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Guidelines for Management of Unexplained Antenatal Intrapartum or

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					                                                                                           Maternity Services




        Guidelines for Management of Unexplained Antenatal,
                 Intrapartum or Postpartum Collapse

   Policy number                                   MAT 166                                  Version                              5

   Author

   Approved by                                     JCNC                                     Date approved                        18/09/2008

   Ratified by                                     Wiltshire PCT Trust                      Date ratified                        18/09/2008
                                                   Board

   Date issued                                                                              Date expires                         17/09/2011

   Target audience                                 All maternity staff
                                                   This policy has had an impact assessment against race,
   Equality & diversity
                                                   disability, gender, age, sexual orientation and religion and
                                                   belief equality and diversity criteria in line with current
                                                   legislation and the requirements of the Single Equality
                                                   Scheme.

                                                   NHS Wiltshire is committed to promoting equality and respect
                                                   for the people of Wiltshire and for our staff. Our aim is to
                                                   ensure that the way we work with individuals and communities
                                                   - and their representatives - and with our staff, challenges
                                                   inequality and affirms difference. This means all our services
                                                   are accessible, appropriate and sensitive to the needs of
                                                   individuals.



    Wiltshire Community Health Service is the arm’s-length provider body of Wiltshire PCT
                 and is wholly owned by and accountable to Wiltshire PCT




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                                                                            Contents
                                                                                                                                                      Page

            1.0              INTRODUCTION ....................................................................................... 3
            3.0              GENERAL PRINCIPLES OF MANAGEMENT........................................... 4
            3.1              HIGH DEPENDENCY CARE ..................................................................... 4
            3.1.1            Who should receive this care?................................................................... 4
            3.1.2            Monitoring .................................................................................................. 5
            4.0              PULMONARY THROMBO-EMBOLISM..................................................... 5
            5.0              AMNIOTIC FLUID (AF) EMBOLISM .......................................................... 5
            6.0              UTERINE RUPTURE................................................................................. 6
            7.0              UTERINE INVERSION .............................................................................. 6
            8.0              AUDITABLE STANDARDS........................................................................ 7
            9.0              REFERENCES .......................................................................................... 7
            10.0             List of Appendices ..................................................................................... 7




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   1.0          INTRODUCTION

                Although this situation is very rare in modern obstetrics, it has made significant
                and increasing contribution to the maternal deaths over the last few decades.
                Sudden antenatal, intra or postpartum collapse can result from a variety of
                conditions, some more common than others. The speed of maternal collapse and
                the degree of diagnostic dilemma can also be variable, and hence only broad
                general recommendations can be made in these guidelines regarding
                appropriate management.


   2.0          AETIOLOGY

                  Pulmonary thrombo-embolism
                  Amniotic fluid embolism

                  Internal haemorrhage:                               Uterine rupture
                                                                      Parageneal haematoma (pelvic/broad ligament)
                                                                      Rupture of hepatic capsule (very rare)
                  Underestimated external haemorrhage
                  Uterine inversion (neurogenic shock)
                  Septic shock
                  Anaesthetic complications: Aspiration of gastric contents
                                                                      Total spinal or epidural block
                  Cardiovascular:                                     Acute myocardial infarction
                                                                      Decompensation of pre-existing cardiac disease
                                                                      Acute left ventricular failure
                                                                      Arrhythmia
                  Cerebro-vascular                                    Intracranial haemorrhage
                  accident:
                  Respiratory:                                        Spontaneous pneumothorax
                                                                      Acute adult respiratory distress syndrome
                                                                      Hypoglycaemia




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   3.0          GENERAL PRINCIPLES OF MANAGEMENT

                Awareness of high risk factors (severe pre-eclampsia, previous history of
                pregnancy complications, medical disorders etc) and frequent monitoring of
                maternal and fetal condition.

                As soon as maternal collapse is suspected:
                •            SUMMON HELP – Obstetric registrar and Senior House Officer (SHO),
                             anaesthetist on duty, obstetric and anaesthetic consultants.
                •            Get the emergency resuscitation trolley and defibrillator (situated near the
                             Central Delivery Suite reception) in the vicinity if necessary.
                •            Administer oxygen by mask.
                •            In the event of cardio-respiratory arrest, follow the protocol of “Adult.
                •            Advanced Life Support” by the European resuscitation Council, continuous
                             monitoring including ECG should be commenced.
                •            Insert two grey cannulae (Venflons) and take blood samples for full blood
                             count, cross-matching, clotting screen and others as indicated.
                •            Start a cardiotocograph (CTG) if not already on.
                •            It is very likely that after initial management, these patients will have to be
                             looked after in the intensive care unit.
                •            DIAGNOSIS - As the resuscitative measures are going on, the obstetric
                             registrar should perform a careful maternal examination to arrive at a
                             provisional diagnosis. Further investigations and intervention will depend
                             upon the possible aetiology as outlined below. Some helpful diagnostic
                             features of occult collapse are summarised in Appendix 1 (page 5).
                The treatment of important conditions is dealt with below.


