CLINICAL GUIDELINES

PERIPARTUM COLLAPSE Register No: 04252

Status: Public

Developed in response to: Intrapartum NICE Guidelines

RCOG guideline
Contributes to CQC Outcome No 4

Consulted With Post/Committee/Group Date

Mr Kennedy Clinical Director for Womens, Childrens and Sexual Health Directorate December 2013
Miss Joshi Consultant for Obstetrics and Gynaecology
Alison Cuthbertson Interim Chief Nurse and Acting Head of Midwifery
Deb Cobie Lead Midwife Labour Ward and Acute Inpatient Services Manager
Chris Berner Maternity Risk Manager
Diane Roberts Lead Midwife Community Services; Named Midwife Safeguarding
Sarah Moon Specialist Midwife for Guidelines and Audit
Gemma May Practice Development Midwife
Paula Hollis Team Leader Labour Ward
Claire Fitzgerald Pharmacist
Professionally Approved By
Miss Rao Lead Consultant for Obstetrics and Gynaecology December 2013

Version Number 4.0

Issuing Directorate Obstetrics and Gynaecology
Ratified By Document Ratification Group
Ratified On 23rd January 2014
Trust Executive Sign Off Date February 2014
Implementation Date 5th February 2014
Next Review Date January 2017
Author/Contact for Information Sam Brayshaw, Anaesthetic Consultant
Policy to be followed by (target staff) Midwives, Obstetricians, Paediatricians
Distribution Method Intranet & Website. Notified on Staff Focus
Related Trust Policies (to be read in 04071 Standard Infection Prevention
conjunction with) 04072 Hand Hygiene
06036 Guideline for Maternity Record Keeping
07039 Amniotic Fluid Embolism
05110 Management of Eclampsia and Severe Pre-eclampsia
04234 Management of Postpartum Haemorrhage
07072 Management of a Patient Reporting an Antepartum Haemorrhage
05119 Severe Sepsis Evaluation Procedure
07024 Emergency Transport of Blood and Specimens in the Event of Major
Obstetric Haemorrhage
09095 Severely Ill Pregnant Patient
04266 Management of Diabetes in Pregnancy
04232 Guideline to Assist Medical and Medical and Midwifery Staff in the
Provision of High Dependency Care and Arrangements for Date and Timely
Transfer to ITU
04247 Resuscitation in pregnancy

Review No Reviewed by Review Date

1.0 Judy Evans October 2005
2.0 Nina Smethurst October 2008
3.0 Paula Hollis February 2011
4.0 Sam Brayshaw, Anaesthetic Consultant January 2014
It is the personal responsibility of the individual referring to this document to ensure that they are viewing the latest version which will always be
the document on the intranet

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INDEX

1. Purpose

2. Equality and Diversity

3. Aim of the Guideline

4. The Possible Causes of Peripartum Collapse

5. Immediate Action

6. Continuation of Care

7. Staff and Training

8. Supervisor of Midwives

9. Infection Prevention

10. Audit and Monitoring

11. Guideline Management

12. Communication

13. References

14. Appendices

A. Appendix A Management of Maternal Collapse

B. Appendix B - Anaphylactic Algorithm

C. Appendix C - Management of an Asthma Attack

D. Appendix D Management of Severe Local Anaesthetic Toxicity

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1.0 Purpose

1.1 A delay in recognition of life-threatening illness contributes to avoidable mortality and

morbidity in pregnant patients. The early detection of severe illness in mothers remains a
challenge to all involved in their care. The relative rarity of such events combined with the
normal changes in physiology associated with pregnancy and childbirth compounds the
problem.

1.2 The purpose of this guideline is to ensure that those patients who have the potential to
develop critical illness, i.e. patient with underlying medical problems and, those who
develop serious problems during pregnancy and childbirth, are identified early when their
clinical condition is beginning to deteriorate before a serious adverse event occurs. It will
also ensure early and appropriate involvement of clinicians outside of the maternity
service.

1.3 This guideline must be used by midwives, obstetricians, obstetric anaesthetists the High
Dependency Unit (HDU) / Outreach Team, and may be referred to by surgeons, general
physicians, neurologists, cardiologists, and the cardiac arrest team.

2.0 Equality and Diversity

2.1 The Trust is committed to the provision of a service that is fair, accessible and meets the
needs of all individuals.

3.0 The Aims of Management

3.1 To recognise the early signs of deterioration in a pregnant patient

3.2 To recognise peripartum collapse

3.3 To involve appropriate staff (senior level) as quickly as possible

3.4 To recognise the underlying cause and give appropriate treatment as quickly as possible
to help stabilize the patient.

