RCOG IRC Bangladesh

Protocol for Maternal Collapse in Pregnancy and Puerperium

Table of Contents

(Based on RCOG, ACOG, WHO and Bangladesh National Guidelines)

Definition

Maternal collapse is the acute loss of consciousness with absence of effective circulation in pregnancy or within 6 weeks postpartum, requiring immediate resuscitation.

Common Causes

Remember the 4Hs & 4Ts

  • Cardiac: Myocardial infarction, arrhythmia, cardiomyopathy, congenital heart disease, cardiac arrest.
  • Respiratory: Massive pulmonary embolism (PE), amniotic fluid embolism (AFE), severe asthma, anaphylaxis, aspiration.
  • Hemorrhage: Antepartum or postpartum hemorrhage (PPH), uterine rupture, trauma.
  • Hypertensive: Severe pre-eclampsia/eclampsia, intracranial bleed, stroke.
  • Sepsis: Chorioamnionitis, puerperal sepsis.
  • Metabolic: Hypoglycemia, electrolyte disturbance.
  • Others: Trauma, anesthesia-related events.

Initial Response (First Responder)

A–E approach with maternal–fetal considerations

  1. Call for Help → Activate Maternal Emergency Team.
    • Alert senior obstetrician, anesthetist, neonatologist, ICU.
    • Inform blood bank.
  2. Airway → Maintain airway patency; insert airway if needed.
    • Give 100% oxygen via face mask.
    • Consider early intubation by skilled anesthetist.
  3. Breathing → Assess chest rise, SpO₂, respiratory rate.
    • Bag–mask ventilation if inadequate.
    • Rule out aspiration, bronchospasm, PE, AFE.
  4. Circulation
    • Check pulse, BP, ECG, establish IV access (2 large-bore).
    • Start IV fluids (crystalloids).
    • Send blood: FBC, group & cross-match, coagulation, ABG, electrolytes.
    • Control hemorrhage: bimanual compression, uterotonics, balloon tamponade.
    • If shock → follow WHO maternal near-miss emergency protocol.
  5. Disability → Check GCS, pupils, seizure activity.
    • If eclampsia → IV Magnesium sulfate.
  6. Exposure → Look for bleeding, trauma, rash, uterine rupture.
    • Keep patient warm (blankets/warmer).

Cardiac Arrest in Pregnancy

  • Start CPR immediately: high-quality chest compressions (100–120/min, depth 5 cm).
  • Hand position slightly higher on sternum.
  • 30:2 compression–ventilation ratio if no advanced airway.
  • Manual left uterine displacement (LUD) if uterus >20 weeks.
  • Avoid supine hypotension.
  • Defibrillation: Use standard energy (no change for pregnancy).
  • Drugs: Standard adult doses (adrenaline, amiodarone).

Perimortem Cesarean Section (PMCS)

Indication: Maternal cardiac arrest, uterus >20 weeks, no ROSC within 4 minutes.

Action:

  • Perform resuscitative hysterotomy by 5 minutes.
  • Aim: Improve maternal venous return & fetal survival.
  • Location: Do not transfer; perform at site of arrest.

Definitive Management Based on Cause

  • PPH: Uterotonics (oxytocin, misoprostol, ergometrine, tranexamic acid), balloon tamponade, B-Lynch, hysterectomy.
  • Eclampsia/HTN: IV MgSO₄, antihypertensives, stabilize BP.
  • Sepsis: IV broad-spectrum antibiotics, fluids, source control.
  • Anaphylaxis: IM Adrenaline, airway support, fluids, antihistamine, steroids.
  • PE/AFE: Supportive care, anticoagulation (PE), ECMO (where available).
  • MI/Arrhythmia: ACLS protocols, cardiology input.

Team Roles in Bangladesh Context

  • Team Leader: Senior obstetrician/anesthetist.
  • Airway & Breathing: Anaesthetist.
  • Circulation & IV Access: Obstetric SHO/nurse.
  • Monitoring & Documentation: Midwife/nurse.
  • Neonatal Resuscitation: Pediatrician.
  • Blood & OT Arrangement: Junior doctor/nurse.

Post-Resuscitation Care

  • Transfer to ICU/HDU.
  • Monitor vitals, urine output, ABG, electrolytes.
  • Provide psychological support and family counseling.
  • Debrief team for clinical learning.

References

  • RCOG Green-top Guideline No. 56: Maternal Collapse (2022).
  • ACOG Committee Opinion: Cardiopulmonary Resuscitation in Pregnancy.
  • WHO Maternal Near-Miss Approach (2019).
  • Bangladesh National Guidelines on Maternal Health (DGHS, updated 2022).


Compiled By:

Dr. Polly Ahmed
Dr. Sumaiya Binte Asif


Contributors

  1. Prof Fawzia Hossain
  2. Prof KH Shahnewaz
  3. Prof Firoza Begum
  4. Dr Arifa Sharmin Maya
  5. Dr Runa Akter Dola
  6. Dr Taslima Akter
  7. Dr Maniza
  8. Dr Tamanna
  9. Dr Mahamoda Sultana
  10. Dr Maskura Jahan
  11. Dr Nipa Ghosh
  12. Dr Syeda Farhana Islam
  13. Dr Jinat Fatema
  14. Dr Syeda Ummay Kulsum
  15. Dr Nigar Sultana Lia