Amniotic fluid embolism AFE is rare unpredictable and

§ Amniotic fluid embolism § (AFE) is rare, unpredictable and unpreventable § AFE occurs when amniotic fluid enters the maternal circulation via the uterus or placental site; § maternal collapse can be rapidly progressive. § -The body responds to AFE in two phases. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 1

§ 1 - The initial phase is one of pulmonary vasospasm causing: § - hypoxia § -hypotension § - pulmonary oedema § - cardiovascular collapse. § 2 -The second phase sees; § - the development of left ventricular failure § -with haemorrhage § - coagulation disorder Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 2

§ - further uncontrollable haemorrhage. § - Mortality and morbidity are high § -though early diagnosis may lead to better outcome § - early transfer to an intensive care unit § -Emergency drills for maternal resuscitation should be regularly practised in clinical areas in all maternity units Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 3

Predisposing factors § § § -Amniotic fluid embolism can occur at any gestation. - It is mostly associated with labour - and its immediate aftermath -cases in early pregnancy and postpartum have been documented -Chance entry of amniotic fluid into the circulation under pressure may occur through the uterine sinuses of the placental bed § -The barrier between the maternal circulation and the amniotic sac may be breached during periods of raised intra-amniotic pressure, such as termination of pregnancy or during placental abruption. § - Procedures, such as ARM § - insertion of an intrauterine catheter, have been associated with AFE Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 4

§ - Amniotic fluid embolism can also occur during an intrauterine manipulation, such as internal podalic version or during a caesarean section. § -It is a condition that is difficult to predict and equally difficult to prevent. § -Amniotic fluid embolism is associated with a high maternal mortality rate. § - A total of 17 women died in the years 2003– 2005, diagnosis having been confirmed clinically and by post mortem Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 5

-Premonitory signs and symptoms § - restlessness § -abnormal behaviour § - respiratory distress and cyanosis) may occur before collapse § -There is maternal hypotension and uterine hypertonus. § -The latter will induce fetal compromise and is in response to uterine hypoxia. § - Cardiopulmonary arrest follows quickly. § - Only minutes may elapse before arrest. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 6

§ -Blood coagulopathy develops following the initial collapse, if the mother survives. § Box 33. 4 Summary of key signs and symptoms of amniotic fluid embolism § • Fetal compromise § • Respiratory § – Cyanosis § – Dyspnoea § – Respiratory arrest § • Cardiovascular § – Tachycardia § – Hypotension Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 7

§ § § § § – Pale clammy skin/shivering – Cardiac arrest • Haematological – Haemorrhage from placental site – Coagulation disorders, DIC • Neurological – Restlessness, panic – Convulsions – Pain less likely. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 8

Emergency action § -Any one of the above symptoms is indicative of an acute emergency. § -As the mother is likely to be in a state of collapse, resuscitation needs to be commenced at once. § - An emergency team should be called, § - since the midwife responsible for the care of the mother requires immediate help Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 9

§ -If collapse occurs in a community setting, basic life support should be commenced prior to the arrival of emergency services. § -Despite improvements in intensive care the outcome of this condition is poor. § -Specific management for the condition is life support, and high levels of oxygen are required. § - Mothers who survive are likely to have suffered a degree of neurological impairment Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 10

Complications of amniotic fluid embolism § -Disseminated intravascular coagulation (DIC) is likely to occur within 30 min of the initial collapse. § - In some cases the mother bleeds heavily prior to developing amniotic fluid embolism, which contributes to the severity of her condition. § -It has also been reported that the amniotic fluid has the ability to suppress the myometrium, resulting in uterine atony. § -Acute renal failure is a complication of the excessive blood loss and the prolonged hypovolaemic hypotension. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 11

§ - The mother will require continuous assessment of urinary output, using an indwelling catheter. § - Accurate records of fluid intake and urinary output and urinalysis should be maintained by the midwife. § - A urinary output of <30 m. L/hr should be reported, as should the presence of proteinuria. § -Prompt transfer to an intensive therapy unit for specialized care improves the outcome in AFE Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 12

