Globally pregnancy and child-birth are periods of high morbidity and mortality for
women.Annually,approximatelyeight million womensufferpregnancy-related compli-
cations and over half a million die. Tragically, 80% of maternal deaths could be pre-
vented. Key to reducing the risks associated with pregnancy and childbirth is the
recognition of the ill woman and provision of high quality care. The Millennium Development Goals
aspire to reduce by three quarters the maternal mortality ratio. As a background to this, Basket describes how, in the last 20 years, in developed countries, maternalmortality rates havefallen suchthat analysis of cases of severe maternal morbidity is necessary to provide enough numbers to give a clinically relevant assess-
ment of the standard of maternalcare.Differentapproachestotheauditofseverema-
ternal morbidity exist and include: need for intensive care, organ system dysfunction,
and clinically defined morbidities.
The aims of critical care management are broad. Critical illness in pregnancy is es-
pecially pertinent as the patient is usually young and previously fit, and management
decisions must also consider the fetus. Assessment must consider the normal physio-
logical changes of pregnancy, covered in this edition by Carlin & Alfirevic. These may
make diagnosis of disease and scoring levels of severity difficult. Lombaard & Pattinson
deal with the fact that critically ill pregnant women may be suffering from any medical
or surgical problem. There are increasing numbers of pregnancies in those with high-
risk medical conditions such as cardiac disease. The chapter by Willians et al. details
specific pathologies unique to pregnancy that may be life-threatening, including pre-
eclampsia and hypertension, thromboembolic disease, massive obstetric haemorrhage
and others. Paruk discusses the globally important issue of severe sepsis. Price, Slack
and Nelson-Piercy outline the aims of management in an organ system-based ap-
proach,focusingonimportantgeneralprinciplesofcriticalcaremanagementwithcon-
siderations for the pregnant patient. and Northwick Park In the UK, the Confidential Enquiry into Maternal deaths have stressed the importance of multidisciplinary working. Guise notes that
Inquiry
because of the complexity and acuity of critical care medicine, which often relies on
more than one medical team, teamwork skills are essential and covers the history
and importance of teamwork in high reliability fields, reviews key concepts and skills
in teamwork, and discusses approaches to training and working in teams. This is com-
plemented by chapters on the roles of Obstetricians, midwivesby Simpson and Barker
and Anaesthetists by Plaat and Wray. It is also important that importance of other dis-
ciplines are not forgotten. Training of midwives and doctors in the recognition and
management of critical illness is vital to reducing morbidity and mortality. Martin
and Hutchon discuss why the best way to address these issues is with multidisciplinary
training. Suchtrainingallowseachteammember tounderstandhis/herroleandthat of
each of the other disciplines involved.
Patient safety in obstetric critical care is paramount, because of its complexity and
the vulnerability of the critically ill patient to error. There, however, things that can be
done to make improvements using the principles of risk management and its various
components.
Early recognition of the ill patient should lead to better outcomes. This and critical
careoutreachmay helpin preventingwomendeterioratingto the point that theyneed
intensive care, but if they do, safe transfer is essential. Barret and Yentis discuss these
points in their chapter.
Bogaert and Dhai deal with ethical issues in obstetrics hinging around the maternal-
fetal relationship.With accessto thenecessary informationand support, most women
strive to improve their chance of having healthy babies. However, there could be sit-
uations where their interests do not correspond with fetal interests, thereby giving
rise to conflict situations.
This publication should provide clinicians with a concise resource on the important
topic of obstetric critical illness, which is important in moving towards the millennium
development goal.

Helen Scholefield MB, CHB, MRCOG
Consultant Obstetrician
Clinical Director of Obstetrics
Liverpool Women’s NHS Foundation Trust,

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