Maternal collapse and obstetric emergencies

obstetric emergencies

1. DR .SHANAWAZ ABDUL RASH EED.
MD; FRCA, CCT.
CONSULTANT ANA ESTHESIOLOGIST
BURJEEL HOSPITAL.
Maternal Collapse in Pregnancy Maternal Collapse in Pregnancy
and the Puerperium and the Puerperium

2. IntroductionIntroduction

Rare – but serious (life threatening)Rare – but serious (life threatening)
–14 – 600 per 100,000 births14 – 600 per 100,000 births
–Once every 7 years in a unit delivering 1000/yearOnce every 7 years in a unit delivering 1000/year

Has a diverse range of causesHas a diverse range of causes

Fetal survival depends primarily on effective maternal Fetal survival depends primarily on effective maternal
resuscitationresuscitation

Maternal survival depends on...Maternal survival depends on...
–AetiologyAetiology
–Facilities availableFacilities available
–The training and expertise of those on the spotThe training and expertise of those on the spot

3. Leading causes of Direct DeathsLeading causes of Direct Deaths
(Mortality rates/Million Maternities)(Mortality rates/Million Maternities)

5. CAUSESCAUSES

Shock syndromesShock syndromes
–Vasovagal*Vasovagal*
–Haemorrhage (see below)Haemorrhage (see below)
–AnaphylaxisAnaphylaxis
–SepsisSepsis
–Uterine inversion (3Uterine inversion (3
rdrd
stage labour) stage labour)

CardiacCardiac
–ArrhythmiaArrhythmia
–Acute heart failureAcute heart failure

CerebralCerebral
–Post ictal (epilepsy)*Post ictal (epilepsy)*
–EclampsiaEclampsia
–Cerebrovascular accidentCerebrovascular accident
–*Spontaneous recovery likely*Spontaneous recovery likely

6. CAUSESCAUSES

Drugs & MetabolismDrugs & Metabolism
Prescribed e.g. MgSO4Prescribed e.g. MgSO4
Illicit drugs and toxinsIllicit drugs and toxins
HypoglycaemiaHypoglycaemia

Concealed HaemorrhageConcealed Haemorrhage
Blood in the uterus (APH or PPH)Blood in the uterus (APH or PPH)
Or vagina/paravaginal spaceOr vagina/paravaginal space
Blood in the abdominal cavityBlood in the abdominal cavity
Ruptured liver, spleen or splenic arteryRuptured liver, spleen or splenic artery
Post CaesareanPost Caesarean
Blood in the chestBlood in the chest
Aortic dissectionAortic dissection

PulmonaryPulmonary
ThromboembolismThromboembolism
Amniotic fluid embolismAmniotic fluid embolism
PneumothoraxPneumothorax
Aspiration syndromeAspiration syndrome

7. Lessons learned from reviewsLessons learned from reviews
Hemorrhagic death Hemorrhagic death
•93% of all deaths were potentially preventable.93% of all deaths were potentially preventable.
•Lack of appropriate attention to clinical signs of hemorrhage. Lack of appropriate attention to clinical signs of hemorrhage.
•Failure to restore blood volume, to act decisively with life-Failure to restore blood volume, to act decisively with life-
saving interventions.saving interventions.
Severe Hypertension Severe Hypertension
•60% of maternal deaths were potentially preventable. 60% of maternal deaths were potentially preventable.
•Failure to control blood pressure, to recognize HELLP Failure to control blood pressure, to recognize HELLP
syndrome, to diagnosis and treat pulmonary edema.syndrome, to diagnosis and treat pulmonary edema.
Pulmonary Embolism Pulmonary Embolism
•““Single cause of death most amenable to reduction by Single cause of death most amenable to reduction by
systematic change in practice.” systematic change in practice.”
•Failure to use adequate prophylaxis.Failure to use adequate prophylaxis.
Berg CJ, et al. Obstet Gynecol 2005;106:1228-34
Cantwell R, et al. BJOG 2011 Mar;118 Suppl 1:1-203
Clark, SL. Semin Perinatol 2012;36(1):42-7

