Maternal Collapse Flashcards
What is a common factor in most women who die during childbirth/pregnancy?
Most had underlying health problems or other risk factors
What groups are at risk of maternal death?
Black and Asian women, older women, women from deprived areas
What are the leading causes of maternal death up to 6 weeks after end of pregnancy?
Thromboembolism and cardiac disease
What are the leading causes of maternal death from 6 weeks up to 1 year after pregnancy?
Cancer and suicide
What are the principles of management for an obstetric emergency?
Anticipation and preparation are key
Two lives are at risk but prioritise mother
Get help early = maternity emergency bleep or maternity cardiac arrest bleep
What is the maternal Obstetric Early Warning chart?
Like a NEWS chart but with urine passage and proteinuria categories = red or amber needs review
What can respiratory or cardiac distress lead to?
Cardiac arrest
What are the 5H’s of maternal collapse?
Head, hypoxia, heart, haemorrhage, hazards and whole body
What are some head and heart pathologies that may cause maternal collapse?
Head = eclampsia, epilepsy, cerebrovascular accident, vasovagal response Heart = MI, arrhythmias, peripartum cardiomyopathy
What are some causes of hypoxia and haemorrhage which may lead to maternal collapse?
Hypoxia = asthma, PE, pulmonary oedema, anaphylaxis Haemorrhage = abruption, atony, trauma, uterine rupture, uterine invasion, ruptures aneurysm
What are some hazards and whole body causes of maternal collapse?
Hypoglycaemia, amniotic fluid embolism, trauma, septicaemia, drug overdose, anaesthetic complications
How do you assess whether an airway is patent?
Awake = ability to speak, noisy breathing, foreign body Unconscious = head tilt-chin lift, look and listen for breathing
How do you assess breathing?
Respiratory rate, added sounds, patient position and use of accessory muscles, chest examination
What actions can be taken if you encounter a problem when assessing breathing?
Administer oxygen if hypoxic
Non-rebreathe mask will deliver 65-85% oxygen
How do you assess circulation?
Pulse rate and volume, BP, capillary refill, skin temperature, urine output
What actions can be taken if a problem is found when assessing circulation?
Gain venous access, take appropriate bloods, consider rapid fluid bolus
How is disability assessed and managed?
Assessment = AVPU, pupil reactivity/size, glucose level Action = nurse unconscious patients in left lateral position, give glucose if blood glucose <4
How is exposure assessed?
Top to toe examination = temperature, rashes, injury, bleeding, signs of infection
Why are pregnant women more difficult to resuscitate?
Gravid uterus, presence of foetus and placenta, more likely to aspirate, more difficult to intubate
How does pregnancy impact lung function?
20% decrease in pulmonary functional capacity and 20% increase in oxygen consumption = makes resuscitation more difficult
Why does a gravid uterus make resuscitation more difficult?
Causes aortocaval compression
Ventilation difficult due to pressure on diaphragm
Why do the foetus and placenta make resuscitation more difficult?
Steal oxygen and circulation from mother
What stage of pregnancy does aortocaval compression begin at?
From 20 weeks gestation = compression of IVC and aorta in supine position, reduces venous return, returns to normal after delivery
How does aortocaval compression cause supine hypotension?
Reduces cardiac output by up to 40%
What can supine hypotension lead to?
Maternal collapse = can be reversed by turning woman into left lateral position
What position should women be kept in during CPR?
Supine with left uterine displacement = manually displace uterus or use 30 degree tilt if on table
Do CPR compression alter if they are being done on a pregnant woman?
No = normal rate and depth used
How effective are chest compressions in a non-pregnant person?
Achieve around 30% of normal cardiac output = reduced to around 10% of this by aortocaval compression in pregnant women
When should a baby be delivered following a maternal collapse?
If there is no response to correctly performed CPR after 4 minutes = don’t more to operating theatre and continue CPR throughout
Why is diathermy not needed when delivering a baby during maternal collapse?
There is little blood loss as there is no cardiac output
What drugs are given if a shockable rhythm is detected?
Give 1mg adrenaline after third shock and then every other cycle (every 4 minutes)
Give 300mg amiodarone after third shock
What drugs are given if a non-shockable rhythm is detected?
