Obstetric EmergenciesNatasha Singh

Consultant ObstetricianLead for clinical research

Chelsea and Westminster Hospital

At the end of this talk..

• Understand a bit more about what triggers the inner mind of the obstetrician.

• How we should approach obstetric emergency

• Proactive not reactive

Total number of reported CNST claims by specialty 01/04/1995—31/03/2008

Total number of reported CNST claims by specialty 01/04/1995—31/03/2008

Ten Years of Maternity ClaimsAn Analysis of NHS Litigation Authority Data

Who are we concerned about?

The unexpected term admission to NICU

Cerebral palsy 1:400

Healthy outcome

Change in obstetrics over the years

• Increase caesarean section rates

• Increase in placenta accreta, percreta

• Increase in women opting for VBAC

• Women are having babies older

• Increase in multiple pregnancy

• Increase in obstetric haemorrhage rates

Obstetric Emergencies

Disaster preparedness

Labour ward = Multidisciplinary team

• Handover – Introduction of staff

• Ward rounds – multidisciplinary

• Equipment – MOH, Eclampsia trolleys

• Emergency escalation process – 2222

Clinical situations on labour ward

• Changes rapidly – fetal bradycardia, uterine rupture, obstetrician or fetal distress

• Risk assessment continuously

• Situational awareness

Effective communicationRecommendation in successive

confidential enquiriesSBARS Situation eg EclampsiaB Background eg 34 weeks with severe PETA Assessment eg BP 180/120, abnormal LFTsR Recommendation – stabilise mother and needs LSCS

Emergency LSCS room 1 – what does this mean?

Is the obstetrician crying wolf?I am worried about the airway?Is there time to top up epidural?Can we do a single shot spinal?Why is the anaesthetist being difficult?

Category of LSCS

• Category 1

Urgent threat to the life of a woman or fetus within 30 minutes

• Category 2

Maternal or fetal compromise but not immediately life threatening - 30 and 75 minutes for category 2 caesarean section.

• Category 3

No maternal or fetal compromise but needs early delivery.

• Category 4

Delivery timed to suit woman or staff with no urgency for delivery.

Obstetric emergencies you can be called about

• Fetal distress

• Obstetric haemorrhage

• Placental abruption

• Placenta praevia and accreta

• Other rare possibilities

Fetal monitoring

• Cardiotocographic trace (CTG)

5 Features of CTG

• Baseline fetal heart rate

• Baseline variability

• Accelerations

• Decelerations

• Contractions

Fetal monitoring

• Cardiotocographic trace (CTG)

acceleration

variability

contractions

Main findings in CTG claims 2000-2010

• Failure to recognise an abnormal CTG and act on it –‘pattern recognition’

• Only 21% of claims involved high risk pregnancies –effective monitoring in ALL women

• 60% of the claims were due to events out of hours –2000-0830

• Failure to appreciate that the CTG was abnormal and get obstetric review

• Highest number of claims occurred at 40-41 weeks of pregnancy

• Total value of claims – Ƚ466 million

Fresh eyes and buddy check

Fetal distressObstetrician stress or true acidosis

What are WE thinking? What are YOU thinking?We want to deliver because we worry about fetal distress and acidosis

Decelerations• A drop in the baseline of >15bpm for >15 seconds

Respiratory organGas exchange

Cord compression orReduction in uteroplacentalcirculation

Disturbance of fetoplacentalCirculation

Hypoxia and acidosis in the fetus

Compensation in the babyChemoreceptors

1. Gradual fall in oxygen, activation of sympathetic pathway, release ofcathecholamines to SA node, Increase FHR and cardiac output. Increase blood to the placenta to be oxygenated

2. Abrupt loss of oxygen – vagal stimulation, fetal bradycardia

Baroreceptors

Hypotension –Sympathetic activation,increase cardiac output via cathecholaminerelease

Hypertensive –vagal stimulation,release of acetycholine,reduction in cardiac output

Bradycardia

3 – 6 – 9 – 12 – 15 min ‘rule’ – Immediate CS9 minutes move to theatre, no recovery by 12 minutes, deliver by 15 minutes

CTG suspicious/pathological = Situational awareness

• Clinical background

• Epidural just sited

• Maternal hypotension

• Maternal pyrexia or dehydration

• Position of mother

• Meconium

• Sepsis

• Active intrauterine resusitation

Meconium aspiration

CTG as a predictor of hypoxia

• CTG has a very good sensitivity but a very poor specificity and positive predictive value for intrapartum hypoxic injury.

• False positive rate is high.

• Abnormal CTG - Only 40-60% of fetuses actually have intrapartum hypoxia

• Positive predictive value of a pathological CTG for metabolic acidosis is approximately 30%

Intelligent Fetal Monitoring Study

Five-year project to reduce the number of stillbirths, neonatal deaths and brain injuries occurring as a result of incidents during term labour by 50% by 2020.

Caesarean section rates

Caesarean section rate and its impact on stillbirth rate

10%

25%

Obstetric haemorrhage

Placenta praevia Morbidly adherent placenta

Minor

Major

Mega Plan for Mega Haemorrhage

• Antenatal planning – counselling of the woman• Anesthetist and a friend• Obstetrician and a friend• Radiologist• Theatres• Vascular surgeon• General surgeons• Urologist• Blood transfusion• Scribe • Runner

Compression

Brace suture or B Lynch Cook’s Balloon

MOH audit at Chelsea

• 1500-1999mls – White European or British, perineal trauma, atony

• 2000mls and above – ethnic minority, manual removal of placenta, placenta praevia and accreta

Put the plug in!6 steps to reducing PPH/MOH

1. Risk assess all women antenatally and intrapartum (look for risk factors eg IOL, previous PPH, fibroids, previous ERPC, prolonged second stage, polyhydramnios, multiple pregnancy, placenta praevia)

2. Ensure controlled delivery of the baby’s head and guarding of the perineum

3. Administer syntocinon/syntometrine with delivery of the anterior shoulder

4. Immediate recognition of blood loss ≥500mls. Act early and escalate early.

5. Perform early bimanual compression6. Prompt suturing of perineal trauma and removal of placenta.

Anticipate large blood loss and move to theatre early.

Obstetric haemorrhage

• Placental abruption (when associated with intrauterine demise)

Mother

Haemorrhage

DIC

Severe PET

Baby

Fetal anaemia

Hypovolemia

Stillbirth

DeliveryRapid volume resusitation of the motherPulmonary edema

Obstetric haemorrhage

Normal uterus Couveillaire’s uterus

• Cardiac arrest

• Anaphylaxis secondary to local anaesthetic toxicity

• Uterine rupture

• Cord prolapse

Rare but can happen so suspend your disbelief

Cord prolapse – Category 1 delivery

Improve safety in maternityHuman Factors is at the core

• Leadership• Communication• Situational awareness• Escalation• Delegation • Completion of task• Recapping and reviewing • Knowledge• Implementation of policy/guideline

Delegation and Team workingThink of Chelsea

AirwayOxygen

DrugsBlood pressure PulseOxygen saturation

Blood transfusionFluidsOxytocin infusion

CatheterBimanual compressionSuturing etc

Scribe

Good leadershipHelicopter view

Runner

Staff/Debrief

Be a part of it!

Train together Develop our Human Factors

• MOMS Chelsea

• OCRM Cambridge

We are a team and together we can make a difference

Thank you

Questions?