Obstetric ICU

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Obstetric ICU — Care of the Critically Ill Mother

The obstetric ICU and HDU bring skilled, early care to women with life-threatening complications. This guide follows the Government of India (MoHFW) guidelines on unit design, staffing, admission, monitoring, protocols, discharge, and referral, with organ support in pregnancy and the CRITICAL approach.

🎯 AT A GLANCE — THE OBSTETRIC ICU

An obstetric high-dependency unit (HDU) and intensive care unit (ICU) care for women with life-threatening complications of pregnancy, childbirth, or the puerperium — "when things go wrong in obstetrics, they go wrong fast"

HDU = step-up and step-down care for single-organ or no-organ support; ICU = multi-organ failure or advanced support (ventilation, inotropes, dialysis), led by an intensivist

The main reasons for admission are haemorrhage, hypertensive disorders (eclampsia, HELLP), sepsis, heart disease, respiratory failure, and acute kidney or liver failure

Pregnancy changes everything: airway, oxygenation, blood pressure targets, drug choice, and the fetus — treat the mother first, because a stable mother is the best treatment for the baby

Early transfer saves lives: do not wait for the woman to deteriorate; the right level of care, at the right time, by trained staff

🚨 MOVE FROM HDU TO ICU IF (MoHFW)

Pulmonary oedema, acute respiratory distress syndrome (ARDS), or oxygen need that rises despite treatment

Systemic inflammatory response (SIRS), septic shock, or poor cardiac output despite fluids

Disseminated intravascular coagulation (DIC) or multi-organ failure

Need for ventilation, inotropes, or dialysis, or a falling level of consciousness

🗺️ THE PATHWAY AT A GLANCE

1 · RecogniseEarly-warning score triggers; senior review without delay

2 · TriageWard, HDU, or ICU; obstetrician and intensivist decide together

3 · StabiliseAirway, oxygen, circulation, left tilt, treat the cause

4 · SupportOrgan support, fetal plan, thromboprophylaxis, nutrition

5 · MonitorHourly observations in the acute phase; protocols and records

6 · Step downDischarge criteria, follow-up, counselling, case review

STEP 1 · THE UNIT — design, staff, and equipment (MoHFW guidelines)

🏥 HDU AND ICU — SPACE, STAFF AND EQUIPMENT

Topic	Details (Ministry of Health and Family Welfare)
HDU versus ICU	HDU: between the labour ward and the ICU; single-organ or no-organ support; usually not for ventilated or multi-organ failure patients; ICU: multi-organ failure or advanced support, led by an intensivist
Number of beds	Up to 250 deliveries a month: 4 beds; 250–500: 8 beds; over 500: increase in proportion; one isolation room (about 150 sq ft) for infectious cases
Space and location	About 120–130 sq ft per HDU bed and 130–150 per ICU bed; next to the labour room and theatre, near the ICU, laboratory, radiology, and blood bank; one entry, emergency exits
Staff	Nurse-to-patient ratio 1:2 in HDU and 1:1 in ICU; HDU headed by a full-time obstetrician; 8-bed HDU: 4 nurses and 2 emergency obstetric care medical officers per shift; 4-bed ICU: 4 nurses and an intensivist; anaesthetist present 24 hours; on-call physician, paediatrician, surgeon, radiologist
Equipment	Bedside monitors (oxygen saturation, blood pressure, ECG, respiration, temperature), infusion and syringe pumps, ultrasound with colour Doppler, cardiotocography, defibrillator and crash cart, transport and non-invasive ventilators, arterial blood gas machine, blood warmer, eclampsia box, Bakri balloon, intubation equipment
Per bed	At least 2 oxygen, 1 air, and 2 suction outlets and about 10 power points; backup power, fire safety, biomedical waste management, ambulance with newborn transport support
Training	Orientation for nurses and medical officers; 3 months of ICU posting for medical officers; emergency drills every 3 months; emergency trolley checked daily; everyone trained in CPR

