Maternal Collapse

Question 1

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

Answer 1

Most had underlying health problems or other risk factors

Question 2

What groups are at risk of maternal death?

Answer 2

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

Question 3

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

Answer 3

Thromboembolism and cardiac disease

Question 4

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

Answer 4

Cancer and suicide

Question 5

What are the principles of management for an obstetric emergency?

Answer 5

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

Question 6

What is the maternal Obstetric Early Warning chart?

Answer 6

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

Question 7

What can respiratory or cardiac distress lead to?

Answer 7

Cardiac arrest

Question 8

What are the 5H’s of maternal collapse?

Answer 8

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

Question 9

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

Answer 9

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

Question 10

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

Answer 10

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

Question 11

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

Answer 11

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

Question 12

How do you assess whether an airway is patent?

Answer 12

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

Question 13

How do you assess breathing?

Answer 13

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

Question 14

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

Answer 14

Administer oxygen if hypoxic

Non-rebreathe mask will deliver 65-85% oxygen

Question 15

How do you assess circulation?

Answer 15

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

Question 16

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

Answer 16

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

Question 17

How is disability assessed and managed?

Answer 17

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

Question 18

How is exposure assessed?

Answer 18

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

Question 19

Why are pregnant women more difficult to resuscitate?

Answer 19

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

Question 20

How does pregnancy impact lung function?

Answer 20

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

Question 21

Why does a gravid uterus make resuscitation more difficult?

Answer 21

Causes aortocaval compression

Ventilation difficult due to pressure on diaphragm

Question 22

Why do the foetus and placenta make resuscitation more difficult?

Answer 22

Steal oxygen and circulation from mother

Question 23

What stage of pregnancy does aortocaval compression begin at?

Answer 23

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

Question 24

How does aortocaval compression cause supine hypotension?

Answer 24

Reduces cardiac output by up to 40%

Question 25

What can supine hypotension lead to?

Answer 25

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

Question 26

What position should women be kept in during CPR?

Answer 26

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

Question 27

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

Answer 27

No = normal rate and depth used

Question 28

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

Answer 28

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

Question 29

When should a baby be delivered following a maternal collapse?

Answer 29

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

Question 30

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

Answer 30

There is little blood loss as there is no cardiac output

Question 31

What drugs are given if a shockable rhythm is detected?

Answer 31

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

Question 32

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

Answer 32

Give adrenaline every 3-5 mins

Question 33

What are the reversible causes of cardiac arrest?

Answer 33

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

Question 34

What are some specific drug treatments for causes of collapse?

Answer 34

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

Question 35

What is the management for eclampsia/seizures?

Answer 35

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

Question 36

How is anaphylaxis managed?

Answer 36

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

Question 37

When would you give glucose?

Answer 37

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

Question 38

What is the criteria for diabetic ketoacidosis?

Answer 38

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

Question 39

When do amniotic fluid embolisms tend to occur?

Answer 39

During labour = mortality of 30%

Question 40

What occurs in an amniotic fluid embolism?

Answer 40

Amniotic fluid enters maternal circulation = collapse +/- arrest

Question 41

How does an amniotic fluid embolism present?

Answer 41

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

Question 42

How is an amniotic fluid embolism treated?

Answer 42

Supportive ITU

Question 43

How is an amniotic fluid embolism confirmed on post mortem?

Answer 43

Squames on right sided circulation

Question 44

When are women most at risk of a massive PE?

Answer 44

Postnatally

Question 45

What are the symptoms of a PE?

Answer 45

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

Question 46

What are the signs of a PE?

Answer 46

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

Question 47

Why is a CXR done to investigate a PE?

Answer 47

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

Question 48

What investigations are done for a PE?

Answer 48

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

Question 49

How is a PE treated?

Answer 49

Heparin

Question 50

What are some causes of a cerebrovascular accident?

Answer 50

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

Question 51

How can a cerebrovascular accident present?

Answer 51

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

Question 52

What investigations can be done for a cerebrovascular accident?

Answer 52

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

Question 53

What is a cord prolapse?

Answer 53

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

Question 54

What are some associations of a cord prolapse?

Answer 54

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

Question 55

What is the management of cord prolapse?

Answer 55

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

Question 56

What does shoulder dystocia refer to?

Answer 56

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

Question 57

What occurs in shoulder dystocia?

Answer 57

Bony impaction of foetal anterior shoulder on maternal symphysis

Question 58

What are the risk factors for shoulder dystocia?

Answer 58

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

Question 59

What are the signs of shoulder dystocia?

Answer 59

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

Question 60

What does head bobbing during labour refer to?

Answer 60

Head consistently retracts back between contractions during active second stage

Question 61

What does turtling during pregnancy refer to?

Answer 61

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

Question 62

What are the risks of shoulder dystocia?

Answer 62

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

Question 63

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

Answer 63

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

Question 64

What is the management of shoulder dystocia?

Answer 64

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

Question 65

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

Answer 65

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