Guideline Obs 122 Division of Surgery Directorate of Obstetrics and Gynaecology

Transcription

1 Guideline Obs 122 Division of Surgery Directorate of Obstetrics and Gynaecology Guidelines for the management of Peri-arrest or Peri-mortem Caesarean section Written by Hari Muppala and Apollo Meskhi, revised by Zahida Khan and David A Jones, September Ratified by SIT: 17 th November 2010 Latest date for review: September 2013 Introduction When cardiac arrest occurs in a pregnant woman, standard resuscitation guidelines apply. This will be according to the Resuscitation Council (UK) 2010 guidelines. In late pregnancy, the effectiveness of cardiopulmonary resuscitation (CPR) is compromised by aortocaval compression, with obstruction of the inferior vena cava limiting venous return to the heart. The stroke volume of a term pregnant woman lying supine is only 30% of normal, but if the patient is in a left lateral tilt, stroke volume and cardiac output increase by at least 25%. Lateral tilting should therefore be the first manoeuvre in the event of cardiac arrest. If sufficient cardiac output is not achieved within 4 minutes, a Caesarean delivery should be considered and delivery should be accomplished within 5 minutes. Emptying of the uterus will increase cardiac output by 60-80% of pre-delivery level, and thus gives a chance for recovery of mother and fetus. The total number of peri-mortem caesarean sections performed for all mothers in last triennium, 52, has almost doubled since the previous report, when only 27 cases were assessed (CEMACH 2007). In this report 20 babies survived, but their chances of survival were greatly improved with advanced gestational age, improved resuscitation techniques, availability of adequate and appropriately trained staff and the location, such as in delivery suite or operating theatre. Factors to consider when deciding peri-arrest or peri-mortem caesarean section: 1. The gestational age - emptying the uterus after 20 weeks gestation improves chances of maternal survival 2. The probability of neonatal survival - you are doing it for the mother and not the fetus, so this should not affect your decision While the optimal interval from arrest to delivery is 5 minutes, there are case reports of infant survival after more than 20 minutes of maternal cardiac arrest. Evidence suggests that, if the fetus survives the neonatal period, then the chances of normal development are good.

2 Medico-legal issues You must always act in the best interests of the mother. Never do a procedure to save the fetus the fetus has no legal rights. In these situations, the woman will lack capacity and, subject to no contrary valid advance directive having been made by the mother, the clinician may proceed with treatment that he /she considers to be in the patient s best interests (which is wider than simply medical best interests, and must take into account other factors such as the wishes and beliefs of the patient when competent, their general well being and their spiritual and religious welfare). Only essential treatment should be carried out, including treatment to preserve life, health, or well being of the patient. Ideally, the proposed treatment must be discussed with the patient s relatives, or a person with a valid lasting power of attorney with regard to the mother s welfare, or a carer (who is not a paid carer), or anyone who is interested in the mother s welfare, and, where there is no relative or carer, other than a paid carer, the proposed treatment should be discussed with an Independent Mental Capacity advocate, in accordance with the Mental Capacity Act, It is however very unlikely that this will be feasible in this situation whilst still allowing timely intervention (see below). The patient may have written an advance directive and it is essential to take care to make sure the terms are specific and the circumstances detailed in the advance directive have come to pass. Where there is any doubt as to the validity of consent, and time is of the essence, action should be taken to preserve the life or prevent serious deterioration of the mother. Procedure Action 1. The Resuscitation Council (UK) has recommended that prompt caesarean delivery should be considered as a resuscitative procedure for cardiac arrest in near-term pregnancy. 2. It is important anaesthetist is in attendance at the earliest opportunity 3. Early involvement of senior obstetrician and neonatologist is mandatory. Rationale This will reduce maternal oxygen consumption, increase venous return, make ventilation easier and allow CPR in the supine position. This will also allow access to the infant so that newborn resuscitation can begin. To provide a protected airway, ensure continuity of effective chest compressions and adequate ventilation breaths as well as helping to determine and treat any underlying cause. To provide appropriate care to the mother and the neonate. 2

