Scenario in a Nutshell
Patient with known repaired Tetralogy of Fallot (ToF) suffers new-onset, regular, narrow complex tachycardia which is unresponsive to medical management requiring DC cardioversion under general anaesthesia.
Stage 1: Initial assessment of narrow complex tachycardia in labouring parturient with adult congenital heart disease (ACHD).
Stage 2: Correction of electrolytes, perform vagal manoeuvres, administer adenosine for continued tachyarrhythmia.
Stage 3: Medical management for tachyarrhythmia unsuccessful, adverse features now present.
Stage 4: DC cardioversion and caesarean section.
Target Learner Groups
All members of the multidisciplinary obstetric team: anaesthetists, midwives, obstetricians, operating department practitioners and cardiologists.
|Specific learning opportunities|
|Assessment of narrow complex tachycardia in adult congenital heart disease (ACHD) patients|
|Knowledge of algorithm for management of tachyarrhythmia|
|Consideration of anaesthetic plan for DC cardioversion in pregnancy|
|Importance of senior MDT obstetric and cardiology input in ACHD parturients|
|Suggested learners (to represent their normal roles)||In the room from the start||Available when requested|
|Midwife in room||√|
|Operating Department Practitioner (ODP)/anaesthetic nurse||√|
|Faculty to play role of student midwife giving handover at time of emergency buzzer||√|
Details for Facilitators
Booking weight: 64 kg
Scenario Summary for Facilitators
29-year-old 36-week primipara woman, with history of repaired Tetralogy of Fallot, attends delivery suite in spontaneous labour. She has been complaining of sudden onset of palpitations and feels her heart is racing. She has a confirmed narrow complex tachyarrhythmia on the monitor.
Her past surgical history is repaired TOF with Waterston shunt, followed by a repair of pulmonary valve and closure of VSD. Recent echo shows signs of moderate pulmonary regurgitation and mild RV dysfunction. She attended the joint obstetric, cardiac, anaesthetic clinic 6 weeks ago. (For the Anaesthetic letter see Figure 33.1. For the echocardiogram report see Figure 33.2.)
Figure 33.1 Anaesthetic Clinic Letter.
Figure 33.2 Patient’s echocardiogram report.
On arrival on the delivery suite, she is reviewed by the team. All investigations performed and bloods taken. Potassium and magnesium corrected.
Although initially stable with tachyarrhythmia, it does not respond to vagal manoeuvres, adenosine or beta blockers.
Patient then becomes hypotensive and complains of chest pain. Decision made for DC cardioversion in theatre.
The patient is intubated and cardioverted successfully.
CTG remains suspicious, the obstetric team proceed to perform an emergency LSCS.
Set-up Overview for Facilitators
For core equipment checklist, see Chapter 9.
|Additional equipment specific to scenario|
|Arterial line||Resuscitation trolley with defibrillator||Pads for defibrillation|
Information Given to the Learner
|SBAR Handover by faculty (playing the role of midwife) to the obstetric and anaesthetic on-call team|
|Situation: 29 years old. 36 weeks primipara in spontaneous labour. She has a past history of adult congenital heart disease and is now complaining of palpitations.|
|Background: She was diagnosed with Tetralogy of Fallot in childhood and has had surgical repair. She has been seen in obstetric anaesthetic clinic (see Figure 33.1). She has been symptom-free in pregnancy until yesterday, when she started suffering with palpitations. She has just arrived in hospital and is in spontaneous labour, which commenced about 3–4 hours ago.|
|Assessment: I was just about to perform some observations but thought it best to get you immediately.|
|Recommendations: Would you like me to get the clinic letter while you meet Michelle?|