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Responding to
Amniotic Fluid Embolism
YVONNE A. DOBBENGA-RHODES, RNC-OB, MS, CNS
New! Complete this CE activity
online at aorn.org/CE
A
mniotic fluid embolism (AFE) is
an uncommon obstetric emergency that can be difficult to diagnose and can result in the death of
the mother, child, or both. Reporting
rates and theories regarding the pathophysiology of AFE vary. According to a
study of 3 million births, AFE occurs in
7.7 per 100,000 births and has a fatality
rate of 21.6%.1 Other reports cite even
higher mortality rates (ie, up to 37%).2-4
Amniotic fluid embolism remains unpredictable, unpreventable, and incompletely understood.
The earliest written description of
AFE was published in a Brazilian medical journal in 1926.5 The condition was
not widely recognized, however, until
Steiner and Lushbaugh6 published a report in 1941 of the autopsy findings on
eight pregnant women who experienced sudden shock and pulmonary
edema during labor. In all the cases described in their report, squamous cells
or mucin, presumably fetal in origin,
were found in the patients’ pulmonary
vasculature at autopsy.6 In a later report
of 14 cases of AFE published by Liban
and Raz in 1969,7 cellular debris also was
observed in these patients’ kidneys, livers, spleens, pancreases, and brains. Unfortunately, because it is still unclear
indicates that continuing education contact
hours are available for this activity. Earn the contact hours by reading this article and taking the
examination on pages 1089–1090 and then completing the answer sheet and learner evaluation
on pages 1091–1092. The contact hours for this
article expire June 30, 2012.
© AORN, Inc, 2009
2.1
today what actually causes AFE, its
rapid occurrence makes diagnosis difficult because clinician’s often must exclude many other obstetric complications before arriving at a diagnosis of
AFE and beginning treatment.
AFE
IN THE
PERIOPERATIVE SETTING
In many hospitals, perioperative nurses take an active role in the birthing
process. Cesarean deliveries or high-risk
vaginal deliveries may be performed in
an OR staffed by traditional perioperative department personnel or in an obstetric unit with a fully independent
obstetric OR. Regardless of the setting,
perioperative nurses may find themselves responding to various obstetric
emergencies in their practice. Responses
may range from reallocation of resources
in the main OR to sending all available
staff members to the labor and delivery
department to help with resuscitation.
ABSTRACT
Amniotic fluid embolism (AFE), an uncommon disorder
with a high fatality rate, is an obstetric emergency that requires swift recognition and intervention to save both the
mother’s life and that of her child.
The high mortality rate and varying theories as to its cause
make it difficult to diagnose AFE, which can occur at any
point during labor and delivery, including during cesarean
birth. These factors make it important for perioperative
nurses to understand and recognize AFE when it occurs in
the OR. Rapid delivery of the fetus is imperative for the
survival of both mother and child. Monitoring and aggressively providing respiratory and circulatory support interventions are required if the mother is to survive AFE.
Key words: amniotic fluid embolism, amniotic fluid, obstetric emergencies, cesarean birth emergencies. AORN J 89
(June 2009) 1079-1088. © AORN, Inc, 2009.
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The abrupt onset of AFE may catch the bedside care provider unprepared. This event can
happen in any location, even during a cesarean birth.1 The devastating and rapid effects of
AFE, coupled with its low incidence, often
lead nurses and obstetricians down a path of
exclusion before identifying AFE as the cause
of the series of rapidly unfolding events. Some
of the other obstetric or medical emergencies
that must be considered include septic shock,
anaphylactic shock, placental abruption,
eclamptic seizure, uterine rupture, transfusion
reaction, toxic response to local anesthetic, or
sudden cardiac insult.8 Preparation for AFE
emergencies should be included in emergency
drills in both the perioperative and obstetric
units.
