Maternal Collapse Flashcards

1
Q

What is a common factor in most women who die during childbirth/pregnancy?

A

Most had underlying health problems or other risk factors

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2
Q

What groups are at risk of maternal death?

A

Black and Asian women, older women, women from deprived areas

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3
Q

What are the leading causes of maternal death up to 6 weeks after end of pregnancy?

A

Thromboembolism and cardiac disease

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4
Q

What are the leading causes of maternal death from 6 weeks up to 1 year after pregnancy?

A

Cancer and suicide

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5
Q

What are the principles of management for an obstetric emergency?

A

Anticipation and preparation are key
Two lives are at risk but prioritise mother
Get help early = maternity emergency bleep or maternity cardiac arrest bleep

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6
Q

What is the maternal Obstetric Early Warning chart?

A

Like a NEWS chart but with urine passage and proteinuria categories = red or amber needs review

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7
Q

What can respiratory or cardiac distress lead to?

A

Cardiac arrest

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8
Q

What are the 5H’s of maternal collapse?

A

Head, hypoxia, heart, haemorrhage, hazards and whole body

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9
Q

What are some head and heart pathologies that may cause maternal collapse?

A
Head = eclampsia, epilepsy, cerebrovascular accident, vasovagal response
Heart = MI, arrhythmias, peripartum cardiomyopathy
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10
Q

What are some causes of hypoxia and haemorrhage which may lead to maternal collapse?

A
Hypoxia = asthma, PE, pulmonary oedema, anaphylaxis
Haemorrhage = abruption, atony, trauma, uterine rupture, uterine invasion, ruptures aneurysm
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11
Q

What are some hazards and whole body causes of maternal collapse?

A

Hypoglycaemia, amniotic fluid embolism, trauma, septicaemia, drug overdose, anaesthetic complications

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12
Q

How do you assess whether an airway is patent?

A
Awake = ability to speak, noisy breathing, foreign body
Unconscious = head tilt-chin lift, look and listen for breathing
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13
Q

How do you assess breathing?

A

Respiratory rate, added sounds, patient position and use of accessory muscles, chest examination

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14
Q

What actions can be taken if you encounter a problem when assessing breathing?

A

Administer oxygen if hypoxic

Non-rebreathe mask will deliver 65-85% oxygen

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15
Q

How do you assess circulation?

A

Pulse rate and volume, BP, capillary refill, skin temperature, urine output

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16
Q

What actions can be taken if a problem is found when assessing circulation?

A

Gain venous access, take appropriate bloods, consider rapid fluid bolus

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17
Q

How is disability assessed and managed?

A
Assessment = AVPU, pupil reactivity/size, glucose level
Action = nurse unconscious patients in left lateral position, give glucose if blood glucose <4
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18
Q

How is exposure assessed?

A

Top to toe examination = temperature, rashes, injury, bleeding, signs of infection

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19
Q

Why are pregnant women more difficult to resuscitate?

A

Gravid uterus, presence of foetus and placenta, more likely to aspirate, more difficult to intubate

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20
Q

How does pregnancy impact lung function?

A

20% decrease in pulmonary functional capacity and 20% increase in oxygen consumption = makes resuscitation more difficult

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21
Q

Why does a gravid uterus make resuscitation more difficult?

A

Causes aortocaval compression

Ventilation difficult due to pressure on diaphragm

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22
Q

Why do the foetus and placenta make resuscitation more difficult?

A

Steal oxygen and circulation from mother

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23
Q

What stage of pregnancy does aortocaval compression begin at?

A

From 20 weeks gestation = compression of IVC and aorta in supine position, reduces venous return, returns to normal after delivery

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24
Q

How does aortocaval compression cause supine hypotension?

A

Reduces cardiac output by up to 40%

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25
Q

What can supine hypotension lead to?

A

Maternal collapse = can be reversed by turning woman into left lateral position

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26
Q

What position should women be kept in during CPR?

A

Supine with left uterine displacement = manually displace uterus or use 30 degree tilt if on table

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27
Q

Do CPR compression alter if they are being done on a pregnant woman?

A

No = normal rate and depth used

28
Q

How effective are chest compressions in a non-pregnant person?

A

Achieve around 30% of normal cardiac output = reduced to around 10% of this by aortocaval compression in pregnant women

29
Q

When should a baby be delivered following a maternal collapse?

A

If there is no response to correctly performed CPR after 4 minutes = don’t more to operating theatre and continue CPR throughout

30
Q

Why is diathermy not needed when delivering a baby during maternal collapse?

A

There is little blood loss as there is no cardiac output

31
Q

What drugs are given if a shockable rhythm is detected?

A

Give 1mg adrenaline after third shock and then every other cycle (every 4 minutes)
Give 300mg amiodarone after third shock

32
Q

What drugs are given if a non-shockable rhythm is detected?

A

Give adrenaline every 3-5 mins

33
Q

What are the reversible causes of cardiac arrest?

