Obstetric Emergencies: Learning Objectives

OBSTETRIC ANAESTHESIA
Obstetric emergencies Learning objectives

Ahmed Essa After reading this article, you should be able to:
C understand common causes of obstetric emergencies and their
Graeme G Flett
management
C be aware of the need for early detection and management of the
Abstract critically unwell parturient

C understand the differences in resuscitation of the pregnant
For more than 60 years the Confidential Enquiry into Maternal Deaths
triennial reports and later reports from Mothers and Babies: Reducing patient
C understand the role of simulation in the reinforcement of
Risk through Audits and Confidential Enquiries across the UK
(MBRRACE-UK) have helped build a picture of maternity care within teaching and retention emergency skills
the UK highlighting not only our successes but failures in caring for
women within the puerperal period. Despite most obstetric emergen-
Thrombosis and thromboembolism remain the leading cause
cies being well described and having clear management strategies
of direct maternal death during or up to 6 weeks after the end of
and guidance, there continues to be substandard management with
pregnancy. Deaths due to obstetric hemorrhage and pregnancy-
poor outcomes recorded. This article describes some common ob-
related sepsis occur as frequently as each other and are the next
stetric emergencies with which the anaesthetist will become involved.
commonest causes of maternal death, followed by suicide.
It emphasizes management related to some deficiencies identified in
Maternal suicide remains the leading cause of direct deaths
the MBRRACE-UK report as well as highlighting a multidisciplinary
occurring within a year after the end of pregnancy. Deaths
approach throughout. Good communication between team members
directly related to anaesthesia remain extremely low with only
is paramount in all aspects of medical care but this approach should
one death recorded in the reporting period.1
be fostered routinely to ensure that rapid and appropriate decisions
Overall, 211 women died in 2017e19 during or within 42 days
are made in a safe and timely manner.
of the end of pregnancy in the UK. A maternal death rate of 8.79
Keywords Amniotic fluid embolus; emergency caesarean section; per 100,000 maternities compared to 9.71 per 100,000 mater-
local anaesthetic toxicity; magnesium toxicity; maternal collapse;
nities (95% CI 8.46e11.09) in 2016e18.1 This article identifies
maternal resuscitation; MBRRACE; multidisciplinary obstetric emer-
some causes of common emergencies in obstetrics seen (Table 1)
gency simulation; sepsis
and highlights key treatment points in their management to help
Royal College of Anaesthetists CPD Skills Framework: Obstetrics
improve outcome. Major haemorrhage, pre-eclampsia and
eclampsia are mentioned in detail within other articles in this
series, as are emergencies related specifically to anaesthetic
practice.
Maternal sepsis
Introduction
Sepsis is one of the most important causes of maternal death in
The MBRRACE report published in November 2021, looking at the UK, and there is an 8% risk of mortality across high in-
reports from the period of 2017e2019, showed a statistically non- come countries. Morbidity, not insignificant in survivors, has
significant decrease in the overall maternal death rate in the UK an estimated morbidity/mortality ratio of 50:1.2 The World
which suggests that continued focus on implementation of the Health Organization (WHO) reports the prevalence of puer-
recommendations of these reports is needed to achieve a reduc- peral sepsis alone in live births as 4.4%.2 As per Sepsis-3
tion in maternal deaths.1 Deaths related to direct causes in (published in 2016), new definitions were addressed for
particular have non-significantly decreased in 2017e2019 report sepsis and septic shock while previously used terms such as
when compared to the previous report.1 severe sepsis and systemic inflammatory response syndrome
Figure 1 shows a graphical representation of the leading (SIRS) were dropped. The two current definitions in use are
causes of maternal death in the 2017e2019 report. now as follows.
Cardiac disease remains the largest single cause of indirect
maternal deaths with neurological causes (epilepsy and stroke) Sepsis: life-threatening organ dysfunction caused by a dysregu-
being the second most common cause of maternal death.1 lated host response to infection.
Septic shock: sepsis associated with vasopressor requirements to

