Management of common Obstetric Emergencies

Table of content

1. Severe Pre-Eclampsia

2. Eclampsia

3. Antepartum Haemorrhage

4. Postpartum Haemorrhage

5. Shoulder Dystocia

6. Umbilical Cord Prolapse

7. Anaphylaxis

8. Local Anaesthetic Toxicity

9. TotalSpinal/HighEpidura

10. References

Severe Pre-eclampsia

• Manage as team with Obstetrician, Anaesthetist & Midwife (Refer to Severe pre-eclampsia guidelines on intranet)
• Commence 15-minute MOEWS monitoring   RR, pulse oximetry, HR, BP, urine output, temperature Increase frequency if unstable
• IV access and bloods for U+E, LFT, FBC, Clotting, G+S, Urate
• Admit to Maternity critical care unit and commence Maternity critical care unit observation chart
• Commence Magnesium (bolus then infusion) – continue until 24 hours after delivery
• Control BP initially with PO medication
• Control BP with IV anti-hypertensive if not able to control with PO
• Commence arterial BP monitoring
• Fetal monitoring and delivery plan to be decided by obstetricians
• Fluid restrict to 80ml/hr (including all infusions) – Monitor hourly fluid balance
• 6 hourly bloods (U+E, FBC, Clotting, Urate)
• Treat Magnesium toxicity with 10ml 10% calcium gluconate

Drug doses and cautions

• Magnesium LOADING DOSE:     4g (in 50ml pre-mixed bag) Give over 5-10 minutes – rate 300-600ml/hr
• MAINTENANCE: 1g / hour (in 250ml pre-mixed bag) Rate 10ml/hr
• Monitor: Respiratory Rate & O2 saturation, hourly urine output and 4 hourly patella reflex – Do not routinely monitor magnesium levels

 

Labetalol (1st choice)

• Contraindication: Severe asthma                     
• Caution: Cardiac disease
• Per oral dose: 200mg – repeated after 30 mins
• IV Bolus: 50mg (10mls of 5mg/ml) given over at least 5 mins – repeat dose every 10mins (maximum 200mg)
• IV Infusion (5mg/ml preparation): Commence at 4 ml/ hr – double every 30 mins to maximum of 32 ml/hr until BP stable
• If BP not <160/105 after 90 mins or if SBP >160mmHg despite 32ml/hr add in second line agent

 

Nifedipine modified release

• Per Oral dose: 10mg capsules 4-6hrly

 

Hydralazine IV Bolus:

• 2.5mg IV over 5 mins – repeat at 20 min intervals as required to max 20mg.
• Monitor BP every 5 mins. If required consider infusion.
• IV infusion: 40mg in 40mls normal saline (1-5ml/hr)

 

Eclampsia

• Pull emergency buzzer Summon Consultant Obstetrician and Consultant Anaesthetist to attend immediately
• Turn patient to left lateral position
• Assess and maintain airway
• Apply oxygen 15L/min via non-rebreathe mask      
• Secure IV access and take blood (FBC, U+E, Clotting, G+S, blood sugar)
• Give Magnesium BOLUS dose (4g IV over 5-10 mins)
• Start Magnesium MAINTENANCE infusion 1g/hr (10ml/hr)
• If fit not terminated / patient fits again:  Repeat magnesium bolus 2g bolus (or 4g bolus if booking weight >70Kg) over 5-10 mins   Increase infusion to 1.5g/hr (rate 15ml/hr)
• Obstetrician to make plan for fetal monitoring and delivery
• Resistant seizures may require general anaesthesia ± anticonvulsants (refer to Trust guidelines; involve Anaesthetist)
• Consider other causes of seizure

 

Drug doses and cautions

Magnesium

LOADING DOSE:     4g (in 50ml pre-mixed bag)

Give over 5-10 minutes – rate 300-600ml/hr

Persistent / repeated fits:  Repeat as for normal loading dose if booking weight >70kg

If booking weight <70kg:  Give 25ml (half) of 50ml pre-mixed bag at 150-300ml/hr

MAINTENANCE:     1g / hour (in 250ml pre-mixed bag)

Rate 10ml/hr

Persistent / repeated fits:  increase rate to 15ml/hr (1.5g/hr)

Considerations-Consider other causes of seizure

• Hypoglycaemia (check BM)
• Epilepsy (past medical history)
• Drugs (prescribed and recreational)
• Intra-cerebral bleed (check for other signs)

 

Antepartum Haemorrhage

Bleeding from or into the genital tract, from 24+0 weeks onwards and prior to the birth of the baby

