MATERNAL COLLAPSE IN PREGNANCY AND PUERPERIUM - CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline 2. The Guidance

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1 MATERNAL COLLAPSE IN PREGNANCY AND PUERPERIUM - CLINICAL GUIDELINE 1. Aim/Purpose of this Guideline 2. The Guidance 2.1. Incidence The rate of maternal collapse lies between 0.14 and 6/1000 (14 and 600/ ) births. As it is such a rare event, with potentially devastating consequences, it is essential that caregivers are skilled in initial effective resuscitation techniques and are able to investigate and diagnose the cause of the collapse to allow appropriate, directed continuing management. It should be noted that vasovagal attacks and the post-ictal state following an epileptic seizure are the most common causes of maternal collapse and are not covered by this guideline Identification A Maternity Early Obstetric Warning Scoring system (MEOWS) should be used for all women who require more than the basic routine observations; this includes ante natal, intrapartum and postpartum observations. This is to allow early recognition of the woman who is deteriorating and becoming critically ill. In some cases maternal collapse occurs with no prior warning, although there may be existing risk factors that make this more likely. Antenatal care for women with significant medical conditions at risk of maternal collapse should include multidisciplinary team input with a pregnancy and delivery management plan in place Causes The common reversible causes of collapse in any woman can be remembered using the well known aide memoire employed by the Resuscitation Council (UK) of the 4 T s and the 4 H s. Thromboembolism (include Amniotc fluid embolism/anaphylactoid Syndrome of pregnancy) Toxicity Tension pneumothorax Tamponade (cardiac) Hypovolaemia, Hypoxia Hypo/hyperkalaemia and other electrolyte disturbances Hypothermia 1 Eclampsia and intracranial haemorrhage should be added to above list. Although consideration should be given to the cause of the collapse throughout the resuscitation process, this should never delay the initiation or continuation of resuscitation. Page 1 of 10

2 Hypovolaemia due to bleeding is the most common cause of a maternal collapse, but hypovolaemia can also occur secondary to a high spinal block and septic shock (see guideline The management and early recognition of the severely ill pregnant woman ). Other causes more commonly occurring in the maternity setting include Magnesium toxicity- antidote is 10mls of 10% calcium gluconate given by slow IV injection Local anaesthetic toxicity (Bupivicaine). Consider use of Intralipid 20% 1.5ml/kg over 1min (100ml for 70kg woman) followed by an IV infusion of 0.25ml/kg/min (400ml over 20mins). The bolus injection can be repeated twice at 5 minute intervals. See AAGBI guideline 2. Advanced life support and CPR should be continued throughout administration of intralipid until an adequate circulation is restored. All cases of lipid rescue should be reported to the Lipid rescue site ( 2.3 Resuscitation Initiate immediate Basic life support according to the Resuscitation Council (UK) guidelines with the inclusion of the following Left uterine displacement. Aortocaval compression significantly reduces cardiac output from 20 weeks of gestation onwards. In the supine position the gravid uterus can compress the inferior vena cava and aorta (to a much lesser extent), thus reducing venous return and, as a consequence, cardiac output by up to 30 40%, causing what is known as supine hypotension. Supine hypotension itself can precipitate maternal collapse, which is usually reversed by turning the woman into the left lateral position. Maternal cardiac arrest To achieve a perimortem caesarean section within 5 minutes it is essential the obstetric registrar is included in the cardiac arrest call team. Stating maternal cardiac arrest will ensure the obstetrician is included in the emergency call. Perimortem section within 5 minutes of confirmation of cardiac arrest. If there is no response to correctly performed CPR within 4 minutes of collapse delivery should be undertaken to assist maternal resuscitation. The perimortem section should be performed where resuscitation is taking place and not delayed by moving the woman. The gravid uterus of more than 20 weeks gestation impairs venous return and reduces cardiac output secondary to aortocaval compression. Delivery of the fetus and placenta reduces oxygen consumption, improves venous return and helps both chest compressions and ventilation. Training: Page 2 of 10