maintain a mean arterial pressure (MAP) 65 mmHg in the
Ahmed Essa MBBCh MSC EDAIC FCAI is a Clinical Fellow in Anaesthesia
and Intensive Care Medicine at Manchester University Hospitals NHS absence of hypovolaemia and a serum lactate >2 mmol/litre.
Foundation Trust, Manchester, UK. Conflicts of interest: none The World Health Organization in 2017 adopted the following
declared. definition of maternal sepsis: a life-threatening condition with
organ dysfunction resulting from infection during pregnancy,
Graeme G Flett BSc (Hons) MB ChB MRCP (UK) FRCA AFHEA is a Consultant
in Obstetric and General Anaesthesia at St Mary’s Hospital, childbirth, post-abortion, or in the postpartum period. Since
Manchester University Hospitals NHS Foundation Trust, Manchester, publication, the bedside tools, quick sequential (sepsis-related)
UK. Conflicts of interest: none declared. organ failure assessment (qSOFA) and the sequential organ
ANAESTHESIA AND INTENSIVE CARE MEDICINE 23:8 460 Ó 2022 Published by Elsevier Ltd.
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Figure 1
failure assessment (SOFA) have been used to aid prognosis and and New Zealand and these are seen in Tables 2 and 3 respec-
diagnosis of sepsis. However, these are unvalidated in pregnant tively. Standard scoring is used in the obstetrically modified
or puerperal women, and direct application is complicated by the SOFA score and scoring 2 or more in the qSOFA is associated
physiological differences of healthy pregnancy.2 There has with increased mortality.
however been proposed an obstetrically modified SOFA and Causes of sepsis in an obstetric population can be divided into
qSOFA scores2 by the Society of Obstetric Medicine of Australia obstetric sources (further divided into genital tract, and non-
Obstetric emergencies which may present challenges to the anaesthetist

Haemorrhage: e antepartume post-partum Fetal distress of any cause
Sepsis Emergency caesarean section e for any cause
Pre-eclampsia and eclampsia Uterine rupture
Thromboembolism Uterine inversion
Amniotic fluid embolism Shoulder dystocia
Maternal cardiorespiratory arrest Cord prolapse
Anaphylaxis Emergency cervical cerclage
Anaesthetic related:
e total/high spinal anaesthesia
e failed/difficult intubation
e local anaesthetic toxicity
Anaesthetic-related emergencies mentioned for completeness.
Table 1
Obstetrically modified SOFA score2

0 1 2
CNS Alert Rousable to voice Rousable to pain
CVS (MAP mmHg) >70 mmHg <70 mmHg Vasopressors required
Respiration (PaO2/FiO2) >400 300e400 <300
Renal (creatinine mmol/litre) <90 91e120 >120
Liver (bilirubin mmol/litre)) <20 20e32 >32
Coagulation (platelet count) >150 100e150 <100
CNS, central nervous system; CVS, cardiovascular system; MAP, mean arterial pressure; SOFA, sequential organ failure assessment.
Table 2
Coagulation: the cumulative effect of increased microvascular

