Maternal collapse (1290)

A Maternity Early Warning Score (MEWS) should be used for all women. This includes antenatal, intrapartum, and postpartum observations. This is to allow early recognition of the woman who is deteriorating and becoming critically ill. It is also recommended that clinical judgement must be incorporated. If a woman looks or feels unwell, despite the score, her care should be escalated.

In some cases, maternal collapse occurs with no prior warning, although there may be existing risk factors which make this more likely. Antenatal care for those women with significant medical conditions that are at risk of maternal collapse should include multidisciplinary team input in pregnancy with an antenatal, intrapartum, and postnatal management plan in place.

Maternal collapse can result from many causes which may or may not be pregnancy related. A systematic approach to assessment facilitates identification of the cause of collapse. A systematic ABCDE approach should enable the clinical team to identify the most common causes of collapse.

The 4 H’s

• Hypoxia

• Hypovolaemia

• Hyper or hypo glucose/potassium/calcium/magnesium

• Hypothermia

The 4 T’s

• Thrombosis

• Tension pneumothorax

• Toxins

• Tamponade

The 4 P’s

• Pre-eclampsia and eclampsia

• Puerperal sepsis

• Placental/uterine complications

• Peripartum cardiomyopathy

Haemorrhage

Major obstetric haemorrhage is among the most common causes of maternal collapse. Causes of major obstetric haemorrhage include postpartum haemorrhage and major antepartum haemorrhage from placenta praevia, placental abruption, uterine rupture and ectopic pregnancy. In most cases of major haemorrhage, the cause is obvious but concealed haemorrhage should be actively excluded as a possibility – including rarer causes such as splenic artery rupture or hepatic rupture. Uterotonics should be given to manage a postpartum haemorrhage as per the NHSGGC guideline 597 Management of Postpartum Haemorrhage.

Amniotic Fluid Embolism (AFE)

AFE presents as collapse during labour or birth, or within 30 minutes of birth, in the form of acute hypotension, respiratory distress and acute hypoxia. Seizures and cardiac arrest may also occur. Coagulopathy often develops if the mother survives long enough leading to massive postpartum haemorrhage. Risk factors for AFE include maternal age >35 years, multiple pregnancy, placenta praevia, induction of labour, and operative delivery.

Cardiac Disease

The majority of deaths secondary to cardiac causes occur in women with no prior cardiac history. The main cardiac causes of maternal deaths are ischaemia and sudden arrhythmic cardiac death within a structurally normal heart. Other cardiac causes include aortic dissection, cardiomyopathy, coronary artery dissection, acute left ventricular failure, infective endocarditis, and pulmonary oedema. Most cardiac events have preceding signs and symptoms.

Drug Toxicity and Overdose

Drug toxicity and overdose must be considered in all cases of collapse. Substance misuse should be considered as a potential cause of collapse especially outside of hospital. In cases of therapeutic drug toxicity, the most commonly used agents in obstetrics are magnesium sulphate and local anaesthetic agents. Toxic effects from local anaesthetics usually result from excessively high plasma concentrations. Convulsions and cardiovascular collapse can occur very rapidly following inadvertent intravenous injection.

 Intracranial Haemorrhage

Intracranial haemorrhage is a significant complication of uncontrolled, particularly systolic, hypertension, but can also result from ruptured aneurysms and arteriovenous malformations. The initial presentation may be maternal collapse but often severe headache precedes this.

Anaphylaxis

Anaphylaxis is a severe, life-threatening generalised or systemic hypersensitivity reaction. Anaphylaxis is likely when all of the following three criteria are met:

1. sudden onset and rapid progression of symptoms

2. life-threatening airway and/or breathing and/or circulation problems

3. skin and/or mucosal changes (flushing/urticaria/angioedema

Exposure to a known allergen for the woman supports the diagnosis, but many cases occur with no previous history. Mast cell tryptase levels can be useful in confirming the diagnosis. Ideally three timed samples should be taken: as soon as resuscitation has started (without delaying resuscitation); 1-2 hours after the start of symptoms; 24 hours later. Anaphylaxis should be managed with intramuscular adrenaline – 1mg/ml (1:1000) concentration, 0.5ml or 500 microgram dose. A fluid challenge with 500-1000mls of crystalloid should be given. See NHSGGC guideline 526 Emergency Management of Anaphylaxis for further information.

Uterine Inversion

Uterine inversion is uncommon and may result from mismanagement of the third stage. It can occur when traction on the umbilical cord is attempted before uterine contraction and placental separation are established. It can present with severe lower abdominal pain, cardiovascular collapse and bradycardia due to vagal nerve stimulation and haemorrhage. The degree of shock is often disproportionate to the apparent blood loss.

Uterine Rupture

Uterine rupture most commonly occurs in women with a uterine scar from a previous caesarean birth or following uterine surgery such as myomectomy. Most cases of uterine rupture will occur during labour but can also be associated with instrumental birth or manual removal of placenta. Rarely it may present with antenatal collapse.

