Medical or Surgical Patient in Maternity Triage, Acute Management (990)

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

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.

Maternal observations (HR, BP, Temperature, RR, SpO_2, 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)

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

• 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

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.

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.

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.