Maternal collapse Flashcards by Hiba Alhasso

What should you do if a heavily pregnant woman collapses and is lying on her back? and why?

check for danger and call for help

She should be rolled into the left lateral position to avoid aortocaval compression causing vasovagal syncope

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What are direct causes of maternal death

VTE, PPH, pulmonary oedema

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What are indirect causes of maternal death

cardiac arrest

mental health conditions

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Whose life do you have to save first, the mother or the baby

Mother, otherwise you cant save the baby

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Who should you ask for when you call 2222/999

maternity team + arrest team

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What is maternal collapse a sign of

respiratory or cardiac distress

may range from syncope to cardiac arrest

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What are the reversible causes of cardiac arrest

4H’s + 4T’s

Hypoxia 
Hypovolaemia 
Hypothermia 
Hyper/Hypokalaemia 
Pre eclampsia 
Toxins 
Tension pneumothorax 
Tamponade 
Thromboembolic disease - amniotic fluid embolism

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What emergency bloods should you ask for

FBC 
U+E 
LFT 
lactate 
cultures 
ABG 
Crossmatch 
GLUCOSE

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What level of glucose is bad

<4 to the floor

Treat!

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Who is Mrs MUD

All pregnant women

Manual Uterine Displacement

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When is Mrs MUD done

during resuscitation and CPR

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After how many minutes of CPR should a baby be delivered, do you need to go to theatre?

4 minutes - decision made / prepare for peri-mortem c-section
5 minutes - baby is out
No, can be done there and then with just a scalpel

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Can CPR continue whilst you deliver the baby at 4 min

Yes

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What medication do you give in cardiac arrest

1 mg Adrenaline every 2 min

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What medication do you give for VF/VT

300mg amiodarone

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What are the shockable rhythms

VF and pulseless VT

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What are the NON shockable rhythms

PEA and asystole

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What medication is given in opioid overdose

0.4-0.8mg naloxone

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What medication is given for magnesium sulphate overdose

1g Calcium gluconate

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What medication is given for local anaesthetic overdose

1.5ml 20% Intralipid

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How do you manage an eclamptic seizure

call for help 
make patient safe - remove objects that could cause harm 
record timing and duration 
after seizure - give:
high flow O2
left lateral position 
open airway 
monitor baby

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What is happening after 5 minutes of seizure

status epilepticus

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Management of anaphylaxis

remove allergen 
high flow O2 
IM adernaline every 5 minutes 
IV crystalloid bolus 
IV chlopheniramine 
IV hydrocortisone 
Neb salbutamol

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Pregnant women may be normoglycaemic in DKA, true or false

TRUE

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Signs + Management of amniotic fluid embolism

``` supportive and intensive care foetal distress resp distress DIC seizure Increased Zn coproporphyrin levels Clinical diagnosis largely ```

Can you thrombolyse a pregnant women with a massive PE

Yes with heparin

how severe is cord prolapse

obstetric emergency | causes direct compression and cord spasm - hypoxia and death

Features of cord prolapse

``` malpresentation pre term ruptured membranes 2nd twin may or may not see cord come down ```

How soon should a baby be delivered if there is cord prolapse

ASAP - category 1 c-section

What should always be done before artificial rupture of membranes ARM

Palpate the abdomen to ensure the head is engaged and avoid a cord prolapse

Shoulder dystocia is an obstetric emergency, true or false

TRUE

What is the management of shoulder dystocia

``` HELPERR H - Help E - consider Episiotomy L - Legs in McRoberts manoeuvre P - external suprapubic Pressure E - Enter vagina with internal pressure R - Remove posterior arm R - Rotate mother on all fours ```

What are the 5 H's that cause maternal collapse

``` Head Heart Hypoxia Haemorrhage wHole body and Hazards ```

Head: causes of collapse

eclampsia epilepsy cerebrovascular incident vasovagal response

Heart: causes of collapse

MI arrythmias peripartum cardiomyopathy

Hypoxia: causes of collapse

asthma PE pulmonary oedema anaphylaxis

Haemorrhage: causes of collapse

``` uterine rupture placental abruption atony trauma ruptured aneurysm ```

wHole body and Hazards: causes of collapse

``` hypoglycaemia amniotic fluid embolism sepsis trauma anaesthetic complications drug overdose ```

why is it harder to resuscitate a pregnant woman

pregnant uterus causes aortocaval compression pressure on diaphragm causes ventilation difficulty foetus "steals" oxygen therefore at more risk of hypoxia more likely to aspirate due to hormonal relaxation of oesophageal sphincters more difficult to intubate

As soon as infant is delivered, vena cava returns to normal and cardiac output is restored True or false

TRUE

How do you do MUD

Keep mother in supine position and apply left MUD to displace uterus to relieve pressure on aorta and vena cava which improves venous return to the heart

What should be ensured when an AED indicates shock

ensure no one is touching the patient | ensure oxygen mask is far away

When do you give adrenaline in cardiac arrest with shockable rhythms

1mg adrenaline should be given after the 3rd shock with defibrillator and then every other cycle (every 4 minutes)

When should amiodarone be given in cardiac arrest with shockable rhythms

after the 3rd shock with the defibrillator

When should adrenaline be given in non-shockable rhythms

every 3-5 minutes

Signs of massive PE in a pregnant woman

``` raised JVP enlarged liver parasternal heave fixed splitting of 2nd heart sound +- evidence of DVT ```

What is shoulder dystocia

any cephalic presentation where manoeuvres other than gentle traction are required to deliver the baby after the head has been delivered bony impaction of foetal anterior shoulder on maternal pubis symphysis

What signs can be seen in shoulder dystocia

head bobbing | turtle sign

in which position should pregnant women be assessed

left lateral position

what systems can you use in the assessment of maternal collapse

ABCDE | primary obstetric survey / PROMPT - starts at the head and works downwards

describe the PROMPT assessment

head - AVPU, responsive heart - CRT, pulse, BP, murmur chest - air entry, RR, O2 sats, breath sounds, trachea central abdomen - rebound, guarding, tenderness, foetus alive? Vagina - bleeding, stage of labour, inverted uterus legs - sign of DVT

what interventions can you make if the cause of maternal collapse is not obvious

fluid resuscitation ? laparotomy Sepsis 6? intensive care?

contraindications to fluid resuscitation

pulmonary oedema as a result of severe pre-eclampsia or renal failure

what is the secondary survey

take a history / revisit history read notes / ask relatives examine from top to toe again investigations: ABG, troponin, glucose, lactate, ECG, CXR, USS, high vaginal swab

causes of maternal collapse 5H's

``` Head Heart Hypoxia Haemorrhage wHole body and Hazards ```

potential causes of maternal collapse: HEAD

``` eclampsia epilepsy CVA intracranial haemorrhage vasovagal response ```

potential causes of maternal collapse: HEART

``` MI arrythmias peripartum cardiomyopathy congenital heart disease thoracic aortic dissection cardiac arrest ```

potential causes of maternal collapse: HYPOXIA

asthma PE pulmonary oedema anaphylaxis

potential causes of maternal collapse: HAEMORRHAGE

``` placental abruption uterine atony genital tract trauma uterine rupture uterine inversion ruptured aneurysm ```

potential causes of maternal collapse: wHole body and Hazards

``` hypoglycaemia amniotic fluid embolus sepsis trauma complications of anaesthesia anaphylaxis ```

management of uterine atony as a cause of PPH

expel clots and massage uterus IV access + bloods: FBC, coagulation, cross match IV fluids uterotonics - syntocin/ergometrine/carboprost tranexamic acid urinary catheter