§ -Midwifery support and advice should be continued for the family. § -The mother should be given the opportunity to talk about emergency treatment when she has recovered sufficiently Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 13

Effect of amniotic fluid embolism on the fetus § -Perinatal mortality and morbidity are high where amniotic fluid embolism occurs before the birth of the baby. § -Delay in the time from initial maternal collapse to delivery needs to be minimal if fetal compromise or death is to be avoided. § - However, maternal resuscitation may, at that time, be a priority. § -is a summary of the key points relating to amniotic fluid embolism. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 14

Summary of key points for amniotic fluid embolism § Major cause of maternal death worldwide § • Universal features: maternal shock, dyspnoea and cardiovascular collapse § • Fetal compromise § • Can occur at any time, most common immediately after labour § • Should be suspected in cases of sudden collapse or uncontrollable bleeding. -All cases of suspected or proven amniotic fluid embolism, whether fatal or not, should be reported to the National Amniotic Fluid Embolism Register Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 15

Acute inversion of the uterus § -This is a rare but potentially lifethreatening complication of the third stage of labour. § -A midwife's awareness of the precipitating factors enables her to take preventive measures to avoid this emergency. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 16

Classification of inversion § Inversion can be classified according to severity as follows: § • first-degree – the fundus reaches the internal os § • second-degree – the body or corpus of the uterus is inverted to the internal os Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 17

§ • third-degree – the uterus, cervix and vagina are inverted and are visible. § It is also classified according to timing of the event: § • acute inversion – occurs within the first 24 hrs § • subacute inversion – occurs after the first 24 hrs, and within 4 weeks § • chronic inversion – occurs after 4 weeks and is rare § -It is the first of these, acute inversion, that the remainder of this section considers. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 18

Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 19

Causes § Causes of acute inversion are associated with uterine atony and cervical dilatation, and include: § • mismanagement in the third stage of labour, involving excessive cord traction to manage the delivery of the placenta actively § • combining fundal pressure and cord traction to deliver the placenta § • use of fundal pressure while the uterus is atonic, to deliver the placenta § • pathologically adherent placenta Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 20

§ § § spontaneous occurrence, of unknown cause • primiparity • fetal macrosomia • short umbilical cord • sudden emptying of a distended uterus. -Careful management of the third stage of labour is needed to prevent inversion. § - In active management of the third stage, palpation of the fundus is essential to confirm that contraction has taken place, prior to controlled cord traction. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 21

Warning signs and diagnosis § -The major sign of acute inversion is profound shock and usually haemorrhage. § - The blood loss is within a range of 800– 1800 m. L § -Inversion of the uterus will cause the woman severe abdominal pain. On palpation of the uterus, the midwife may feel an indentation of the fundus. § - Where there is a major degree of inversion the uterus may not be palpable abdominally but may be felt upon vaginal examination or in a severe case the uterus may be seen at the vulva. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 22

§ -The pain is thought to be caused by the stretching of the peritoneal nerves and the ovaries being pulled as the fundus inverts. § - Bleeding may or may not be present, depending on the degree of placental adherence to the uterine wall. § - The cause of the symptoms may not be readily apparent and diagnosis may be missed if inversion is incomplete. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 23

Management Immediate action § A swift response is needed to reduce the risks to the mother. § -Throughout the events the mother and her partner should be kept informed of what is happening. § -Assessment of vital signs, including level of consciousness, is of utmost importance. § 1 Urgent medical help is summoned. § 2 The midwife in attendance should immediately attempt to replace the uterus. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 24

§ - If replacement is delayed the uterus can become oedematous and replacement will become increasingly difficult. § -Replacement may be achieved by pushing the fundus with the palm of the hand, along the direction of the vagina, towards the posterior fornix. § -The uterus is then lifted towards the umbilicus and returned to position with a steady pressure (Johnson's manoeuvre Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 25