STEP 2 · ADMISSION AND TRIAGE — who needs which level of care

🚪 WHO SHOULD BE ADMITTED

Level	Typical conditions
HDU (MoHFW list)	Severe anaemia, haemorrhage, pre-eclampsia, eclampsia, HELLP syndrome (haemolysis, elevated liver enzymes, low platelets), sepsis, DIC, placental problems; cardiac disease, thyroid disorders, diabetic complications, dengue, malaria, asthma; surgical or trauma cases; or clinical judgement
ICU (physiological thresholds)	Very low or very high blood pressure, low Glasgow coma score, abnormal electrolytes or pH, low oxygen despite oxygen therapy, need for ventilation or inotropes, DIC, ARDS, multi-organ failure (use the national tables for exact values)
Common triggers (general)	Respiratory rate over 30 or under 10, saturation under 90% on oxygen, systolic pressure under 90, urine under 0.5 mL/kg/hour for 2 hours, lactate over 4, seizures or coma, platelets under 50,000 with bleeding
Who decides	Obstetrician with the intensivist or anaesthetist; ICU referral only after ICU admission is assured; a mother's baby moves with her if already delivered

STEP 3 · ORGAN SUPPORT IN PREGNANCY — what changes at the bedside

🫁 SUPPORT BY SYSTEM — SPECIAL POINTS IN PREGNANCY AND AFTER BIRTH

System	Advice
Airway	Difficult and failed intubation are commoner (oedema, large breasts, obesity); aspiration risk; pre-oxygenate well (desaturates quickly); senior operator, video laryngoscope, smaller tube
Breathing	Target saturation of 95% or more and PaO₂ of 70 or more; lung-protective ventilation (6 mL/kg ideal body weight); avoid high PaCO₂ (above about 45–50) because it acidifies the fetus; normal pregnant PaCO₂ is 28–32 (see the ABG sheet)
Circulation	Left lateral tilt (about 15°) if over 20 weeks; mean arterial pressure of 65 or more; noradrenaline first for septic shock; restrict fluids in pre-eclampsia (pulmonary oedema risk)
Kidney	Hourly urine output; avoid nephrotoxic drugs (NSAIDs, aminoglycosides); dialysis for refractory acidosis, hyperkalaemia, overload, or uraemia
Brain	Seizures: magnesium sulfate for eclampsia (see the neurology sheet); exclude other causes (stroke, cerebral venous thrombosis, hypoglycaemia)
Blood	Massive haemorrhage protocol, tranexamic acid 1 g, correct DIC (fibrinogen above 2 g/L, platelets above 50,000 if bleeding); Bakri balloon for atony
Infection	Cultures and broad-spectrum antibiotics within the first hour; find and remove the source (retained products, abscess, hysterectomy)
Metabolic and nutrition	Avoid hypoglycaemia; early enteral feeding; correct electrolytes; treat ketoacidosis with insulin infusion
Thromboprophylaxis	Low molecular weight heparin (weight-based) and stockings unless bleeding or very low platelets
Analgesia and sedation	Adequate pain relief; avoid over-sedation; check drug safety for breastfeeding

STEP 4 · CONDITION-SPECIFIC CARE — the commonest reasons for admission

🩺 KEY ICU ACTIONS BY CONDITION

Condition	Key actions
Severe pre-eclampsia, eclampsia, HELLP	Treat severe hypertension within 30–60 minutes (labetalol, nifedipine, hydralazine); magnesium sulfate with monitoring of reflexes, respiration, and urine; restrict fluids; deliver after stabilisation; watch for pulmonary oedema, renal failure, liver haematoma
Obstetric haemorrhage and DIC	Haemostatic resuscitation (red cells, plasma, platelets, fibrinogen), tranexamic acid, surgical control, warm the patient, correct calcium
Sepsis and septic shock	Antibiotics within an hour, fluids with caution, noradrenaline for a mean pressure under 65, source control; influenza in pregnancy: oseltamivir at once without waiting for a test
Heart disease	Peripartum cardiomyopathy and valve disease: echocardiography, diuretics, rate control, anticoagulation as indicated; avoid fluid overload
Amniotic fluid embolism	Supportive care, manage the coagulopathy, consider extracorporeal support
ARDS and pneumonia	Lung-protective ventilation, prone positioning is possible, treat the infection, extracorporeal support if refractory
Acute fatty liver and acute liver failure	Deliver, glucose monitoring, correct coagulopathy, liver unit referral (see the liver sheet)
Diabetic ketoacidosis	Insulin infusion, fluids, potassium; can occur at near-normal glucose in pregnancy (see the diabetes sheet)

