Obstetric ICU: Treating Moms in Critical Care Environments

Caring for maternal patients in critical care settings is a complex and highly specialized area that requires a deep understanding of both obstetric and intensive care principles. Because only a very few pregnancies are complicated by illness severe enough to warrant admission to an intensive care unit (ICU), such admissions can be spread out across many units; so the ability to develop and maintain expertise in the care of critically ill peripartum patients is limited. This lack of expertise may become a greater issue, as an increasing number of ICU clinicians do not have an anesthesia background and may therefore not have encountered maternity patients since medical school (Royal College of Anesthetists, 2018).

Key Principles of Maternal Critical Care

• Caring for these patients in the ICU environment requires a multidisciplinary collaborative approach involving obstetricians, intensivists, cardiologists, anesthesiologists, neonatologists and specialized nurses working together to ensure optimal outcomes.
• Early recognition of deterioration is critical. An early warning system modified for obstetrics is fundamental and should be used for all patients presenting to acute care services who are pregnant or who are within six weeks of delivery. Use of obstetric-specific early warning systems helps detect clinical decline early and prompts the escalation of care.
• During pregnancy, the growing fetus places increased demand on the mother's body, leading to a range of physiological changes. These changes include:
  • Increased blood volume: The body produces more blood to support the fetus’s needs and to compensate for potential blood loss during delivery.
  • Increased Heart Rate: The heart works harder to pump more blood, increasing heart rate and the amount of blood pumped per minute. 
    • Increased cardiac output by 30%-50%
    • Decreased systemic vascular resistance
  • Vasodilation: Blood vessels widen to accommodate increased blood flow, which can sometimes lead to swelling in the extremities (Kepley, Bates & Mohiuddin, 2023).

Critical Care Conditions in the Obstetric Patient

In 2020, according to the Centers for Disease Control and Prevention (CDC), the six most frequent underlying causes of pregnancy-related death — hypertensive disorders, hemorrhage, infection, cardiomyopathy, embolism and mental health disorders — accounted for over 82% of pregnancy-related deaths. Pregnancy-related deaths occurred during pregnancy, delivery and up to one year postpartum. Over 80% of pregnancy-related deaths were determined to be preventable (CDC, 2024). However, there has been a sharp increase in pregnancy-related deaths, which is driven by worsening maternal health outcomes and racial disparities. For example, Black patients are three times more likely to die from pregnancy-related causes than white patients. Severe maternal morbidity — defined as unexpected outcomes of labor and delivery that result in significant short- or long-term consequences for a patient’s health — has increased 200% from 1993 to 2024 (CDC, 2024).

Data on 525 pregnancy-related deaths among patients residing in 38 states during 2020 were shared with the CDC through the Maternal Mortality Review Information Application (CDC, 2024). In 2020, the U.S. maternal mortality rate was 23.8 deaths per 100,000 live births, with 861 known deaths due to maternal causes. The United States continues to be an outlier among industrialized nations, with a maternal mortality rate several times higher than that of other high-income countries. For example, the maternal mortality rate in the United States is nearly three times higher than that of France, the country with the next highest rate.

For the purposes of this blog, I will focus on the top five primary indications of obstetric admission to the ICU for obstetric patients: hypertensive disorders, hemorrhage, infection/sepsis and cardiomyopathy.

Hypertensive Disorders of Pregnancy (Preeclampsia and Eclampsia)

• What? Hypertensive disorders of pregnancy (HDP) are one of the leading causes of pregnancy-related mortality and often lead to premature birth (CMQCC, 2025). Severe eclampsia is a life-threatening obstetric complication of pregnancy that demands immediate and expert care. It’s the progression of preeclampsia, which is a disorder marked by high blood pressure (BP) and signs of organ damage.
• Who? Obstetric patients typically after 20 weeks gestation or those patients who have delivered and are postpartum
• Signs and Symptoms?
  • Systolic BP ≥160 mmHg or diastolic BP ≥110 mmHg
  • Proteinuria
  • Signs of end-organ damage (e.g., elevated liver enzymes, low platelets)
  • Neurological symptoms such as headache, visual disturbances or altered mental status and seizures (defining feature of eclampsia)
  • Pulmonary edema
  • Kidney failure
  • Monitor for complications such as HELLP syndrome (hemolysis, elevated liver enzymes, low platelets); disseminated intravascular coagulation (DIC); and stroke or cerebral hemorrhage.
• Best Practice Strategies? Immediate interventions include:
  • Frequent vital signs, especially BP and respiratory rate. Frequency of vital signs depends on the medications given
  • Neurological checks: level of consciousness, deep tendon reflexes, pupil response
  • Urine output monitoring to assess renal function and magnesium clearance
  • Ensure airway patency, and administer oxygen to prevent hypoxia.
  • Position patient on their side to reduce aspiration risk during seizures and protect them from injury by padding bedrails and removing harmful objects. If seizures occur, monitor duration, type and postictal response.
  • Medications:
    • Magnesium sulfate for seizure prophylaxis
      • Monitor for signs of magnesium toxicity: decreased deep tendon reflexes, respiratory depression, low urine output Have calcium gluconate available as an antidote for magnesium toxicity.
    • Antihypertensives (e.g., IV labetalol, IV hydralazine, PO nifedipine) to control severe hypertension
  • Monitoring: Continuous maternal and fetal monitoring in the ICU to ensure mother and fetal well-being
  • Delivery: Often the definitive treatment; timing depends on gestational age and maternal/fetal stability

