Semina On Maternal Collapse and Neonatal Resuscitation

CAUSE OF MATERNAL
MORTALITY AND PREIMORTUM,

CS, NEONATAL RESUSTATION
BY :AFEWORK JERSA
ABENEZER TLAHUN
Instructor:Mr. Getahun.D(BSC,MSC ANESTHESIA)

Mr.Mebratu.M(BSC,MSC ANESTHESIA)
CONTENT
• Objective
• Introduction
• Etiology of maternal collapse
• Physiological change in pregnancy
• Optimal management of maternal collapse
• Perimortem C/S
• Neonatal resuscitation
03/17/2024 by afwork and abenezer

OBJECTIVES
• Describe physiologic change in pregnancy and
effect on resuscitation.
• Describe resuscitation of pregnant women
and modification to CPR.
• Have knowledge of the cause of maternal
collapse and managment.

INTRODUCTION
 Maternal collapse is an acute event involving the cardiorespiratory system
and brain causing reduced or absent conscious level at any point during
pregnancy and up 6 weeks postpartum
 As collapse is not a reported event the true incidence is difficult to
estimate but it could be as high as 6;1000 birth
 However, where death has occurred , poor resuscitation has been recurring
theme
 The most common cause of collapse are vasovagal and epilepsy.

Who are at risk?
Can women of at risk of impending collapse be identified early?
 The women who are critically ill.
 In some case maternal collapse occurs with no prior warning, also there
may be existing risk factor that make this more likely
 Early warning score system are now extensively used in acute sitting and
critical care, although it has not been possible to identify the optimal
system.

Early warning score system

CONT.

CAUSES

CONT.
 Hemorrhage
 Pulmonary embolism
 Cardiac disease: MI, cardiomyopathy, valve lesions, arrhythmias
 Pre-eclampsia / Eclampsia
 Amniotic fluid embolism
 Local anesthetic toxicity
 High regional block (total spinal)
 Failed intubation/ventilation _ Hypoxia
 Anaphylaxis
 Sepsis
 Intracranial pathology
HEMORRHAGE
 It is the most common cause of maternal collapse.
 Major obstetric hemorrhage has an estimated incidence of

3.7/1000 maternities.
 Cause major obstetric hemorrhage include PPH, APH(PP, PA,
uterine rupture) and ectopic pregnancy.
 Other rare cause of concealed hemorrhage include splenic artery
rupture and hepatic rupture.
 Blood loss is often underestimated specially slow, steady bleeding.

THROMBOEMBOLISM
 Is the formation of blood clot inside a blood vessel, obstructing the flow of
blood through the circulation system.
 In the last CEMACH report there were 41 death from thromboembolism
(33 PE and 8 cerebral vein thrombosis).

CARDIAC DISEASE
 The majority of death secondary to cardiac cause occur in women
with no previous history.
 The main cardiac cause of death MI, aortic dissection an
cardiomyopathy.
 The incidence of 1° cardiac arrest in pregnancy is much rare at
around 1/30,000 maternity.
 Other cardiac cause include dissection of the coronary artery, acute LVF,
IE and pulmonary edema.

SEPSIS
• Sepsis has been recognized for centuries as a significant cause of
maternal morbidity and mortality
• Substandard care continues to feature in the cases that result in death
• Bacteremia which can be present in the absence of pyrexia or raised
white cell count, can progress rapidly to severe sepsis and septic shock
leading to collapse
• The most common organism implicated in obstetric are the
streptococcal group A,B and D ,pneumococcus and E.coli

DRUG TOXICITY/OVERDOSE
 Drug toxicity/overdose should be considered in all case of collapse.
 Illicit drug overdose should be remembered as potential cause of

collapse outside of hospital.
 In term of drug toxicity, the most common sources in obstetric
practice are mgso4 in the presence of renal failer and LAA injected
iv by accident.
 Interims of local anesthetic ,total spinal ,high spinal ,epidural blokes
are also considered.

SIGN AND SYMPTOM
 Feeling of inebriation lightheadedness followed by sedation.
 Circumorally parenthesis and twitching convulsion can occur in sever
toxicity.
 On IV injection convulsion will occur rapidly
 Sign of sever toxicity include sudden LOC with or with out tony
colonic convulsion and CVS collapse.

ECLAMPSIA
• Eclampsia as the case of maternal collapse is usually obvious in the patient
setting as often the dx of pre eclampsia.

INTRACRANIAL HEMORRHAGE
 It is significant complication particularly uncontrolled systolic HTN,

ruptured aneurysms and arteriovenous malformation.
 The initial presentation may be maternal collapse but often sever headache
precedes this.

