In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.
Classification of evidence levels (1++ to 4) and grades of recommendations (A–D) are defined at the end of the "Major Recommendations" field.
Can Women at Risk of Impending Collapse Be Identified Early?
D - An obstetric early warning score chart should be used routinely for all women, to allow early recognition of the woman who is becoming critically ill.
In some cases maternal collapse occurs with no prior warning, although there may be existing risk factors that make this more likely. Antenatal care for women with significant medical conditions at risk of maternal collapse should include multidisciplinary team input with a pregnancy and delivery management plan in place. Often there are clinical signs that precede collapse. In the latest Confidential Enquiry into Maternal and Child Health (CEMACH) report, substandard care was often identified where these signs and symptoms were not recognised and acted upon. The report recommended that a national obstetric early warning scoring system should be introduced and used for all obstetric women, including those being cared for outside the obstetric setting. [Evidence Level 4]
What Are the Causes of Maternal Collapse?
See the original guideline document for a discussion of the common causes of maternal collapse, including haemorrhage, thromboembolism, amniotic fluid embolism, cardiac disease, sepsis, drug toxicity/overdose, eclampsia, intracranial haemorrhage, anaphylaxis, and other causes.
What Is the Optimal Initial Management of Maternal Collapse?
C - From 20 weeks of gestation onwards, the pressure of the gravid uterus must be relieved from the inferior vena cava and aorta.
C - A left lateral tilt of 15° on a firm surface will relieve aortocaval compression in the majority of pregnant women and still allow effective chest compressions to be performed.
A left lateral tilt of 15° can be achieved on an operating table using a Cardiff wedge by having someone kneel on the right side of the woman with their knees under the woman's thorax, although this has the disadvantage of the tilt being removed for defibrillation; alternatives are using an upturned chairback or using manual displacement of the uterus to the left. [Evidence level 2+]
In cases of major trauma, the wedge should be placed under the spinal board. In the absence of a spinal board, manual displacement of the uterus should be used. Using soft surfaces such as a bed or objects such as pillows or blankets is not nearly as effective and compromises effective chest compressions, but is better than leaving the woman supine.
B - In the absence of breathing despite a clear airway, chest compressions should be commenced immediately.
Chest compressions should not be delayed by palpating for a pulse, but should be commenced immediately in the absence of breathing and continued until the cardiac rhythm can be checked and cardiac output confirmed. Compressions may be made difficult because of obesity and the tilted position. Hand position should be over the centre of the chest, and it is important to ensure that the direction of compression is perpendicular to the chest wall, thus the angle of tilt must be taken into account. Compressions should be performed at a ratio of 30:2 ventilations unless the woman is intubated, in which case chest compressions and ventilations should be desynchronised, with compressions being performed at a rate of 100/minute and ventilations at a rate of 10/minute. Because chest compressions are not as effective after 20 weeks of gestation, there should be early recourse to delivery of the fetus and placenta if cardiopulmonary resuscitation (CPR) is not effective. [Evidence level 2++]
C - Abdominal ultrasound by a skilled operator can assist in the diagnosis of concealed haemorrhage.
Very occasionally, ultrasound by a skilled operator can aid diagnosis in cases of massive abruption and intra-abdominal bleeding, although laparotomy should not be delayed if the findings are negative or the index of suspicion is high. However, this should not interfere with the resuscitation process. [Evidence level 2+]
B - The same defibrillation energy levels should be used as in the nonpregnant patient.
If defibrillation is required, the same settings should be used as in the nonpregnant patient as there is no change in thoracic impedance. Adhesive defibrillator pads are preferable to defibrillator paddles, and the left defibrillation pad should be applied lateral to the left breast. The energy from the defibrillation shock is directed across the heart and there is no evidence that shocks from a direct current defibrillator have an adverse effect on the fetus. Uterine monitors should be removed before shock delivery. [Evidence level 2++]
D - Common, reversible causes of maternal cardiopulmonary arrest should be considered throughout the resuscitation process.
When, Where and How Should Perimortem Caesarean Section Be Performed?