8. Treatable Causes of CollapseTreatable Causes of Collapse
4 H4 H’’s and 4 Ts and 4 T’’s plus Es plus E
HypovolaemiaHypovolaemia
HypoxiaHypoxia
Hypo or Hyperkalaemia/HypoglycemiaHypo or Hyperkalaemia/Hypoglycemia
Hypothermia Hypothermia
ThromboembolismThromboembolism
ToxinsToxins
Tension PneumothoraxTension Pneumothorax
Tamponade (cardiac)Tamponade (cardiac)
EclampsiaEclampsia

9. Obstetric Physiology impacts on Obstetric Physiology impacts on
ResuscitationResuscitation
Aortocaval compressionAortocaval compression
–Also known as supine hypotensionAlso known as supine hypotension
–Progressively increases from 20wProgressively increases from 20w
–May reduce cardiac output by up to 40%May reduce cardiac output by up to 40%
–Always use a 15 degree tilt positionAlways use a 15 degree tilt position
Pregnant uterus compromises external cardiac massage (ECM)Pregnant uterus compromises external cardiac massage (ECM)
- By up to 90%- By up to 90%
- Also compromises chest ventilation- Also compromises chest ventilation
- So hypoxaemia occurs more rapidly- So hypoxaemia occurs more rapidly
-Empty the uterus if mother is not responding to ECM within 4 – 5 minutesEmpty the uterus if mother is not responding to ECM within 4 – 5 minutes
Blood volume is increasedBlood volume is increased
- By up to 50%- By up to 50%
-But mother may tolerate blood volume loss up to 30%But mother may tolerate blood volume loss up to 30%
Increased risk of stomach regurgitation and aspirationIncreased risk of stomach regurgitation and aspiration

10. Vasovagal SyndromeVasovagal Syndrome

Now after all that excitement let us Now after all that excitement let us
consider the most common cause consider the most common cause
of maternal collapseof maternal collapse......

11. Vasovagal syndromeVasovagal syndrome

Typically occurs when mother gets up too soon after Typically occurs when mother gets up too soon after
her deliveryher delivery

Make sure that she is not shocked from blood lossMake sure that she is not shocked from blood loss
–Check PR, BP, Fundus and PV lossCheck PR, BP, Fundus and PV loss

If the mother has a slow but good volume pulseIf the mother has a slow but good volume pulse

And she is pink and breathing...And she is pink and breathing...

Put her in the coma position and monitor recoveryPut her in the coma position and monitor recovery

If she is hypovolaemic get in 1 – 2 IV cannulae ASAP If she is hypovolaemic get in 1 – 2 IV cannulae ASAP
and commence resuscitation with fluidsand commence resuscitation with fluids

12. Acute uterine inversionAcute uterine inversion

Typically occurs with cord traction and the Typically occurs with cord traction and the
uterus disappears from the abdomen…uterus disappears from the abdomen…

Because it is inside out & in the vaginaBecause it is inside out & in the vagina

Degree of shock is out of proportion to blood Degree of shock is out of proportion to blood
loss loss

Resuscitate with IV FluidsResuscitate with IV Fluids

Analgesia if necessaryAnalgesia if necessary

Attempt manual replacement of the uterus Attempt manual replacement of the uterus
followed by manual removal placentafollowed by manual removal placenta

13. SEPSISSEPSIS

May present without fever or a raised white cell May present without fever or a raised white cell
count (WCC)count (WCC)
- Beware the patient with low WCC- Beware the patient with low WCC

Can progress very rapidlyCan progress very rapidly

Principal obstetric organisms...Principal obstetric organisms...
- Streptococci A, B and D- Streptococci A, B and D
- Pneumococci- Pneumococci
- E Coli- E Coli

14. Septic ShockSeptic Shock

Requires multidisciplinary careRequires multidisciplinary care

Take blood culture Take blood culture beforebefore giving antibiotics giving antibiotics

