger, etc... with clear preemptive communication.
Based on what I see at the two places we do OB it is all high risk. Continually poor decisions by OB staff. In two days had an accreta here that was not given good preop judgement (my co resident had that). I had a complete previa brought up to me like no big deal, hey this girl at so and so weeks is bleeding, who was in their pre labor wing holding area for 4 hours. Also some bleeding like stink after Vag del who we come and help and they are all like, just sewing some laceration. Umm there are two buckets of blood there and patient is whiter than a ghost. I am hoping this is just academic OB.
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deleted171991
Academic OB should be high-risk. Otherwise it's not really academic.
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High Risk = any laboring patient that is unlucky enough to happen to be in labor when I am asked to cover the deck.