D - If there is no response to correctly performed CPR within 4 minutes of maternal collapse or if resuscitation is continued beyond this in women beyond 20 weeks of gestation, delivery should be undertaken to assist maternal resuscitation. This should be achieved within 5 minutes of the collapse.
What Does the Continuing Management Consist of?
A - Septic shock should be managed in accordance with the Surviving Sepsis Campaign guidelines.
The Surviving Sepsis Campaign has updated the management of sepsis and septic shock. The speed and appropriateness of therapy administered in the initial hours after severe sepsis develops are likely to influence outcome, with early resuscitation improving survival rates. A multidisciplinary team approach is required including midwives, consultant obstetricians, consultant anaesthetists, consultant haematologists, consultant intensivists and consultant microbiologists. The following 'care bundle' should be applied immediately or within 6 hours, and has been shown to significantly improve survival rates:
- Measure serum lactate.
- Obtain blood cultures/culture swabs prior to antibiotic administration.
- Administer broad-spectrum antibiotic(s) within the first hour of recognition of severe sepsis and septic shock according to local protocol
- In the event of hypotension and/or lactate >4 mmol/l:
- Deliver an initial minimum of 20 ml/kg of crystalloid/colloid
- Once adequate volume replacement has been achieved, a vasopressor (norepinephrine, epinephrine) and/or an inotrope (e.g., dobutamine) may be used to maintain mean arterial pressure over 65 mm Hg.
Further management consists of:
- In the event of hypotension despite fluid resuscitation (septic shock) and/or lactate over 4 mmol/l:
- Achieve a central venous pressure of at least 8 mm Hg (or over 12 mm Hg if the woman is mechanically ventilated) with aggressive fluid replacement
- Consider steroids.
- Maintain oxygen saturation with facial oxygen. Consider transfusion if haemoglobin is below 7 g/dl.
Continuing management involves continued supportive therapy, removing the septic focus, administration of blood products if required and thromboprophylaxis. [Evidence level 1+]
Many drug overdoses have specific therapy dependent on the drug in question, and appropriate help should be sought in the management of such cases. In obstetric practice, the two main drugs that can give rise to overdose or toxic problems are magnesium sulphate and local anaesthetic agents.
The antidote to magnesium toxicity is 10 ml 10% calcium gluconate given by slow intravenous injection.
Local Anaesthetic Agents
C - Lipid rescue should be used in cases of collapse secondary to local anaesthetic toxicity.
A - In cases of anaphylaxis, all potential causative agents should be removed, and the A, B, C, D, E approach followed.
A - The definitive treatment for anaphylaxis is 500 micrograms (0.5 ml) of 1:1000 adrenaline intramuscularly. PLEASE NOTE THIS DOSE IS FOR INTRAMUSCULAR USE ONLY.
Adrenaline treatment can be repeated after 5 minutes if there is no effect. In experienced hands it can be given intravenously as a 50 microgram bolus (0.5 ml of 1:10 000 solution). Adjuvant therapy consists of chlorpheniramine 10 mg and hydrocortisone 200 mg. Both are given intramuscularly or by slow intravenous injection. [Evidence level 1+]
D - All cases of maternal death should be reported to the Centre for Maternal and Child Enquiries (CMACE).
A - Life support training reduces morbidity and mortality.
C - Small-group interactive practical training is recommended.
Grades of Recommendation
A - At least one meta-analysis, systematic review or randomised controlled trial rated as 1++ and directly applicable to the target population; or
A systematic review of randomised controlled trials or a body of evidence consisting principally of studies rated as 1+ directly applicable to the target population and demonstrating overall consistency of results
B - A body of evidence including studies rated as 2++ directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C - A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D - Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Point - Recommended best practice based on the clinical experience of the guideline development group
Classification of Evidence Levels
1++ High-quality meta-analyses, systematic review of randomised controlled trials or randomised controlled trials with a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a low risk of bias
1- Meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a high risk of bias
2++ High-quality systematic reviews of case–control or cohort studies or high quality case–control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal
2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal
2- Case–control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal
3 Non-analytical studies, e.g., case reports, case series
4 Expert opinion