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Obstetric EmergenciesNatasha Singh
Consultant ObstetricianLead for clinical research
Chelsea and Westminster Hospital
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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
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Total number of reported CNST claims by specialty 01/04/1995—31/03/2008
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Total number of reported CNST claims by specialty 01/04/1995—31/03/2008
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Ten Years of Maternity ClaimsAn Analysis of NHS Litigation Authority Data
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Who are we concerned about?
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The unexpected term admission to NICU
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Cerebral palsy 1:400
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Healthy outcome
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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
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Obstetric Emergencies
Disaster preparedness
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Labour ward = Multidisciplinary team
• Handover – Introduction of staff
• Ward rounds – multidisciplinary
• Equipment – MOH, Eclampsia trolleys
• Emergency escalation process – 2222
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Clinical situations on labour ward
• Changes rapidly – fetal bradycardia, uterine rupture, obstetrician or fetal distress
• Risk assessment continuously
• Situational awareness
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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?
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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.
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Obstetric emergencies you can be called about
• Fetal distress
• Obstetric haemorrhage
• Placental abruption
• Placenta praevia and accreta
• Other rare possibilities
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Fetal monitoring
• Cardiotocographic trace (CTG)
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5 Features of CTG
• Baseline fetal heart rate
• Baseline variability
• Accelerations
• Decelerations
• Contractions
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Fetal monitoring
• Cardiotocographic trace (CTG)
acceleration
variability
contractions
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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
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Fresh eyes and buddy check
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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
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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
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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
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Bradycardia
3 – 6 – 9 – 12 – 15 min ‘rule’ – Immediate CS9 minutes move to theatre, no recovery by 12 minutes, deliver by 15 minutes
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CTG suspicious/pathological = Situational awareness
• Clinical background
• Epidural just sited
• Maternal hypotension
• Maternal pyrexia or dehydration
• Position of mother
• Meconium
• Sepsis
• Active intrauterine resusitation
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Meconium aspiration
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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%
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Intelligent Fetal Monitoring Study
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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.
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Caesarean section rates
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Caesarean section rate and its impact on stillbirth rate
10%
25%
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Obstetric haemorrhage
Placenta praevia Morbidly adherent placenta
Minor
Major
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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
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Compression
Brace suture or B Lynch Cook’s Balloon
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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
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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.
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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
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Obstetric haemorrhage
Normal uterus Couveillaire’s uterus
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• Cardiac arrest
• Anaphylaxis secondary to local anaesthetic toxicity
• Uterine rupture
• Cord prolapse
Rare but can happen so suspend your disbelief
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Cord prolapse – Category 1 delivery
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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
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Delegation and Team workingThink of Chelsea
AirwayOxygen
DrugsBlood pressure PulseOxygen saturation
Blood transfusionFluidsOxytocin infusion
CatheterBimanual compressionSuturing etc
Scribe
Good leadershipHelicopter view
Runner
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Staff/Debrief
Be a part of it!
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Train together Develop our Human Factors
• MOMS Chelsea
• OCRM Cambridge
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We are a team and together we can make a difference
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Thank you
Questions?