Obstetrically modified qSOFA score2 thrombus formation, microcirculation dysregulation, tissue
0 1 hypoperfusion and end-organ dysfunction.2
CNS (altered mentation) Alert Non alert
Management
CVS (systolic blood pressure mmHg) >90 mmHg <90 mmHg
Recommendations state that all consultant-led delivery suites
Respiration rate <25/minute >25/minute
should have a level 2 high-dependency care area managed by a
CNS, central nervous system; CVS, cardiovascular system; qSOFA, quick multidisciplinary team.2 Management should be encouraged to
sequential (sepsis-related) organ failure assessment. follow the sepsis-3, hour-1 bundle as well as the sepsis 6 rule.2,4
The sepsis-3 hour-1 bundle can be summarized as follows:
Table 3
1. Measure baseline lactate and repeat it if elevated
genital sources) and non-obstetric sources (e.g. community-ac- 2. Intravenous (IV) fluid resuscitation
quired pneumonia, cellulitis etc.). The largest risk factor for 3. Maintain organ perfusion with vasopressors where fluid
developing sepsis is surgery or trauma to the uterus or genital resuscitation fails to achieve this
tract, whilst patient factors such as obesity, anaemia, impaired- 4. Obtain blood cultures
glucose-tolerance and sickle-cell disease or trait may also in- 5. Start empirical IV antibiotics.
crease risk. Genital tract infection with Group A streptococcus Taking each of these in turn we get a picture of the manage-
was the risk factor most associated with progression to severe ment of sepsis in pregnancy and the puerperium.
sepsis and septic shock and most commonly occurs in early
pregnancy and peripartum.2 The most common causative or- Measure lactate level: if the initial lactate is elevated (>2mmol/
ganism associated with genital tract infection in the second litre)2,4 it should be remeasured within 2e4 hours to guide
trimester was Escherichia coli.3 resuscitation efforts.2,4 The aim is to normalize lactate levels as a
marker of improved tissue hypoperfusion.2,4
Diagnosing obstetric sepsis
The physiological changes of pregnancy and labour may mask or Administer IV fluid: initial IV fluid resuscitation at a rate of
confuse these criteria; signs of critical illness are often attributed 30 ml/kg is modified to 20 ml/kg by the Royal College of Ob-
to pregnancy, labour and pain. Temperature rises in labour are stetricians and Gynaecologists (RCOG) due to an increased risk of
common; the heart rate increases by 25%; the respiratory rate pulmonary oedema in pregnancy caused by decreased colloid
may increase to 15 breaths/minute during pregnancy and further oncotic pressure.2,4 Crystalloids are the primary choice of IV
to 22e70 breaths/minute labour; there is a leucocytosis of up to fluids (human albumin could be used as a colloid)2,4 and are
15 109 cells/litre in labour and immediately after. These values considered with a blood lactate of >4 mmol/litre and/or to
should return towards normal post-delivery, therefore persever- achieve a MAP >65 mmHg.
ance or recrudescence of abnormal values post-delivery should
cause concern.5 Apply vasopressors: vasopressors should be commenced within
The Modified Early Obstetric Warning Score System the first hour to achieve a MAP of 65 mm Hg (if fluid resus-
(MEOWS) is a helpful tool to identify the ill patient but is how- citation failed to achieve this). Hydrocortisone at a dose of
ever notoriously non specific, with a sensitivity and specificity of 200 mg/day can be considered in refractory shock (hypotension
89% and 79% respectively.2 Research has thus focused on the despite initial fluid resuscitation and vasopressors).2,4
use of biomarkers such as procalcitonin to diagnose sepsis and
track the response to treatment. Procalcitonin is a pro-peptide of Obtain blood cultures prior to antibiotics: at least two sets
calcitonin and is typically un-recordable in health. A raised level (aerobic and anaerobic) are required,2,4 however administration
would therefore suggest the presence of a bacterial infection and of appropriate antibiotic therapy should not be delayed obtaining
should prompt investigation and treatment. blood cultures.2,4 Blood cultures can show preliminary results
The effects of sepsis in pregnant women not contributed to by after only 24 hours but usually require 48 hours before bacteria
the physiological changes of pregnancy could be systematically can be positively identified and antibiotic sensitivities are known
summarized as follows. at which point antibiotics can be reviewed. In addition, swabs/
samples of all potential source sites such as breast milk, urine
CVS: myocardial depression with cumulative haemodynamic and even nasopharyngeal aspirate or throat swab (for those with
collapse. respiratory tract signs or symptoms) should be obtained.
Respiratory: increased pulmonary microvascular pressure and Administer broad-spectrum antibiotics: there should be im-
permeability and acute lung injury with cumulative effect of mediate, empiric and broad-spectrum antibiotic therapy with at
susceptibility to pulmonary oedema, rapid decrease in oxygena- least one or more of these delivered intravenously. This should
tion, acute respiratory distress syndrome (ARDS) and decreased be guided by local antibiotic protocols and expert microbiology
ability to compensate for a metabolic acidosis. input.2e4 Every hour of delay in administering antibiotic therapy
is thought to increase mortality by 8%.6 Table 4 shows some
Renal: ischaemia, vasoconstrictive and cytokine-mediated renal
antibiotic choices and their limitations.2,4
injury with the cumulative effect of acute kidney injury.
There are several other elements that contribute to the overall
management of sepsis in the puerperium. The prophylactic use of
Antimicrobial choices and limitations of antimicrobial5

