Obstetric Emergency

1
Obstetric Emergency
2
Objectives

• Examine the care I delivered in an emergency
  situation that ensured the patient remained safe.
• Examine the normal anatomical and physiological
  parameters of a patient undergoing surgery
• Compare the altered AP changes associated with
  the emergency (Obstetrics) and how these changes
  impacted on the care delivered to the patient.

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Scenario Overview

• Obstetric anaesthetic placement on the Maternity
  Unit.
• Moderate previous exposure to Obstetrics with
  fair underpinning knowledge.
• Patient Age 22, 1st child, failure to progress
  in natural labour led to fetal decelerations,
  listed as Category 2 C-Section under Spinal
  Anaesthesia.
• Subsequently suffered a Massive Post Partum
  Haemorrhage in recovery which required a Total
  Abdominal Hysterectomy to arrest the bleed.

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Rationale

• Limited exposure to Obstetrics.
• No experience of managing a major/massive
  haemorrhage in Obstetrics
• Good opportunity to learn and gain a new insight.
• Reflecting on past experience is integral to
  developing and improving future practice (Benner,
  2001).
• RCM (2011) suggests effective and efficient
  management of Obstetric emergencies is reliant
  upon continuous education, training and exposure
  of staff to emergency scenarios.

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How were changes identified?

• Graded classification system identifying urgency
  of Caesarean Section (AAGBI, 2013) Audit
  Categories
• WHO Surgical Safety Checklist for maternity cases
  (NPSA, 2010)
• Cardiotocography Fetal Decelerations- identified
  using fetal heart rate monitoring (WFSA, 2013).
• Assessment Identification of women at risk of
  PPH (RCOG, 2009)
• Physiological Monitoring / Discharge Criteria
  (AAGBI, 2007) Indicates clinical signs of
  deterioration/shock
• Identification of PPH Estimating blood loss
  -Notoriously Difficult! (AnaesthesiaUK, 2007.
  Vital for effective fluid resuscitation (Ward,
  2012)

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• Classification of urgency of caesarean section
• 1. Immediate threat to the life of the woman or
  fetus
• 2. Maternal or fetal compromise which is not
  immediately life-threatening
• 3. No maternal or fetal compromise but needs
  early delivery
• 4. Delivery timed to suit woman or staff.
• (AAGBI, 2013)
• Audit Categories
• 90 category-1 caesarean sections should have a
  decision-to-delivery interval 30 min
• 90 category-2 caesarean sections should have a
  decision-to-delivery interval 75 min
• (AAGBI, 2013)

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• Discharge Criteria - Obstetrics
• Pain score 3
• Nausea score 2
• Sedation score 2
• Respiratory rate 10 b/min
• BP gt 100mmHg SYSTOLIC
• Heat rate gt 50 b/min
• Temperature between 36-37.2
• Documentation of the wound and vaginal loss.
  (AAGBI, 2007)
• MINIMUM 30 minutes to 1 hour in recovery (NICE,
  2004 )

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Post Partum AP changes Anaesthetic Implications
for the Post Partum Patient undergoing GA
Change Anaesthetic Implication
Capillary engorgement/Airway Oedema Increased incident of difficult airway (Poor visualisation)
Increased O2 requirements and CO2 production Greater risk of desaturation after GA. Adequate oxygenation essential
Decrease in FRC Greater risk of desaturation after GA. Adequate oxygenation essential.
Increased Progesterone levels (Lowest levels noted 1 week post partum) Decreased function tone of lower oesophageal sphincter, increased risk of aspiration pneumonitis
Increased intra-abdominal (gastric pressure) delayed gastric emptying Increased risk of aspiration pneumonitis. Opioids slow gastric emptying further. Stool passage slow due to relaxin effect on bowel
Increased susceptibility to CNS depressants Decrease in dose requirements for GA and adjuvants
Weight gain and large breasts Positioning Intubation difficulties, IV access issues
(GLOWM, 2009)
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Altered AP ? Impact on care?Why rapid sequence
induction?