Antibiotics as per local agreed protocol or as advised by a Antibiotics as per local agreed protocol or as advised by a
microbiologistmicrobiologist

Measure Serum lactateMeasure Serum lactate

For hypotension and/or lactate >4 mmol/LFor hypotension and/or lactate >4 mmol/L
–Give IV crystalloids 20 ml/KgGive IV crystalloids 20 ml/Kg
–Then pressor agents to maintain BP >65 MAPThen pressor agents to maintain BP >65 MAP

If not responding...If not responding...
–Insert CVP and intubate for IPPVInsert CVP and intubate for IPPV
–Maintain CVP 8 – 12 mm HgMaintain CVP 8 – 12 mm Hg
–Consider steroidsConsider steroids

15. Acute Pulmonary Oedema (CCF)Acute Pulmonary Oedema (CCF)

Typically occurs in the known cardiac patient Typically occurs in the known cardiac patient
in the third stage of labourin the third stage of labour

But can occur in the profoundly anaemic But can occur in the profoundly anaemic
patient who is given too much fluid (blood) patient who is given too much fluid (blood)
too quicklytoo quickly

Nurse uprightNurse upright

Give oxygenGive oxygen

Give IV FrusemideGive IV Frusemide

CPAP/NIV.CPAP/NIV.

16. Drug ReactionsDrug Reactions

The maximum dose of Lignocaine is 4mg/KgThe maximum dose of Lignocaine is 4mg/Kg
–Or 6 mg/Kg for Lignocaine with adrenalineOr 6 mg/Kg for Lignocaine with adrenaline
–That is 28 ml 1% Lignocaine in a 70 Kg womanThat is 28 ml 1% Lignocaine in a 70 Kg woman
–First sign of overdose is numbness tongue and mouth, slurred First sign of overdose is numbness tongue and mouth, slurred
speechspeech
–Then convulsions and arrestThen convulsions and arrest
–Treat with CPR, ventilation, sedation and 20% Intralipid (100 ml Treat with CPR, ventilation, sedation and 20% Intralipid (100 ml
stat and 400 ml in 20 min)stat and 400 ml in 20 min)

Penicillin or other antibiotic anaphylaxisPenicillin or other antibiotic anaphylaxis
–Adrenaline may be life savingAdrenaline may be life saving
–The dose is 0.5 mg The dose is 0.5 mg maximummaximum and and intramuscularintramuscular
–(IV adrenaline 1.0 mg is only for cardiac asystole)(IV adrenaline 1.0 mg is only for cardiac asystole)
–Add IV antihistamine and hydrocortisone 200 mgAdd IV antihistamine and hydrocortisone 200 mg

17. Cerebrovascular AccidentCerebrovascular Accident

Typically occurs with a hypertensive crisisTypically occurs with a hypertensive crisis

May be after ergometrine given to a preeclamptic May be after ergometrine given to a preeclamptic
patientpatient

There may be localising CNS signsThere may be localising CNS signs
–Check pupils, DTR’s and PlantarsCheck pupils, DTR’s and Plantars

Look for neck stiffnessLook for neck stiffness
–A sign of meningeal irritationA sign of meningeal irritation

May require perimortem Caesarean sectionMay require perimortem Caesarean section
–NB Hypertension and bradycardia are signs of NB Hypertension and bradycardia are signs of
cerebral coningcerebral coning

19. ““Obstetrics is Obstetrics is
Bloody BusinessBloody Business””**
PostpartumPostpartum
HemorrhageHemorrhage
*Cunningham, et. al: Williams Obstetrics, 21
st
ed., 2001

20. Risk Factors for Postpartum
Haemorrhage

21. Causes of Postpartum Causes of Postpartum
HemorrhageHemorrhage

22. Classification of Classification of
HaemorrhageHaemorrhage
Class Acute Blood
Loss
% Lost
1 900cc 15
2 1200-1500cc 20-25
3 1800-2100cc 30-35
4 2400cc 40
Baker R, Obstet Gynecol Annu, 1997

