The connection between critical care units and maternity wards has been a focus of Wendy Pollock for more than 25 years.
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Since 1992, she has researched why pregnant and postpartum women end up in intensive care units, how their cases are recorded and how to better connect different units within hospitals.
She shared her knowledge at Bendigo Health's Regional Critical Care Conference this week.
Dr Pollock spoke about maternal admissions to intensive care units, and highlighted the effort Victoria had made in reporting events and recording data about the admitted pregnant or postpartum woman.
The two-day conference focused on the critical care required for diverse populations in a number of settings.
Dr Pollock worked in the Royal Melbourne Hospital ICU before going to study midwifery.
"For a variety of different reasons I went back to ICU and they all said 'great, you've done midwifery, you'll know everything'," she said.
"We had no maternity services on site, this is was when Royal Women's (Hospital) was up the road. We we would get women in with all sorts of stuff but there were no midwives or obstetricians on staff.
"There was a total gap in service. That was in 1992."
Dr Pollock grew up in Bendigo. Her work has since brought her back to the region, where she has taught a number of people.
"For the past 18 years or so I've sat on the Maternal Mortality Morbidity Committee for the state and reviewed all the maternal deaths that have occurred," she said.
"I have also been part of measuring the intensive care admissions for the state.
"My understanding with Bendigo Health is they have a very good relationship with midwives coming to visit women in ICU but they don't have any dedicated roles. That's not unusual, nobody has dedicated roles."
Dr Pollock said there were two groups of women who typically required the intensive care unit during their pregnancy.
One was women with known high-risk and pre-existing illnesses who would have potential issues while pregnant.
"(Those women) tend to have medically-led maternity care, a lot of disciplinary supports and a planned, highly-managed labour and birth," Dr Pollock said.
"It might include a midwife on the team, it might not, but I would argue you need to have a midwife on the team because the woman doesn't want her whole birth experience to be about the illness.
"She wants to know how to pack a bag for hospital and what the baby needs. She wants the birth to have a baby focus. I would argue for those women having a critical care midwife able to be part of her ongoing care gives her continuity. That would be an ideal role, but nobody in Victoria does that."
The second group of women admitted to the ICU were those who were postpartum and had unexpected complications during birth.
Dr Pollock said the most common reason for a sudden admission was an obstetric haemorrhage.
"These are women who may or may not have risk factors but who have a large bleed - I'm talking two or three litres of blood loss - after the baby is born," she said.
"Haemorrhage is now such an issue that one in 70 women who give birth receives a blood transfusion. That's a lot of haemorrhages."
Looking at reasons behind haemorrhaging was important, which made the collection of data necessary for Dr Pollock.
"We know from studies that about 40 percent of ICU admissions are preventable if the issue is picked up early enough," she said. "If a woman has a 600ml blood loss, which is in the morbidity rate and is classified as postpartum haemorrhrage, and that's where it stops, terrific.
"It gets to 1500ml or 2.5 litres or four litres. What drives that volume of blood loss along that spectrum of morbidity to death? It's actually us and the system around us. It's not the woman.
"Whether she's old, has had twins or any other risk factors - that doesn't matter. It's what we do. Are we observing properly? Are we documenting properly? Are we picking it up early and doing the right thing to stop it where it's at?"
Dr Pollock said there were liaison nurses for critical care who went from the ICU to clinical areas when necessary in most hospitals.
She said it was important those critical care nurses understood the normal physiology of a pregnancy and what to look for if something was potentially critical.
"A critical care midwife could give that as part of a multi-discipline team," Dr Pollock said.
"There's nobody advocating for a change because it's such a fringe of every area.
"Illness in pregnancy is a tiny, tiny fringe of obstetrics, it's a tiny fringe of ICU, it's bit of chunk of midwifery. So some women slip through the gaps and there's no organised service to care for them in that sense."
Dr Pollock said a rise in ICU complications in pregnant women showed the need for such a role.
"Having a dedicated role will help," she said. "Plenty of nurses are trained critical care and as midwives but there's no capacity to integrate the knowledge.
"They're separate spaces, even if (the nurses) practise in both areas, it's on separate rostering systems and is mutually exclusive. They don't need to be."
Dr Pollock's push for more data on maternal ICU admissions and better liaison between intensive care and maternity units began in 1993.
"I wrote to every unit in Victoria and asked, 'do you keep data on ICU admissions?' No one did," she said. "It took 25 years to get Victoria to start counting ICU admissions. July 1, 2017, was the first time they started collecting it.
"That's what got me in, there was no data. Without data we have got a service gap. You can't demonstrate a service gap without the data.
"Once we get the data and demonstrate the service gap can we start generating knowledge, skill sets and training. I think it will take quite a while. Years. But we're already seeing lessons being learnt."
Dr Pollock said it was critical to pick up early signs of unexpected complications in pregnancy.
"Victoria has done a good job in establishing reporting maternal ICU events, which allows us to start counting," she said. "We're the only state in Australia to do that. That's a beginning point for us to understand."
She said women should prepare for pregnancy to minimise risks.
"They should enter pregnancy as well as they can," Dr Pollock said ."(That means) a healthy weight. Age also makes a difference, more women are having their first baby over the age of 35, which is not great.
"Most women's bodies are made to have a baby. The physiology is in place and most time it works well. (Women should) have the belief it will be okay because for most women it will go well."