Authors: Cesar R. Padilla, M.D.; Sarah Rae Easter, M.D.
ASA Monitor 03 2017, Vol.81, 44-46.
Cesar R. Padilla, M.D., is an Obstetric Anesthesiology Fellow, Brigham and Women’s Hospital, Harvard Medical School, Boston.
Sarah Rae Easter, M.D., is a Maternal-Fetal Medicine Fellow, Brigham and Women’s Hospital, Harvard Medical School, Boston.
Let’s imagine the world of obstetric anesthesiology in 1948. Neonatal and maternal mortality were incredibly high in comparison to today’s standards. Anesthesia-related events accounted for 30 percent of mortality.1 Furthermore, only 24 percent of hospitals offered 24-hour anesthesiology service.1 The field of obstetric anesthesiology was in its infancy. Although epidural anesthesia was introduced in this era for laboring patients, it was rarely used for this reason.
Recognizing the need for improvements in safety and advocacy, several physicians from different medical subspecialties convened to establish a society dedicated to obstetric anesthesiology and improving maternal safety. James Elam M.D., father of cardiopulmonary resuscitation, along with Otto Phillips M.D., chair of the ASA Committee on Maternal Welfare (later renamed the “Obstetric Anesthesia Committee”), agreed on plans to create an organization dedicated to this very cause. The first meeting, held on May 25, 1968, included six physicians and was held at Chicago’s O’Hare Airport. This meeting was the foundation for what later evolved into the Society for Obstetric Anesthesia and Perinatology (SOAP).1
The blueprint of SOAP’s foundation has not only withstood the test of time, but has evolved into a major organization for advocacy, research and innovation.
Almost 50 years later, maternal demographics are slowly changing the practice of obstetric medicine. Obstetric anesthesiology is once again being faced with similar challenges it faced upon the inception of SOAP.
While advancements have been made in all the subspecialties of pediatric, regional and cardiac anesthesiology, obstetric anesthesiology is faced by a unique dilemma that few other fields face: a rise in obstetric mortality. The decrease in maternal mortality, long a beacon and benchmark of medical success in the developed world, is on the rise in the United States. Although considerable success has been made in lowering mortality from postpartum hemorrhage and pre-eclampsia by instituting evidence-based protocols, other unsuspecting diseases, such as cardiomyopathy, sepsis and congenital heart disease, have reared their ugly heads. An increase in cardiovascular disease, including congenital heart disease, cardiomyopathy and congestive heart failure, has been shown to be the leading cause of maternal mortality in developed countries.2
When it comes to creating a system to decrease maternal mortality, we’ve seen great contributions from our obstetric colleagues. In 2015, the American College of Obstetricians and Gynecologists (ACOG) and Society of Maternal-Fetal Medicine (SMFM) outlined “Maternal Levels of Care.” The goal of this document is to stratify hospitals based on the availability of medical care to aid in triaging patients for delivery in a center equipped to manage their unique medical comorbidities. The levels are straightforward: Level I (Birth Center) to Level IV, also referred to as a “Regional Perinatal Health Care Center,” which is equipped with the resources and infrastructure for management of medically comorbid pregnancies. These centers focus on maternal care by employing a multidisciplinary approach to clinical care and quality improvement with the goal of decreasing severe maternal morbidity and mortality.3 These maternal “supercenters” are aimed precisely at attacking maternal mortality head on.
Although tremendous progress is being made by the establishment of Maternal Levels of Care and outlining quality improvement review processes for cases of severe maternal morbidity, there is still more work to be done. Tackling the timely task of maternal mortality will take years of careful strategy, passion and will. More important, it will take a concerted effort from our mentors, program directors and section chiefs in inspiring a new generation of doctors to take on this task. This effort has to go beyond anesthesia and be a true multidisciplinary strategy.
This is why when I received an invitation from Dr. Lisa Leffert, Chief of Obstetric Anesthesiology at Massachusetts General Hospital, to meet with other residents and fellows interested in maternal critical care, I knew this meeting would be special. In short, a small group of interested obstetric anesthesiologists and obstetricians from both Brigham & Women’s Hospital and Massachusetts General Hospital met to discuss the emerging concept of the specialty of “Maternal Critical Care.” The energy and excitement during our meeting was palpable. We all agreed that the only way forward was through a multispecialty approach.
It turns out expert consensus has already confirmed this. Leading experts have repeatedly called for a multidisciplinary team approach, which includes a critical care team, when treating high-risk maternal patients.4 -6 There is even a call by international experts to change our very definition of high-risk maternal care. Experts have now abandoned the term “obstetrical critical care” in favor of “maternal critical care,” which describes patient-centered, multidisciplinary care rather than specialty-focused care.5 Introducing these concepts early in the training of obstetric and anesthesia residents is essential to transform the future culture of maternal care to be more inclusive and multidisciplinary in nature.