• Pull emergency buzzer Summon Obstetrician and Anaesthetist to attend immediately
• Record all vital signs and calculate MEOWS
• Apply 15L/min oxygen via non rebreathe mask
• Cannulate with wide bore cannula – Take bloods for FBC, clotting and X-match 4 units of blood (send samples to lab by hand, not pod)
• Send Kleihauer if mother is Rhesus D negative
• Commence IV fluids 1000ml Hartmann’s solution
• Assess her pain:  If continuous – consider abruption If with contractions – consider labour
• Palpate the abdomen
• Listen for fetal heart +/- commence CTG (depending on gestation)
• Perform a speculum examination:  Assess cervical dilatation   Visualise lower genital for cause of APH
• Do a VE if labour suspected – NOT if placenta praevia suspected

 

Considerations

• Activate Major Obstetric Haemorrhage Protocol if:  Over 1.5L blood loss with ongoing loss Ongoing blood loss with haemodynamic instability
• Alert:  Consultant Obstetrician and Consultant Anaesthetist (must be informed) Theatre staff (if not already in attendance) Coordinator to liaise with Blood Bank staff
• Consider:  Tranexamic acid 1g IV, Cell salvage

 

Postpartum Haemorrhage PPH

Blood loss >500ml within 24hrs of delivery; Major >1.5L, Massive >2,5L

• Pull emergency buzzer Summon Obstetrician and Anaesthetist to attend immediately
• Request PPH trolley
• Apply oxygen 15L/min via non-rebreathe mask       
• Secure 2 x IV access (grey cannula if possible) – Take blood for FBC, U+E, Clotting, Fibrinogen and X-match 4u
• Commence IV fluids 1000ml Hartmann’s solution
• Record all vital signs and calculate Modified Obstetrics Early Warning Score MOEWS
• Establish source of bleeding ASSESS 4 T’s: Tone, Trauma, Tissue, Thrombin
• If atonic uterus:  Rub up a contraction Insert urinary catheter
• Commence drug algorithm for uterine atony (see appendix A below)
• Consider bimanual uterine compression
• Consider Examination Under Anaesthesia in theatre
• Consider Bakri balloon insertion
• 2 units O negative blood are in Blood Fridge
• Activate the Major Obstetric Haemorrhage Protocol
• Weigh all swabs – Document swab count (on board & in notes

 

(Appendix A) Uterine atony drugs and cautions

• Syntometrine (IM) can be repeated if used at time of delivery (avoid if ↑BP)
• Ergometrine can be given if syntometrine not used (avoid if ↑BP)
• Syntocinon   2nd bolus of 5iu

IV Infusion – 30iu in 500ml 0.9% saline at 150ml/hr

• Haemabate 250mcg IM repeated every 15 mins maximum 8 doses (avoid if asthmatic) Misoprostol 1000mcg (5 x 200mcg tablets) PR
• Administer tranexamic acid 1g IV

 

Shoulder dystocia

• Pull emergency buzzer -Summon Obstetrician, Midwifery Coordinator, Neonatal team and Anaesthetist
• Advise the woman to STOP pushing
• Lie flat with tilt – move buttocks to end of bed
• Follow FLOWCHART OVERLEAF for manoeuvres
• Only use routine axial traction – do not pull downwards
• If manoeuvres have failed, you must inform the Obstetric Consultant

 

Umbilical cord prolapse

• Pull emergency buzzer Call for Obstetrician, Midwifery coordinator, Neonatal team and Anaesthetist
• Do not handle the cord (if possible)
• If second stage and parous: Expedite immediate vaginal delivery for maternal / neonatal safety-Consider instrumental delivery
• Manually elevate presenting part or fill the bladder
• Encourage into the following position:  Left lateral   Head down   with a pillow placed under left knee or knee to chest position
• Ensure continuous fetal monitoring (if not already in place)
• Consider tocolysis Terbutaline 250 mcg subcutaneous or GTN spray 2 puffs sublingual
• Emergency transfer to Delivery suite
• Assess and assist birth by quickest means
• Urgency of birth dependent on Fetal Heart rate and gestational age
• If emergency caesarean section required, spinal may not be appropriate – Discuss with anaesthetist

 

Determining fetal viability

• If the cord is not pulsating at the time of the INITIAL examination:  Ascertain by ultrasound whether a fetal heartbeat is present
• If the fetus is no longer alive – vaginal delivery should be facilitated
• If the fetal heart has definitely been recorded within the preceding 5 minutes – consider category 1 caesarean section

 

Anaphylaxis

Symptoms include: hypotension, tachycardia, wheeze, rash, swelling, altered mental state

• Pull emergency buzzer Summon the Anaesthetist and Obstetrician
• Remove potential causative agents (e.g. antibiotics, gelofusine, latex, chlorhexidine)
• Apply oxygen 15L/min via non-rebreathe mask
• Lie patient flat with tilt and elevate legs
• Give Adrenaline:  IM 0.5ml of 1:1000 (small ampoule) – repeat PRN

