Obstetric resuscitation - asja

Report
Prepared by Ahmed El-Henawy, MD.
Lecturer of Anesthesia, Ain Shams University
Presented by Wael Samir, M.Sc.
Assistant Lecturer of Anesthesia, Ain Shams
University
INTRODUCTION
During resuscitation there are two
patients, mother & fetus.
The best hope of fetal survival is
maternal survival.
Consider the physiologic changes
due to pregnancy.
PHYSIOLOGICAL CHANGES
CARDIOVASCULAR SYSTEM
RESPIRATORY SYSTEM
GASTROINTESTINAL SYSTEM
AIRWAY CHANGES
CARDIOVASCULAR SYSTEM

Blood volume (90ml/Kg)
- 50% increase in plasma volume
- 30% increase in RBC volume
 COP (40%)
- 30% increase in stroke volume
- 15% increase in heart rate
 SVR
- Due to vasodilatory effects estrogen ,
progesterone and prostacyclin.
 SUPINE HYPOTENSION SYNDROME
 Because of these cardiovascular changes and the
tendency for blood flow to be shunted from the
uteroplacental circulation under conditions of
hypovolemia, patients can bleed extensively
before normally recognizable physical signs such
as tachycardia and hypotension occur.
SUPINE HYPOTENSION
SYNDROME
 5 to 8% of pregnant women experience a 30 to 50%
drop in blood pressure in the supine position
 Becomes evident from the 20th week of pregnancy
 It can be associated with signs of shock such as pallor,
sweating, nausea and vomiting
 Caused by the near total occlusion of the IVC by the
GRAVID UTERUS
 Compression of the aorta does not cause maternal
hypotension , instead it cause arterial hypotension
leading to inadequate uterine blood flow and fetal
asphyxia.
AIRWAY CHANGES
Increased risk of difficult intubation:
- Intrinsic and extrinsic deposition of adipose tissue
- Large tongue
- Edema of upper airway
- Limited cervical spine mobility
RESPIRATORY SYSTEM
 Increase in MV ( mainly due to larger tidal volumes )
 Increase in Oxygen consumption
 Decrease in FRC
As a result
 Closing capacity may exceed FRC with subsequent airway
closure, V/Q mismatch, right to left shunt and hypoxemia.
 Rapid desaturation during periods of apnea.
 Supine, trendlenburg and lithotomy positions are poorly
tolerated.
GASTROINTESTINAL
SYSTEM
 GERD and increased incidence of aspiration:
Upward displacement of the stomach leads to an
incompetent LES
2. Progesterone effect , with a decrease in the tone of
the LES
3. Increased intragastric pressure
4. Delayed gastric emptying during labour
1.
ETIOLOGY OF CARDIAC
ARREST
BEAU-CHOPS









Bleeding
Embolism
Anesthesia related
Uterine atony
Cardiac disease
Hypertensive diseases
Others
Placenta previa/abruption
Sepsis
INITIAL INTERVENTION FOR
THE FIRST RESPONDER
Call for HELP
CODE – OB
The team should include:
1. Usual code blue team
2. Obstetrician
3. Obstetric anesthesiologist
4. Newborn resuscitation team and equipment
5. Surgical nurse with emergency cesarean section
tray
INITIAL INTERVENTION FOR
THE FIRST RESPONDER
 Left uterine displacement ( LUD )
 Administration of 100% oxygen
 Venous access by 2 wide bore venous cannulae
ABOVE THE DIAPHRAGM.
 Search and treat any reversible cause of cardiac
arrest
- IV Calicum chloride for Mg toxicity
- IV fluid bolus for hypovolemia
SPECIAL CONSIDERATIONS
Position
Airway
Circulation
Defibrillation
Emergency Caesarian section
POSITION
 Left uterine displacement
 Aiming to relieve aortocaval compression of the
gravid uterus.
-Inferior vena caval occlusion is the norm in the supine
position at term and results in >60% reduction in venous
return. In order to reduce this pelvic tilt is required.
However cardiac compressions becomes progressively more
difficult to perform effectively the more the patient is
tilted: A tilt of between 15 – 30° is suggested.
 Method
- One handed technique
- Two handed technique
- Wedge under the right hip
- Human wedge
ONE HANDED TECHNIQUE
TWO HANDED TECHNIQUE
Patient in a 30° left-lateral
tilt using a firm wedge
AIRWAY
Apply continuous cricoid pressure during
positive pressure ventilation
unconscious pregnant woman.
for
Early endotracheal intubation
- Performed by skilled personnel
- ETT with smaller ID
- Be prepared for a difficult intubation
any
CIRCULATION
 The
incidence of ineffective external chest
compressions is higher in pregnant women due to:
- Large breasts
- Upward displacement of the heart
- 15 to 30 degree lateral tilt
 In order to overcome this problem the operator’s hand
should be placed slightly above the middle of the
sternum.
 After this adjustment if chest compressions are still
not effective ( no carotid pulse OR poor capnograph
trace ) a thoracotomy and open cardiac massage
should be considered.
DEFIBRILLATION
 Follow standard ALS guidelines
 There is no evidence that shocks from a direct current
defibrillator have adverse effects on the heart of the
fetus.
 If fetal or uterine monitors are in place, remove them
before delivering shocks.
 Adhesive pads are safer and easier to apply than
manual paddles
EMERGENCY CESAREAN
SECTION
WHY ?
WHEN ?
HOW ?
WHAT GESTATIONAL AGE?
WHY?
 Delivery of the baby empties the uterus, relieving both
the venous obstruction and the aortic compression.
 Delivery also allows access to the infant so that
newborn resuscitation can begin.
 Allows open cardiac massage as the heart can be
reached relatively easy through the diaphragm.
 It is important to remember that you will lose both
mother & infant if you cannot restore blood flow to the
mother’s heart.
WHEN?
 CPR leader should consider the need for an ER
cesarean section as soon as a pregnant woman
develops cardiac arrest.
 The best survival rate for infants 24-25 weeks in
gestation occurs when the delivery of the infant occurs
no more than 5 minutes after the mother’s heart stops
beating.
 This typically requires that the provider begin the
delivery about 4 minutes after cardiac arrest.
HOW ?
 A midline ( classical ) incision has been recommended
as it is helped by the separation of the recti muscles
that occur later in pregnancy.
 The delay caused by aseptic precautions may itself be
fatal.
 A scalpel , pair of forceps and gloves for the operator’s
protection maybe all that’s required.
WHAT GESTATIONAL AGE?
Gestational age < 20 weeks:
 Need not be considered because this size gravid uterus
is unlikely to significantly compromise maternal
cardiac output.
Gestational age 20 to 23 weeks:
 Perform to enable successful resuscitation of the
mother, not the survival of the delivered infant, which
is unlikely at this gestational age.
Gestational age > 24 weeks:
 Perform to save the life of both the mother & infant.
CONCLUSION
Maternal and fetal survival depend on rapid
and
skilled resuscitation.
Consider early (< 5 min) Cesarean delivery.
Training in ALS for pregnant woman is essential
for maternity unit personnel.
Beware of aspiration and difficult intubation
LUD is essential for successful resuscitation

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