maternal & fetal resuscitation · maternal resuscitation dr robyn aldridge monash health ....
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Maternal Resuscitation
Dr Robyn Aldridge Monash Health
Director Clinical Governance Women’s Health
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Outline
• Definitions
• Adaptations to pregnancy
• Early Warning systems
• Causes
• Modifications to resuscitation
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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)
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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
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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
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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
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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
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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
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Physical Adaptations Hematological Adaptations • Gastric emptying delayed
• Oesphageal sphincter lower
• Larger breasts
• Decreased or altered exercise, loss
of fitness
• Increased BMI, increased uterine size
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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
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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
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Maternal Collapse
Incidence – Uncertain – 14 – 600 / 100,000 births
Rapid & unexpected Identification of risk factors Substandard care
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Causes of Maternal Collapse
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Massive Obstetric Hemorrhage
Antepartum Hemorrhage: • (Ectopic pregnancy) • Placenta previa/accreta • Placental abruption • Uterine rupture
Postpartum Hemorrhage: • Primary • secondary
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Massive Obstetric Hemorrhage
Antepartum Hemorrhage: • (Ectopic pregnancy) • Placenta previa/accreta • Placental abruption • Uterine rupture
Postpartum Hemorrhage: • Primary • secondary
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Massive Obstetric Hemorrhage
Antepartum Hemorrhage: • (Ectopic pregnancy) • Placenta previa/accreta • Placental abruption • Uterine rupture
Postpartum Hemorrhage: • Primary • secondary
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Massive Obstetric Hemorrhage
Antepartum Hemorrhage: • (Ectopic pregnancy) • Placenta previa/accreta • Placental abruption • Uterine rupture
Postpartum Hemorrhage: • Primary • secondary
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Estimating blood losses
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Estimating blood losses
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Estimating blood losses
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Modifications to Resuscitation
• Uterine displacement
» Manual displacement » Tilt » Resuscitator's knees
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Modifications to Resuscitation
• Uterine displacement
» Manual displacement » Tilt » Resuscitator's knees
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Modifications to Resuscitation
• Uterine displacement
» Manual displacement » Tilt » Resuscitator's knees
• Altered angle of compressions if woman tilted
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Modifications to Resuscitation
• Uterine displacement
» Manual displacement » Tilt » Resuscitator's knees
• Altered angle of compressions if woman tilted
• Early airway protection
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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
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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
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Perimortem C/S
Equipment
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Perimortem C/S
Equipment
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Perimortem C/S
Equipment Location
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Perimortem C/S
Equipment Location Incision
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Perimortem C/S
Equipment Location Incision If resuscitation successful
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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
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Multidisciplinary Teams
• PRactical Obstetric Multi-Professional Training
• Managing Obstetric Emergencies and Trauma
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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)
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Clinical Governance
• Documentation of collapse • Incident reporting • Training • Debriefing
• The woman • Her family • The staff
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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
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Comments or Questions?
Thank you for your attention
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Fetal Hemorrhage
• Chronic • Acute
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Fetal Hemodynamics
• Each trimester • During labour