Co-amoxiclav Does not cover meticillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas and there is
concern about an increase in the risk of necrotizing enterocolitis in neonates exposed to co-
amoxiclav in utero
Metronidazole Only covers anaerobes
Clindamycin Covers most streptococci and staphylococci, including many MRSA, and switches off exotoxin
production with significantly decreased mortality. Not renally excreted or nephrotoxic
Piperacillinetazobactam (Tazocin) and Covers all except MRSA and are renal sparing (in contrast to aminoglycosides)
carbapenems
Gentamicin (as a single dose of 3e5 mg/kg) Poses no problem in normal renal function but if doses are to be given regularly serum levels
must be monitored
Table 4
compression stockings, intermittent lower limb compression, cardiopulmonary resuscitation (CPR) emphasizing the impor-
and low-molecular-weight or unfractionated heparin is recom- tance of simulation skills and drills. Maternal CPR also presents
mended.2,4 IV immunoglobulin is recommended for severe some unique problems and variations from standard adult
invasive streptococcal or staphylococcal infection if other thera- resuscitation guidelines.
pies have failed because of its immunomodulatory effect.2,4 The
decision of delivering the fetus or continuing the pregnancy is Causes of maternal collapse
influenced by the patient’s condition, gestational age, fetal status, For ease of memory, these are divided by the Resuscitation
presence of chorioamnionitis, and labour.2,4 This decision can be Council UK into the ‘4 H’s’ and ‘4 T’s’. In pregnant women
made jointly with the multidisciplinary team. General anaes- however, eclampsia and intracranial haemorrhage should be
thesia (GA) is favourable to regional anaesthesia for caesarean added. The commonest causes of maternal collapse are hae-
delivery as septic hypotensive patients may not tolerate the morrhage, thromboembolism, amniotic fluid embolism, cardiac
sympathetic block and vasodilatation associated with spinal diseases, sepsis, drug toxicity and overdose, eclampsia, intra-
anaesthesia. Additionally, the associated coagulopathy or cranial haemorrhage, and anaphylaxis.8
thrombocytopenia increases the risk of epidural haematoma,
abscess, or meningitis.2,4 Throughout this period one should Management
target oxygen saturations to 94% with a mixed venous oxygen Maternal collapse resuscitation should follow the Resuscitation
saturation (SvO2) of 65% or a ScvO2 of 70% in critically ill pa- Council UK guidelines using the standard ABCDE approach, with
tients.2,4 In the last trimester of healthy pregnancy, the SvO2 is some modifications for maternal physiology, in particular relief
approximately 80%, and currently there is limited evidence to of aortocaval compression8 published by The Resuscitation
guide the optimum SvO2 in the critically ill pregnant patient.2,4 Council UK (www.resus.org.uk). It should be emphasized how-
Imaging is also important and should be performed as appro- ever that difficulties and differences do exist from a standard
priate for the suspected source, e.g. chest X-ray, pelvic/abdom- adult population (Table 5). Firstly, maternal patients are at an
inal ultrasound or CT. increased risk of both aspiration and difficult intubation.
Obtaining a secure airway can thus be more challenging for the
Maternal collapse and resuscitation anaesthetist and access to difficult airway adjuncts and tech-
Cardiac arrest in pregnancy affects approximately 1 in 34,000 niques is therefore of benefit. This is compounded by the in-
women.7 Figures are rising and are thought to be due to crease in oxygen consumption at term of up to 25%, making time
increasing maternal age and morbidity. The rarity of cardiac ar- from apnoea to desaturation significantly shorter. Aortocaval
rest in pregnancy results in maternity staff being unfamiliar with compression by the gravid uterus occurs as it moves out of the
Similarities and differences between standard adult resuscitation and resuscitation in a pregnant patient6
Identical to ALS guidelines Relevant differences
Rate/rhythm/depth of compressions Airway difficulties