Maternal Hemorrhage

• What? Maternal hemorrhage — especially postpartum hemorrhage (PPH) — is one of the leading causes of maternal morbidity and mortality worldwide. It refers to excessive bleeding during or after childbirth and requires a rapid, coordinated intervention to prevent life-threatening complications. According to the World Health Organization (WHO), every year millions of patients experience PPH, resulting in about 70,000 maternal deaths globally (WHO, 2023). Even when the postpartum mother survives, she often needs urgent surgical interventions to control the bleeding and may be left with lifelong reproductive disability. In recognition of the growing need for global action to improve PPH prevention and care, the WHO worked with key stakeholders to start an initiative called “A roadmap to combat postpartum haemorrhage between 2023 and 2030” (WHO, 2023). 
  • PPH: Blood loss >1,000 mL after vaginal or cesarean delivery, or any amount that causes hemodynamic instability
  • Primary PPH: Occurs within the first 24 hours after delivery
  • Secondary (late) PPH: Occurs between 24 hours and 12 weeks postpartum
• Who? Obstetric patients who are at risk may include those with a history of placental abnormalities, prior cesarean section, prior uterine surgery, prior uterine ablation, history of endometrial ablation, uterine fibroids, history of PPH, multiple episodes of vaginal bleeding, BMI >50, bleeding disorders or coagulopathies, hematocrit <26, abnormal clotting labs, anemia, multiple gestations, prolonged oxytocin >24 hours, prolonged second stage of labor
• The common causes of PPH are known as the four T’s:
  • Tone — Uterine atony (most common cause)
  • Tissue — Retained placenta fragments
  • Trauma — Lacerations, uterine rupture or uterine inversion
  • Thrombin — Coagulopathies (e.g., prothrombin gene mutation, DIC, HELLP syndrome)
• Signs and Symptoms?
  • Heavy vaginal bleeding
  • Hypotension
  • Tachycardia
  • Pallor
  • Dizziness
  • Altered mental status
  • Decreased urine output
• Best Practice Strategies?
  • Establish two large-bore IVs
  • Ensure type and crossmatch
  • Fundal massage to stimulate uterine contraction
    • To perform a fundal massage, gently but firmly massage the top of the uterus (fundus) just below the navel/belly button to stimulate uterine contractions and reduce postpartum bleeding.
    • Locate the fundus: Place one hand just above the pubic bone to stabilize the uterus. Use the other hand to palpate the top of the uterus (fundus), usually just below the navel.
    • Assess uterine tone: A firm fundus is normal. A “boggy” (soft) fundus indicates uterine atony and risk of hemorrhage.
    • Massage the fundus: Use gentle, circular motions with the palm or the fingertips. Apply firm pressure, gradually increasing if the uterus is boggy. Continue for two to three minutes or until the uterus firms up.
    • Support the lower uterus during massage to prevent displacement.
    •  Monitor response: Watch for signs of discomfort, bleeding or uterine contraction. Reassess uterine tone frequently.
  • Administer uterine contraction medications.
  • IV fluids and blood products to restore volume
    • Activate a massive transfusion protocol (MTP): a transfusion of 10 or more units of red blood cells (RBCs) within 24 hours, transfusion of four units of RBCs within one hour when an ongoing need for more blood is anticipated, or replacement of a complete blood volume. An MTP should be activated when ongoing bleeding equates to a blood loss of 1,500 mL or more with abnormal vital signs (tachycardia and hypotension).
  • Monitor labs, especially fibrinogen. Fibrinogen is a predictor of severe PPH. A fibrinogen level <200 mg/dL is an excellent predictor of severe PPH, defined as a need for transfusion of multiple units of blood and blood products, a need for angiographic embolization or surgical management of hemorrhage, or maternal death.
    • A target fibrinogen level of >200 mg/dL is commonly recommended for patients with obstetric hemorrhage with some clinicians advocating to achieve a fibrinogen level >300 mg/dL in patients with active bleeding.
  • Monitor vital signs frequently.
  • Monitor blood loss by saving and measuring any blood-soaked items such as peri-pads, linens, etc. Use a scale to weigh these items and to estimate blood loss. Usually >500 mL is considered abnormal and warrants additional monitoring.
  • Monitor urine output continuously as a full bladder can hinder uterine contraction.
  • Prepare for insertion of an intrauterine tamponade balloon if bleeding persists.
  • Prepare for surgical intervention if bleeding persists (e.g., interventional radiology for artery embolization and in rare cases a hysterectomy).

