November 21, 2014

Special Delivery Unit Provides Comprehensive Care for Complicated Births

SDU manages complicated fetal and maternal conditions

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By Sabine Iben, MD

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In the first 17 months after Cleveland Clinic Children’s Special Delivery Unit (SDU) opened in February 2012, 130 mothers with complicated pregnancies delivered there. What’s notable is that more than a quarter of those deliveries (n = 35) occurred in the SDU because of serious maternal conditions.

To our knowledge, Cleveland Clinic Children’s has the first SDU in the nation designed to provide specialized care for both mothers and newborns with serious medical issues.

A diverse case mix

The SDU’s multidisciplinary team of specialists cares for two broad groups of patients:

• Mothers with significant, potentially life-threatening health issues (see sidebar for examples) complicating a sometimes long-desired pregnancy

• Babies with prenatally identified birth defects requiring subspecialty care not available outside a dedicated children’s hospital (see sidebar for examples)

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Our patient population also includes women requiring surgical interventions during pregnancy who are monitored perioperatively in the SDU to ensure fetal well-being. When required, certain fetal interventions, such as percutaneous umbilical blood sampling and fetal transfusions, can also be performed in the SDU.

The aim of the SDU across all these populations is to optimize our ability to provide the best possible care for the infant-mother dyad.

Care coordination and mother-child togetherness

More than 11,000 deliveries occur within the Cleveland Clinic health system each year, so there are many families in need of meticulous management and delivery planning because of fetal or maternal health issues.

Our past practice, like the current practice of many freestanding children’s hospitals, was to transport critically ill newborns immediately after delivery from community level III intensive care units to receive sometimes lifesaving subspecialty care. This practice inevitably resulted in separation of critically ill infants from their mothers, who often had surgery themselves and were not able to accompany their newborns during this critical time.

A significant number of women are referred to the SDU for their own medical issues (Figure 1). This includes pregnant women who were born with congenital heart disease and are at high risk for cardiac decompensation and death from carrying a pregnancy. Our maternal-fetal medicine specialists and renowned cardiologists specializing in heart disease management during pregnancy are involved in these women’s care early on and ensure that those risks are minimized.

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Close postpartum monitoring may require admission to a cardiac intensive care unit that is readily available on Cleveland Clinic’s main campus, very close to the SDU.

The SDU was not designed to handle a large number of patients but rather provide individualized care for high-risk situations. Most families delivering in the SDU have received comprehensive care, careful evaluation and delivery planning coordinated by Cleveland Clinic Children’s Fetal Care Center.

These families include those expecting babies with lethal malformations for which interventions may be limited to comfort care and maximizing time spent with the family. Preparation and education of families, arranging for needed support, specialty consultation, imaging and follow-up are all part of the Fetal Care Center’s antenatal preparation services.

Fig. 1

SDU facilities and staffing

The SDU includes the following physical components:

• Two labor and delivery suites

• A dedicated operating room large enough to accommodate teams for both mother and baby

• A triage room

• An advanced neonatal resuscitation area

Adjacent to the SDU is a pediatric hybrid cardiac catheterization suite where patients with congenital heart disease can receive lifesaving interventions combining catheterization and surgical procedures immediately after birth.

The unit is staffed by experienced labor and delivery room nurses who also rotate through one of the high-volume delivery units at our community hospitals as well as by 24/7 in-house obstetric staff with support from a team of maternal-fetal medicine specialists who are on call.

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The neonatal intensive care and pediatric critical care units are located close to each other, and both are staffed around the clock with in-house intensivists, neonatal nurse practitioners and experienced nursing staff. A neonatal and pediatric extracorporeal membrane oxygenation (ECMO) program is available and co-managed by the neonatal and critical care teams.

Babies with congenital heart disease requiring surgical intervention shortly after delivery are cared for in the pediatric intensive care unit in close collaboration with the consulting neonatology team.

Case Study of a Distinctive SDU:

Equipped to Serve Moms (as Well as Babies) with Serious Conditions

Tabitha McClendon was born with a bicuspid aortic valve but had no symptoms until she became pregnant in her late 20s, when an echocardiogram revealed aortic stenosis. She was referred to Cleveland Clinic, where she was managed collaboratively by an adult congenital heart disease specialist and a high-risk maternal-fetal medicine specialist.

Tabitha’s stenosis progressed dramatically over the course of her pregnancy. By the third trimester, she was having chest pain, lightheadedness and dyspnea. She was told she would need a valve replacement, but her management team was confident it could wait until after her baby’s birth.

With close monitoring and vigilant care, she was able to carry to term and deliver a healthy baby, Olivia, by cesarean section under general anesthesia in Cleveland Clinic Children’s Special Delivery Unit (SDU) in May 2012. After the birth, Olivia was monitored in the SDU while Tabitha was monitored in the nearby cardiac intensive care unit.

Five months later, Tabitha underwent a successful tissue valve replacement, and she is now expecting her second baby under care from Cleveland Clinic specialists.

About the Author

Dr. Iben is a staff physician in the Department of Neonatology and the Neonatology Director of the Fetal Care Center.

Figure 1. Distribution of indications for Special Delivery Unit referrals over the unit’s first 17 months of operation. Total exceeds 130 because some deliveries involved more than one indication.

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