Scenario in a Nutshell
Concealed abruption with hypovolaemic cardiac arrest requiring perimortem section in A+E.
Stage 1: Initial assessment of parturient with severe abdominal pain and reduced fetal movements.
Stage 2: Handover to MDT obstetric team, identification of placental abruption and activation of major haemorrhage pathway.
Stage 3: Cardiovascular collapse despite resuscitation.
Stage 4: Management of hypovolaemic PEA arrest and perimortem section.
Target Learner Groups
Appropriate members of the receiving A+E team and multidisciplinary obstetric team.
| Specific learning opportunities |
|---|
| Knowledge of differential diagnosis of acute onset abdominal pain in pregnancy |
| Recognition of concealed haemorrhage |
| Knowledge of massive haemorrhage protocol |
| Knowledge of obstetric emergency equipment in A+E |
| Demonstrate safe, effective CPR with timely perimortem section |
This scenario is written with an absent fetal heart beat from the start. However, if you wanted to involve the neonatal team, faculty can alter the scenario to include a live fetus.
| Suggested learners (to represent their normal roles) | In the room from the start | Available when requested |
|---|---|---|
| A+E nurse | √ | |
| A+E ST3+ | √ | |
| Obstetric ST3+/Consultant | √ | |
| Midwife | √ | |
| Anaesthetic CT2/ST3+ | √ | |
| Other responding members of A+E team | √ | |
| Neonatal resuscitation team (if able to run a simultaneous neonatal resuscitation scenario*) | √ | |
| Suggested facilitators | ||
| Faculty to play role of triage nurse in A+E | √ |
Details for Facilitators
Patient Demographics
Name: Olivia Age: 35 Gestation: 28 Booking weight: 60 kg Parity: P0 |
Scenario Summary for Facilitators
Patient attends A+E with severe abdominal pain and reduced fetal movements.
Haemodynamically unstable, unresponsive to fluids.
When examined found to have hard, woody uterus. If available, ultrasound confirms fetal death in utero. Sonicaid shows no fetal heart beat.
Massive haemorrhage recognised and massive haemorrhage protocol activated. Before able to transfer to theatre, patient becomes less responsive and then suffers a hypovolaemic PEA cardiac arrest. Resuscitation with blood/blood products and perimortem section required.
Set-up Overview for Facilitators
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Medical Equipment
For core equipment checklist see Chapter 9.
| Additional equipment specific to scenario | ||
|---|---|---|
| Arterial line | Resuscitation trolley with defibrillator | Pads for defibrillation |
| Rapid fluid infuser | O-negative blood | Other simulated blood products |
Drugs:
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Information Given to the Learners
| Handover to the A+E team from triage nurse (played by faculty member) who has brought patient straight to resus bay |
|---|
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Suggested Topics for Debrief Discussion
How well prepared do you think your A+E department is to receive obstetric emergencies?
If you were transferring to theatre, how quickly could you get the patient there?
Interpretation of point of care coagulation tests.
Discussion
Introduction
Cardiac arrest in pregnancy fortunately remains a rare event in the UK occurring in approximately 1 in 36,000 pregnancies (Beckett et al., 2017; Datner and Promes, 2006). It is one of the most dreaded and stressful events for all staff involved and optimal management requires clear leadership and effective communication between multiple specialities above the demands of a standard cardiac arrest. Thromboembolism and haemorrhage remain the leading causes of direct maternal deaths (Knight et al., 2016) and haemorrhage is the most common cause of maternal collapse (Royal College of Obstetricians and Gynaecologists, 2014). The majority of cardiac arrests in pregnancies occur in hospitals, where outcomes are better than those occurring at home or during ambulance transfer (Beckett et al., 2017).
Antepartum Haemorrhage
Antepartum haemorrhage (APH) is defined as bleeding from or in to the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby (Royal College of Obstetricians and Gynaecologists, 2011). APH complicates 3–5% of pregnancies and can be associated with significant maternal and fetal mortality and morbidity (Calleja-Agius et al., 2006). The causes of APH are shown in Box 25.1 (Luesley and Kilby, 2016). Pregnancies complicated by APH are at increased risk of adverse outcomes and increased risk of preterm delivery, stillbirth, fetal anomalies and decreased birthweight (Magann et al., 2005; McCormack et al., 2008).
Box 25.1 Causes of Antepartum Haemorrhage
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