15 – Anaphylaxis in Labour

15 Anaphylaxis in Labour

Andrew Parkes and Shuayb Elkhalifa

Scenario in a Nutshell

Severe life-threatening anaphylaxis following benzypenicillin IV for intrapartum antibiotic prophylaxis for group B streptococcal colonisation.

Stage 1: Recognition of anaphylaxis and initial management.

Stage 2: Patient continues to deteriorate, with airway, respiratory and cardiovascular compromise.

Stage 3: Continuing severe life-threatening anaphylaxis.

Stage 4: Patient continues to deteriorate, requiring intubation, ventilation and referral to critical care.

Target Learner Groups

All members of the multidisciplinary obstetric team: midwives, obstetricians, anaesthetists.

Specific learning opportunities
Knowledge of common causes of anaphylaxis
Recognition of anaphylaxis
Knowledge of algorithm for treatment of severe life-threatening anaphylaxis
Orientation – knowledge of emergency equipment to treat anaphylaxis in local environment

Suggested learners (to represent their normal roles)	In the room from the start	Available when requested
Anaesthetic CT2		√
Anaesthetic ST3+		√
Obstetric ST3+		√
Midwife Coordinator		√
Suggested facilitators
Midwife		√ (first to respond)
Faculty to play role of partner	√

Details for Facilitators

Patient Demographics

Name: Kira

Age: 38

Gestation: 37

Booking weight: 87 kg

Parity: P3 (Prev NVD)

Scenario Summary for Facilitators

38-year-old para 3, 37 weeks pregnant, admitted to delivery suite in active labour. Spontaneous rupture of membranes (SROM) 2 hours ago, examined 1 hour ago, cervix 4 cm dilated. Receiving first dose of antibiotics for group B Streptococcus.

Previous baby with group B streptococcal infection as neonate. Baby spent prolonged period on NICU and parents very anxious.

Shortly after receiving first dose of IV benzylpenicillin (3 g in 100 ml normal saline running over 1 h as per guidelines) patient complains of feeling unwell – hot, light-headed and difficulty breathing.

Partner (facilitator) alerts staff to the problem. He notices that she appears rather red and flushed.

Treatment of severe life-threatening anaphylaxis ensues, requiring repeated IM/IV adrenaline boluses, bronchodilators and intubation/ventilation and delivery.

Set-up Overview for Facilitators

Clinical setting	On delivery suite in a delivery bed
Patient position	Lying semi-recumbent on bed
Initial monitoring in place	CTG monitor
Other equipment	20G venflon dorsum hand through which benzylpenicillin infusion is running (3 g in 100 ml normal saline running over 1 h or as per local guideline)
Useful manikin features	Abnormal breath sounds (wheeze) Palpable pulses Tongue swelling Intubation

Medical Equipment

For core equipment checklist see Chapter 9.

Additional equipment specific to scenario
Nebuliser	Benzylpenicillin in 100 ml saline running through Baxter pump
Adrenaline 1:1000 1:10,000 Hydrocortisone Chlorphenamine	Metaraminol Ephedrine Noradrenaline Drugs for intubation	Salbutomol Inhalers, nebulisers, infusion Magnesium Aminophylline

Information Given to the Learners

Patient’s relative approaches passing midwife alerting her to his concerns

Time: 21:00
Please can you help? My wife doesn’t look very well!
From the team midwifery handover you know:
Patient is 38 years old, otherwise fit and well. 37 weeks pregnant. G4 P3.
SROM 2 hours ago, in active labour, 4 cm dilated at last examination 1 hour ago. Previous neonatal sepsis due to Group B Streptococcus. Commenced on benzylpenicillin as per protocol. No known drug allergies.