STEP 5 · MONITORING, FETUS AND DISCHARGE — the whole picture

📈 MONITORING, THE FETUS AND STEP-DOWN

Topic	Details
Monitoring (MoHFW)	Temperature, blood pressure, heart rate, respiratory rate, oxygen saturation, and urine output at least hourly in the acute phase; fluid and electrolyte balance; treat the cause
The fetus	Continuous cardiotocography when viable; left lateral tilt about 15° and oxygen; corticosteroids if under 34 weeks; magnesium for neuroprotection before 32 weeks; deliver when it helps the mother (pre-eclampsia, chorioamnionitis, abruption, fatty liver) — not simply to improve a mother's lungs or heart
Protocols (MoHFW)	Written SOPs for admission and discharge, resuscitation, major haemorrhage, pre-eclampsia and eclampsia, severe blood pressure disorders, diabetic ketoacidosis, sepsis, difficult intubation, anaesthesia and analgesia, post-dural puncture headache, thromboprophylaxis
Discharge from HDU (MoHFW)	Stable circulation, no need for intensive monitoring, no continuous intravenous drugs or frequent blood tests, no active bleeding or oxygen need, walking; HDU stay is usually 24–72 hours
Records and referral (MoHFW)	History, diagnosis, tests, operative notes, summary, dated and signed entries, consent and family counselling documented; referral slip, emergency drugs, escort with infusions, monitoring, secure airway
Family and follow-up	Daily, honest communication; support for the woman's mental health (depression and post-traumatic stress are common); breastfeeding, contraception, and counselling for future pregnancy; near-miss review of every ICU admission (see the collapse sheet)

⚠️ COMMON PITFALLS

Late recognition and late transfer; treating on the ward what needs the HDU

Using non-pregnant targets (PaCO₂, blood pressure, oxygen) or forgetting left tilt

Fluid overload in pre-eclampsia, or too little fluid in haemorrhage and sepsis

Delivering a very sick mother for the baby's sake before she is stabilised

No thromboprophylaxis, no hourly chart, poor handover, or no record of consent

Forgetting the baby, the family, and the woman's mind after she leaves the unit

Memory Aid

CRITICAL

Eight rules for the critically ill mother.

C

Choose the right level — ward, HDU, or ICU; obstetrician and intensivist together

R

Recognise early — early-warning score and hourly observations

I

Intervene on the cause — bleeding, blood pressure, sepsis, heart, lungs

T

Tilt and oxygen — left lateral tilt, saturation 95% or more

I

Involve the team — obstetrician, intensivist, anaesthetist, neonatologist, nurse

C

Care for the fetus — monitor, steroids under 34 weeks, deliver when it helps her

A

Audit and record — protocols, signed notes, near-miss review

L

Look after family and follow-up — mental health, contraception, next pregnancy

Remember: recognise early, choose the right level, treat the cause, and care for the whole family.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Unit design, bed numbers, staffing, equipment, admission lists, transfer triggers, hourly monitoring, protocols, training, discharge criteria, and referral and records follow the Ministry of Health and Family Welfare (MoHFW) Guidelines for Obstetric HDU and ICU (nhm.gov.in), as summarised from the document; the exact physiological admission thresholds in its tables were not extracted. The organ-support advice, general triggers, and condition-specific actions are from memory of the American College of Obstetricians and Gynecologists (ACOG), the Society for Maternal-Fetal Medicine (SMFM), and the Surviving Sepsis Campaign guidance. Check the full national guideline and local protocols before use; thresholds, intervals and regimens vary between guidelines — follow local protocol, obtain consent, and involve a senior obstetrician in any high-risk case.