29 – Pneumonia and Respiratory Failure in a Pregnant Woman

29 Pneumonia and Respiratory Failure in a Pregnant Woman

James Hanison and Dougal Atkinson

Scenario in a Nutshell

Antenatal viral pneumonia progressing to respiratory failure, requiring intubation. Then develops tension pneumothorax.

Stage 1: Initial assessment and commence sepsis 6.

Stage 2: Patient deteriorates with respiratory failure, requiring intubation.

Stage 3: Patient difficult to ventilate, develops tension pneumothorax.

Target Learner Groups

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

Specific learning opportunities
Effective team management of two emergencies – respiratory failure and tension pneumothorax
Timely recognition of sepsis and consideration of viral pneumonia as a potential diagnosis
Efficient completion of the sepsis 6
Assess access on the delivery unit to: emergency intubation equipment, oseltamivir, chest drain insertion equipment

Suggested learners (to represent their normal roles)	In the room from the start	Available when requested
Anaesthetic ST3+		√
Obstetric ST3+		√
Midwife Coordinator		√
Triage midwife	√
Operating Department Practitioner (ODP)/anaesthetic nurse		√
Suggested facilitators
Faculty to play role of patient’s partner	√

Details for Facilitators

Patient Demographics

Name: Rita

Age: 35

Gestation: 25+6

Booking weight: 65 kg

Parity: P2

Scenario Summary for Facilitators

35-year-old 25-week pregnant multiparous woman. Telephoned antenatal ward and described a 4-day history of fever and shortness of breath. Advised to attend triage for assessment.

Arrives in triage presenting with hypoxia, shortness of breath and pyrexia.

Transferred to delivery unit high-dependency area.

Rapidly deteriorates with worsening hypoxia and reduced level of consciousness.

Intubation and ventilation is required, following which patient develops cardiovascular instability despite resuscitation.

Tension pneumothorax. Requires decompression.

Emergency chest drain.

Set-up Overview for Facilitators

Clinical setting	On triage trolley
Patient position	Semi-recumbent
Initial monitoring in place	None – just arrived
Other equipment	None
Useful manikin functions	Intubation Unilateral and bilateral chest movement Normal and abnormal breath sounds

Medical Equipment

For core equipment checklist, see Chapter 9, including advanced airway equipment.

Additional equipment specific to scenario
Anaesthetic drugs: Propofol Thiopentone Suxamethonium Rocuronium Opioid: fentanyl/alfentanil Remifentanil/propofol or other sedative infusions	Antibiotics/antiviral drugs (or as per local guidelines): Co-amoxiclav Clarithromycin Oseltamivir/zanamivir	Cardiovascular drugs: Metaraminol Ephedrine Phenylephrine Atropine Adrenaline 1:10,000
Doppler fetal monitor/pinard stethoscope
Aprons, gloves, surgical masks with eye protection, FFP3 face masks	Local microbiology antibiotic guidelines

Information Given to the Learners

Information given to the midwife starting in the room.

Time: 18:35
This handover is given by a facilitator playing the role of the midwife who has just brought the patient round from reception to a triage room because she looks unwell.
The SBAR handover is as follows:
Situation: This is Rita – I have brought her round as she was feeling unwell and looking short of breath in the waiting room.
Background: She is a 35-year-old, who is 25+6 weeks pregnant with her third child. Two previous normal vaginal deliveries. She doesn’t have any allergies. She has mild asthma. She has been feeling generally unwell with a temperature for the last 4 days and has become short of breath over the last 24 hours.
Assessment: We’ve brought her straight round but haven’t had a chance to do her observations yet.
Recommendation: The coordinator said you were free to take her – is that right?
Midwife handing over patient leaves.