3.5 To continue to care for the patient in the subsequent recovery phase appropriately.

4.0 The Possible Causes of Peripartum Collapse

4.1 Amniotic fluid embolism - the entry of liquor amnii, which contains vernix and other
solids, into the maternal circulation via sinuses of the placental site.
(Refer to the guideline for Amniotic fluid embolism; register number 07039)

4.2 Anaphylaxis a severe, life threatening condition causing generalized or systemic

hypersensitivity reaction
(Refer to Appendix B)

4.3 Asthma - common chronic inflammatory disease of the airways characterized by variable
and recurring symptoms, reversible airflow obstruction and bronchospasm
(Refer to Appendix C).

4.4 Cerebrovascular accident an intracranial bleed or embolus causing acute damage; to

be considered when severe hypertension or clotting problems have been noted in the
history.
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4.5 Drug toxicity most commonly opiate overdose / reaction; or local anaesthetic toxicity
(Refer to Appendix D)

4.6 Eclampsia tonic/clonic seizures associated with other features of severe pre-
eclampsia.
(Refer to the guideline for the management of eclampsia and severe pre-eclampsia;
register number 05110)

4.7 Haemorrhage (hypovolaemic shock)

(Refer to the guideline for the Management of postpartum haemorrhage; register
number 04234 and guideline for the management of a patient reporting an antepartum
haemorrhage; register number 07072)

4.8 Hypoglycaemia particularly pertinent in known diabetic.

(Refer to the guideline for the Management of diabetes in pregnancy; register number
04266)

4.9 Myocardial Infarction - following a history of severe crushing chest pain (although may
be in the neck or radiating down the arm). Be aware in those patients with a history of
heart disease.

4.10 Sepsis (septic shock) - Normally relating to a period of infection / suspected infection.
Observations of tachycardia, hypotension, tachypnoea and pyrexia may precede this.
(Refer to the guideline for Severe sepsis evaluation procedure; register number 05119)

4.11 Tension pneumothorax - sudden onset of pleuritic chest pain with diminished breath
sounds.

4.12 Pulmonary embolism - apprehension, pleuratic chest pain, sudden dyspnoea, cough,
heamoptysis and collapse are suggestive.

4.13 Uterine inversion - occurs only in third stage. Profound hypotension is apparent. May be
partial therefore diagnosis not always obvious.

5.0 Management of Maternal Collapse

5.1 Acute Collapse - sudden unexpected maternal collapse before, during or after delivery
constitutes a medical emergency. When this occurs, the flow chart Basic Life Support
and Maternal Collapse must be followed.

5.2 Basic life support and maternal collapse - Additional help should always be
summoned when faced with maternal collapse:
(Refer to the guideline entitled Resuscitation in pregnancy; register number 04247)
(Refer to appendix A)

Call for help, emergency bell if available. Code Red - 4444

(Cardiac Arrest call if deemed necessary for arrest / peri-arrest situation 2222)
Off site or Birthing units - dial 999 stating; obstetric emergency
Labour Ward Co-ordinator (#6555 2017)
Obstetric senior house officer
On call obstetric registrar
On call anaesthetist

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 On call anaesthetist assistant
Paediatric SHO
Theatre scrub team

5.3 During the resuscitation procedure:

The Resuscitation Council now recognises that tilting the patient during resuscitation
is difficult and advocates manual displacement of the uterus

Gain IV access 2 x 16g cannulae

Give facial oxygen at 15 litres / minute via non-re breathable face mask

Monitor and record blood pressure and pulse

Monitor and record the oxygen saturation rate, and respiratory rate

These observations should be undertaken every 5 minutes initially. It is good practice

to check the pulse manually so that rate, rhythm and depth can be noted and
documented accordingly in the MEOWS chart and the patients healthcare records
(Refer to the guideline for the Severely ill pregnant patient; register number 09095)

Take bloods for group and save, full blood count, clotting, urea and electrolytes, liver
function tests and send to lab on category 1 (or code yellow if patient bleeding). Also
check blood glucose level on finger tip stab to assess whether hypoglycaemic.
(Refer to the guideline for Emergency transport of blood and specimens in the event
of major obstetric haemorrhage; register number 07024)

Commence an intravenous infusion of 1 litre of Hartmanns solution, titrate as

necessary depending on cause for collapse (i.e. give rapidly for hypovolaemic /
hypotensive patient but with caution in cases with raised blood pressure and
suspected heart failure)

If the patient is pregnant, commence continuous fetal monitoring (if appropriate/

possible) or auscultate fetal heart rate using pinnard or sonicaid

Assess neurological status using AVPU score or Glasgow coma scale if able

Where possible undertake ECG rhythm strip to note any arrhythmias. If appropriate
undertake a 12 lead ECG for a more thorough picture.