Obstetric Sepsis

• What? Sepsis in obstetric patients is a critical emergency that can occur during pregnancy, childbirth or postpartum. It’s now recognized as the second-leading cause of maternal mortality and the third-leading cause of severe maternal morbidity. Obstetric sepsis is such a rising problem that The Joint Commission (TJC) and the Centers for Medicare & Medicaid Services (CMS) are introducing a severe maternal morbidity quality measure this year. Prompt recognition and rapid treatment are essential to prevent progression to septic shock and multiorgan failure.
• Common sources of infection include:
  • Chorioamnionitis (infection of the fetal membranes)
  • Endometritis (postpartum uterine infection)
  • Urinary tract infections (especially pyelonephritis)
  • Pneumonia
  • Retained products of conception
  • Surgical site infections (e.g., cesarean incision, episiotomy)
  • Septic abortion
• Signs and Symptoms? Obstetric patients may not present with classic sepsis symptoms due to physiological changes in pregnancy. Key indicators include:
  • Temperature <36°C or ≥38°C
  • Heart rate >110 bpm
  • Respiratory rate >24 bpm
  • WBC <4,000 or >15,000
  • Mental status changes
  • Decreased urine output
  • Lactic acid ≥2 mmol/L (≥4 mmol/L if laboring)
  • A positive sepsis screen should trigger immediate evaluation and treatment within 10 minutes.
• Best Practice Strategies?
  • Fluid resuscitation
  • Empiric antibiotics: based on suspected source (e.g., broad-spectrum for chorioamnionitis or endometritis)
  • Labwork: CBC, CMP, coagulation profile, lactic acid, blood cultures
  • Continuous pulse oximetry
  • Frequent vital signs
  • Urine output and mental status hourly
  • Electronic fetal monitoring if ≥23 weeks gestation
  • Development of an obstetric sepsis protocol, such as the one at Stanford Medicine, is highly recommended to ensure patients receive immediate lifesaving interventions.

Peripartum Cardiomyopathy

• What? Obstetric cardiomyopathy — more commonly referred to as peripartum cardiomyopathy (PPCM) — is a rare but serious form of heart failure (HF) that occurs during the last month of pregnancy or within five months postpartum in patients who previously had no history of heart disease. Cardiovascular disease accounts for more than one-third of pregnancy-related deaths (Mehta, et al., 2021). PPCM can escalate rapidly and requires multidisciplinary care — obstetricians, cardiologists, intensivists and neonatologists. Early recognition is crucial, especially since symptoms can mimic normal postpartum recovery. Some patients recover fully, while others may have lasting cardiac dysfunction or require advanced therapies such as LVAD or transplant.
• Who? It occurs during the last month of pregnancy or five months after pregnancy. The exact cause is unknown, but it’s believed to involve inflammation, hormonal changes, and increased vascular stress due to the increased blood volume to supply the fetus that occurs during pregnancy.
  • Maternal age of 35-plus
  • High BP, including preeclampsia or gestational hypertension
  • Multiple gestations (e.g., twins)
  • PPCM is more common in patients who identify as Black, although it is not understood how race plays a role in the development of PPCM.
• Signs and Symptoms? PPCM may be difficult to detect, because symptoms of HF, such as shortness of breath and swelling in the feet and legs, can mimic those of pregnancy.
  • Fatigue
  • Shortness of breath, especially at rest
  • Orthopnea
  • Swelling in legs
  • Palpitations — often mistaken for normal pregnancy symptom
  • Elevated jugular venous pressure or presence of jugular venous distention (JVD)
  • May have a heart murmur or gallop
  • Weight gain of >3 lbs. over a day or two
• Best Practice Strategies?
  • Echocardiogram showing reduced left ventricular ejection fraction (LVEF <45%)
  • Blood tests: BNP or NT-proBNP to assess cardiac stress, CBC to assess anemia, kidney, electrolytes, liver and thyroid function labs
  • Similar to standard HF management but modified to protect the fetus or breastfeeding infant
    • May include diuretics, beta-blockers, ACE inhibitors (postpartum) and anticoagulation, as needed
  • Continuous telemetry
  • Noninvasive and/or invasive hemodynamic monitoring
  • Multidisciplinary approach: Team of maternal fetal medicine physicians, cardiologists, anesthesiologists, advanced practice practitioners, nurses, social workers and pharmacists. A comprehensive delivery plan should be created to ensure a safe and well-planned birth.
    • Cardiothoracic surgery and critical care unit specialists included, as needed.
    • Vaginal delivery is recommended for most pregnant patients with HF if there are no obstetrical contraindications, because cesarean delivery can be associated with increased fluid shifts and higher risk for infection.
  • Continue to monitor the mother in the fourth trimester (the first 12 weeks after delivery).

