maternal & fetal resuscitation · maternal resuscitation dr robyn aldridge monash health ....

Maternal Resuscitation

Dr Robyn Aldridge Monash Health

Director Clinical Governance Women’s Health

Outline

• Definitions

• Adaptations to pregnancy

• Early Warning systems

• Causes

• Modifications to resuscitation

Maternal Collapse

“An acute event involving the cardiorespiratory systems and/or brain, resulting in a reduced or absent conscious level (and potentially death), at any stage in pregnancy and up to six weeks after delivery”

(RCOG “Maternal Collapse in Pregnancy and the Puerperium” Jan 2011)

The differences…

Two lives, one of which is reliant on the other for survival Rare and unexpected event Often already an emotional environment Physiological adaptations to pregnant state

Adaptation to Pregnancy Cardiovascular Adaptations Respiratory Adaptations • CO increased by about 40%

• Plasma volume increased 50%

• Heart rate increased 10-20 bpm

• Blood pressure decreased T1,T2

• Systemic vascular resistance decreased 25-30%

• Venous return decreased

• Uterine blood flow 10% of CO

Adaptation to Pregnancy Cardiovascular Adaptations Respiratory Adaptations • CO increased by about 40% Increased CPR circulation demands • Plasma volume increased 50% Dilution anaemia – reduced oxygen carrying capacity • Heart rate increased 10-20 bpm Increased CPR circulation demands • Blood pressure decreased T1,T2 Decreased reserve • Systemic vascular resistance

decreased 25-30% Sequesters blood during CPR • Venous return decreased Increased CPR circulation demands, decreased reserves • Uterine blood flow 10% of CO Potential for rapid massive hemorrhage

Adaptation to Pregnancy Cardiovascular Adaptations Respiratory Adaptations • CO increased by about 40% Increased CPR circulation demands • Plasma volume increased 50% Dilution anaemia – reduced oxygen carrying capacity • Heart rate increased 10-20 bpm Increased CPR circulation demands • Blood pressure decreased T1,T2 Decreased reserve • Systemic vascular resistance

decreased 25-30% Sequesters blood during CPR • Venous return decreased Increased CPR circulation demands, decreased reserves • Uterine blood flow 10% of CO Potential for rapid massive hemorrhage

• Oxygen consumption increased 20%

• Metabolic rate increased 15%

• Respiratory rate increased

• Functional residual capacity dec 25%

• Arterial PCO2 decreased

• Laryngeal odema

Adaptation to Pregnancy Cardiovascular Adaptations Respiratory Adaptations • CO increased by about 40% Increased CPR circulation demands • Plasma volume increased 50% Dilution anaemia – reduced oxygen carrying capacity • Heart rate increased 10-20 bpm Increased CPR circulation demands • Blood pressure decreased T1,T2 Decreased reserve • Systemic vascular resistance

decreased 25-30% Sequesters blood during CPR • Venous return decreased Increased CPR circulation demands, decreased reserves • Uterine blood flow 10% of CO Potential for rapid massive hemorrhage

• Oxygen consumption increased 20% Hypoxia develops more quickly • Metabolic rate increased 15% Hypoxia develops more quickly • Respiratory rate increased Decreased buffering capacity, acidosis • Functional residual capacity dec 25% Decreased buffering capacity, acidosis • Arterial PCO2 decreased Decreased buffering capacity, acidosis • Laryngeal odema Difficult intubation

