MATERNAL RESUSCITATION Education and …...MATERNAL RESUSCITATION Education and Training The King...
Transcript of MATERNAL RESUSCITATION Education and …...MATERNAL RESUSCITATION Education and Training The King...
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???
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