23. ASSESSMENT OF BLOOD LOSS ASSESSMENT OF BLOOD LOSS
AFTER DELIVERYAFTER DELIVERY
•DifficultDifficult
•Mostly Visual estimation (So, Subjective & Mostly Visual estimation (So, Subjective &
Inaccurate)Inaccurate)
•Underestimation is likelyUnderestimation is likely
•Clinical picture –MisleadingClinical picture –Misleading
• Mothers-Malnourished, Anaemic, Small built, Less Mothers-Malnourished, Anaemic, Small built, Less
blood volumeblood volume

24. SYMPTOMS & SIGNSSYMPTOMS & SIGNS
Blood loss Blood loss
(% B Vol)(% B Vol)
Systolic BPSystolic BP
( mm of Hg)( mm of Hg)
Signs & SymptomsSigns & Symptoms
10-1510-15 NormalNormal HR postural hypotensionHR postural hypotension
15-30 15-30 slight fallslight fall PR, thirst, weaknessPR, thirst, weakness
30-4030-40 60-8060-80 pallor,oliguria, confusionpallor,oliguria, confusion
40+40+ 40-6040-60 anuria, air hunger, coma, anuria, air hunger, coma,
deathdeath
Recognition is late - >30% B Vol loss

25. Vigilance is great, but you haveVigilance is great, but you have
to remember that studies showto remember that studies show
the half-life of vigilance isthe half-life of vigilance is
about 15 minutes.about 15 minutes.
Author unknownAuthor unknown

26. TEAM - Obstetrician, TEAM - Obstetrician,
- Anesthesiologist, - Anesthesiologist,
- Haematologist and - Haematologist and
- Blood Bank - Blood Bank
- Intensivist.- Intensivist.
Correction of hypovolaemiaCorrection of hypovolaemia
Ascertain origin of bleedingAscertain origin of bleeding
Ensure uterine contractionEnsure uterine contraction
Surgical managementSurgical management
Management of special situationManagement of special situation
MANAGEMENT OF PPH

27. Massive Obstetric Haemorrhage Massive Obstetric Haemorrhage
TreatmentTreatment

MedicalMedical

SurgicalSurgical

Blood Component TherapyBlood Component Therapy

Post Treatment CarePost Treatment Care

28. Management of Obstetrical Hemorrhage
Oxygen by mask 15 liter/min.
– to keep O2 saturation > 94%
1st IV Line: Ringer Lactate with Pitocin 20-40 units at 1000 ml/
30 minutes
2
nd
IV Line: 14/16 G IV: warm RL - administer wide open
 Sample blood; CBC, fibrinogen, PT/PTT, platelets, T&C and
order 4u PRBCs
Monitor I&O, urinary Foley catheter
Get help -Senior
Obstetrician, Anesthesiologist,
Interventional Radiology, Intensivist,
Haemotologist etc.

29. Massive Obstetric HaemorrhageMassive Obstetric Haemorrhage
MedicalMedical

Volume Replacement (Crystalloid,Colloid)Volume Replacement (Crystalloid,Colloid)

Blood (O –tive, Group Specific, X Matched)Blood (O –tive, Group Specific, X Matched)

Coagulation Support (FFP, Cryoprecipitate, Platelets)Coagulation Support (FFP, Cryoprecipitate, Platelets)

Inotropic SupportInotropic Support

Uterine Massage / CompressionUterine Massage / Compression

Uterotonic Agents (Syntocinon ,Ergotamine, Carboprost Uterotonic Agents (Syntocinon ,Ergotamine, Carboprost Misoprostol )Misoprostol )

