Maternal Collapse in Pregnancy
Published: 15 December 2021
Published: 15 December 2021
Maternal collapse is a rare, life-threatening event with a wide range of possible causes that may or may not be pregnancy-related.
Defined as an acute event resulting in a reduced or absent consciousness and potential cardiac arrest, maternal collapse can occur at any stage of pregnancy and up to six weeks postnatally (Chu, Johnston & Geoghegan 2019).
With both mother and baby at risk of potentially life-threatening repercussions, prompt recognition and treatment are vital for effective management. In all cases, the wellbeing of the mother should always take priority in acute collapse scenarios, and only once the mother’s condition has been stabilised should action be taken to support the wellbeing of the baby (Brunskill & Ferriman 2018). Fortunately, maternal collapse is rare in Australia (Hingston 2021) and is an emergency that few midwives will see during their careers.
The outcomes for both mother and baby are dependent on swift action and effective resuscitation, yet, as Catling-Paull et al. (2021) point out, the early warning signs of impending maternal collapse are often absent or go unrecognised.
Maternal deaths are usually expressed as a maternal mortality ratio (MMR), which is the number of maternal deaths per 100,000 women giving birth. Whilst recent evidence points to the rate of maternal morbidity increasing year-on-year, Chu, Johnston and Geoghegan (2019) suggest this is more likely to reflect the changing demographics of women and better reporting, rather than a decline in care.
As Hingston (2021) notes, maternal collapse can occur any time during pregnancy and up to 42 days following delivery, however, not all maternal deaths are preceded by an identifiable collapse, and not all maternal collapses result in death.
Even though it’s not always possible to predict which women will be at the greatest danger of collapse, some of the most common risk factors can be identified and include:
Of all the potential causes of maternal collapse, haemorrhage is thought to be the most common (Maternal Collapse 2020). Postpartum haemorrhage, antepartum haemorrhage from a placenta praevia, placental abruption, uterine rupture, uterine inversion and ectopic pregnancy are all potential causes of catastrophic maternal haemorrhage (Chu, Johnston & Geoghegan 2019).
Hingston (2021) makes the point that although the leading causes of direct maternal death in Australia are thromboembolic disease and obstetric haemorrhage, other less common causes of collapse also need to be considered. These include:
(South Australian Perinatal Practice Guideline 2020)
In addition to standard resuscitation procedures, some additional factors need to be taken into consideration for pregnant women, such as placing the mother in the left lateral position and administering oxygen whilst all vital signs are being recorded. Assessment of fetal wellbeing should also be performed, but only after the mother’s condition has been assessed and, if possible, stabilised (Chu, Johnston & Geoghegan 2019).
As Hingston (2021) suggests, there are many physiological changes that occur in pregnancy that could potentially make resuscitation more difficult. For example:
Brunskill and Ferriman (2018) suggest the following key steps that should always be performed in cases of maternal collapse:
Hingston (2021) expands on this and emphasises the importance of maintaining left-lateral displacement of the uterus to reduce the degree of aortocaval compression. This should be achieved manually, with one member of the maternity team using a hand to push the uterus to the side while the mother is supine. Ultimately, it may be necessary to consider expediting delivery with an emergency caesarean section to give both mother and baby the best possible chance of survival.
In cases where maternal collapse proceeds to cardiac arrest, survival rates tend to be poor, with only 42% of mothers recovering. Swift action is critical, with one study finding that there was a median time of just 3 minutes from collapse to operative delivery for those mothers who survived, and a median time of 12 minutes for those who died (Warren 2021). Beckett, Knight and Sharpe (2017), on the other hand, are slightly more optimistic, suggesting that maternal survival rates of 58% could be achieved with prompt resuscitation.
With such potentially devastating outcomes, women who are in a high-risk category for maternal collapse should be referred to appropriate specialists who can create a specific pregnancy management plan that highlights any ‘red-flag’ symptoms that might require an urgent referral or specialist review (Bhatti & Penna 2012).
As Catling-Paull et al. (2021) note, it’s a sobering topic that requires a constant updating of training packages, as well as relevant in-service education programs and training in optimal teamwork should collapse occur.
Hingston (2021) sums up the situation succinctly by suggesting that, as with everything in obstetrics, one of the biggest challenges with maternal collapse is the unpredictability and the need for constant vigilance, however rare these events might be.