• Women in the postpartum period have demonstrated
  delayed gastric emptying in the first 2 hours
  when compared to a non-pregnant female population
  (WFSA, 2000)
• Increased aspiration risk upto 8 hours after
  delivery (James et al, 1984)
• General anaesthetic with RSI is advocated if the
  patient is actively bleeding or coagulopathic
  (AnaesthesiaUk, 2007)
• Key anaesthetic considerations in PPH
• Haemodynamic stability (fluid resuscitation,
  tranfusion, vasoactives) optimal respiratory
  state.
• If hypovolemia and haemodynamic instability occur
  GA is needed to proceed with the invasive
  surgical procedure (GLOWM, 2009).

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Obstetric Patient (At term) Post Partum Patient Normal patient
Minimum alveolar concentration lt by 40 Returns to normal by 3rd day post partum Less sensitive to volatile agents
FRC lt by 20 and O2 consumption gt35 gt RR rapid desaturation TV, Min Vol, VC FRC return to normal values within 1-3 weeks Normal FRC Longer time before desaturation (More Reserved O2)
Increased blood volume (1000-1500ml at term). Vulnerable to overload Returns to normal 1-2 weeks post partum. Approx 5 litres (less in females)
HR gt by 30, SV gt 30 CO increases Returns to normal 2 week post partum. CO elevated 24-48hrs Declines to normal range after 10 days
Aortocaval compression occurs due to gravid uterus in supine (Left lateral tilt indicated) ltCO Enlarged uterus could still cause some compression, CO effected Returns to normal size after approx 6 weeks
Systolic Diastolic values decrease Remain unchanged from late pregnancy until about 12 weeks post partum. After 2 weeks SV increases by 30 After 12 weeks BP increases to normal range.
Fivefold increase in thromboembolism due to hypercoagulable state helps minimize blood loss in delivery Even greater risk in post partum period (first 3 weeks after delivery) At risk if vascularly compromised/long surgery
(Dutta 2004, Ricci Kyle 2009)
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Impact on patient care

• Organisation Comminication Teamleader
  Delegation of tasks (RCOG, 2009)
• Women should have a group-and-save or crossmatch
  sample taken according to a localy policy (RCOG,
  2007)
• Fluid Blood component administration sets must
  be readily available ? effective fluid
  resusciation essential is mortality reduction
  (Ward, 2012)
• Adequate fluid warming devices must be readily
  available in all emergency theatres (AAGBI, 2010)
  ? Reduces Perioperative Hypothermia (Smith et
  al, 1998)
• Rapid infusion device Level 1 or equivalent
  should be readily available for the management of
  major haemorrhage ? Essential for rapid fluid
  resuscitation
• A supply of O rhesus negative blood should be
  immediately available (within five minutes) to
  the delivery suite at all times for emergency use
  ? Universal donor
• Grouping can be performed in approximately 10
  minutes and group-specific blood should be
  delivered within 20 minutes of request
  (Appropriate delegation is essential)
  Cross-matched roughly 40 minutes (AAGBI, 2013)

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Impact on patient care

• Difficult intubation trolley - variety of
  laryngoscopes, LMAs E.T must be available
  along with supraglottic airway devices (Protects
  from gastric contents)
• Fibre-optic Laryngoscope readily available
• Lipid emulsion, dantrolene and sugammadex should
  be readily available
• Hemocue (Hb analysis) device to estimate
  coagulation such as thromboelastography (TEG)
  strongly recommended
• Cell Salvage available at all times for
  emergency and elective C-Sections in units that
  deliver women who decline blood transfusion. NICE
  (2004) supports its use for major/massive
  obstetric haemorrhage managagement
• Cardiac arrest trolley Defibrillator
• Identify Extreme emergencies are the most
  error-prone situations. Use of pre-operative
  checklists and team briefings are essential
  (AAGBI, 2013)

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Protocol for Massive PPH(Blood loss gt 1500mls or
signs of clinical shock)