   3.1          HIGH DEPENDENCY CARE

                All labouring women at Princess Anne Wing are cared for individually on the
                Central Delivery Suite (CDS). Some mothers require high dependency care
                antenatally and/or postnatally. This is best provided in room 11 on CDS. In
                exceptional circumstances, intensive care may be necessary.


   3.1.1 Who should receive this care?

                Any woman who needs more dependent care than can be routinely offered on
                the ante/postnatal ward.
                This may include those with:
                   • Severe pre-eclampsia
                   • Major haemorrhage
                   • Major sepsis.

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   3.1.2 Monitoring

                All mothers should be cared for in room 11, ideally on a 1:1 basis. Senior
                obstetric staff should undertake regular reviews at a minimum at 08:30, 13:00,
                17:00 and 22:00 hours. Where appropriate other specialties will be involved
                including anaesthetists, physicians and general surgeons. Facilities should be
                available to undertake invasive monitoring including central venous pressure
                (CVP) measurements, continuous pulse oximetry and invasive continuous
                arterial blood pressure (BP) monitoring.


   4.0          PULMONARY THROMBO-EMBOLISM

                When it is thought likely that the cause of collapse/arrest is major pulmonary
                embolus (Appendix 1, page 5), intravenous heparin 20,000 units should be given
                (deSwiet, 1995). In addition, prolonged cardiac massage is advisable since this
                may break-up the initial clot. Subsequently, those who show any of the following
                features one hour later:

                             a) Systolic BP less than 90
                             b) PaO2 less than 60 mmHg or
                             c) Urine output less than 20 ml/hour

                should be considered for pulmonary angiography (also an attempt to fragment
                the clot with a guide-wire), thrombolytic therapy (streptokinase) and then possible
                surgery in the form of pulmonary thrombolectomy using cardiopulmonary bypass
                (deSwiet, 1995).



   5.0          AMNIOTIC FLUID (AF) EMBOLISM

                This rare condition presents with similar features as pulmonary thromboembolism
                but occurs around the time of delivery (or caesarean). An AF embolism is soon
                followed by acute disseminated intravascular coagulation (DIC) and postpartum
                haemorrhage. The other risk factors such as rapid labour or augmentation have
                very poor correlation. Initial management is directed to cardio-pulmonary
                resuscitation, continued ventilatory support and treatment of acute DIC and
                haemorrhage (replacement of clotting factors and blood). Involvement of
                consultant haematologist is recommended. Also, refer to protocol for
                management of massive PPH when necessary and early recourse to
                hysterectomy may be life saving (Report on Confidential Enquiries into Maternal
                Deaths in the United Kingdom 2000-2002).



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   6.0          UTERINE RUPTURE

                Catastrophic maternal collapse is fortunately rarer with rupture of previous lower
                segment caesarean scar. Rupture of upper segment caesarean scar or
                unscarred uterus (previous unrecognised trauma like uterine perforation may be
                a predisposing cause) presents with acute abdominal pain, hypotension (shock),
                variable amount of vaginal bleeding and fetal bradycardia or death.

                In multiparous women, cephalo-pelvic disproportion (CPD) and obstructed
                labour, particularly in the presence of oxytocin or prostaglandin augmentation,
                can lead to uterine rupture and hence great care should be exercised in these
                circumstances. On examination, the abdomen is very tender and fetal parts are
                felt very superficially. Vaginal examination may reveal that the presenting part
                has disimpacted from the pelvis.

                Immediate surgical exploration/laparotomy together with resuscitation should be
                performed when uterine rupture is suspected. A ruptured caesarean scar can be
                repaired. A ragged uterine tear and uncontrolled haemorrhage may necessitate
                hysterectomy, and this should be performed before the mother is in extremis.
                Counselling regarding future pregnancy and sterilisation should be arranged if a
                repair is performed.