Drugs used and doses Shorter apnoea to desaturation time
Energies for defibrillation Aortocaval compression
Time cycles Diffrent causes (Mg2þ overdose, LA toxicity)
30:2 ratios Peri-mortem caesarean section
ALS, advanced life support; LA, local anaesthetic.
Table 5
pelvis to become an abdominal organ as early as the 20th week, Britain and Ireland guidelines).10 CPR itself may be prolonged
and this is increased with multiple pregnancies and poly- and where available cardiopulmonary bypass may be necessary.
hydramnios. Up to 50% of the cardiac output (CO) returns via
the inferior vena cava, therefore aortocaval compression will Amniotic fluid embolus (AFE)
significantly reduce CO and decrease the likelihood of a return of
Amniotic fluid embolus (AFE) is a rare but serious complication
spontaneous circulation (ROSC). This may be compounded by
of pregnancy with a noteworthy morbidity and mortality. It sits
any coexistent regional sympathetic block. Manual lateral
as the sixth commonest cause of direct maternal death at
displacement of the uterus is preferred, as effective chest com-
>0.3:100,000 maternities in the 2017e19 report.1 Between 2005
pressions are performed poorly when a wedged lateral tilt is
and 2014, there were 120 confirmed cases of AFE in the UK
utilized, unless the patient is already on a tilting table, bearing in
Obstetric Surveillance System (UKOSS)register, which gives an
mind that even 30 of tilt can still leave significant aortic
incidence of 1.7 per 100,000 maternities and a case fatality of
compression.9
19%. AFE occurrence was significantly associated with induction
Perimortem caesarean section (PMCS) has long had a place in
of labour and multiple pregnancy and an increased risk is also
maternal CPR, greatly improving maternal resuscitation and
noted in older ethnic minority women.
possibly facilitating survival of the fetus. Guidance advocates
Caesarean delivery was also associated with postnatal amni-
commencement of a PMCS in women >20 weeks’ gestation if
otic fluid embolism.
there is no ROSC by 4 minutes who are in cardiac arrest, with the
This multisystemic disorder can occur at any point in preg-
aim of delivery of the fetus and placenta within 1 minute.2
nancy though 70% occur in labour.11 Various risk factors have
Equally however, you do not have to wait, and women do
been identified although the most common are increased
continue to die with the uterine contents intact. Resuscitation
maternal age, multiparity, induction of labour and rapid or
trolleys should contain a scalpel blade and cord clamps in order
hyper-stimulation of the uterus.11
to facilitate PMCS without transfer to theatre. The primary aim
There are two main suggested theories explaining the mech-
behind PMCS is to improve maternal survival. Delay in making
anism of AFE: mechanical (anaphylactoid) and immune medi-
the decision to perform PMCS in order to confirm fetal life is not
ated. Both fail to explain the pathogenesis clearly when used on
advocated.2 PMCS requires a surgeon or emergency medicine
their own, but when combined they give a broader picture.11 AFE
physician to be prepared to carry out this procedure in a timely
can thus be described in a biphasic response, as follows.
manner.9
There are situations where cardiac arrest may have been
Phase 1: Lasts about 30 minutes and is thought to follow the initial
caused iatrogenically and therefore will respond to specific
entry of amniotic fluid into the circulation. This is characterized by
measures and antidotes. Treatment of pre-eclampsia with Mg2þ
an increase of the pulmonary artery pressure and right ventricular
can lead to Mg2þ overload and toxicity. Where this is suspected,
failure followed by microvascular damage and hypotension.11
magnesium should be discontinued and antidote administered
intravenously as 1 gram of calcium, (10 milliliters of 10% cal-
Phase 2: In patients who have survived phase 1, this is charac-
cium chloride or 30 milliliters 10% calcium gluconate).9 Local
terized by left ventricular failure, endothelial activation and
anaesthetic (LA) toxicity is a recognized cause of unresponsive
leakage, uterine atony and disseminated intravascular coagula-
cardiac arrest where LA has been given via the wrong route
tion.11 The amount of fetal debris required to cause this sequence
inadvertently, or where there is toxic systemic absorption. As
of events and syndrome however is variable and may involve
well as discontinuing any LA infusion this should be treated with
just minute quantities.
early administration of 20% intralipid 1.5 ml/kg bolus over
1 minute (with up to two further boluses after 5 minutes) and a Diagnosis
15 ml.kg1.hr1 infusion (doubled to 30 ml.kg1.hr1 if no This is mainly clinical and is essentially a diagnosis of exclusion.
improvement, or condition worsens) up to a maximum cumu- Many possible obstetric and non-obstetric differential diagnoses of
lative dose of 12 ml/kg (Association of Anaesthetists of Great maternal collapse exist (Table 1) and should be considered before
diagnosing AEF. UKOSS has its own diagnostic criteria which is
A classification relating the degree of urgency to the presence or absence of maternal or fetal compromise15
Spectrum of urgency Definition Category
Immediate threat to life of woman or fetus 1

