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This chapter provides an overview of hospital and departmental service delivery issues, which hospitals may use in formulating a service for the critically ill parturient. In general, critically ill parturients are cared for in the delivery unit or in an obstetric high dependency unit (HDU); alternatively they may be admitted or transferred to a medical or surgical intensive care unit (ICU). Generally, the HDU may be appropriate for pregnant or puerperal women who are conscious and who have single-organ dysfunction. Ideally, the HDU should be located in or in close proximity to the labor and delivery ward. The HDU physician director and nurse/midwife director can give clinical, administrative and educational direction through guidelines and education of the HDU nursing, medical, and other ancillary staff. Simulation can encompass a large range of activities ranging from basic skills and drills to more sophisticated multidisciplinary training in purpose-built simulation centers.
The prevention and management of postdural puncture headache (PDPH) in the obstetric patient continues to challenge the anesthesiologist. This chapter discusses the clinical management of PDPH in obstetric patients and suggests recommendations based on current, relevant evidence. The presence of focal neurological signs may point toward other neurological problems and prompt further investigations and assessments. The low cerebrospinal fluid (CSF) volume causes a drop in subarachnoid pressure. The incidence of PDPH in obstetric patients is relatively high due to the effects of gender and young adult age. It is also related to the size and design of the needle used and the experience of the anesthesiologist carrying out the procedure. Larger randomized controlled trials may help provide insight into the optimal use of the epidural blood patch (EBP) and other treatments. Such trials will be difficult to perform due to the low incidence of accidental dural puncture (ADP) and PDPH.
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