5.4 By now you should be trying to determine the cause for the collapse.
Consider:

Bleeding - revealed or concealed

Thromboembolism
Amniotic fluid embolism
Myocardial infarction
Total spinal anaesthesia
Hypotension

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5.5 Investigations will be guided by the clinical circumstances but might usefully include:

Haemoglobin estimation
Blood glucose level
Clotting screen including fibrinogen
Arterial blood gases
Chest x-ray
ECG

5.6 When primary cause for collapse is diagnosed, treat appropriately

(Refer to point 3 and Appendix A, B)

5.7 If appropriate, organise for transfer of patient to specialized care area i.e. obstetric
theatre, ITU, CCU, A&E.
(Refer to the guideline for the Severely ill pregnant patient; register number 09095; and
the Guideline to assist medical and medical and midwifery staff in the provision of high
dependency care and arrangements for date and timely transfer to ITU; register number
04232)

6.0 Continuation of Care

6.1 Following collapse and subsequent recovery, the patient should be monitored closely. If
deemed acceptable by senior staff that the patient can remain within Maternity Unit
setting, then the patient should be observed on Delivery Suite by an appropriately trained
member of staff.

6.2 Observations of respirations, pulse, blood pressure, temperature and oxygen saturation
levels should continue until the patient is stable. The frequency and duration of these
observations may vary depending on the cause for collapse and subsequent speed of
recovery

6.3 The midwife/ nurse must record all observations on the Maternity early obstetric warning
scoring system (MEOWS) chart and document the MEOWS score so that any trends can
be visualised and escalated appropriately.
(Refer to the guideline for the Severely ill pregnant patient; register number 09095)

6.4 The responsible midwife should ensure that Datixweb is completed following the event.

7.0 Staffing and Training

7.1 All midwifery and obstetric staff must attend yearly mandatory training which includes
skills and drills training, maternal resuscitation and early recognition of the ill patient.
(Refer to Mandatory training policy for Maternity Services (incorporating training needs
analysis. Register number 09062; Resuscitation in pregnancy; register number 04247;
and Severely Ill Pregnant Patient; register number 09095)

7.2 All midwifery and obstetric staff are to ensure that their knowledge and skills are
up-to-date in order to complete their portfolio for appraisal.

8.0 Supervisor of Midwives

8.1 The supervision of midwives is a statutory responsibility that provides a mechanism for
support and guidance to every midwife practising in the UK. The purpose of
supervision is to protect women and babies, while supporting midwives to be fit for
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 practice'. This role is carried out on our behalf by local supervising authorities. Advice
should be sought from the supervisors of midwives who are experienced practising
midwives who have undertaken further education in order to supervise midwifery
services. A 24 hour on call rota operates to ensure that a Supervisor of Midwives is
available to advise and support midwives and women in their care choices.

9.0 Infection Prevention

9.1 All staff should follow Trust guidelines on infection prevention by ensuring that they
effectively decontaminate their hands before and after each procedure.

9.2 All staff should ensure that they follow Trust guidelines on infection prevention. All
invasive devices must be inserted and cared for using High Impact Intervention
guidelines to reduce the risk of infection and deliver safe care. This care should be
recorded in the Saving Lives High Impact Intervention Monitoring Tool Paperwork
(Medical Devices).

10.0 Audit and Monitoring

10.1 Audit of compliance with this guideline will be undertaken on an annual audit basis in
accordance with the Clinical Audit Strategy and Policy, the Maternity annual audit work
plan and the NHSLA/CNST requirements. The Audit Lead in liaison with the Risk
Management Group will identify a lead for the audit. .

10.2 The findings of the audit will be reported to and approved by the Multi-disciplinary
Risk Management Group (MRMG) and an action plan with named leads and
timescales will be developed to address any identified deficiencies. Performance against
the action plan will be monitored by this group at subsequent meetings.

10.3 The audit report will be reported to the monthly Directorate Governance Meeting (DGM)
and significant concerns relating to compliance will be entered on the local Risk
Assurance Framework.

10.4 Key findings and learning points from the audit will be submitted to the Patient Quality
and Safety Committee (PSQC) within the integrated learning report.

10.5 Key findings and learning points will be disseminated to relevant staff.

11.0 Guideline Management

11.1 As an integral part of the knowledge, skills framework, staff are appraised annually to
ensure competency in computer skills and the ability to access the current approved
guidelines via the Trusts intranet site.

11.2 Quarterly memos are sent to line managers to disseminate to their staff the most
currently approved guidelines available via the intranet and clinical guideline folders,
located in each designated clinical area.