2
Maternal or fetal compromise
No immediate threat to life of woman or fetus
Requires early delivery
No maternal or fetal compromise 3
At a time to suit the woman and maternity 4
services
Table 6
used for the national registry. Many laboratory tests were Thus, as per the recent RCOG guidelines for management
considered but none of them were thought to be specific enough.11 of the COVID-19 pregnancy published in January 2022,
pregnant COVID-19 patients should be offered early epidural
Clinical presentation analgesia for labour minimalizing the risks of GA and spinal
If presenting before labour then hypotension and acute fetal anaesthetics in situations of emergency C/S leaving the GA
compromise are the most common signs and symptoms with an only if indicated.14
incidence of around 100%. It may also present with a variety of Where a decision for category 1 C/S has been made the patient
other symptoms and signs with variable incidences such as: pul- should be transferred into theatre as soon as practicable. Where
monary oedema and ARDS (93%), cardiopulmonary arrest (87%), there is evident or continued fetal distress intrauterine resuscita-
cyanosis (83%), coagulopathy (83%) , shortness of breath (49%), tion should be commenced while preparation for C/S is made, and
seizures (48%), uterine atony (23%) and bronchospasm (15%). In this may ultimately down-grade the urgency of the C/S.
the critical care setting, patients may present with multi-organ The patient should be immediately positioned left lateral to
dysfunction.11 relieve any continued aortocaval compression, 100% oxygen
should be given to the mother via a tight-fitting facemask or if
Management available high-flow nasal cannulae, and where there is IV syn-
Management of AFE is entirely supportive and based on clinical tocinon running this should be discontinued and removed to
presentation. Whether the fetus is delivered or not and should prevent any accidental bolus during transfer or in theatre. IV
involves senior clinicians (obstetrician, anaesthetist, haematol- fluid resuscitation should be commenced 500e1000 ml crystal-
ogist, intensivist, senior midwife, and neonatologist). An urgent loid (if this is not contraindicated such as in pre-eclamptic pa-
decision to deliver may be needed as well as rapid critical care tients), and where blood pressure is low this can be raised with
support. A systematic approach (ABCDE) as per Adult advanced appropriate boluses of vasopressor (50e100 micrograms of
life support guidelines is the corner-stone in the AFE phenylephrine) aiming to restore blood pressure to within 10%
management.11 of the patient’s baseline. Where there is apparent uterine hy-
perstimulation then tocolysis may be beneficial with the
administration of either two sprays of sublingual glyceryl trini-
Emergency caesarean section (C/S)
trate or 250 micrograms of terbutaline subcutaneously.
Since the maternal confidential enquiry commenced in 1952 Once in theatre the patient should be reassessed to confirm the
there has been a dramatic change in the numbers of caesarean status of the fetus and mother at which point a definite decision as
sections performed both elective and emergency within the UK. to the mode of anaesthesia can be made. Where there is
These generally following an increasing trend. A large proportion continuing fetal distress or ongoing bradycardia then GA may be
of emergency C/S can be anticipated and so there should be the most appropriate choice. This however must be balanced
adequate time in most instances to make plans or even the against the increased risk associated with GA and where there is
provision for expert help to be available. To facilitate this, there significant concern over the patient’s airway such as in morbidly
should be ongoing communication within the multidisciplinary obese patients, it may not be possible to provide GA without se-