Give adrenaline every 3-5 mins
What are the reversible causes of cardiac arrest?
4H’s = hypoxia, hypovolaemia, hypo/hyperkalaemia, hypothermia
4T’s = thrombosis, tamponade, toxins, tension pneumothorax
Pre-eclampsia in pregnant women
What are some specific drug treatments for causes of collapse?
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
What is the management for eclampsia/seizures?
Give high flow oxygen
Don’t restrain patient during fit
Move patient into left lateral position and open airway
How is anaphylaxis managed?
High flow oxygen and nebulised salbutamol
Chlorpheniramine 20mg IV and IV crystalloid bolus
IM adrenaline = every 5 minutes
Hydrocortisone 200mg IV
When would you give glucose?
If blood glucose <3 mmol/l = 50ml IV dextrose or 1mg IM glucagon or glucogel
What is the criteria for diabetic ketoacidosis?
Ketonaemia >= 3mmol/l or significant ketonuria
Blood glucose >11 mmol/l or known diabetes
Venous bicarbonate <15 mmol/l or venous pH <7.3
When do amniotic fluid embolisms tend to occur?
During labour = mortality of 30%
What occurs in an amniotic fluid embolism?
Amniotic fluid enters maternal circulation = collapse +/- arrest
How does an amniotic fluid embolism present?
Acute presentation = profound foetal distress, sudden respiratory distress, seizures, DIC, increased zinc coproporphyrin levels
How is an amniotic fluid embolism treated?
Supportive ITU
How is an amniotic fluid embolism confirmed on post mortem?
Squames on right sided circulation
When are women most at risk of a massive PE?
Postnatally
What are the symptoms of a PE?
Cyanosis, shock, collapse, tachycardia, dyspnoea, pain, cough/haemoptysis, temperature >37C
What are the signs of a PE?
Raised JVP, hepatomegaly, parasternal heave, fixed splitting of second heart sound, 15% have evident DVT
Why is a CXR done to investigate a PE?
To exclude pneumothorax and pneumonia = may see pleural effusion, raised hemidiaphragm or wedge collapse
What investigations are done for a PE?
ABG = may show hypoxia and normal/low CO2
Echo = rules out dissection and tamponade
May do CXR
How is a PE treated?
Heparin
What are some causes of a cerebrovascular accident?
Pre-eclampsia, thrombosis, AFE, AVM, aneurysm, infarct
How can a cerebrovascular accident present?
Headache, vomiting, hypertension, seizure, collapse, focal signs, neck stiffness, papilloedema
What investigations can be done for a cerebrovascular accident?
Head CT or MRI, echo, coagulation screen, carotid Doppler, lumbar puncture, cerebral angiography
What is a cord prolapse?
Obstetric emergency with direct compression and cord spasm = decreased flow leads to hypoxia and death
What are some associations of a cord prolapse?
Malpresentation, preterm labour, second born twin, artificial membrane rupture
What is the management of cord prolapse?
Scan for foetal cardiac activity
Immediate category one delivery
Tocolytic and maternal position to relieve pressure = knee-chest position
What does shoulder dystocia refer to?
Any cephalic presentation where manoeuvres other than gentle traction are needed to deliver the baby after head has delivered
What occurs in shoulder dystocia?
Bony impaction of foetal anterior shoulder on maternal symphysis
What are the risk factors for shoulder dystocia?
Obesity, diabetes, macrosomia, prolonged first or second stage, instrumental delivery
What are the signs of shoulder dystocia?
Slow delivery of head/face/chin, lack of restitution, head bobbing, turtling
What does head bobbing during labour refer to?
Head consistently retracts back between contractions during active second stage
What does turtling during pregnancy refer to?
Delivered head is tightly pulled back against perineum and difficulty delivering chin
What are the risks of shoulder dystocia?
Stillbirth, hypoxic brain injury, brachial plexus injury, PPH, third or fourth degree distress
What lowers the risk of hypoxic brain damage following shoulder dystocia?
If delivery is achieved within 5 mins form time of head being delivered
What is the management of shoulder dystocia?
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
What are the manoeuvres used to correct shoulder dystocia designed to do?
One or more of following:
Increase functional size of bony pelvis
Narrow bisacromial diameter of foetus
Change position of bisacromial diameter within bony pelvis