Temperature Active WarmingTemperature Active Warming

30. Blood Component TherapyBlood Component Therapy
Fresh Frozen Plasma Fresh Frozen Plasma
–INR > 1.5 - 2u FFPINR > 1.5 - 2u FFP
–INR 2-2.5 - 4u FFPINR 2-2.5 - 4u FFP
–INR > 2.5 - 6u FFPINR > 2.5 - 6u FFP
Cryoprecipitate ( 1u/ 10Kg ) Cryoprecipitate ( 1u/ 10Kg )
–Fibrinogen < 100 mg/dl – 10u cryo Fibrinogen < 100 mg/dl – 10u cryo
–Fibrinogen < 50 mg/dl – 20u cryoFibrinogen < 50 mg/dl – 20u cryo
Platelets Platelets
–Platelet. count. < 100,000 – 1u plateletpheresisPlatelet. count. < 100,000 – 1u plateletpheresis
–Platelet. count. < 50,000 – 2u plateletpheresisPlatelet. count. < 50,000 – 2u plateletpheresis

31. Blood Component TherapyBlood Component Therapy
Blood Comp Contents Volume
(ml)
Effect
Packed
RBCs
RBC, Plasma 300 Inc. Hgb by 1 g/dl
Platelets Platelets, Plasma 250 Inc. count by 25,000
FFP
Fibrinogen, antithrombin
III, clotting factors,
plasma
250
Inc. Fibrinogen 10
mg/dl
Cryoprecipit
ate
Fibrinogen, VonWillebrand
F, Factor V111, X111,
Fibronectin
40
Inc. Fibrinogen 10
mg/dl

32. Target ValuesTarget Values
• Maintain systolic BP>90 mmHgMaintain systolic BP>90 mmHg
•Maintain urine output > 0.5 ml per kg per Maintain urine output > 0.5 ml per kg per
hourhour
•Hct > 21%Hct > 21%
•Platelets > 50,000/ulPlatelets > 50,000/ul
•Fibrinogen > 100 mg/dlFibrinogen > 100 mg/dl
•PT/PTT < 1.5 times controlPT/PTT < 1.5 times control
•Repeat labs as needed – every 2 hrsRepeat labs as needed – every 2 hrs

33. Massive Obstetric HaemorrhageMassive Obstetric Haemorrhage
SurgicalSurgical
• EUA RepairEUA Repair
• Uterine Tamponade (78%)Uterine Tamponade (78%)
• B-Lynch Suture (81%)B-Lynch Suture (81%)
• Arterial LigationArterial Ligation
• Radiological Arterial EmbolisationRadiological Arterial Embolisation
• Hysterectomy ( 12%)Hysterectomy ( 12%)

34. Treatment of PPH: Hysterectomy

A conservative option should be quickly efficacious

 The addition of successive conservative approaches is
hazardous
- Risk of delaying radical treatment
 Placenta accreta is a frequent cause of failure of
conservative Treatments
 Hysterectomy may be a life-saving procedure in case of
- Failure of conservative approach
- Uterine rupture
- Placenta accreta
Early Decision

35. Selective Angiographic Embolization Selective Angiographic Embolization
(SAE)(SAE)
Strategically difficult in many
centers

36. Pulmonary
Embolism

37. Pulmonary Embolism
Pulmonary embolism, along with
amniotic fluid embolism, accounts for the
leading cause of maternal mortality in the
United States
(Koonin, et al; MMWR)

38. Radiographic Diagnosis ofRadiographic Diagnosis of
Pulmonary Embolism DuringPulmonary Embolism During
PregnancyPregnancy::
• • Ventilation/Perfusion (V/Q) ScanningVentilation/Perfusion (V/Q) Scanning
• • Pulmonary AngiographyPulmonary Angiography
• • Spiral/Helical CTSpiral/Helical CT

39. TTreatment- Pulmonaryreatment- Pulmonary
Embolism in PregnancyEmbolism in Pregnancy
• • Anticoagulation is mainstay ofAnticoagulation is mainstay of
pharmacotherapypharmacotherapy
• • Supportive care should not be forgotten Supportive care should not be forgotten
during the rush to diagnose and treatduring the rush to diagnose and treat

40. Amniotic Fluid Amniotic Fluid EmbolismEmbolism
““Anaphylactoid syndrome of Anaphylactoid syndrome of pregnancy" pregnancy"