• Communication Delegation Alert team Blood
  Transfusion of Major Haemorrhage
• Rub up contraction
• ABC approach Assess airway breathing - AVPU
  score Pulse BP
• Lay down with head tilt
• Oxygenation 15litres/min Regular Observations
• IV access two large bore cannula 14/16 Gauge
• Take bloods for FBC, clotting, fibrinogen, UE,
  crossmatch blood Send sample immediately (If
  current GS available request cross-matched)
• Begin fluid resuscitation (WarmedCrystalloid or
  Colloid IV) Transfuse blood when available
  (Rapid Transfuser)
• Ensure bladder empty Foleys indwelling catheter
  urometer Aim for gt 30mls/hour urine output.
  Strict fluid management regime
• Determine cause (4 Ts) Tone, Tissue, Trauma,
  Thrombin ?Transfer to theatre
• Standard venous thromboprophylaxis should be
  commenced after bleeding is controlled
  prothrombic state develops rapidly
• RhD- patients resuscitated with RhD blood can
  develop immune anti-d ? causing hemolytic disease
  of newborn in future pregnancies (Anti D to be
  administered)
• (RCOG, 2009)

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ELECTIVE VS EMERGENCY
Pre operative checklists team-briefings Error prone situations, checks shortened due to time constraints (AAGBI, 2013)
Accurate Documentation Incorrect documentation will cause delays (Blood Samples)(RCOG, 2009)
General Anaesthetic Rapid Sequence Induction Application of Cricoid (AAGBI, 2013)
Airway Assessment Usually straightforward Time critical, limited scope for prior assessment, often poor reserve of patient, range of pathologies which may be rapidly evolving, positioning, equipment (Levitan et al, 2004)
Team Leader Management Delegation Effect teamwork communication essential (RCOG, 2013)
Appropriate personnel, Training, Time constraints, lack of suitable personnel with adequate training, little support (Levitan et al, 2004)
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Best Clinical Practice Guidelines

• Association of Anaesthetists of Great Britain
  Ireland (AAGBI)
• Guidelines for Obsestric Anaesthesia Services
  (2013)
• Blood Transfusion The Anaesthetist Management
  of Massive Haemorrhage (2010)
• Recommendations for Standards of monitoring
  during anaesthesia and recovery (2007)
• National Institute for Health and Care Excellence
  (2004) Caesarean Section
• Royal College Of Obsestricians Gynaecologists
• Caesarean Section (2011) Updated version of
  NICE Guidelines
• Postpartum Haemorrghage, Prevention and
  Management (2009) (No. 52)
• Difficult Airway Society (2014) Obstetric
  Difficult Airway Guidelines
• Department of Health (2004) Maternity Services

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Best clinical practice guidelines

• Local guidelines outlining standards of care
  should be available in all departments (Location
  should be given on induction to department)
  (AAGBI, 2013)
• RCOG Guidelines - provision of maternity services
  developed to ensure that obstetric patients
  receive the same standards of care as those
  recommended for the general surgical population
  (AAGBI, 2013)
• High quality womens health care A proposal for
  change. RCOG press, London, 2011.
• Safer childbirth Minimum standards for the
  organization and delivery of care in labour. RCOG
  press, London, 2007
• Utilised to ensure consistency quality of care
  - based on current, evidence-based research and
  literature.

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(Memegen, 2014
18
References