Amniotic Fluid Embolism

• What? Amniotic fluid embolism (AFE) is a rare, life-threatening obstetric emergency requiring rapid recognition and aggressive critical care nursing interventions to optimize maternal and fetal outcomes. AFE occurs when amniotic fluid or fetal material enters the maternal bloodstream, triggering a severe systemic inflammatory and coagulopathic response.
•  AFE is estimated to occur in 1.9-6.1/100,000 births, although the exact prevalence remains uncertain due to inaccurate diagnoses and underreporting of nonfatal cases. Unfortunately, within the first hour following an AFE, an estimated 50% of patients die, and two-thirds face mortality within the first five hours of the event. The peak period of death has been noted to be one to 12 hours after the AFE occurs. A California-based study indicated that 26.4% of affected pregnant patients died, while 66% developed DIC. Maternal survival remains uncommon, but prompt recognition and resuscitation improve prognoses.
• Who? Occurs in obstetric patients. Often, AFE occurs suddenly, typically during labor, delivery or immediately postpartum. A significant majority of AFE cases, about 70%, manifest during labor, with approximately 19% occurring during cesarean sections and 11% following vaginal deliveries.
• Signs and Symptoms?
  • Cardiac arrest, often the first symptom
  • Shortness of breath
  • Difficulty with breathing
  • Hypotension
  • Chest pain
  • Tachycardia
  • Confusion
  • Agitation
  • Seizures
  • DIC

Best Practice Strategies?

• Activate emergency response: Call a rapid response or code blue team immediately.
• Ensure airway and breathing: Administer 100% oxygen via non-rebreather mask or initiate mechanical ventilation if needed.
• Support circulation
  • Initiate IV access with large-bore catheters.
  • Administer IV fluids and vasopressors to manage hypotension.
  • Prepare for advanced cardiac life support (ACLS) if cardiac arrest occurs.
• Continuous fetal monitoring (if undelivered): Assess for signs of fetal distress.
• Maternal monitoring
  • ECG, pulse oximetry, invasive BP monitoring if available
  • Urine output via Foley catheter to assess renal perfusion
• Monitor for DIC: Watch for bleeding from IV sites, gums or surgical incisions.
  • Administer blood products: Packed RBCs, platelets, fresh frozen plasma and cryoprecipitate, as ordered
  • Frequent lab monitoring: CBC, coagulation profile, ABGs and electrolytes
• Multidisciplinary coordination: Work closely with obstetricians, anesthesiologists, intensivists and hematologists.
• Prepare for emergency delivery: Cesarean section may be necessary if the fetus is viable and the maternal condition deteriorates.
•  Emotional support: Provide reassurance to family, explain interventions, and offer grief support if needed

Staffing and Training

• Now more than ever, we must act to end the maternal health crisis in America — a country that spends more per capita on healthcare than any other country — and create a reality where no person fears for their life during pregnancy, especially Black patients.
• Competency Frameworks: It is highly recommended to develop enhanced maternal care guidelines with specific training for critical care nurses to treat acutely ill pregnant patients. Experts have identified the creation of “scoring tools” for the timely identification of obstetric patients at risk of clinical decompensation as an essential strategy to address maternal morbidity and mortality.
• Shared Care Models: ICU teams should integrate obstetric expertise to ensure continuity and appropriateness of care. Multidisciplinary in-situ simulations that cross the obstetric and ICU disciplines are essential to improve readiness for obstetric emergencies, communication and critical reaction times at regular intervals (minimum of one or two times per year).

Additional Resources

• American College of Obstetricians and Gynecologists (ACOG)
• American Heart Association (AHA)
• California Maternal Quality Care Collaborative (CMQCC)
• Centers for Disease and Control and Prevention
• Sepsis Alliance
• The Joint Commission

What education and training do you have to prepare nurses for high-acuity maternal emergencies in the ICU?