14 – Amniotic Fluid Embolism




14 Amniotic Fluid Embolism


Kim Macleod and Yara Mohammed



Scenario in a Nutshell



Sudden maternal collapse with hypoxia, hypotension and haemorrhage resulting from amniotic fluid embolism during twins delivery.


Stage 1: Maternal collapse prior to delivery of twin 2.


Stage 2: Continued respiratory and cardiovascular deterioration.


Stage 3: Worsening pulmonary oedema, massive haemorrhage and DIC.



Target Learner Groups


All members of the multidisciplinary obstetric team: anaesthetists, midwives, obstetricians, operating department practitioners/anaesthetic nurses, theatre team and neonatal emergency team.















Specific learning opportunities
Recognition of differential diagnosis for maternal collapse
Recognition of amniotic fluid embolism as cause of maternal collapse
Knowledge of risk factors for amniotic fluid embolism
















































Suggested learners (to represent their normal roles) In the room from the start Available when requested
Anaesthetic CT2 √
Anaesthetic ST3+ √
Obstetric ST3+ √
Midwife Coordinator/responding midwives √
Midwife in room √
*Operating Department Practitioner (ODP)/anaesthetic nurse/theatre scrub team √
*Neonatal emergency team (if simultaneous neonatal scenario planned) √
Suggested facilitators
Faculty to play role of midwife who knows patient history √




* From stage 3 onwards, this scenario would require a full theatre team. It can also be combined with a simultaneous neonatal resuscitation – the scenario can be fragmented depending on learning objectives and available personnel.



Details for Facilitators



Patient Demographics









Name: Amanda


Age: 39


Gestation: 37


Booking weight: 65 kg


Parity: P4 (Prev 4× NVD)



Scenario Summary for Facilitators



39-year-old, P4 parturient, 37 weeks with DCDA twins has just delivered twin 1, by forceps for a pathological CTG, on delivery suite following induction of labour for pre-eclampsia. She received two prostaglandin pessaries, followed by an ARM and IV oxytocin. She has an epidural for analgesia.


After the delivery of twin 1, the membranes of twin 2 spontaneously rupture. The woman becomes restless and agitated, complaining of difficulty breathing. Twin 2 suffers sustained fetal bradycardia.


The patient is transferred to theatre for resuscitation and caesarean section under general anaesthetic. She develops florid pulmonary oedema, hypotension, and suffers massive obstetric haemorrhage as a result of DIC and uterine atony.



Set-up Overview for Facilitators






















Clinical setting


  • In a delivery room, on a delivery bed

Patient position


  • Semi-recumbent, legs in stirrups

Initial monitoring in place


  • Saturation, HR (from the saturation probe), NIBP

Other equipment


  • 16G cannula in one hand, IV Hartmann’s attached running at 80 ml/h and syntocinon 10 IU in 500 ml normal saline at 36 ml/h



  • Lumbar epidural – PCEA low-dose epidural infusion infusing at 5 ml/h

Useful manikin features


  • Abnormal breath sounds (pulmonary oedema)



  • Bleeding



  • Intubation



Medical Equipment


For core equipment checklist see Chapter 9.























Additional equipment specific to scenario



  • Arterial line


  • Rapid fluid infuser


  • Bakri® balloon




  • Epidural pump and epidural catheter


  • O-negative blood


  • Other simulated blood products




  • Drugs:




    • Syntocinon



    • Syntocinon infusion



    • Haemobate


  • Syntometrine



  • Ergometrine



  • Misoprostol



  • Tranexamic acid


  • Metaraminol



  • Phenylephrine



Information Given to the Learners










Emergency buzzer pulled. Team arrive in delivery room. Handover given by obstetric ST3+ to emergency team (including anaesthetists, midwifery coordinator, other responding midwifery staff).



  • Situation:



  • This is an emergency, there is a fetal bradycardia in twin 2 and maternal agitation, hypotension and shortness of breath.



  • Background:



  • Amanda is 39 years old, para 4, four previous normal vaginal deliveries. She is 37 weeks with DCDA twins being induced for pre-eclampsia using syntocinon. I have delivered twin 1 by forceps for a pathological CTG. Since delivery, membranes have ruptured spontaneously for twin 2, who is now transverse lie, having a fetal bradycardia and Amanda is becoming increasingly agitated, complaining of difficulty breathing. She has good analgesia from her labour epidural.



  • Assessment



  • Her observations, SpO2 80%. Respiratory rate 30 bpm. HR 110. BP 90/50. She is very distressed.



  • Recommendation



  • Can you help with resuscitation?

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Related posts:

  1. 6 – Introduction to Human Factors and Ergonomics in Obstetric Simulation
  2. 13 – Minimising Decision to Delivery Interval (DDI) in a Category 1 Caesarean Section – Pre-Theatre Phase
  3. 23 – Respiratory Arrest in a Woman Using Remifentanil PCA for Labour
  4. 36 – Obstetric Trauma

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Oct 24, 2020 | Posted by in OBSTETRICS | Comments Off on 14 – Amniotic Fluid Embolism

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