   7.0          UTERINE INVERSION

                In this rare postpartum complication, maternal collapse is more pronounced than
                can be accounted for by the bleeding because of the associated neurogenic
                shock. When suspected, a quick abdominal and vaginal examination will
                establish the diagnosis. Immediate resuscitative measure and protocol for
                massive PPH should be instituted. At the same time, the patient should be
                transferred to theatre for manual reposition. Uterine relaxation with halothane
                may be necessary. If the placenta is not separated, reposition should be tried
                without separating it first.

                O’Sullivan’s hydrostatic reposition (1945) is very useful and safe when
                experience with manual reposition is lacking. Two litres of warm (37°C) saline
                are held at a height of 6 metres above the ground, a nozzle attached to wide
                bore tubing that is placed in the vagina, and the introitus is blocked with the
                operator’s hand. Reduction of the inverted uterus is usually achieved in 5-10
                minutes using this technique.

                Alternatively, a 6 cm Silastic vacuum cup with its rubber tubing attached to a can
                of 2 litres of saline can be introduced in to the vagina to achieve conveniently
                hydrostatic repositioning. Intravenous oxytocin infusion should be continued after



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                reposition. Laparotomy may be necessary with correction of the inversion by
                traction or Haultain operation.

                Specific treatment of other much rarer causes of maternal collapse are aimed at
                treating the cause and some are outlined in other guidelines.



   8.0          AUDITABLE STANDARDS

                Compliance with the policy will be monitored:

                •            Audited through individual case review by the multidisciplinary maternity
                             risk management team and any learning outcomes will be disseminated
                             across the service.



   9.0          REFERENCES

         1. deSwiet M (1995) Thromboembolism in: Medical Disorders in Obstetric Practice

         2. O’Sullivan JV (1945) Acute inversion of uterus. British Medical Journal 2:282

         3. Why mothers die. Report on confidential enquiries into maternal deaths in the
            United Kingdom 2000-2004

         4. James DIC et al (1995) High Risk Pregnancy Management options.



   10.0         List of Appendices

                Appendix 1 - Features of some ‘occult’ causes of collapse in pregnancy

                Appendix 2 - Adult Resuscitation Equipment List Acute Unit

                Appendix 3 - Adult Resuscitation Equipment List Community Units

                Appendix 4 - Cardiac Arrest




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                                                                                                                                                    Appendix 1
                                                                                                                                                    Page 1 of 1

          Features of some ‘occult’ causes of collapse in pregnancy

          This table excludes more obvious causes, such as ante or postpartum haemorrhage
                                        and/or inverted uterus.

                                                                                                       Helpful diagnostic features in acute stage
                                         Predisposing                     Common                             Clinical           Investigations
                                        circumstances                presenting features
Amniotic fluid                        Labour, not                    Respiratory distress,                                                Squames in SVC or
embolism                              necessarily                    cyanosis.                                                            sputum
                                      precipitate
Pulmonary embolus                     Increasing age,                Respiratory distress,             JVP + third heart                  ECG, chest X-ray,
                                      multiparity,                   cyanosis, chest                   sound,                             lung scan, blood
                                      thromboembolism,               pain                              parasternal heave                  gas, pulmonary
                                      operative delivery,                                                                                 angiography
                                      bed rest,
                                      oestrogens,
                                      haemoglobinopathy
Myocardial infarction                 Increasing age                 Chest pain,                       Pain character, JVP                ECG
                                                                     respiratory                       + crepitations
                                                                     distress, cyanosis
Dysrhythmia                           Pre-existing heart             Tachycardia/                      Pulse                              ECG
                                      disease                        bradycardia
Aspiration of gastric                 Anaesthesia, not               Respiratory distress,             Bronchospasm
contents                              necessarily with               cyanosis
                                      vomiting
Pneumothorax and                      Previous history,              Chest pain                        Chest signs                        Chest X-ray
pneumomediastinum                     labour
Intra-abdominal                       Labour,     thought            Abdominal pain                    JVP not + signs in
bleeding                              may                                                              abdomen,
                                      occur                                                            laparotomy,
                                      spontaneously                                                    paracentesis,
                                                                                                       culdocentesis
Septicaemia                           Previous infection             Fever, rigors                     Fever, rigors                      Gram stain on blood
                                      (not necessarily)                                                                                   sample. Blood
                                                                                                                                          culture positive.
Intracerebral                         Pre-eclampsia/                 Seizures                          CNS signs, neck                    CT scan
catastrophe                           eclampsia,                                                       stiffness
                                      A-V malformation
Hypoglycaemia                         Diabetes mellitus,             Sweating, loss of                                                    Blood glucose
                                      Addison’s disease,             consciousness
                                      Hypopituitarism,
                                      Hypothyroidism
Hyperglycaemia                        Diabetes mellitus              Hyperventilation                                                     Blood glucose, blood
                                                                                                                                          gas