In order to achieve formidable changes in our approach to maternal critical care, the training of physicians must also be highlighted. The training of ACGME Fellows in obstetric anesthesiology and maternal-fetal medicine is at a crossroads. In obstetric anesthesiology, for example, there is currently no formal requirement for critical care training. In contrast, the maternal-fetal medicine fellowship requires a formal ICU rotation.7 In light of an increasingly complex patient population, obstetric anesthesiology training must be updated to reflect the stable trend of increasing maternal mortality. This is not unique to anesthesiology. It’s not uncommon to hear the phrase “putting the ‘M’ back in MFM” among obstetricians. The meaning of this is to swing the pendulum of focus back from fetal to maternal care, a statement coined by Mary D’Alton, M.D., maternal-fetal medicine expert.8
Important pillars in maternal critical care are already in place as we speak. Banner-University Medical Center Phoenix, in conjunction with the Society for Maternal-Fetal Medicine, offers on site simulation training in critical care obstetrics.6 This is largely the vision of Dr. Michael Foley, Professor and Chair at the University of Arizona and editor of the Obstetric Intensive Care Manual. This simulation program aims to “put the ‘M’ back into maternal-fetal medicine in an effort to reduce our national maternal mortality rate.” 9
Obstetric anesthesiology and critical care trainees would benefit from the expertise and training from simulation courses such as these. This is definitely the time to look across specialties for answers. Within the obstetrical community, and hence by extension within our own community, there is active discussion of how the field of “maternal critical care” will be structured. For example, where is the best location to care for such patients? Is it on a labor and delivery unit, with input from intensivists, or is it in an ICU, with input from obstetrical colleagues? Or perhaps a hybrid model, where physicians in all relevant specialties join forces to care for such patients in a variety of locations, the so-called “Virtual Maternal ICU,” a phrase originated by Dr. Foley and colleagues.10
Moreover, the centralization of complex obstetrical care is being embraced as a means to focus clinical expertise in the treatment of a variety of challenging conditions. For example, the concept of “Centers of Excellence,” for conditions such as abnormal placentation (i.e., accreta), are being developed.10 We have personally seen the benefit of having such a model in place. Here at Brigham and Women’s Hospital, our obstetrics department centralized our efforts to help recruit and treat patients with abnormal placentation.12 Improved outcomes have been shown when delivery is performed at these centers, which emphasize multidisciplinary expertise and experience in the care of placenta accreta.11
With leading experts looking to shape the field of maternal critical care, it’s up to the proper guidance of the next generation of physicians to complete the task and establish the field moving forward. Our leadership must span disciplines and our strategy needs a multidisciplinary approach moving forward. Maternal mortality is the challenge of this generation of maternal critical care providers.
During his candidacy speech in 2015, Dr. Mark Zakowski, the incoming president of SOAP, stated we must “adapt or die” to survive in medicine. To be leaders in maternal critical care we must train and inspire the next generation of intensivists, obstetricians and anesthesiologists to help advance maternal care in the 21st century. Our specialties – and more important, our patients – demand it.
A Celebration of Forty Years: Milestones and Pioneers. Society for Obstetric Anesthesia and Perinatology. April 2008. https://soap.org/pdfs/pioneers-booklet.pdf. Last accessed January 16, 2017.
Kuklina E, Callaghan W . Chronic heart disease and severe obstetric morbidity among hospitalisations for pregnancy in the USA:1995-2006. BJOG. 2011;118(3):345–352. [Article] [PubMed]
American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine, Menard MK, Kilpatrick S, Saade G, et al. Levels of maternal care. Am J Obstet Gynecol. 2015;212(3):259–271. [Article] [PubMed]
Zieleskiewicz L, Chantry A, Duclos G, et al. Intensive care and pregnancy: epidemiology and general principles of management of obstetrics ICU patients during pregnancy. Anaesth Crit Care Pain Med. 2016;35(Suppl 1):S51–S57. [Article] [PubMed]
Girotra V, Mushabmi M. “Maternal Critical Care.” Anaesthesia Tutorial of the Week: 310(2014). World Federation of Societies of Anaesthesiologists. https://www.aagbi.org/sites/default/files/310%20Maternal%20Critical%20Care.pdf. Last accessed January 16, 2017.
Zwart JJ, Dupuis JR, Richters A, Ory F, van Roosmalen J . Obstetric intensive care unit admission: a 2-year nationwide population-based cohort study. Intensive Care Med. 2010;36(2):256–263. [Article] [PubMed]
Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Maternal-Fetal Medicine (Subspecialty of Obstetrics and Gynecology). https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/230_maternal-fetal_medicine_06122016.pdf. ACGME-approved June 12, 2016. Effective June 12, 2016. Last accessed January 17, 2017.
Upcoming events: Critical Care in Obstetrics (onsite course). Society for Maternal-Fetal Medicine. https://www.smfm.org/events/42-critical-care-in-obstetrics-onsite-course. Last accessed January 17, 2017.
D’Alton ME, Bonanno CA, Berkowitz RL, et al. Putting the “M” back in maternal-fetal medicine. Am J Obstet Gynecol. 2013;208(6): 442–448. [Article] [PubMed]
Leovic MP, Robbins HN, Foley MR, Starikov RS . The “virtual” obstetrical intensive care unit: providing critical care for contemporary obstetrics in nontraditional locations. Am J Obstet Gynecol. 2016;215(6):736.e1-736.e4. [Article]
Silver RM, Fox KA, Barton JR, et al. Center of excellence for placenta accreta. Am J Obstet Gynecol. 2015;212(5):561–568. [Article] [PubMed]
Placenta Accreta. Brigham and Women’s Hospital website. http://www.brighamandwomens.org/Departments_and_Services/obgyn/placenta-accreta.aspx. Updated August 3, 2016. Last accessed January 17, 2017.