3 All midwives, obstetricians and obstetric anaesthetists will attend the annual training in obstetric multidisciplinary emergencies (TOME) day, which includes a session on maternal collapse and maternal resuscitation. Incident reporting: Any incident of maternal collapse, what ever the outcome, will be reviewed through the clinical incident review meeting Compliance monitoring: Attendance at the TOMES day will be monitored every 3 months by the maternity risk management forum and an action plan developed and monitored if any deficiencies are identifed Page 3 of 10

4 Maternal Resuscitation Collapsed / showing no signs of life or respiratory arrest Community 999 Shout for HELP and assess patient Request cardiac arrest trolley with AED and perimortum C/S pack Signs of life? NO Left lateral tilt Call 2222 and state Maternal cardiac arrest and request the arrest team, Obstetric registrar and an obstetric anaesthetist. Basic Life Support CPR 30:2 if 2 people. Compressions only if single handed CPR 30:2 ata rate of compressions a minute With oxygen and airway Apply ECG pads /monitor Advanced Life Support When Resuscitation Team arrives Deliver baby within 5 minutes if no response to CPR Successful Stabilise Transfer Delivery Suite or ITU Continue life support until successful or decision to discontinue Page 4 of 10

5 3. Monitoring compliance and effectiveness. Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Maternal collapse in Pregnancy and the Puerperium 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 5 of 10

6 Appendix 1. Governance Information Document Title MATERNAL COLLAPSE IN PREGNANCY AND PEURPERIUM, CLINICAL GUIDELINE FOR Date Issued/Approved: 6 th March 2014 Date Valid From: 6 th March 2014 Date Valid To: 6 th March 2017 Directorate / Department responsible (author/owner): Obs & Gynae Directorate Contact details: Brief summary of contents Guideline for the care of maternal collapse in pregnancy. Suggested Keywords: Target Audience Executive Director responsible for Policy: Date revised: This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes RCHT PCH CFT KCCG Maternal collapse in Pregnancy and the Puerperium Midwifery Guidelines Group Obs & Gynae Directorate Divisional Board Head of Midwifery Name and Post Title of additional signatories Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Not required {Original Copy Signed} Internet & Intranet Links to key external standards CNST 2.8 & 2.9 Intranet Only Clinical / Midwifery and Obstetrics Page 6 of 10

7 Resuscitation Council (UK).Resuscitati Guidelines2010 Related documents: Training Need Identified? None delines/docs/latoxicity07.pdf. CEMACE March 2011.The 8 th Report Reviewing maternal deaths to make motherhood safer Version Control Table Date Version No Summary of Changes Changes Made by (Name and Job Title) [ All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 7 of 10

8 Appendix 2. Initial Equality Impact Assessment Form Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): MATERNAL COLLAPSE IN PREGNANCY AND PUERPERIUM CLINICAL GUIDELINE Directorate and service area: Obs & Gynae Directorate Is this a new or existing Policy? Existing Name of individual completing assessment: Elizabeth Anderson Telephone: Policy Aim* Who is the strategy / policy / proposal / service function aimed at? To provide guidance to obstetricians and midwives on the management of maternal collapse in pregnancy. 2. Policy Objectives* To ensure evidence based advice and management of a pregnant woman declining blood products. 3. Policy intended Outcomes* 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. Safe outcome for women and baby Compliance monitoring Women and new-born No N/A N/A Page 8 of 10

9 7. The Impact Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence Age Sex (male, female, transgender / gender reassignment) Race / Ethnic communities /groups Disability - learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. N/A Signature of policy developer / lead manager / director Date of completion and submission 5 th June 2014 Names and signatures of members carrying out the Screening Assessment 1. Elizabeth Anderson 2. Page 9 of 10

10 Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed: Elizabeth Anderson Date: 6 th March 2014 Page 10 of 10