[CG] Medical or Surgical Patient in Maternity Triage, Acute Management, Obstetrics

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Objectives

The aim of this guideline is to provide guidance regarding the initial assessment and management of the antenatal or postnatal patient who presents to Maternity Triage/ Maternity Assessment Unit due to medical or surgical causes.

The purpose is also to ensure that good communication is established and maintained within the teams during the management of the above patients who can potentially become acutely unwell.

Scope

The policy applies to all staff responsible for the clinical care of the above patient group.

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Over two thirds of the maternal deaths in the UK are due to medical problems during pregnancy and the postpartum period. There is evidence that in complex obstetric cases timely escalation, early involvement of senior staff and effective multidisciplinary communication can improve the outcome reducing maternal morbidity and mortality. The clinicians who are involved in the management of the acutely unwell women should take into account two main points:

  1. The physiological changes in pregnancy can cause atypical presentation, confusion and delay in diagnosis.
  2. Pregnant women usually have the physiological reserves to compensate until abrupt deterioration occurs.

Definition of Terms

ABCDE - Airway, Breathing, Circulation, Disability, Exposure
A&E - Accident and Emergency
ALP - Alkaline Phosphatase
BP - Blood Pressure
CCU - Coronary Care Unit
CPR - Cardiopulmonary Resuscitation
CTG - Cardiotocography
CTPA - CT Pulmonary Angiogram
CXR - Chest X-Ray
ECG - Electrocardiogram
FBC - Full Blood Count
HR - Heart Rate
HDU - High Dependency Unit
ITU - Intensive Care Unit
LFTs - Liver Function Tests
LMWH - Low Molecular Weight Heparin
MRA - Magnetic Resonance Angiogram
MRV - Magnetic Resonance Venography
PET - Preeclampsia
PE - Pulmonary Embolism
RPOC - Retained Products of Conception
RR - Respiratory Rate
SpO2 - Oxygen Saturation
U+Es - Urea and electrolytes
USS - Ultrasound Scan
VQ scan - Ventilation perfusion scan
VTE - Venous Thromboembolism

Initial Risk Assessment

Any woman who is suspected to be unstable (such as significant history of chest pain, breathlessness, collapse or serious injury) should be triaged in the Emergency Department (A&E) to ensure access to multidisciplinary team and the appropriate facilities and equipment. The Obstetric team will also be involved once patient has been stabilised. Any doubt about the safest place of care should be discussed with the senior medical staff.

Responsibilities of the Triage Midwife

Maternal observations (HR, BP, Temperature, RR, SpO2, level of consciousness) should be checked and recorded on the obstetric modified early warning score chart (MEOWS). This aims to allow early recognition of the woman becoming critically ill. A score ≥4 or 3 in any single parameter is a Red Flag itself.

a) UNSTABLE patient

  1. Ask for help
  2. Call 2222 stating “Maternal Collapse” and request the following-
  • Obstetric, anaesthetic, neonatal and cardiac arrest teams
  • Commence resuscitation according to ABCDE approach
  • If CPR is required ensure modifications for maternal physiology (Left lateral position, manual uterine displacement to minimize aortocaval compression)
  • Consider reversible causes
  •  If no response within 4min of the collapse perimortem Caesarean Section is indicated in cases >20 weeks of gestation in order to aid maternal resuscitation

b) STABLE patient

  1. Obtain clinical history
  2. Assess maternal status using A-E approach
    (Abdominal palpation, vaginal examination if required)
  3. Assess fetal wellbeing with Fetal Heart auscultation or CTG if appropriate gestational age
  4. Consider high flow oxygen
  5. IV access (ideally 2 wide bore cannulae), urgent bloods (see Table 1 for guidance), urine sample
  6. IV fluids if volume replacement is required
    (Caution in patients with cardiac disease or preeclampsia)
  7. Document findings in the electronic maternity records (BadgerNet)
  8. Ensure escalation, timely review by medical staff of appropriate level
  9. Ensure availability of Emergency Equipment and Trolleys if required
    (e.g. Airway, Sepsis, Haemorrhage)
  10. Timely actions which can affect the outcome
    (IV antibiotics in suspected sepsis, treatment LMWH in suspected VTE)

Clinical assessment and investigations

Table 1 shows the most common presentations with significant causes which need to be excluded as well as the recommended investigations. The presence of Red Flags indicates likely life threatening conditions and senior review.

