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Clinical Case 074: Resus a deux

This is the scariest case I have done for a while, strap yourself in it is a tough one!  Going to lay it out and let you guys tell me how you would approach it as it is one of those scenarios where there are a lot of decisions made and resources mobilised in  an instant.  Apologies to the Specialists reading this – we are going to cross some departmental divides in rapid fire on this case!

It is 6:00 AM, you are coming to the end of a long night shift.  It is quiet now, you are fighting the Sandman!  Suddenly the ambulance phone rings….  ” we are bringing in a 20 yo woman who might have an ectopic, suffering abdo pain for a few hours and now has had a PV bleed.  She thinks she is pregnant, though not sure of dates…”

OK, now you are awake.  You go into the Resus bay and get your big IVs, some warm fluids, and emergency drugs ready.  Maybe wake up the lab crew if she looks unstable and needing some red cells.  You even call the Obs/Gynae surgeon to let them know she might be  required sooonish.. will let her know.

 5 minutes later the ambo crew arrive.  Things seem calm, the patient is not in much pain, there is however a lot of blood on the trolley as you transfer her over.  You start taking the history and reaching for the IV when she starts screaming…  AH AH, AH  “There it goes again”.  The penny drops, she is in labour.  A quick feel of her belly reveals a fundus at the umbilicus which is hard and contracting.   Time to switch algorithms friends.

OK, you call for the midwife from the labour ward to attend ASAP.  The patients obs: P = 130, BP 80/50, RR 20, she is grunting with contractions, there is a lot of blood coming PV now.  IV fluids running in and you ask for the lab to bring O neg ASAP and process your bloods urgently.

As the midwife arrives you glove up for an examination –  time to play Obstetrician.  We need to know where we are on the partogram to make the next call – imminent delivery or off to theatre.  The Midwife is searching for a fetal pulse with the Doppler – there is a heart rate of about 200.  You have a look, blood, blood, blood – but wait what is that… you feel a tiny foot protruding from the nearly fully dilated cervix.  Time to change algorithms again.  We need back up, pronto.  Get the OBs doc in here ASAP please… BUT – she is out on an early morning ride about 15 minutes out-of-town!  Bugger.

You call for the Neonatal Resus cot and all the paraphernalia ASAP.  But as it is arriving Mum-to-be give a big cry and delivers a breach.  No time to waste you need to get that bub out.  You can feel the umbilical cord pulsing, but it is fast and weak.  One more contraction and the head is out… followed by a huge blood clot and a gush of fresh red blood.

The young lady is looking pale, clammy and nor has a pulse of 150, BP = 70/40.  What to do?

The baby is tiny, we are not accustomed to guessing weights and gestation at this stage.  Initially he took a few gasps of air but is now apneic – you pick him up and onto the Resus cot.  A, B….  is this the right thing to do?  How can we work out gestation, viability of a resus? 

Meanwhile the midwife has jumped in and managed the third stage – but the cord has broken and the placenta remains in utero, the bleeding is continuing… she needs to go to theatre to fix this.

If it comes down to a choice of resources do we take mother to theatre, your back-up is still a way off.  Do we keep resuscitating this baby, who hasn’t taken any spontaneous breaths since you started IPPV and is looking pretty floppy but has a pulse of 110/min?

OK team.  This isn’t a real case – but I have been through a few similar ones over the years – and they are scary!

There is a 30 minute Google Hangout discussion on Case 074 now available!

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Comments

  1. Nicole Ghedina says:

    Hi Casey,
    What a difficult situation. And what the hell was the O+G doing heading out of town when you where expecting an unstable ectopic huh? :)
    Meets the definition of a disaster, your resources at present are overwhelmed.
    Priorities are
    -urgent controll of life threatening meternal hemorrhage, likely secondary to retained placenta with concurrent resuscitation (remembering the ALSO song about tone, trauma, tissue, and thrombin)
    -resuscitation of infant of unclear gestation but likely on border of viability

