Episode 40: Obstetrics Part 3
Author: Eoghan Colgan @eoghan_colgan
Special Guest: Marcus McMillan @1949LAN
13/11/19
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Guest Bios
Marcus McMillan
Marcus McMillan is a consultant obstetrician in Princess Royal Maternity in Glasgow. He has a special interest in abnormally invasive placentas and coordinates care for people with this in Glasgow. He works with the Scottish Multiprofessional Maternity Development Programme for teaching obstetric emergencies and management to maternity staff and other departments.
Show Notes
Marcus McMillan is a consultant obstetrician in Princess Royal Maternity in Glasgow. He has a special interest in abnormally invasive placentas and coordinates care for people with this in Glasgow. He works with the Scottish Multiprofessional Maternity Development Programme for teaching obstetric emergencies and management to maternity staff and other departments. Eoghan and Marcus discuss obstetric emergencies, and in this episode they cover Cardiovascular Collapse, Resuscitative Hysterotomy, and a lot more.
TAKE-HOME POINTS
CardioVascular Collapse in pregnancy
Get Help
ABCDE
standard principles
left-lateral tilt
delivering baby will always make things easier for mum - if life-threateningly unwell then best to deliver to remove the additional load.
ideally stabilise and deliver in theatre if possible
resuscitative hysterotomy may be needed if no gtime to stabilise
Potential Diagnoses:
CardioVascular - e.g. Cardiomyopathy, MI
Massive Blood Loss (may be concealed in abdomen)
PE
Standard Causes that can occur outside of pregnancy
AMNIOTIC FLUID EMBOLISM
typically collapse 30-60 minutes after deliver
very littel treatment = supportive and hoping the recover
Resuscitative Hysterotomy
Timing is important - ideally within 5 minutes of arrest
Have an assistant when performing hysterotomy
this is your only task (do not be part of ongoing resuscitation)
Focus on getting baby out then stitching closed.
It is eassier than it sounds!
Midline vertical incision best for non-obstetritian
Fundus of uterus (top of bump) to symphysis
essentially keep going until you reach baby (which you then pull out)
As Uterus expands it pretty much ‘shoves everything out of the way’ so you will go through abdominal wall and then arrive at uterus (you won’t damage much else!)
The key factor is ‘ not being shy’ and doing it!
outcomes for mother are not great but better than not doing it!!
Placenta
clamp and cut quickly
simply scoop it out with your hands immediately
Can close the uterus/wound if comfortable to do so, alternatively pack it and await surgeon/obstetritian
If output returns, it will bleed heavily so rfemember UTEROTONICS to contract the uterus
If thrombolysis has been given, bleeding from Uterus will be less if ‘closed’ so take a 1.0 suture and stitch as best as you can
Post-Hysterotomy
This is a highly-emotional state
Typically mother and baby will die
Everyone was out of their comfort zone, and likely unsuccessful
Do a hot-debrief
SHould take a break; some may need to go home!
Consider follow-up - counselling etc
PRINCIPLES OF MANAGING A PREGNANT LADY WITH A NON-PREGNANCY-RELATED PROBLEM
In general: think about what you would do if this patient wasn’t pregnant, and do that!
Same rules apply, and best way to get a healthy baby is to treat mum
Remember left-lateral position can help
DRUGS IN LATE PREGNANCY
Typically all emergemncy drugs can be given if mother unwell
Priority is to make mum well
Avoid warfarin
Admitting a pregnant woman with a medical problem
No clear rules on this; should be consultant to consultant
Where will the patient get the best care? - if pregnancy stable then should probably go to a medical ward
remember: Midwives now are often NOT nurse-trained, so not able to look after complex medical problems
PREGNANCY AND MINOR TRAUMA
Perceived Foetal movements are unreliable - mother can ‘feel’ movements even when foetus is dead
Best methods are:
Listening with Doptone
CTG
Ultrasound
In a teriary centre, refer to obstetrics
If working in a remoter community, without support, probably best to learn a simple method to provide reasurance (see options above)