11.3 Guideline monitors have been nominated to each clinical area to ensure a system
whereby obsolete guidelines are archived and newly approved guidelines are now
downloaded from the intranet and filed appropriately in the guideline folders. Spot
checks are performed on all clinical guidelines quarterly.

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11.4 Quarterly Clinical Practices group meetings are held to discuss guidelines. During this
meeting the practice development midwife can highlight any areas for further training;
possibly involving workshops or to be included in future skills and drills mandatory
training sessions.

12.0 Communication

12.1 A quarterly maternity newsletter is issued and available to all staff including an update
on the latest guidelines information such as a list of newly approved guidelines for staff
to acknowledge and familiarise themselves with and practice accordingly.

12.2 Approved guidelines are published monthly in the Trusts Focus Magazine that is sent via
email to all staff.

12.3 Approved guidelines will be disseminated to appropriate staff quarterly via email.

12.4 Regular memos are posted on the guideline notice boards in each clinical area to notify
staff of the latest revised guidelines and how to access guidelines via the intranet or
clinical guideline folders.

13.0 References

With thanks to North Cumbria University Hospitals NHS Trust (2010)

CNST Maternity Clinical Risk Management Standards (2010/11) Version 1, Standard 2,

Criterion 9; High dependency care.

Resus Council UK (2011) Advanced Life Support (sixth edition). January: London

(http://www.resus.org.uk/pages/ALSmRev3.pdf#search="pregnancy")

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Appendix A

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 Appendix B

Anaphylactic Algorithm

Anaphylactic
Reaction

Airway, Breathing, Circulation, Disability, Exposure (1)

Diagnosis - observe for:

Acute onset of illness
Life threatening airway and/or breathing and/or circulation problems
Skin changes

Call for Help

Lie patient flat
Raise patients legs

Give Adrenaline (2)

When skills and equipment available:

Establish airway
Administer high flow oxygen 10 l/min via reservoir mask
Monitor: IV fluid challenge (3)
Monitor pulse oximetry, blood pressure, respirations
Administer chlorophenamine (4), hydrocortisone (5)

Refer to numbered headings 1-5 below

1. Life threatening problems

Airway: swelling, hoarseness, stridor

Breathing: rapid breathing, wheeze, fatigue, cynanosis, oxygen saturation levels of
<92%, confusion
Circulation: pale, clammy, low blood pressure, faintness, drowsy/coma

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2. Adrenaline

Administer via intramuscular injection (IM) unless experienced with IV adrenaline)

IM doses of 1:1000 adrenaline (repeat every 5 min if no better)
Adult 500 micrograms IM (0.5ml)
Adrenaline IV to be given only by experienced specialists
Titrate : Adults 50 micrograms

3. IV fluid challenge

Administer 500 1000 mls

4. Chlorophenamine

10 mgs IM or slow IV

5. Hydrocortisone

200mgs IM or slow IV

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 Appendix C

Management of an Asthma Attack

Mild:

Symptoms - Patient aware of tightness in chest when breathing, however can speak in
sentences

Mild rise in respiration and pulse rate noted (up to 25bpm and 110bpm respectively)

Treatment - Give usual bronchodilator - ventolin (salbutamol inhaler) followed by oxygen

via facemask if deemed necessary

Moderate:

Symptoms - Patient experiencing difficulty in breathing. Cannot speak in complete

Sentences
Respiration rate > 25bpm, pulse rate >110bpm

Treatment - Administer 5mgs of salbutamol by oxygen driven nebulizer.

If necessary repeat nebulizer after 15mins (a further 5mgs of salbutamol) and
consider giving prednisolone 40-50mgs orally or intravenously

Severe (Life Threatening):

Symptoms - Patient showing signs of exhaustion, confusion or is unresponsive

Poor respiratory effort, cyanosis, silent chest, bradycardia, arrthymia, hypotension

Treatment - Obtain senior/ITU help if any life threatening features are present.
Administer a high concentration of oxygen i.e. 10 l/min via reservoir face mask
Administer salbutamol 5mgs plus ipratropium bromide (atrovent) 0.5mgs via oxygen
driven nebulizer
(repeat if necessary after 15mins)
Give 40-50mgs of prednisolone IV
Transfer to appropriate care setting (ITU/medical ward)
Chest X-Ray to be undertaken when possible/appropriate
Refer to asthma liaison nurse/chest clinic.

All patients following an asthma attack must be closely observed and readings of pulse,
respiratory rate, blood pressure, oxygen saturation levels and temperature must be
recorded. Regularity and duration of these observations will be indicated by the severity
of the attack and patients subsequent speed of recovery.

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 Appendix D

AAGBI Safety Guideline

Management of Severe Local Anaesthetic Toxicity

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