ANAPHYLAXIS
 Common triggers are variety of drug ,latex ,animal allergens and foods
 The incidence is between 3 and 10/1000,with the mortality rate of around

1%
 Exposure to known allergen for the women support the dx, but many case
occur without previous history.

OTHER CAUSE
 hypoglycemia and other metabolic or electrolyte imbalance
cause of hypoxia includes:

 air obstruction secondary to aspiration
 air embolism
 tension pneumothoraxes
 cardiac tamponed 2nd to trauma
 hypothermia

WHAT ARE THE PHYSIOLOGY IN
PREGNANCY THAT RISK FOR
MATERNAL COLLAPSE?
 It is essential that involved in the resuscitation of pregnant women in aware

of the physiology differences.
 Aortocaval compression significantly reduced cardiac out put from 20wk
of gestation on ward.
 Thus reducing venous return and cardiac output by up to 30%-40%
causing what is known as supine hypotension.

 In non pregnant women chest compression achieve around 30% of normal
cardiac out put.
 Aorto caval compression further reduce cardiac output to around 10% that
achieved in non pregnant women.
 Cardio pulmonary recantation is less likely to be effective in women who
is 20wk pregnant or more.

WHAT IS OPTIMAL INITIAL
MANAGEMENT OF MATERNAL
COLLAPSE?
• Call for help!!!
• Multidisciplinary team
• Obstetric
• Anesthesiology
• Medicine
• neonatology

• Cardiac arrest management has four main steps:
1. Immediate resuscitation
2. Supportive management is undertaken immediately once CPR is

effective and mother is resuscitated Move the patient to obstetric ICU
3. Try to undertake a differential diagnosis to determine the cause of the

sudden collapse once supportive management is started
4. Continuing management: correct the reversible causes for the sudden

collapse

CAN'T
 Two wide bore cannula should be inserted as soon as possible . there
should be an aggressive approach to volume(beware of pre eclampsia)
 Abdominal u/s by skilled operate can assist in the diagnosis of concealed
hemorrhage(massive abruption and intra-abdminal bleeding)

TILT
 A left lateral tilt of 30° on a firm surface will relieve aortocaval
compression in the majority of pregnant women.
 In case of major trauma the wedge should be placed under spinal boarded.
 In the absence of a spinal board manual displacement of the uterus should
be used.

CARDIFF WEDGE
 Inclined at 27° to the development of the Cardiff Wedge.
 If no wedge available, rolled up bed sheet under pts right hip or knee resus
team member under pts right hip.

CIRCULATION

CIRCULATION
 In the absence of breathing despite a clear airway, chest compression
should be commenced immediately.
 CPR should not be delayed by palpating for pulse ,but commenced
immediately in the absence of breathing.
 Hand position should be over the Centre of the chest, and perpendicular to
the chest wall, thus the angle of tilt must be taken into account.

CONT.
 Compression should be performed at ratio 30:2 ventilation unless the
women is intubated.
 In which case CPR and ventilation should be desynchronized, with
compression being performed at rate 100/min and ventilation 10/min.
 There should be early recourse to delivery of the fetus and placenta if CPR
is not effective.

AIRWAY
 airway should be protected as soon as possible by intubation with cuffed
ETT
BREATHING
 Supplement oxygen should be administer as soon as possible
 b/c of the increased O2 requirement and rapid onset of hypoxia in

pregnancy, it is important to ensure optimal O2 delivery by adding high
flow 100% O2
 BMV should be undertaken until intubation can be achieved

CAN'T
Ventilation
 by face mask
 By supraglotic device
 and self inflating bag
 cuffed endotracheal tube, may be more difficult b/c of the physiology

change of pregnancy described above

 Drug
 There should normally be no alteration in algorithm drugs or doses
 Common , reversible cause of maternal cardiopulmonary arrest should be
considered throughout the resuscitation
 IF
 There is no response to correctly performed CPR within 4 min of maternal
collapse
 Resuscitation is continued beyond 4 min in women beyond 20 wks of
gestation
 Delivery should be undertaken to assist maternal resuscitation

PER MORTEM CESAREAN SECTION
WHEN, WHERE AND HOW TO PER
MORTEM C/S PERFORMED ?
 Timing within 5 minute of the collapse

Indication
• No ROSC after 4 min of cardiac arrest
-despite good BLS & ACLS and
correction of reversible cause
• Unsuccessful chest compressions

Factor to conciderr
• Gestational age
• Resources of the institution
• Fetal viability
• Timeframe from maternal arrest
• consent

THE RATIONALE FOR THIS
TIMESCALE
1. Is that the pregnant women became hypoxemic more quickly than the
none pregnant women and irreversible brain damage can ensure within 4
– 6 minutes
2. Delivery of fetus and placenta reduce oxygen consumption improve

venous return and cardiac output facilitate chest compressions improve
venues return and cardiac output