team to ensure that the anaesthetist is kept aware of arising nior assistance. The Difficult Airway Society and Obstetric
problems on the delivery unit so that action plans can be initi- Anaesthetists’ Association have produced a difficult airway algo-
ated. There will of course remain an unpredictable number of rithm that includes a risk assessment table to help guide the
cases, which require the skill and timely management of the anaesthetist on whether to continue with the surgery in the event
resident team to ensure a good outcome for mother and baby. of a failed intubation.13 A pre-intubation checklist can be used to
There is a diverse range of reasons why an emergency C/S reduce the risk of error occurring through omission as a result of
may be requested (Table 1). Whatever the reason, the urgency the high-pressure nature of a GA section. Where there is uncon-
should be classified according to RCOG good practice guidance trolled hypertension in pre-eclamptic patients, GA should not be
(Table 6) introduced in 2010.12 This emphasizes a continuum of commenced without adequate blood pressure control and suitable
urgency that may vary within any one category but fosters uni- attenuation of the pressor response to intubation. If the CTG has
versal communication between team members allowing an normalized, then there may be time to perform spinal anaesthesia.
indication of the degree of urgency and a recommended decision Rapid sequence spinal anaesthesia has been described and
to delivery time. It must be remembered that situations can although effective, requires strict adherence to time limits (and
change rapidly and subsequent review once the patient has good situational awareness) to ensure the avoidance of repeated
entered theatre should be performed which may up-grade or attempts to the detriment of maternal or fetal wellbeing. Maternal
down-grade the initial urgency. This may reveal a resolving pre-oxygenation should continue during this time. Epidural top-up
bradycardia from measures performed to improve the car- may also be an option with 15e20 milliliters 0.75% ropivacaine
diotocography (CTG) status (intrauterine resuscitation), which allowing the development of rapid and effective block. However, it
may alter the initial choice of anaesthesia and increase overall is important that the epidural has been functioning well during
safety and maternal satisfaction in an already stressful situation. labour, that there has been no immediately preceding low-dose
GA for emergency C/S has been challenging since the top-up which may prevent further top-up in theatre, and that there
coronavirus disease (COVID-19) pandemic started due to the is time available to wait for the development of an adequate block.
personal protection equipment guidance protocols as well as the Again, if there is time pressure it may be best to abandon an
risks of transmitting COVID-19 or worsening the symptoms of epidural in favour of spinal anaesthesia or, in extreme urgency,
already present maternal COVID-19.14 GA.
Multidisciplinary obstetric emergency simulation 3 Sepsis in pregnancy, bacterial (Green-top Guideline 64a). https://
www.rcog.org.uk/globalassets/documents/guidelines/gtg_64a.
Despite most obstetric emergencies being handled with skill and
pdf (accessed March 2022).
expertise, sadly in the minority they still result in devastating
4 Evans L, Rhodes A, Alhazzani W, et al. Executive summary: sur-
consequences with either the loss of the mother, fetus or both.
viving sepsis campaign: International guidelines for the manage-
There is continued evidence that in certain circumstances ob-
ment of sepsis and septic shock 2021. Crit Care Med November
stetric emergencies are subject to mismanagement.2 Two reports
2021; 49: e1063e143. https://doi.org/10.1097/CCM.
by the Institute of Medicine speculated, that team training and