A

4H’s = hypoxia, hypovolaemia, hypo/hyperkalaemia, hypothermia
4T’s = thrombosis, tamponade, toxins, tension pneumothorax
Pre-eclampsia in pregnant women

34
Q

What are some specific drug treatments for causes of collapse?

A

Cardiac arrest = 1mg adrenaline every 2 mins
VF/VT = 300mg amiodarone
Opiate overdose = 0.4-0.8mg naloxone
Magnesium toxicity = 1g calcium gluconate
Local anaesthetic toxicity = 1.5ml of 20% Intralipid

35
Q

What is the management for eclampsia/seizures?

A

Give high flow oxygen
Don’t restrain patient during fit
Move patient into left lateral position and open airway

36
Q

How is anaphylaxis managed?

A

High flow oxygen and nebulised salbutamol
Chlorpheniramine 20mg IV and IV crystalloid bolus
IM adrenaline = every 5 minutes
Hydrocortisone 200mg IV

37
Q

When would you give glucose?

A

If blood glucose <3 mmol/l = 50ml IV dextrose or 1mg IM glucagon or glucogel

38
Q

What is the criteria for diabetic ketoacidosis?

A

Ketonaemia >= 3mmol/l or significant ketonuria
Blood glucose >11 mmol/l or known diabetes
Venous bicarbonate <15 mmol/l or venous pH <7.3

39
Q

When do amniotic fluid embolisms tend to occur?

A

During labour = mortality of 30%

40
Q

What occurs in an amniotic fluid embolism?

A

Amniotic fluid enters maternal circulation = collapse +/- arrest

41
Q

How does an amniotic fluid embolism present?

A

Acute presentation = profound foetal distress, sudden respiratory distress, seizures, DIC, increased zinc coproporphyrin levels

42
Q

How is an amniotic fluid embolism treated?

A

Supportive ITU

43
Q

How is an amniotic fluid embolism confirmed on post mortem?

A

Squames on right sided circulation

44
Q

When are women most at risk of a massive PE?

A

Postnatally

45
Q

What are the symptoms of a PE?

A

Cyanosis, shock, collapse, tachycardia, dyspnoea, pain, cough/haemoptysis, temperature >37C

46
Q

What are the signs of a PE?

A

Raised JVP, hepatomegaly, parasternal heave, fixed splitting of second heart sound, 15% have evident DVT

47
Q

Why is a CXR done to investigate a PE?

A

To exclude pneumothorax and pneumonia = may see pleural effusion, raised hemidiaphragm or wedge collapse

48
Q

What investigations are done for a PE?

A

ABG = may show hypoxia and normal/low CO2
Echo = rules out dissection and tamponade
May do CXR

49
Q

How is a PE treated?

A

Heparin

50
Q

What are some causes of a cerebrovascular accident?

A

Pre-eclampsia, thrombosis, AFE, AVM, aneurysm, infarct

51
Q

How can a cerebrovascular accident present?

A

Headache, vomiting, hypertension, seizure, collapse, focal signs, neck stiffness, papilloedema

52
Q

What investigations can be done for a cerebrovascular accident?

A

Head CT or MRI, echo, coagulation screen, carotid Doppler, lumbar puncture, cerebral angiography

53
Q

What is a cord prolapse?

A

Obstetric emergency with direct compression and cord spasm = decreased flow leads to hypoxia and death

54
Q

What are some associations of a cord prolapse?

A

Malpresentation, preterm labour, second born twin, artificial membrane rupture

55
Q

What is the management of cord prolapse?

A

Scan for foetal cardiac activity
Immediate category one delivery
Tocolytic and maternal position to relieve pressure = knee-chest position

56
Q

What does shoulder dystocia refer to?

A

Any cephalic presentation where manoeuvres other than gentle traction are needed to deliver the baby after head has delivered

57
Q

What occurs in shoulder dystocia?

A

Bony impaction of foetal anterior shoulder on maternal symphysis

58
Q

What are the risk factors for shoulder dystocia?

A

Obesity, diabetes, macrosomia, prolonged first or second stage, instrumental delivery

59
Q

What are the signs of shoulder dystocia?

A

Slow delivery of head/face/chin, lack of restitution, head bobbing, turtling

60
Q

What does head bobbing during labour refer to?

A

Head consistently retracts back between contractions during active second stage

61
Q

What does turtling during pregnancy refer to?

A

Delivered head is tightly pulled back against perineum and difficulty delivering chin

62
Q

What are the risks of shoulder dystocia?

A

Stillbirth, hypoxic brain injury, brachial plexus injury, PPH, third or fourth degree distress

63
Q

What lowers the risk of hypoxic brain damage following shoulder dystocia?

A

If delivery is achieved within 5 mins form time of head being delivered

64
Q

What is the management of shoulder dystocia?

A

Evaluate for episiotomy
McRobert’s manoeuvre for legs and apply suprapubic pressure before entering using rotational manoeuvre
Remove posterior arm and roll patient onto knees

65
Q

What are the manoeuvres used to correct shoulder dystocia designed to do?

A

One or more of following:
Increase functional size of bony pelvis
Narrow bisacromial diameter of foetus
Change position of bisacromial diameter within bony pelvis