• Assess responsiveness – if no response seek immediate help

• Pull emergency buzzer, dial 2222 in hospital setting

State: obstetric emergency and ask for maternal +/- neonatal emergency teams

If cardiac arrest already confirmed also activate adult resuscitation team

• Turn the woman onto her back and ask additional person to manually displace the uterus to the left using two hands. A 30-degree tilt can be used if the woman is on a firm surface that can be tilted such as an operating table

• Open the airway using head tilt and chin lift manoeuvres

• Assess breathing for up to 10 seconds. Agonal gasps (infrequent gasping in the absence of other breathing) occur commonly in the first few minutes after cardiac arrest and should not be confused with normal breathing. Look for other signs of life such as colour and movement

• If there are no signs of life commence basic life support until help arrives to provide advanced life support.

1. Confirm cardiac arrest

2. Lie flat, apply manual uterine displacement to left

3. Commence CPR and request cardiac arrest trolley

   • Perform CPR 30:2 with standard hand placement

   • Evaluate potential causes

4. Identify team leader and allocate roles including a scribe

5. Apply defibrillation pads and check cardiac rhythm (defibrillation is safe in pregnancy and no changes to standard shock energies are required)

6. Maintain airway and ventilation

   • Give 100% supplementary oxygen

   • Intubate early

7. Optimise circulation

   • Gain IV access above the diaphragm

   • If fails then use upper limb intraosseous (IO)

8. Perimortem Caesarean Birth

   • Perform if ≥20 weeks (fundus level with umbilicus)

   • Consider if resuscitation is not successful in 4 minutes, should be performed by 5 minutes

   • Do not move the patient to operating theatre, perform where collapse has occurred

   • Perform immediately if maternal fatal injuries or prolonged pre-hospital arrest

9. Consider use of mechanical chest compression device

   • If prolonged resuscitation is required this can be requested from ITU

Perimortem caesarean birth should be performed to aid maternal resuscitation on any patient ≥20 weeks gestation if there is no response to CPR within 4 minutes. The aim is to achieve delivery within 5 minutes. Preparations for delivery are therefore required the moment that a cardiac arrest is declared. A PMCB should not be delayed by moving the patient to an operating theatre. It should be performed where the maternal collapse has occurred and with resuscitation ongoing. The surgeon should use an abdominal incision to facilitate the most rapid access. This may be a midline vertical incision or a suprapubic transverse incision. A scalpel and 2 cord clamps are the only equipment required. If a PMCB is being performed at ≥22 weeks gestation then a 2222 call should be put out for a neonatal emergency team.

While resuscitation is ongoing, and for the period immediately afterwards, all elective workload within the maternity unit should be stopped. This includes planned caesarean births and inductions. It may also be appropriate to stop syntocinon infusions in labouring women. Senior staff should consider if a divert of women to another GGC maternity unit is necessary. Midwifery staff should offer to contact another family member to support the birth partner/ relative of the patient in cardiac arrest.

Following a PMCB, if the resuscitation is successful then the woman should be transferred to theatre to complete the operation and for stabilisation. Assessment and management of a surviving infant should be overseen by the neonatal team. The ongoing management of the woman will require close collaboration within the multidisciplinary team and will be dependent on the cause of the collapse. If resuscitation is unsuccessful, the NHSGGC guideline 1193 Maternal Death should be followed.

• Assess responsiveness – if no response, seek immediate help

• The midwife should phone 999 or ask someone else if available to phone 999. State there is a maternal collapse that requires immediate transfer to the nearest hospital with an obstetric unit

• If a second person is present, ring 999 and ask for the location and code of the nearest Automated External Defibrillator (AED) and send someone else, if possible, to fetch it.

• Turn the woman onto her back

• Open the airway using head tilt and chin lift

• If there is a third person present, ask them to manually displace the uterus to the left using two hands

• Assess breathing for up to 10 seconds. Agonal gasps occur commonly in the first few minutes following cardiac arrest. They are an indication to commence CPR

• While assessing for breathing, assess for other signs of life such as colour and movement

• If there are no signs of life commence basic life support (BLS) until help arrives or the woman shows signs of life

• In the community if there is one person they should perform cardiac compressions. If a second trained healthcare practitioner is present they should attempt ventilation ideally with a bag valve mask. If a third person is present they should manually displace the uterus

• If the woman shows signs of life she should be placed in the recovery or left lateral position

• Ideally inform the local obstetric unit if possible

Accurate documentation is essential in all cases of maternal collapse, whether or not resuscitation is successful. If possible assign someone to scribe during the resuscitation. All those involved should then write full notes as soon as possible after the event.

All cases of maternal collapse should generate a clinical incident form (via DATIX) and the care should be reviewed through the appropriate clinical governance process.

All cases of maternal death should be reported to MBRRACE-UK. All cases of AFE should be reported to the AFE Register at UKOSS.

Debriefing is recommended for the woman, her family and the staff involved in the event. Maternal collapse can be associated with post-traumatic stress disorder and postnatal depression. Effective debriefing is usually carried out immediately after the incident in a ‘hot’ debrief and latterly, more comprehensively. Wellbeing support should be considered for staff involved in the incident.

All maternity staff should have annual, formal multidisciplinary training in generic life support and the management of maternal collapse. Life support training improves resuscitation skills and as a result the outcomes of women who collapse.

From: Quick Reference Handbook - Obstetric Anaesthetists’ Association https://www.oaa-anaes.ac.uk/oaa-quick-reference-handbook/qrh