CONT.
3. It also allows the heart to be compressed easily through the diaphragm

against the chest wall by placing the hand behind them heart and compressing
it agents posterior aspect of anterior wall of the chest
Before 20wk there is no benefit from delivery of the fetus

CONT
 Delivery within 5 min of maternal collapse improve the chances of
survival for the baby , but this is not the reason for delivery. Should be
done even if the fetus is already dead
 Per mortem C/S should not be delayed be moving the women-it should be
performed where resuscitation is taking place
 The operator should use the incision that will facilitate that most rapid
access

CONT
 If resuscitation is successful following delivery there should be prompt
transfer to an appropriate environmental at that point, as well as anesthesia
and sedation to control ensuring hemorrhage and complete the operation

Contraindication
• Known gestation less than 24 weeks
• Return of spontaneous circulation after brief
period of resuscitation.

Survival
• Infant survival rates range from 11-70%
• Uteroplacental blood flow may required up to
30% of cardiac output.
• Delivery of the near-term fetus provides a 30-
80% improvement in cardiac output
&maternal survive

WHAT DOSE THE CONTINUE MANAGEMENT?
 Continuing management depends very much on the underlining cause of

the collapse.
 Signor staff must be involved early.
 It is essential the women is transferred to a high-dependency / critical care

area with appropriate staff and monitoring facilities

HEMORRHAGE
 In the cause of maternal collapse 2nd to APH ,the fetuses and the placenta
should be delivered to allow control of the hemorrhage, even if the fetus is
dead.

AMNIOTIC FLUID EMBOLISM
 The management of AFE is supportive rather than specific , as there is no

proven effective therapy.
 Early involvement of senior experienced staff, including obstetrician
anesthetic hematologist and intensives, is essential to optimize outcome.
 Coagulopathy needs early , aggressive treatment ,including aggressive use
of fresh frozen plasma

CARDIAC DISEASE
 After successful resuscitation, cardiac case should be managed by an
expert cardiology team
 management of cardiac diseases similar to the in the non pregnant state ,
although delivery will be necessary to facilitate this.
 Caution should be exercised in the perioperative period.

SEPSIS/SEPTIC SHOCK
 • Remove the source of infection or nidus for unlimited inflammatory

response
 • Antimicrobial therapy directed against offending organisms
 • Support organ function
 • Alpha agonists to maintain vasomotor tone

DRUG DOSE TOXICITY
 In obstetric practice, the two main drug that can give rise to overdose or
toxic problem are mgso4 and LAA
 Magnesium sulphate
 The antidote to magnesium toxicity is 10ml 10% calcium gluconate given

by slow iv injection
 Local anesthetic agent
 If local anesthetic toxicity is suspected, stop injecting immediately.
 Lipid rescue should be used in case of collapse 2 nd to local anesthetic

toxicity

CONT.
 Intralipid 20% should be available in all maternity units
 CPR should be continued throughout this process until an a adequate
circulation has been restored, and this may taken over an hour
 Manage arrhythmias as usual recognizing that they may be very refractory
to treatment

ANAPHYLAXIS
 All potential causative agent should be discontinue
 The definitive treatment for Anaphylaxis is 500 mcg(0.5ml ) of 1:1000

adrenaline IM
 In experienced hands it can be given IV as a 50 mcg bolus(0.5mml of
1:10000 solution)
 The adjuvant therapy consist of chlopheniramine 10mg and hydrocotisol
200 mg. both are given IM or by slow IV injection

CLINICAL GOVERNANCE
 Accurate documentation in all cases of maternal collapse , whether or not
resuscitation is successful, is essential
 Poor documentation remain a problem in all aspect of medicine and can
potential medico-legal consequences
 Contemporaneous note-keeping is difficult in a resuscitation situation .
those involved should write full notes as soon as possible after the event

Neonatal
Resuscitation
Fetal physiology
• The placenta, receives nearly half the fetal cardiac
output, is responsible for respiratory gas exchange.
• lungs receive little blood flow and the pulmonary
and systemic circulations are parallel instead of in
series, as in the adult. results in unequal ventricular
flows
• This arrangement is made possible by two cardiac
shunts—the foramen ovale and the ductus
arteriosus:

Fetal physiology
1Well-oxygenated blood from the placenta mixes with
venous blood returning from the lower body and flows
via the IVC into the RA.
2. RA anatomy preferentially directs blood flow from
the IVC through the foramen ovale into the LA.
3. LA blood is then pumped by the LV to the upper body
(mainly the brain and the heart).
4. Poorly oxygenated blood from the upper body
returns via the SVC to the RA