Table 2 provides guidance for the interpretation of the clinical and laboratory findings in pregnant women.

 

Table 1. Differential Diagnosis of serious symptoms in obstetric patients

Symptom

Likely cause

Red Flags

Investigations

Chest pain

PE VTE guideline
Acute Coronary Syndrome
Aortic dissection
Pneumonia
Pneumothorax

Sudden onset
Central, radiating to arm, shoulder, back, jaw
Requiring opioids
Haemoptysis
Breathlessness
Syncope

Bloods 
(include Troponin levels)

ECG
CXR
Chest CT
Echocardiogram

Shortness 

of 

Breath

PE VTE guideline
Peripartum cardiomyopathy
Anaphylaxis
Asthma
Pneumonia
Pneumothorax
Covid-19

Sudden onset
Orthopnoea
Tachycardia, Tachypnoea (RR>20/min)
Sat O2 <94%
Pleuritic chest pain
Syncope
Haemoptysis
Peripheral oedema

Bloods (FBC, coagulation) Arterial Blood Gas

ECG
CXR
Echocardiogram
V/Q, CTPA

Headache

Intracranial haemorrhage

Cerebral Venous Thrombosis VTE guideline

Meningitis

Sudden onset
Persisting >48h
Excessive use of opioids
Pyrexia
Seizures
Focal neurology
Signs of raised intracranial pressure
(vomiting, papilloedema)

Bloods
(FBC, U+Es, LFTs, coagulation)

Urine 
(exclude proteinuria)

Head CT, CT venogram
MRI, MRA, MRV

Collapse

Hypovolemia, haemorrhage
Trauma
Cardiac disease
PE VTE guideline
Metabolic disorders, drugs
Diabetes
Anaphylaxis
Epilepsy
Sepsis sepsis guideline

Preceded by central chest pain, breathlessness or severe headache
Vomiting
Signs of raised intracranial pressure
Focal neurology

Bloods 
(FBC, coagulation, Glucose, Lactate, Group+Save)

ECG

Seizures

Epilepsy

Cerebral Venous Thrombosis VTE guideline

Stroke

Drug, alcohol withdrawal

Metabolic causes, hypoglycaemia

Signs of raised intracranial pressure- headache/blurred vision/confusion/vomiting

Focal neurology

Bloods
(FBC, Glucose, U+Es, LFTs, coagulation)
Urine sample (exclude proteinuria-PET)

Head CT, MRI

Pyrexia

Sepsis  sepsis guideline

Intraabdominal infection

Covid-19

Generally unwell
Tachycardia, hypotension

Bloods 
(FBC, CRP, U+Es, LFTs, Lactate, Blood Cultures)

Urine sample
Vaginal swab Throat swab if indicated
Ultrasound scan if postnatal-RPOC

Abdominal pain

Trauma

Appendicitis
Cholecystitis
Pancreatitis

Bowel obstruction

Ureteric obstruction

Aneurysm rupture 
(e.g. splenic artery)

Intra-operative damage to adjacent structures (CS).

