Prepared by Helen Cooke

1
Maternal Resuscitation
Prepared by Helen Cooke August 2008
2
Goals

• Discuss the incidence and causes of cardiac
  arrest/maternal collapse in pregnancy
• Discuss the physiological changes in pregnancy
  that make women susceptible
• Discuss resuscitation techniques and management
  of cardiac arrest in pregnancy
• Amniotic fluid embolism
• Perimortem caesarean section

3
Background

• Cardiac arrest is a very rare maternity emergency
• It occurs in 1/30,000 pregnancies
• Usually it is as a result of other maternity
  emergencies
• Up to 50 of maternal deaths are preventable if
  managed well
• Many maternal deaths occur from potentially
  treatable causes

4
Pregnancy-Related (Direct)Maternal Death 2002-
2005
5
What makes Pregnancy Different?

• Major body changes for the pregnant woman that
• improve blood supply for fetal nutrition
• promote breast development in preparation for
  neonatal feeding, and
• alter the internal organ placement to make room
  for the growing fetus and uterus

6
Blood changes

• Blood volume increases in pregnancy by 40 -50
• The uterus receives 20 -30 of the maternal blood
  flow
• Pregnancy is a high flow, low-resistance state.
  Lots of blood and very little pressure at the
  placental bed
• Uterine arteries do not control their own BP
  (autoregulated), therefore any drop in maternal
  blood pressure will decrease uterine perfusion

7
Hormonal Influences

• Oestrogen
• ? excitability in uterine muscle fibres
• ? susceptibility to catecholamines
• Progesterone
• ? tidal volume and respiratory rate
• hyperventilation causes ? CO2 and compensated
  respiratory alkalosis

8
Physiological changes

• Increasing blood volume increases cardiac output
  and heart rate
• Clotting factors increase
• Breast tissue increases
• Diaphragm rises by about 7cm and the organs move
  to make way for the growing uterus
• Gut peristalsis slows
• Respiratory rate rises to increase oxygen
  requirements and cope with decreased lung volume

9
Pregnant CPR

• TILT 27 angle as compression of the aorta by
  the gravid uterus causes 30 of cardiac output to
  be sequestered
• left side using ? Human wedge / similar
• Compressions need to be stronger due to the
  increased breast size and chest wall resistence
• Intubation is difficult due to the pharyngeal and
  nasal oedema

10

• insert slide photo

11
First PhaseCPR

• Danger safety for self, others woman
• Response level of consciousness
• Airway open the airway
• Breathing provide positive-pressure ventilations
  2 initial breaths
• Circulation give chest compressions
• 30 compressions to 2 breaths
• Defibrillation assess, and shock VF or pulseless
  VT

12
Second Phase CPR

• Airway
• Ensure airway is patent and protected from
  aspiration
• Consider early intubation
• Breathing
• Confirm placement of tube
• Secure device
• Confirm adequate oxygenation

13
Second Phase CPR

• Circulation
• Establish IV access
• Identify rhythm and monitor
• Administer appropriate drugs
• Differential Diagnosis
• Search for, treat identified reversible causes

14
Drugs for Resuscitation

• Adrenaline 1 mg IV bolus, repeat q 3-5 min.
• Be aware of all the drugs on the emergency
  trolley as with any resuscitation they all may be
  used
• Picture of drug trays or info for staff etc MN
  suggests

15
Four Minute Rule

• 4 minutes following an arrest
• Maternal apnoea occurs associated with rapid
  declines in arterial pH and PaO2
• Fetus of an apnoeic and asystolic mother has lt2
  minutes of oxygen reserve
• After 4 minutes without restoration of
  circulation, dramatic action must occur

16
Pre-requisites for Perimortem Caesarean

• The arrest must be witnessed
• Skilled personnel and equipment available
• No spontaneous maternal circulation for four
  minutes
• Potential fetal viability singleton _at_ 23-24
  weeks or greater
• Facilities and personnel available to care for
  mother and infant postoperatively
• A perimortem caesarean section can save two lives

17
Amniotic Fluid Embolism (AFE)

• Occurs when there is an opening between the
  amniotic sac and the uterine veins in
  approximately 120,000 births
• risk factors include multiparity, abruption,
  intrauterine fetal demise, tumultuous labour and
  oxytocin hyperstimulation

18

• Amniotic fluid may enter the maternal circulation
• Amniotic fluid passes through the maternal heart
  and becomes trapped in maternal pulmonary
  circulation causing L) sided heart failure and
  bronchospasm
• This leads to localised disseminating
  intravascular coagulopathy that then spreads
  quickly throughout the mother
• May be an anaphylactic reaction associated with
  the amniotic fluid in maternal circulation

19
Symptoms of AFE

• Symptoms occur very rapidly
• Sudden dyspnoea and respiratory distress
• Shock without obvious blood loss
• Maternal collapse
• Seizures are common in about 30 of cases
• DIC
• Diagnosis is usually made postmortem

20
Management / Treatment

• Call for help
• Supportive and resuscitative ABCs
• Two large bore IV cannulae
• Consider X-ray and ECG
• Immediate delivery if still pregnant

21
Summary of AFE

• Very rare Obstetric emergency
• Very poor prognosis for both maternal and fetal
  outcome
• Maternal mortality has historically been as high
  as 85
• With better diagnosis and ICU treatment this rate
  has been reduced to 27

22
Summary

• Cardiac arrest is a rare event
• 44-50 of maternal deaths are preventable if we
  improve management of other emergencies
• Remember the CPR changes of 27 tilt and working
  around the increased breast tissue
• Perimortem caesarean delivery can save two lives 

23
Conclusion

• Working together as a team can help to improve
  outcomes
• Documentation, documentation, documentation
  timing of all interventions, drugs administered
• Debriefing after the event with all staff present
  and associated with the event is of utmost
  importance