41. Amniotic Fluid EmbolismAmniotic Fluid Embolism
AFE is an - unpredictableAFE is an - unpredictable
- unpreventable and- unpreventable and
-an untreatable -an untreatable
(for the most part)(for the most part)

obstetric emergencyobstetric emergency

42. Amniotic Fluid EmbolismAmniotic Fluid Embolism
• • Frequency- 1/15,000 - 1/20,000Frequency- 1/15,000 - 1/20,000
PregnanciesPregnancies
• • Catastrophic ConsequencesCatastrophic Consequences
• • Multisystem CollapseMultisystem Collapse
• • Mortality Quoted as High as 80%Mortality Quoted as High as 80%
(Probably Lower Now(Probably Lower Now))

43. Clinical presentationClinical presentation
The classic clinical presentation of the The classic clinical presentation of the
syndrome has been described by five signs syndrome has been described by five signs
that often occur in the following sequence:that often occur in the following sequence:
(1) Respiratory distress(1) Respiratory distress
(2) Cyanosis(2) Cyanosis
(3) Cardiovascular collapse (3) Cardiovascular collapse cardiogenic shockcardiogenic shock
(4) Hemorrhage (4) Hemorrhage
(5) Seizure & Coma. (5) Seizure & Coma.

44. National registryNational registry’’s criteria for s criteria for
diagnosis of amniotic fluid diagnosis of amniotic fluid
embolism embolism

45. AFE- Differential Diagnosis AFE- Differential Diagnosis
• Pulmonary Embolism
• Venous Air Embolism
• Myocardial Infarction
• Eclampsia
• Anaphylaxis
• Local Anesthetic Toxicity

46. Management of AFEManagement of AFE


IMMEDIATE MEASURES :IMMEDIATE MEASURES :
- Set up IV Infusion, - Set up IV Infusion,
-O-O
22 administration. administration.
- Airway control - Airway control  endotracheal intubation endotracheal intubation
maximal ventilation and oxygenation.maximal ventilation and oxygenation.

LABS :LABS : CBC,ABG,PT,PTT,fibrinogen,FDP.CBC,ABG,PT,PTT,fibrinogen,FDP.
RECOGNITION
FIRST STEP

47. Management of AFEManagement of AFE
Treat hypotensionTreat hypotension, increase the circulating , increase the circulating
volume and cardiac output with crystalloids.volume and cardiac output with crystalloids.
After correction of hypotension, After correction of hypotension, restrict fluid restrict fluid
therapy therapy to maintenance levels since ARDS to maintenance levels since ARDS
follows in up to 40% to 70% of cases.follows in up to 40% to 70% of cases.
Steroids Steroids may be indicated (recommended but no may be indicated (recommended but no
evidence as to their value)evidence as to their value)
NorAdrenalineNorAdrenaline infusion if patient remains infusion if patient remains
hypotensive (myocardial support).hypotensive (myocardial support).
Treat CoagulopathyTreat Coagulopathy

48. RESUSITATION RESUSITATION
OF OF
CARDIAC ARRESTCARDIAC ARREST

49. CardiopulmonaryCardiopulmonary
Resuscitation in PregnancyResuscitation in Pregnancy
 If you think that this will never happen to you,
you are wrong!
 Being an Obstetrics provider is no excuse not to be
CPR literate.
 Non-Obstetrics providers may know more than you
do about CPR, but they may know little or nothing
about pregnancy, fetal evaluation, etc.

50. Cardiac Arrest in PregnancyCardiac Arrest in Pregnancy

Maternal diagnosisMaternal diagnosis

Fetal condition and maturityFetal condition and maturity

How rapidly and appropriately medical and How rapidly and appropriately medical and
nursing personnel respondnursing personnel respond

Resources available in hospitalResources available in hospital
What happens next depends on:What happens next depends on:

51. Cardiac Arrest in Pregnancy:Cardiac Arrest in Pregnancy:
Complicated by Physiologic Complicated by Physiologic
ChangesChanges

Rapid development of hypoxia, hypercapnia, Rapid development of hypoxia, hypercapnia,
acidosis acidosis

