Maternal collapse is defined as an acute cardiorespiratory or neurological event resulting in impaired consciousness during pregnancy or up to 6 weeks postpartum. Although uncommon, collapse of a mother in the delivery suite may represent serious underlying pathology and demands rapid treatment; the mother may also rapidly respond to relatively simple measures, thus avoiding disaster.
Problems and special considerations
The management of a collapsed mother on the labour ward presents a challenge to all staff concerned. Typically, labour ward staff are less familiar with emergency equipment and drugs than staff in the operating theatres, so continuous support and education of staff is required; regular ‘drills’ have been recommended, though this may be difficult in a busy and possibly understaffed unit. In addition, the labour ward is often situated in an isolated or remote area of the hospital, so access to other key clinical areas, such as the radiology suite and intensive care unit, is not always easy. Finally, pregnant women are usually fit and healthy and often clinical deterioration may go unnoticed; the use of a modified early obstetric warning score (see Chapter 156) may help earlier detection.
Collapse on the labour ward may have several causes, some of which require specific investigation and/or management (Table 80.1).
Management options
Initial resuscitation in the undelivered patient is influenced by the risk of aortocaval compression and aspiration, and the fact that the fetus is at risk. The airway should be secured, the lungs ventilated and the circulation supported with fluids, vasoactive drugs or cardiac massage as appropriate, with measures taken to displace the uterus or deliver the fetus.
Concurrent with treatment is the need to determine the cause, with further management directed as appropriate.
All staff should be familiar with basic resuscitative techniques, and protocols should exist for the more important causes, for example eclampsia and haemorrhage. Rapid delivery of relevant information about the collapsed mother to the medical staff resuscitating her is also crucial in directing management towards a particular possible cause. This will be easier in delivery suites where there is good multi-professional communication about routine as well as problem cases.
Table 80.1 Causes of collapse on the labour ward
|
A: |
Anaesthesia |
Regional anaesthetic sympathetic block, local anaesthetic toxicity, total spinal |
|
B: |
Bleeding |
Antenatal, e.g. placenta praevia, abruption; postnatal, e.g. splenic artery rupture |
|
C: |
Cardiac |
Congenital heart disease, infarction/arrest, arrhythmias, vasovagal syncope, aortocaval compression |
|
Cerebral |
Epilepsy, stroke, tumour |
|
|
D: |
Drugs |
Magnesium, antihypertensives, opioids, sedatives, illicit drug use |
|
E: |
Embolism |
Amniotic fluid, air, thrombus |
|
F: |
Fever |
Sepsis |
|
G: |
General |
Anaphylaxis, hypoxia, electrolyte disturbance |
|
H: |
Hypertension |
Eclampsia |
Key points
• Collapse on the labour ward has many causes including obstetric, anaesthetic and medical factors.
• Immediate management is as for the non-pregnant patient, but with avoidance of aortocaval compression.
Further reading
Royal College of Obstetricians and Gynaecologists. Maternal Collapse in Pregnancy and the Puerperium. Green-top Guideline 56. London: RCOG, 2011. www.rcog.org.uk/en/guidelines-rese arch-services/guidelines/gtg56 (accessed December 2018).