§ -If replacement cannot be achieved immediately the foot of the bed can be raised to reduce traction on the uterine ligaments and ovaries § -An intravenous cannula should be inserted, blood should be taken for crossmatching prior to starting an infusion. § -Analgesia such as morphine may be given to the mother. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 26

§ -If the placenta is still attached, it should be left in situ as attempts to remove it at this stage may result in uncontrollable haemorrhage. § -Once the uterus is repositioned, the operator should keep the hand in situ until a firm contraction is palpated. § - Oxytocics should be given to maintain the contraction Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 27

Medical management § -The hydrostatic method of replacement involves the instillation of several litres of warm saline infused through a giving set into the vagina. § -The pressure of the fluid builds up in the vagina and restores the uterus to the normal position, while the operator seals off the introitus by hand or using a soft ventouse cup. § -If the inversion cannot be replaced manually a cervical constriction ring may have developed. § -Drugs can be given to relax the constriction and facilitate the return of the uterus to its normal position. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 28

§ - Surgical correction via a laparotomy may be needed to correct inversion. § -Full support and explanation of the emergency should be offered to the mother in the postnatal period Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 29

Basic life-support measures § -Cardiac arrests are rare in maternity units but they can and do happen and their management is sometimes suboptimal. § -Emergency drills for maternal resuscitation should be regularly practised in clinical areas in all maternity units. § - These drills should include the identification of the equipment required and appropriate methods for ensuring that cardiac arrest teams know the location of the maternity unit and theatres in order to arrive promptly Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 30

§ - Specialized courses such as Advanced Life Support in Obstetrics (ALSO) and Managing Obstetric Emergencies and Trauma (MOET) provide additional training for obstetric, midwifery and other staff. § -Standards of basic life support have been agreed internationally for health professionals and lay people § - Basic life support refers to the maintenance of an airway and support for breathing, without any specialist equipment other than possibly a pharyngeal airway. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 31

-The basic principles are: § § A – airway B – breathing C – circulation. -1 -The level of consciousness is established by shaking the woman's shoulders and enquiring whether she can hear. § 2 -If there is no response urgent assistance is called for by the most appropriate means. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 32

§ 3 -The woman is laid flat on her back removing pillows. A pregnant woman should be further positioned with a left lateral tilt to prevent aortocaval compression. § 4 -The woman's head should be tilted back and the chin lifted upwards to open the airway. § -If needed, mucus or vomit should be cleared away. § – listen for breath sounds § – look for chest movements. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 33

§ 5 -If the midwife is experienced in clinical assessment then she should feel for the presence of a carotid pulse for no more than 10 seconds. § 6 -The hands are placed palm downwards in the centre of the chest one on top of the other with the fingers interlinked. The heel of the lower hand is positioned in the middle of the sternum Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 34

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§ - With arms straight, the midwife undertakes chest compressions depressing 4– 5 cm. § - releasing at the same rate as compression. The chest should recoil completely after each compression. § 7 -The action should be repeated 100 times/min. Interruptions to chest compressions should be minimized. § 8 -The midwife may need to kneel over the woman or find something to stand on to ensure that she is suitably positioned to carry out resuscitation Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 36

§ -The surface under the woman must be firm for the manoeuvre to succeed. § 9 - After 30 chest compressions the midwife should give two rescue breaths preferably by bag and mask but mouth-to-mouth if necessary, remembering to pinch the woman's nose to make a seal. § - Each breath should only last for 1 s. The midwife should ensure that the woman's chest rises with each breath and is seen to fall again Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 37

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Summary of basic life-support guidelines § § § § Shake and shout 2 Call for help 3 Check breathing 4 Check pulse 5 Use 2 breaths to 30 compressions 6 Continue until help arrives. -Chest compression and rescue breathing should be continued until help arrives and until those experienced in resuscitation are able to take over. -A ratio of 30 chest compression to two breaths should be maintained § -The exact sequences of resuscitation will depend on the training of staff and their experience in assessment of breathing and circulation Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. 39

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