Risk of pulmonary aspirationRisk of pulmonary aspiration

Difficult intubationDifficult intubation

AORTO-CAVAL COMPRESSION AORTO-CAVAL COMPRESSION by pregnant by pregnant
uterus when mother supineuterus when mother supine

Changes greater in multiple pregnancy, Changes greater in multiple pregnancy,
obesityobesity

52. Cardiac Arrest in Pregnancy:Cardiac Arrest in Pregnancy:
Special ProblemsSpecial Problems
•Cardiac output during closed chest massageCardiac output during closed chest massage
in CPR is only ~ 30% normalin CPR is only ~ 30% normal
•Cardiac output in the supine pregnant Cardiac output in the supine pregnant
woman is decreased 30-50% due to woman is decreased 30-50% due to
aortocaval compressionaortocaval compression
•Combined effect of above: There may be Combined effect of above: There may be
NO cardiac output!NO cardiac output!

53. Cardiff Resusitation WedgeCardiff Resusitation Wedge

55. Why is Urgent Delivery Why is Urgent Delivery
Indicated?Indicated?

Maternal brain damage may start at ~ 4-6 minMaternal brain damage may start at ~ 4-6 min

What is good for mother is usually good for babyWhat is good for mother is usually good for baby

Most intact newborns delivered within 5 minMost intact newborns delivered within 5 min

Closed chest massage is less effective with timeClosed chest massage is less effective with time

CPR may be totally ineffective before delivery:CPR may be totally ineffective before delivery:Many Many
reports of mother “coming back to life” after deliveryreports of mother “coming back to life” after delivery

56. Advantages of Early Advantages of Early
DeliveryDelivery

Aortocaval compression relieved:Aortocaval compression relieved: Venous Venous
return return , Cardiac output , Cardiac output 

Ventilation improved:Ventilation improved:-Functional Residual -Functional Residual
Capacity Capacity 
-Oxygenation improved-Oxygenation improved
Oxygen consumption Oxygen consumption , CO, CO
2 2 production production 

Improved maternal and newborn survivalImproved maternal and newborn survival

57. The Cesarean Delivery Decision - The Cesarean Delivery Decision -
Not an Easy One!Not an Easy One!
•Has 3-4 min passed since cardiac arrest?Has 3-4 min passed since cardiac arrest?
•Has the mother responded to resuscitation?Has the mother responded to resuscitation?
•Was resuscitation optimal - can it be Was resuscitation optimal - can it be
improved?improved?

58. Early
Haemorrhage
Hypotentio
n
Shock
Cardiac Arrest
Deliver the baby < 5mts
Early intervention
Late intervention
Early Recognition
Prevent shock
Resusitation
CPR

59. ““Perimortem” Cesarean SectionPerimortem” Cesarean Section

Start by 4 minutes, deliver by 5 Start by 4 minutes, deliver by 5
minutes (From the time of Arrest)minutes (From the time of Arrest)

Perform operation in patient’s room:Perform operation in patient’s room:
Can move to OT Can move to OT afterafter delivery delivery

Don’t worry about sterilityDon’t worry about sterility

Vertical abdominal incision quickestVertical abdominal incision quickest

Prepare for uterine hypotonia and Prepare for uterine hypotonia and
bleedingbleeding

60. Essential Equipment (Should be Essential Equipment (Should be
available in Labour ward)available in Labour ward)

Pulse oximeterPulse oximeter

Cardiac arrest cart; defibrillatorCardiac arrest cart; defibrillator

Automatic Electric Defibrillator (AED)?Automatic Electric Defibrillator (AED)?