• AnaesthesiaUK (2007). Management of Obstetric
  Haemorrhage. http//www.frca.co.uk/article.aspx?ar
  ticleid100758 Accessed 2/12/2014
• Association of Anaesthetists of Great Britain and
  Ireland (AAGBI) (2013). OAA / AAGBI Guidelines
  for Obstetric Anaesthetic Services 2013.
  http//www.oaa-anaes.ac.uk/ Accessed 20/11/2014
• AAGBI (2010) AAGBI Safety Guideline. Blood
  Transfusion and the Anaesthetist Management of
  Massive HaemorrhageBI (2010). http//www.aagbi.org
  .uk Accessed 27/11/2014
• AAGBI (2007) Recommendations for Standards of
  monitoring during anaesthesia and recovery (4th
  edition). London. http//www.aagbi.org.uk
  Accessed 27/11/2014
• Benner, P. (2001). From Novice to Expert
  Excellence and Power in Clinical Nursing Practice
  / (Commemorative ed.). London Prenntice Hall
  Ltd
• Department of Health (2004) Maternity Services.
  http//www.gov.uk Accessed 9/12/14
• Difficult Airway Society (2014) Obstetric
  Difficult Airway Guidelines. http//wwww.das.uk.co
  m Accessed 9/12/14
• Dutta, D.C. (2004) Textbook of Obstetrics. 6th
  Edition. Calcutta, India. New Central Book Agency
  (P) Ltd.
• Global Library of Womens Medicine (2009)
  Analgesia and Anesthesia for Labor.
  http//www.glowm.com/section_view/heading/Analgesi
  a20and20Anesthesia20for20Labor20and20Deliver
  y/item/21624891 Accessed 2/12/2014
• James, C. F., Gibbs, C. P., Banner, T. (1984)
  Postpartum Perioperative Risk of Aspiration
  Pneumonia. Operative Obstetrics and Anaesthesia.
  Vol 40. 8519
• Kyle, T., Ricci, S.S. (2009) Maternity and
  Pediatric Nursing. Lippincott Williams Wilkins.

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• Memegen (2014) http//www.memegen.com/meme/wsyb2z
  Image Accessed 6/12/2014
• National Institute for Health and Care Excellent
  (2011) Caesarean Section. NICE guidelines CG13.
  https//www.nice.org.uk/guidance/cg13 Accessed
  20/10/14
• NPSA (2010) National Patient Safety Agency. WHO
  surgical safety checklist for maternity cases
  only. http//www.nrls.npsa.nhs.uk/resources/type/g
  uidance/?entryid4583972 Accessed 20/11/2014
• Royal College of Obstetricians Gynaecologists
  (RCOG) (2007) Safer childbirth Minimum standards
  for the organization and delivery of care in
  labour. RCOG press, London
• RCOG (2009) Postpartum Haemorrhage, Prevention
  and Management(Green-top Guideline No.52).
  http//www.rcog.org.uk/en/guidelines-research-serv
  ices/guidelines/gtg52/ Accessed 1/12/2014
• RCOG (2008) Blood Transfusion in obstetrics
  (Green-top Guideline No.47) http//www.rcog.org.uk
  Accessed 1/12/2014
• RCOG (2011) High quality womens health A
  proposal for change. RCOG press, London.
• RCOG (2011) Caesarean Section. NICE Clinical
  Guideline. http//wwww.nice.org.uk Accessed
  10/12/2014
• Royal College of Midwives (2011). Teamwork in
  obstetric emergencies. https//www.rcm.org.uk/lear
  ning-and-career/learning-and-research/ebm-articles
  /teamwork-in-obstetric-emergencies Accessed
  20/11/2014
• Smith, C.E. (1998). Warming intravenous fluids
  reduces perioperative hypothermia in women
  undergoing ambulatory gynecological surgery.
  http//www.ncbi.nlm.nih.gov/pubmed/9661542
  Accessed 3/12/2014
• Ward, A. M. (2012). A Comprehensive Textbook of
  Postpartum Hemorrage An Essential Clinical
  Reference for Effective Management. The Midwife
  Confronts Postpartum Hemorrage. 2nd Edition.
  Global Library of Womens Medicine, Sapiens
  Publishing.
• World Federation Of Societies of
  Anaesthesiologiest (2013) Fetal Heart Rate
  Monitoring Principles and Interpretation of
  Cardiotocography. Anaesthesia Tutorial Of The
  Week 294 23rd Septempber 2013. http//www.aagbi.or
  g.com Accessed 1/12/2014
• WFSA (2000) Pre-operative Fasting Guidelines.
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