CON’T
5 RA anatomy preferentially directs flow from
the SVC into the RV.
6. RV blood is pumped into the pulmonary
artery.
7. B/C of high PVR, 95% of the blood ejected
from the RV (60% oxygen saturation) is shunted
across the ductus arteriosus , into the
destending aorta, and back to the placenta and
lower body.
Physiological transition of the fetus at birth
• Hypoxia and acidosis as well stimulation—cord

clamping, pain, touch, and noise help initiate and
sustain respiration
• Lung expansion↑ Pao2& pAo2is a potent stimulus
for pulmonary arterial vasodilation →↓ PVR.
• ↑ PBF and augmented flow to the left heart elevates
LAP and functionally closes the foramen ovule.

Neonatal Resuscitation?
• Series of actions, used to assist newborn babies who
have difficulty with making the physiological ‘transition’
from the intrauterine to extrauterine life
• Assists babies who fail to initiate or sustain regular
breathing at birth
• 10% neonates require some assistance at birth.
• 1% neonates need extensive resuscitative measures.
• Asphyxia accounts for 20-25% newborn deaths

Consequences of interrupted transition ?
• The compromised baby may exhibit 1 or more of the

following clinical findings:
- Low muscle tone
- Respiratory depression (apnea / gasping)
- Bradycardia
- Cyanosis

Equipment Needed for Resuscitation
• Radiant warmer
• Warm towel and blankets
• Resuscitation bag and mask – Self inflating bag –
Anaesthetic bag
• Endotracheal tubes
• Laryngoscope
• Stethoscope
• Oxygen source and tubing • Suction source and tubing
• Drugs and fluids • Syringes, needles, cannulae, IV lines
• +/-Umbilical lines
Equipment Needed

Steps in Resuscitation
• Warmth and stimulation and assessment for the 1st
30 seconds
– Use warm cloth
– Replace when wet
– Rapidly assess
• Tone
• Colour
• Respiratory efforts

Steps in Resuscitation - ABCDE
• Airway
– Clear airway if required
– Removal of secretions if present
Suction mouth and nose do not suction if aw is clear
– Positioning
• Supine or lateral
• Head in neutral or slightly extended position

Neonatal Position for Opening the Airway –
‘neutral position’

• Breathing
• Assessment of respiratory effort and colour
• Indications for oxygen administration
– Cyanosis
– Respiratory distress
– Give free flowing oxygen 5L/min

Breathing: Indications for positive pressure
ventilation

Indications of endo-tracheal Intubation
• – Prolonged positive-pressure ventilation (PPV)
required
• – Bag & mask ineffective: Inadequate chest
expansion
• – If chest compressions required: Intubation may
facilitate coordination and efficiency of ventilation
• – Tracheal suction required

• Circulation
• Assessment of heart rate and response to
previous measures
–Umbilical arteries
– Apex beat
– Auscultation

Steps in resuscitation - ABCDE
• Drugs
• Adrenaline
• Volume Expanders
• Naloxone

Epinephrine
Indication
If the heart has failed to increase to greater than 60
bpm within one minute of adequate ventilation and
chest compression

THANK YOU

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CAUSE OF MATERNAL

MORTALITY AND PREIMORTUM,

Instructor:Mr. Getahun.D(BSC,MSC ANESTHESIA)

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

 Major obstetric hemorrhage has an estimated incidence of

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

 Illicit drug overdose should be remembered as potential cause of

03/17/2024 by afwork and abenezer

colonic convulsion and CVS collapse.

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

 It is significant complication particularly uncontrolled systolic HTN,

03/17/2024 by afwork and abenezer

 The incidence is between 3 and 10/1000,with the mortality rate of around

03/17/2024 by afwork and abenezer

cause of hypoxia includes:

 cardiac tamponed 2nd to trauma

03/17/2024 by afwork and abenezer

 It is essential that involved in the resuscitation of pregnant women in aware

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

2. Supportive management is undertaken immediately once CPR is

3. Try to undertake a differential diagnosis to determine the cause of the

4. Continuing management: correct the reversible causes for the sudden

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

 b/c of the increased O2 requirement and rapid onset of hypoxia in

03/17/2024 by afwork and abenezer

 and self inflating bag

 cuffed endotracheal tube, may be more difficult b/c of the physiology

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

 Timing within 5 minute of the collapse

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

2. Delivery of fetus and placenta reduce oxygen consumption improve

venues return and cardiac output

03/17/2024 by afwork and abenezer

3. It also allows the heart to be compressed easily through the diaphragm

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

03/17/2024 by afwork and abenezer

 Continuing management depends very much on the underlining cause of

 It is essential the women is transferred to a high-dependency / critical care