    BUT other way to think about this is in terms of skills required
    -You have IV access for Mum
    -- nurse can make up and start syntocinon 30IU in 500mL NaCl 0.9% start at 240mL/hr
    -- Start O neg blood as soon as available, otherwise crystalloid IV up to 2L, orderlys can squeeze pump sets
    -- need at least 1 more doc on site to be able to go to OT, so cant get to theatre until you have backup so may as well have 2 backup docs on their way (preferably one a paediatrician!). You also need more nursing staff, call paeds nurse down from ward and theatre team in.
    -Baby needs intubation, not a skill you can expect of your midwife
    -could consider intubating baby while awaiting backup to get to OT as long as other staff were able to manage hemodynamic resus of mother
    -if Mum crashed whilst attending to baby, ie, PEA/ loss of conciousness of loss of spontaneous resps then I would ask midwife to continue to bag bub until help arrived whilst I resuscitated Mum.
    -Bub should be in a plastic bag for warmth and resuscitaire on to maintain temp
    -get paed nurse on arrival to set up for umbi line/IVC for bub and check baby’s obs and BSL

    I am looking forward to reading everyone else’s take on the situation
    Fantastic website Casey

    • Thanks Nicole
      Nice plan -- division of labour and resource allocation is crucial. I like it. You need to do the skilled stuff and rely on team to do the rest.
      Practical tips around set up for neonatal resus, love it. Our team do a true Neonate resus maybe once every few months!
      Most small hospitals are staffed by general RNs and midwives -- no Paeds nurses, no Paediatricians, no Neonatal team -- just you and adult / general RNs the norm in the bush.

      The O&G is allowed a life! She rides every morning from 5:30 -- 6:30! unfortunately about 5 -- 10 minutes notice is the norm for our “heads up” from the Ambos (largely volunteers) so we are often caught off guard when it comes to calling the cavalry!

      Any other practical tips out there?
      C

  2. As above, it’s a disaster!

    MW should be competent for neonatal resus whilst you manage PPH and await others to arrive

    Our contract in SA allows the oncall A&E, obs and anaes doc to be up to 40 mins away…and their is no on site doctor -- they all have to be called in…

    …guess the Health Dept feels that this is reasonable.

    I don’t

  3. Bek Adams says:

    Hey guys, Nic- fancy meeting you here!
    Just in terms of the baby, whatever has caused the bleed/possible abruption may well have lead to some fairly good going IUGR so the gestation of the baby may be much more advanced than you think. I have been involved with a case in a different part of the North, no antenatal care, labouring, palped at the umbi, delivered a 550g infant who the paeds later guessed by how well they faired in nicu was about a 30-31 weeker with severe IUGR.. A few things to look at would be if the eyes were still fused indicating <24-25 weeks, and I think the gasping and holding a good heart rate with simple resus measures are a good prognostic sign. The midwife could definitely keep that going while you waited for the troops and someone could grab a plastic bag to keep him warm. You could get some phone help from NETs too for support for the neonatal resus while you got mum to theatre.

  4. Mark Raines says:

    Depends where you are.
    I recall uterine blood flow is 600ml/minute
    Help maybe too far away.
    You have midwife and self.
    You have mother bleeding out and small baby who has heart rate but not yet breathing.
    Midwife can bag and mask. Ventilation may be all that is needed even given size.
    Mum has HR 150 and BP 70/40; suggests physiology is running on reserve.
    Placenta needs to come out or mother may die.
    I will be gloving up and manually removing the placenta in the anticipation that tone will improve and bleeding settle. Maybe a little midazolam and fentanyl, oxygen going. Fluids running.

    Third world medicine? Inaction and waiting for experts may mean an unwelcome conversation with just a grieving father.

    • Thanks Mark
      I completely agree re: manual removal in ED.
      This move is likely to make the bleeding stop which should always be the primary goal in a haemorragic shock.
      It is a relatively simple procedure, at least can be initially be done to get as much tissue out as possible to allow the oxytocics to do their thing. Remember the ergometrine, misoprostol, maybe some PGF2a if all else fails
      Maybe a smidge of ketamine in a monitored bay with a senior RN at the airway.
      Not “standard of care” but a lot better than watchful waiting until the cavalry arrives.
      Fixing the bleeding will free up a lot of resources.
      Thanks
      Casey

  5. Agree with the above with the addition that this might be a good time to try either/both bi-manual compression of the uterus or aortic compression to save blood and time while help is en route.

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