0000000000005337.
the implementation of “team behaviors” could reduce medical
5 Singh S, McGlennan A, England A, et al. A validation study of the
errors and improve patient safety, and obstetrics lends itself well
CEMACH recommended modified early obstetric warning system
to this “multidisciplinary team training”.15 The use of simulators
(MEOWS). Anaesthesia 2012; 67: 12e8.
in medicine is spreading fast. Anaesthesia has been both at the
6 Kumar A, Roberts D, Wood KE, et al. Duration of hypotension
forefront and a principal investigator of its use. Several studies
before initiation of effective antimicrobial therapy is the critical
have looked at its use particularly within obstetrics, although
determinant of survival in human septic shock. Crit Care Med
these have varied in study design as well as methods of training
2006; 34: 1589e96.
(whether that be low or high fidelity), and their ultimate outcome
7 O’Connor M, Smith A, Nair M, et al. UKOSS annual report 2015.
measurements. A common theme in all however, is that team
Oxford: National Perinatal Epidemiology Unit, 2015.
training potentially leads to a better recognition of intrapartum
8 Resuscitation Council UK and Obstetric Anaesthetists’ Associa-
problems, which together with appropriate and timely interven-
tion. Obstetric cardiac arrest quick reference guide. UK Resusci-
tion, can result in better outcomes for mother and child. It may
tation Council, 2021.
particularly improve the resultant chain of action between deci-
9 Royal College of Obstetricians and Gynaecologists. Green-top
sion for delivery and actual birth of the child.15 Already many
Guideline 56. Maternal collapse in pregnancy and the puerperium.
courses exist both locally and nationally such as PROMPT (www.
2001, http://www.rcog.org.uk/womens-health/clinical-guidance/
promptmaternity.org) and MOET (www.alsg.org/uk/MOET)
maternal-collapse-pregnancy-and-puerperium-green-top-56
which provide the ability for teams to come together and train in
(accessed March 2022).
a safe environment, and to practice communication and clinical
10 The Association of Anaesthetists of Great Britain & Ireland 2010.
skills related to common and uncommon emergencies. Regular
Management of severe local anaesthetic toxicity 2. 2010. A4
skills and drills can also be performed in house, although this can
sheet, http://www.aagbi.org/sites/default/files/la%20toxicity%
be difficult to organize on an already busy labour ward. Despite
202010%200.pdf (Accessed March 2022).
this, it is more accessible, allows for repeated exposure and
11 Metodiev Y, Ramasamy P, Tuffnell D. Amniotic fluid embolism.
frequent updates, and is a core requirement for local clinical
BJA Educ 2018; 18: 234e8.
negligence management. There is currently no evidence to sup-
12 Classification of urgency of caesarian section e A continuum of
port an additional benefit to training in a simulation centre.15A
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goodpractice11classificationofurgency.pdf (Accessed April 2019).
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Obstetric Emergencies: Learning Objectives

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OBSTETRIC ANAESTHESIA

Obstetric emergencies Learning objectives

Abstract critically unwell parturient

Septic shock: sepsis associated with vasopressor requirements to

Obstetric emergencies which may present challenges to the anaesthetist

Anaesthetic-related emergencies mentioned for completeness.

Obstetrically modified SOFA score2

Coagulation: the cumulative effect of increased microvascular

Antimicrobial choices and limitations of antimicrobial5

Rate/rhythm/depth of compressions Airway difficulties

ALS, advanced life support; LA, local anaesthetic.

Immediate threat to life of woman or fetus 1

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