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Take the Challenge Out of Managing the Complex Obstetric Patient

Take the Challenge Out of Managing the Complex Obstetric Patient

In a specialty such as obstetrics, we are often faced with a complex patient who requires us to be proactive in identifying risk factors early in the course of care. This type of preparedness is necessary to prevent adverse events and to identify individual risk factors that would best guide us in management plans for a patient’s possible hospital-acquired conditions or in adverse event prevention plans to achieve high-quality outcomes.

Obstetrics poses unique challenges because of the possible risks of venous thromboembolism (VTE) and unknown thrombophilia, as well as other myriad risks, including those associated with morbid obesity. Anticipating and overcoming these challenges is a necessary action that requires forethought, planning, communication, and readily available tools, equipment, and resources. 

Biophysical Profile

This measure of fetal well-being is scored based on five criteria:

- Fetal movement.
- Volume of amniotic fluid.
- Fetal tone.
- Fetal breathing.
- Non-stress test.

Each criterion is given a max score of 2, and the highest possible score is 10.

A score of 4 warrants labor induction if gestational age is
> 32 weeks.

Here is one example of a unique, complex, obstetrical case involving a super morbidly obese (BMI > 67) patient who underwent a cesarean delivery with anesthesia, and had other complex medical issues:

M is a 36-year-old woman, admitted at 37 and 3/7 weeks’ gestation for a primary cesarean delivery because of a breech presentation. This is M’s fourth pregnancy. Two of those ended with term vaginal deliveries, and one pregnancy was spontaneously miscarried. Her living children are 7 and 12 years of age, and her miscarriage occurred two years previously.

She was originally scheduled for delivery at 39 weeks, but a biophysical profile score (being done routinely because of her risk factors) of 4/10, in addition to patient reports of decreased fetal movement, prompted early delivery (Box). Upon admission, she denied leakage of fluid, vaginal bleeding, or contractions. External fetal monitoring was not successful because of the patient’s size.

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