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MATERNAL RESUSCITATION
Education and TrainingThe King Edward
ExperienceLinda Long
CNS AnaesthesiaKing Edward Memorial Hospital for
Women
Case Presentation(Marisa)
►36 year old G2 P1
►2006; Previous non-elective caesarean section for pre-eclampsia, twins at 36/40
2008; pregnant despite presence of mirena coil; 32 weeks gestation
Normal pregnancy .........so far
Cardiac arrest in pregnancy
►Is a rare event 1:20-30,000
►Two patients to consider; mother + baby
►Speed and skill of response is critical for outcomes
►Staff do not retain information regarding resuscitation well, therefore `mock drills` essential at helping to prepare for the event.
►Crucial differences in resuscitating the pregnant patient
Physiological Changes
►Respiratory
• Dramatic increase in oxygen consumption
• Rapid onset of hypoxia
• Airway oedema
Physiological changes
►Gastro-intestinal
• Increased incidence of reflux• Delayed gastric emptying
Physiolgical changes
►Cardiovascular
• cardiac output less than 10% of normal during CPR
• increased heart rate
• Decreased resting blood pressure
• Aortocaval compression when supine
Implications for Resuscitation
►Increased risk of difficult airway
►Early endotracheal intubation ? With a smaller ET Tube
►? Cricoid pressure, diverts resources and may make intubation even more difficult
►Measures to prevent aortocaval compression
Uterine displacement
►Displacement of the uterus essential
►Cardiff Resuscitation wedge
►Manual displacement
Attempts at resuscitation may be futile if this is not performed
Gravid uterus picture
Perimortem Caesarean
►Promoted as early as 1986 to improve fetal survival
►Recommended time frame from maternal collapse to delivery of the fetus is 4-6 minutes (Katz et al 1986)
Perimortem Caesarean
EQUIPMENT
►
Perimortem Caesarean
►Caesarean packs kept in resuscitation trolleys in;
► Labour and birth suite
► Emergency centre
► Operating Theatres
►Soon to be implemented in other areas
TECHNIQUE
►Splash of betadine
►Disposable pre-loaded scalpel
►Midline abdominal incision recommended
What are we doing at KEMH?
►IN TIME course, multi-disciplinary obstetric emergencies workshop day
►Compulsory life support in-service for nurses and midwives
►Monthly mock scenarios – multi-disciplinary drills throughout the hospital
►Obstetric emergencies crisis course for anaesthetic registrars
Simulation Scenarios
►Simulation scenarios can be intermediate or high fidelity
►It allows staff to immerse themselves in the clinical proceedings without exposing patients to harm
► Realistic, pregnant manikins were required
Pregnant manikins!
To perform peri-mortem sections on!
CASE PRESENTATIONRemember Marisa ?
►36 year old G2 P1
►Previous non-elective caesarean section for pre-eclampsia, twins at 36/40 in 2006
►2008; despite presence of mirena coil; 32 weeks pregnant
►Uneventful pregnancy…………..so far!
Case Presentation Continued
►Collapsed at home on the sofa
►Brought in by ambulance
►Remained conscious during her transfer by ambulance
►Glasgow coma score was 15
►Heart rate 150
►Blood pressure unrecordable
Case presentation continued
►Transferred directly to labour and birth suite
►Patient became unresponsive, lost consciousness, and stopped breathing
►CPR commenced and code blue medical called
Management of Arrest
►Patient intubated and peri-mortem caesarean section performed in delivery suite
►On incision, four litres of blood in the abdominal cavity
►Code blue paediatric emergency called
Maternal Management
►CVC, arterial line and use of rapid infuser
►Given 170 units red cells, FFP, cryo and platelets
►Inotropes and vasopressin infusions to maintain systolic blood pressure at 90mmHg
Fetal delivery
►Male baby delivered at 8 mins from maternal collapse
►pH was 6.9
►Heart rate < 60
►Apgar score was 1 at birth, 6 five mins later
►Neonatology team commenced CPR and baby intubated
Outcome of mother following perimortem caesarean
►Prompt return of maternal circulation post delivery
►Mother transferred to operating theatre
►Laparotomy, proceeding to total abdominal hysterectomy
Cause of Arrest
►Spontaneous uterine rupture with previously undiagnosed placenta percreta
►Patient developed severe metabolic acidosis and DIC
►Massive haemorrhage -40 litre blood loss
Mother and Baby
►Mother transferred to ICU post operatively
►Followed by transfer to rehabilitation facility for 4 weeks post event
►Baby Owen spent 7days in NICU, two weeks in HDU,
►Discharged home into the care of his aunty
A Happy Family Portrait
Acknowledgements and thanks
►Dr. Nolan McDonnell- Consultant Anaesthetist
►Jenny Owen – Midwifery Educator
►The whole collaborative team that worked tirelessly throughout the night.
QUESTIONS???
?