Physical Adaptations Hematological Adaptations • Gastric emptying delayed

• Oesphageal sphincter lower

• Larger breasts

• Decreased or altered exercise, loss

of fitness

• Increased BMI, increased uterine size

Physical Adaptations Hematological Adaptations • Gastric emptying delayed Risk of aspiration • Oesphageal sphincter lower Risk of aspiration • Larger breasts Interfere with intubation • Decreased or altered exercise, loss

of fitness Decreased reserves • Increased BMI, increased uterine

size Ventilation more difficult Aortocaval compression Diaphragmatic splinting

Physical Adaptations Hematological Adaptations • Gastric emptying delayed Risk of aspiration • Oesphageal sphincter lower Risk of aspiration • Larger breasts Interfere with intubation • Decreased or altered exercise, loss

of fitness Decreased reserves • Increased BMI, increased uterine

size Ventilation more difficult Aortocaval compression Diaphragmatic splinting

• Hypercoagulable state • Fibrinogen levels increase 50% • Increased Factor VIII, IX & X • Fibrinolytic activity is decreased • Antithrombin and Protein S

decrease • Tests of coagulation remain N • Venous stasis in the lower limbs

Maternal Collapse

Incidence – Uncertain – 14 – 600 / 100,000 births

Rapid & unexpected Identification of risk factors Substandard care

Causes of Maternal Collapse

Massive Obstetric Hemorrhage

Antepartum Hemorrhage: • (Ectopic pregnancy) • Placenta previa/accreta • Placental abruption • Uterine rupture

Postpartum Hemorrhage: • Primary • secondary

Massive Obstetric Hemorrhage

Antepartum Hemorrhage: • (Ectopic pregnancy) • Placenta previa/accreta • Placental abruption • Uterine rupture

Postpartum Hemorrhage: • Primary • secondary

Massive Obstetric Hemorrhage

Antepartum Hemorrhage: • (Ectopic pregnancy) • Placenta previa/accreta • Placental abruption • Uterine rupture

Postpartum Hemorrhage: • Primary • secondary

Massive Obstetric Hemorrhage

Antepartum Hemorrhage: • (Ectopic pregnancy) • Placenta previa/accreta • Placental abruption • Uterine rupture

Postpartum Hemorrhage: • Primary • secondary

Estimating blood losses

Estimating blood losses

Estimating blood losses

Modifications to Resuscitation

• Uterine displacement

» Manual displacement » Tilt » Resuscitator's knees

Modifications to Resuscitation

• Uterine displacement

» Manual displacement » Tilt » Resuscitator's knees

Modifications to Resuscitation

• Uterine displacement

» Manual displacement » Tilt » Resuscitator's knees

• Altered angle of compressions if woman tilted

Modifications to Resuscitation

• Uterine displacement

» Manual displacement » Tilt » Resuscitator's knees

• Altered angle of compressions if woman tilted

• Early airway protection

Modifications to Resuscitation

• Uterine displacement

» Manual displacement » Tilt » Resuscitator's knees

• Altered angle of compressions if woman tilted

• Early airway protection

• “golden 5 minutes” perimortem C/S

Perimortem C/S

Delivery of the fetus:

– Improves the impaired venous return – Improves the cardiac output by reducing the

aortocaval compression – Reduces oxygen consumption – Facilitates chest compressions – Makes ventilation easier

Perimortem C/S

Equipment

Perimortem C/S

Equipment

Perimortem C/S

Equipment Location

Perimortem C/S

Equipment Location Incision

Perimortem C/S

Equipment Location Incision If resuscitation successful

Perimortem C/S

Outcomes – 38 women – 8/38 had perimortem C/S within 4-5 mins – 17/38 no sequelae, 4 >15 mins (30-38/40) – 12/22 sudden/dramatic improvement

Multidisciplinary Teams

• PRactical Obstetric Multi-Professional Training

• Managing Obstetric Emergencies and Trauma

Perimortem C/S

Outcomes – Pre and Post MOET – 55 cases of maternal collapse – 4 perimortem CS pre course (036/year) – 8 post course (1.6/year) (p = 0.001)

Clinical Governance

• Documentation of collapse • Incident reporting • Training • Debriefing

• The woman • Her family • The staff

Summary

• Many of the adaptations in to pregnancy might adversely affect resuscitation

• Early recognition

• Massive Obstetric hemorrhage is most common cause of maternal collapse

• Modifications to resuscitation

Comments or Questions?

Thank you for your attention

Fetal Hemorrhage

• Chronic • Acute

Fetal Hemodynamics

• Each trimester • During labour