                                                                                                                                                    Appendix 2


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                                                                                                                                                    Page 1 of 1
                              Wiltshire Community Health Services
                                                               Maternity Services

                                                   Adult Resuscitation Equipment List
                                                              Acute Unit


         •      Venous cannulae 2 x 14G (orange/brown), 2 x 16G (grey)
         •      VecafixTM x 4 or similar to secure IV cannulae
         •      Blood bottles and request forms/specimen bags for FBC, cross match, U&E,
                clotting
         •      Blood giving sets x 2
         •      ‘HotlineTM fluid warming sets x 2
         •      3-way taps x 6
         •      Wide-bore extension tubing (for use with hotline) x 2
         •      Fluids: 2 x N Saline 1000ml or Hartmann’s, 2 x 50ml Gelofusin
         •      Syringes: 50ml x 1, 20ml x 2, 10ml x 2, 5ml x 2, 2ml x 2
         •      Hypodermic needles: 19G (green), 25G (orange)
         •      Lignocaine 1% 10ml
         •      Pressure ‘squeezing’ bags
         •      TransporeTM tape
         •      Tourniquet


         •      Arterial cannulae 4 x 20G
         •      Blood gas syringes x 2
         •      Giving sets for invasive monitors & 2 x transducers
         •      Square guaze swabs
         •      Additive labels
         •      Fine-bore extension tubing x 1


         •      Triple lumen central venous line x 1
         •      Drum cartridge central venous line x 1
         •      Leader Cath single lumen catheter
         •      Arrow ‘Rapid Infusion Catheter ExchangeTM’ set x 1
         •      VygonTM Basic Universal Set 199:20
         •      Alcoholic chlorhexidine skin prep
         •      Silk suture for securing CV line e.g. SP623
         •      Straight blade e.g. 11 for cutting suture
         •      Dressing for CV line e.g. TegadermTM 1626W

                                                                                                                                                   Appendix 3


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                                                                                                                                                    Page 1 of 1
                              Wiltshire Community Health Services
                                                                  Maternity Services

                                       Adult Resuscitation Equipment List
                                               Community Units

           Airways:                                     Guedel,                                        Infusion sets x 2. Non-pyrogenic
                                                        single use 1, 2,                               Catheter and bag
           Venflons:                                    3, 4                                           Ambu-bag – Laerdal Silicone
           Blood bottles:                               grey, green                                    Ambu-masks – Laerdal Silicone
                                                        pink, yellow,                                  Oxygen masks
           Syringes:                                    purple,                                        Gloves
           Needles:                                     grey, blue
           Vacutainer:                                  2ml, 5ml, 10ml,
                                                        20ml
                                                        orange, blue,
                                                        green
                                                        barrel, needles
           Tourniquet                                                                                  Lab forms
           IV Additive labels                                                                          Drug chart
           2 x 3-way taps                                                                              Fluid chart
           Plasters/dressings                                                                          TPR chart
           Vacafix
           Sterets
           Bandages

           Cardiac arrest drugs                                                                        Sharps Bin
           500mls N Saline x 2                                                                         Resuscitation Flow Chart
           2 litre Hartmanns
           4 x Gelofusion

           Check working:                          Adult suction Unit
                                                   Adult oxygen
                                                   Drug box
                                                   Adult Stethoscope




                                                                                                                                                   Appendix 4

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                                                                                                                                                      Page 1 of 1
                                Wiltshire Community Health Service
                                                                 Maternity Services

                                                                 Cardiac Arrest

                                                         Immediate Response

                 Call for help – emergency bell. Take emergency trolley/oxygen to patient.

                                                       Administer Basic Life Support

                                                 Then contact the following:
                                     (If alone, make phone calls before commencing BLS)

                                                           Ambulance 9 – 999 call
                                                   State Cardiac Arrest at the Maternity Unit

                                                     Minor Injury Units
                                           State Cardiac arrest at the Maternity Unit
                                    Ask for assistance if available. 09:00 – 1700 Mon – Fri

                                     Notify the area where extra assistance is available
                                           State Cardiac arrest at the Maternity Unit

                                                            Out of Hours Doctor
                                                   State Cardiac Arrest at the Maternity Unit

                                            On-Call Midwife
                      Name and number of midwife on notice board in office or on-call rota

                                                         Ring Princess Anne Wing
                                                      To inform them of patient transfer

                                                                 Inform
                                                       Manager/Supervisor of Midwives




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