                                 Anaesthetists only may give IV adrenaline

                                -50mcg (0.5ml of 1:10,000) titrated to response

                                -An infusion may be needed

• IV access and take blood – FBC, clotting, G+S, mast cell tryptase
• Commence IV fluids 1000ml Hartmann’s solution
• Record all vital signs and calculate MOEWS
• Obstetrician to make plan for fetal monitoring and delivery
• Administer chlorphenamine 10mg IV (or IM)
• Administer hydrocortisone 200mg slowly IV (or IM)
• Treat persistent bronchospasm (with inhaled/IV salbutamol, IV aminophylline or magnesium sulphate)
• Summon ICU Anaesthetist – consider arterial and central lines

 

Drug doses and treatments

• IM Adrenaline 1:1000 0.5ml repeat every 5 mins until improvement
• IV Adrenaline bolus – ANAESTHETIST ONLY 50mcg bolus (0.5ml 1:10 000 minijet) titrated to response
• IV Adrenaline infusion 4mg adrenaline in 50ml 5% dextrose Infuse at 5-10ml/hr (approx. 0.05-0.1mcg/kg/min)
• Salbutamol 2.5mg via oxygen driven nebuliser or 250mcg slow IV
• Aminophylline 250mg slow IV
• Magnesium sulphate 2g IV over 20 mins

 

Serial Tryptase

Send blood for Tryptase in red top bottle Immediately, at 2 hours and  at 24 hours

 

Local Anaesthetic toxicity

May occur distant to initial injection. Signs include: Sudden alteration in mental state (agitation/loss of consciousness/fit) Cardiovascular collapse, bradycardia, heart block, arrhythmias, arrest

• Stop local anaesthetic infusion / injection
• Pull emergency buzzer – Note the time Summon the Anaesthetist (if not present) and Obstetrician Request the Adult Resuscitation Trolley
• Assess airway & apply O2 15L/min via non-rebreathe mask Tracheal tube maybe needed to secure airway Hyperventilation may help increase blood pH
• Attach ECG monitoring (3 lead or use defibrillation pads)
• Record all vital signs and calculate MOEWS
• Secure IV access and commence 1000ml Hartmann’s solution
• Control seizures:  Use benzodiazepines, thiopentone &/or propofol
• Commence intralipid: Initial bolus then commence infusion (see overleaf) Repeated boluses & increased infusion rate may be required Use standard ALS algorithms for management of resuscitation
• Obstetrician to make plan for fetal monitoring and delivery
• Note that resuscitation may take considerable time (>1hr)

 

Drug doses and treatment

Intralipid 20%

• Initial bolus 1.5ml/kg over 1minute
• Commence infusion 15ml/kg/hour
• If cardiovascular instability after 5 minutes-Repeat bolus and increase infusion to 30ml/kg/hour
• If cardiovascular instability after another 5 minutes- Final bolus 1.5ml/kg Give maximum of 3 boluses

Do not exceed maximum cumulative dose 12ml/kg       

Follow up

• Monitoring until sustained recovery achieved
• Exclude pancreatitis   
• Regular clinical review
• Daily amylase for 2 days
• Report case to NPSA National patient safety agency
• Report use of intralipid to www.lipidregistry.org     

 

High Epidural block/Total Spinal   

Block of T4 or higher or regional block with adverse signs, including:    Cardiovascular collapse with hypotension & bradycardia, difficulty in     breathing, tingling/numbness in hands, reduced consciousness

• Stop epidural infusion
• Pull emergency buzzer Summon Anaesthetist and Obstetrician to attend immediately
• Apply oxygen 15L/min via non-rebreathe mask    
• Secure IV access – Take bloods for FBC, U+Es, G+S, lactate
• Commence IV fluids 1000ml Hartmann’s solution
• Record all vital signs and calculate MOEWS
• Position of patient depends on haemodynamic stability:  Sit patient up if able to tolerate In case of collapse, lie patient flat with left lateral tilt / uterine displacement
• If airway and breathing compromised or patient unconscious – proceed to intubate and ventilate
• Treat bradycardia with 500mcg atropine bolus (max 3mg)
• Treat hypotension with vasopressors / adrenaline
• Exclude other causes of hypotension
• Obstetrician to make plan for fetal monitoring and delivery       

 

Drug doses and treatment

• For hypotension consider vasopressors/ionotropes:  Ephedrine 6mg bolus, Phenylephrine 100mcg bolus, Metaraminol 500mcg bolus
• For bradycardia:  Atropine 500mcg to maximum 3mg     

 

Consider other causes of hypotension

• Bleeding
• Sepsis
• Local anaesthetic toxicity
• Anaphylaxis

References

Royal Bolton Hospital template for Obstetric emergencies