3 4. Perimortem caesarean section should be carried out within five minutes of a cardiac arrest. Consideration should still be given to performing a CS outside this time limit because it may be advantageous for the resuscitation of the mother 5. Decision to proceed to caesarean section should be made at consultant level, preferably after discussion with the relatives. This will be difficult to discuss; therefore still start the caesarean section by 4 minutes 6. Consider gestational age 1. Gestation <20 weeks. Urgent caesarean delivery need not be considered weeks. Perform an emergency caesarean to enable successful resuscitation of the mother, not the survival of the delivered infant. 3. > 24 weeks. Perform an emergency caesarean to save the life of both the mother and the infant. 7. Protocol for emergency caesarean section should be activated as soon as the cardiac arrest is identified. 8. Moving the mother to an operating theatre (e.g. from a labour room or accident and emergency department) is not necessary. Outcomes of any other circumstances are universally poor Good practice Gravid uterus reaches a size that will begin to compromise aortocaval blood flow at approximately 20 weeks of gestation. After 24 weeks there is a moderate chance of the infant surviving. Establishment of IV access and an advanced airway typically requires several minutes. Pregnant women develop anoxia faster than non-pregnant women and can suffer irreversible brain damage within 4-6 minutes after cardiac arrest To continue resuscitative measures and plan timely perimortem caesarean. If the mother is successfully resuscitated, complete the operation before moving to theatre 3

4 9. Limited equipment required in this situation. A scalpel and dissecting forceps should be sufficient to effect delivery of the baby. 10. Midline subumbilical skin incision may be preferable. However, the obstetrician should use the technique with which they are most comfortable. Care must be taken to prevent any inadvertent injury to internal organs and the baby. Attention should be paid to prevent over extension of fetal neck as is applicable to all caesarean sections Umbilical cord should be doubly clamped. 11. Consider open cardiac massage Should resuscitation be successful, appropriate sedation or general anaesthesia needs to be administered and consideration can be given to moving to theatre. If you have done a section and not completed suturing, when the woman regains cardiac output she may well bleed substantially, so finish the procedure wherever you are. If maternal survival likely, consider broad-spectrum antibiotics. Sterile preparation and drapes are unlikely to improve survival and valuable time may be lost. Classical approach is aided by natural diastasis of recti abdomini that occurs in late pregnancy and a bloodless field in this clinical situation. Delivery of the baby can be accomplished via low transverse incision in less than one minute. To reduce maternal and neonatal morbidity and mortality. To obtain paired cord gases and blood for neonatal haematological, biochemical and acid base studies. The heart can be reached relatively easily through the diaphragm. To provide amnesia and pain relief To reduce the incidence of infection 4

5 12. Abandon CPR if unsuccessful Do not abandon CPR if rhythm continues as Ventricular Fibrillation/Tachycardia. Communication and teamwork When appropriate seek senior input from obstetrician, anaesthetist and midwifery professionals. Ensure that the family is looked after and kept informed. 13. Recruit as many staff as possible. You will need an individual responsible for each of the following: recording events and management, communication and guideline retrieval, runner/porter. A decision to abandon CPR should only be made by the senior clinicians present For optimal management and outcome To support family members in their most distressing hours. To provide uninterrupted resuscitative measures. To ensure completeness of documentation. 5

6 References 1. Charlotte Howell, Kate Grady and Charles Cox. Managing Obstetric Emergencies and trauma-the MOET course manual (2 nd Edition). Mar Saving mothers lives: reviewing maternal deaths to make motherhood safer Seventh report of the CEMACH. Dec Resuscitation Council (UK) Part 10.8: Cardiac arrest associated with pregnancy. Circulation DOI: /circulationaha Whitten M, Irvine LM. Post-mortem and Perimortem caesarean section: what are the indications? J R Soc Med 2000;93:6-9. Process for audit There are no specific audit criteria for this guideline but it will be audited as required dependent on clinical indications. Monitoring compliance. The use of this guideline will be monitored through the clinical incident reporting system as any incident involving a perimortem caesarean section will be investigated as a Serious Untoward Incident 6