Adnexal torsion

Pyrexia
Signs of sepsis
Haematemesis

Bloods 
(FBC, CRP, U+Es, LFTs, Lactate, Blood Cultures, Group+Save)

Urine sample

USS
Abdominal CT/ MRI

  • Recurrent presentations or readmission= Red Flag
  • Reduced or altered conscious level= Red Flag
  • Cases with unusual presentation: consider domestic abuse and mental health problems

 

Table 2. Normal findings and parameters in obstetric patients

Observations

HR ↑ by 10-20bpm BP
↓ by 10-15mmHg

Chest examination

Ejection systolic murmur

ECG

Sinus tachycardia
T wave changes (inversion in III and aVF)
Non-specific ST changes
Small Q waves
Left axis deviation (15 ̊)

CXR

Prominent vascular marking Raised diaphragm

Arterial Blood Gas

PCO2  ↓
Mild respiratory alkalosis

FBC

Hb 105-140g/L (dilutional anaemia) WBC 6-16 x109/L

U+Es

Urea 2.5-4mmol/L
Creatinine <77μmol/L

LFTs

ALP ↑ (up to 3-4 times)

D Dimers

↑ (NOT recommended in the investigation of acute VTE)

Escalation of Care

For any case presenting to Maternity Triage with suspected serious condition (e.g. PE, cardiac issue, acute surgical abdomen) and following the initial assessment, senior medical staff should be informed. There should be agreement about the requested investigations and the following actions.

Questions to be answered after the initial assessment:

  1. Does the patient need admission?
  2. What level of care is required? (inpatient ward, HDU, ITU)
  3. Is delivery likely to be considered if maternal status deteriorates?
    Consider administration of steroids and inform neonatal staff if applicable
  4. Do other specialties need to be involved? If so, how urgently and what grade is required e.g. middle grade or Consultant?

If the patient has initially been seen in the Emergency Department and Obstetric team has been called to review, the same above questions should be answered.

Communication, Referral to other specialties

Important points:

  • Accurate documentation whether and when the review has been requested.
  • Any woman admitted out of hours and requires formal referral should be discussed with the on call Obstetric Consultant.
  • In all cases that women need transfer to CCU, HDU or ITU, the on call Obstetric Consultant needs to be directly involved.
  • Women transferred to non-obstetric ward should be reviewed by the Obstetric Consultant the following morning.
  • Joint inpatient medical and obstetric care (e.g. patient with cardiac disease) with continuous evaluation. A decision may need to be taken regarding timing of delivery if maternal condition deteriorates following discussion at senior (Consultant) level.

Clinical Governance

All cases of maternal collapse should generate a clinical incident to be reported via DATIX and reviewed appropriately.

It is a statutory requirement to report all cases of maternal death (up to 12 months following birth or fetal loss) to MBRRACE-UK.

References
  1. RCOG Green -Top Guideline No.56. Maternal Collapse in Pregnancy and the Puerperium (December 2019)
  2. RCOG Green -Top Guideline No.37b. Thromboembolic Disease in Pregnancy and the Puerperium: Acute Management (April 2015)
  3. Royal College of Physicians. Acute care Toolkit 15. Acute medical Problems in Pregnancy (November 2019)
  4. Care of the critically ill women in childbirth. Enhanced maternal care. Royal College of Anaesthetists (August 2018)
  5. MBRRACE UK 2018. Saving Lives, Improving Mothers’ Care
  6. CEMACH 2007. Confidential Enquiry into Maternal and Child Health. The seventh report published in 2007
  7. NICE Guideline 50. Acutely ill adults in hospital: recognizing and responding to deterioration (2007)
  8. Catherine Nelson-Piercy. Handbook of Obstetric Medicine, Sixth edition (2020)
  9. Woodhead N et al. Surgical causes of acute abdominal pain in pregnancy. The Obstetrician and Gynaecologist 2019;21:27-35

Last reviewed: 19 January 2022

Next review: 01 August 2022

Author(s): Lead author: Julie Murphy

Author Email(s): julie.murphy2@ggc.scot.nhs.uk

Co-Author(s): Original author: Evdokia Karagianni, Specialty Trainee, Obstetrics and Gynaecology RAH

Approved By: GONEC

Document Id: 990