Cesarean section instrumentsCesarean section instruments

Difficult intubation equipment (including LMA, Difficult intubation equipment (including LMA,
jet ventilator, fiberoptic laryngoscope)jet ventilator, fiberoptic laryngoscope)

Blood warmer and rapid fluid infuserBlood warmer and rapid fluid infuser

Central venous and arterial line equipmentCentral venous and arterial line equipment

61. BBest Practice Points
All staff involved in intrapartum care should be familiar
with basic life support guidelines for the pregnant patient
and should follow them during resuscitation attempts.
30 degree left lateral tilt should be used to minimise
aortocaval compression and maximise cardiac output.
Caesarean section should be performed after 4 minutes
of unsuccessful resuscitation.
Senior obstetric, anaesthetic and neonatal staff should
be involved as early as possible.
Record keeping should be meticulous ensuring that
treatment given and timings are clearly identified.

62. Common Problems in Common Problems in
ObstetricsObstetrics

Denial of problem Denial of problem  delay in response delay in response

Communication errorsCommunication errors

Obstetric staff not prepared for catastrophesObstetric staff not prepared for catastrophes

Inadequate response from transfusion or labsInadequate response from transfusion or labs

No specialty in-house surgeons (e.g., for airway, No specialty in-house surgeons (e.g., for airway,
vascular, cardiac problems)vascular, cardiac problems)

No OB-ICU facilitiesNo OB-ICU facilities

63. Family SupportFamily Support

When the mother and infant are gravely ill, When the mother and infant are gravely ill,
keep their familykeep their family

members well informed. members well informed.

Be cool and calm while communicating with the Be cool and calm while communicating with the
family membersfamily members

Allow as much access to the lovedAllow as much access to the loved

ones as ones as
possible.possible.

Get informed consent at each stage.Get informed consent at each stage.

64. WORK FORCE & PROTOCOLSWORK FORCE & PROTOCOLS

65. MEOWSMEOWS
Vital Sign Vital Sign
TriggersTriggers
““Contact doctor if Contact doctor if
one red or two one red or two
yellow scores at yellow scores at
any one time.”any one time.”
Swanton, IJOA 2009; 18: 253-7

66. MEOWS TriggersMEOWS Triggers
Response initiated for one red or two Response initiated for one red or two
yellow triggers:yellow triggers:
Parameter Red Trigger Yellow Trigger
Temperature < 35 or >38 35-36
Systolic BP; mmHg <90 or >160 150-160
Diastolic BP; mmHg >100 90-100
Heart rate <40, >120 100-120, 40-50
Respiratory rate <10 or >30 21-30
Oxygen saturation <95 -
Pain score - 2-3
Neurological
response
Unresponsive, pain Voice
Singh et al. Anesthesia. 2012

67. Two Essential Two Essential
ComponentsComponents

68. • • In such emergency situationIn such emergency situation
It appears important to:It appears important to:
– – Streamline the workflowStreamline the workflow
– – Co-ordinate the efforts Co-ordinate the efforts
of different specialitiesof different specialities

69. • Protocol should be specific for your hospital
(Hospital specific)
• Protocol depends upon your hospital infra- structure
and the availability of Resources/ persons
•Determine the hemorrhage response team
•Determine team member responsibilities
•Update and modify your Protocol periodically
•Conduct periodic Emergency drill
Hemorrhage protocol
Logistics

70. Preparation
Daily tasks Daily tasks
•checking of equipment,checking of equipment,
• drugs and communication systems. drugs and communication systems.
Long term tasks Long term tasks
• training, training,
•audit, audit,
•service development, service development,
•case review case review
•risk management. risk management.

71. Improving outcomes after Improving outcomes after
maternal collapsematernal collapse

Be ReadyBe Ready
–Trained staffTrained staff
–Have emergency equipment assembled & quarantined for Have emergency equipment assembled & quarantined for
emergency useemergency use
–Have systems that assemble more staffHave systems that assemble more staff
–Practice drillsPractice drills

Be ForewarnedBe Forewarned
–Needs an obstetric early warning system to identify...Needs an obstetric early warning system to identify...
–The patient at riskThe patient at risk
–When she is on the slippery slopeWhen she is on the slippery slope

Review and ReviseReview and Revise
–After each eventAfter each event
–And each “near miss”And each “near miss”

72. Those who fail to Those who fail to
prepare are prepared prepare are prepared
to fail.to fail.