THEORIES
ABOUT
AFE
Reluctance to label an obstetric emergency
as a true AFE occurs because of a lack of consensus on the actual pathophysiologic process
taking place in the individual maternal patient. The hypothesis of pulmonary vasculature congested by fetal squamous cells that
originated in the 1940s has been integral to obstetric emergency management for the last 60
years. Many ensuing case studies have supported this traditional description.3,9 Case studies also have shown that certain risk factors are
possible causes of AFE, such as
• age greater than 35 years;1,3,4,10-12
• amniocentesis;13,14
• artificial rupture of membranes;3,4
• cervical laceration;3,11
• cervical suture removal;10,13
• cesarean birth;1,8-11,15,16
• eclampsia;1,11
• fetal demise;4,15,17
• fetal distress;3,11
• fetal macrosomia;4,10-12,15
• instrumented vaginal delivery (eg, with forceps or vacuum-assisted);1,3,11,15
• medical induction of labor;3,10,11,15,18,19
• multiparity;3,4,10,12,20
• multiple gestation (ie, two or more fetuses);11,21,22
• placenta previa;1-3,11,21
• placental abruption;1,2,3,11,15,21
• polyhydramnios;11
• rapid and intense labor;4,6,10,13,15,20
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•
•
therapeutic abortion;10,14,16 and
uterine rupture.3,4,10,11,15,23
With the increase in cesarean births from
20.7% in 1996 to 31.1% in 2006, an increased risk
of both maternal and neonatal mortality has
been reported during elective cesarean birth as
compared to vaginal birth.24,25 This increase in
complications suggests the need for a broader
grasp of the pathophysiology of AFE. It also
suggests the need to provide better education to
nurses who assist with cesarean births to increase AFE awareness and recognition. Sharing
this knowledge with colleagues allows for collaboration during equipment procurement and
emergency response. Current theories about the
cause of AFE differ.
BIPHASIC CARDIAC FAILURE. A recent theory about
AFE is that it is a biphasic response of shortlived, right ventricular cardiac failure with an
initial acute pulmonary hypertension.26 The resulting right heart failure and associated hypoxia may account for patients who experience early, sudden death during labor and delivery. Despite the brevity of this phase, 50% of
all maternal deaths occur in the first hour after
delivery.10,27,28
The remaining 50% of maternal deaths occur
during the second, longer biphasic response
when left ventricular failure occurs. A maternal
patient in a postanesthesia care unit (PACU)
should be monitored closely after cesarean birth,
especially if any of the aforementioned risk factors are present. Decreased left-sided ventricular
filling and consequent systemic hypotension
can occur during this postdelivery period.
These cardiac events trigger an increase in pulmonary capillary wedge pressure; pulmonary
artery pressure; and, consequently, right-sided
ventricular filling pressure and elevated central
venous pressure.29
Both Clark et al30 in the United States and
Tuffnell2 in the United Kingdom have established national registries for suspected clinical
occurrences of biphasic AFE. They agree on four
hallmark signs of AFE:
• acute hypotension or cardiac arrest;
• acute hypoxia;
• coagulopathy or severe clinical hemorrhage
in the absence of other explanations; and
• all of these events must occur during labor,
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cesarean birth, or dilatation and evacuation
within 30 minutes postpartum.2,30
Clark et al have added one additional qualifier:
• absence of any other significant confounding condition or potential explanation of the
hallmark signs and symptoms.30
One case report cautions that systemic hypotension actually may be absent in patients with
coexisting eclampsia.16
MULTI-ORGAN COLLAPSE. Another theory identifies
left ventricular dysfunction, acute lung injury,
and clotting factor activation as the root causes
that lead the patient to a rapid multi-organ collapse or shock.31 This swift sequence of events
ends with a neurologic response to the respiratory and hemodynamic injury. The neurologic
manifestations may include seizures, confusion,
or coma.32,33
DIAGNOSIS
AND
TREATMENT
According to the national registries established by Clark et al30 and Tuffnell,2 70% of patients were in labor when AFE occurred.3
Emergent evacuation of a gravid uterus will
allow additional resuscitative measures to take
place if AFE occurs before delivery. Early diagnosis of AFE for the still-pregnant woman is
the key to her survival. There is no standard
diagnostic scheme to confirm AFE and, unfortunately, there is no time to waste.
Table 1 presents a nursing care plan for patients who experience AFE. Preplanning is not
possible because of the emergent nature of
this condition. In addition to the previously
identified hallmark signs, the nurse should be
alert for rapid decreases in blood pressure,
sudden difficulty breathing, or any unexplained hemorrhage.
TREATMENT RESPONSE. A prompt cesarean birth
is crucial.19 Facilitating such a quick delivery
may mean performing a perimortem cesarean
delivery in a nonsurgical setting (eg, labor
room, birthing room) when it is necessary to
save time by not transporting the patient to
the OR. Some sources advocate delivery within three to four minutes of maternal collapse
and the implementation of advanced cardiac
life support protocols.13,19,33 A rapid response by
the perioperative team to the nonsurgical setting will support all the care providers as well
In some instances where amniotic
fluid embolism occurs before or during
delivery, the fetus also is placed in a
life-threatening situation. Delivery
will increase the chance of fetal as
well as maternal survival.
as bring surgical expertise to the patient.
DELIVERY OF THE FETUS. In some instances where
AFE occurs before or during delivery, the fetus
also is placed in a life-threatening situation. Delivery will increase the chance of fetal as well as
maternal survival. The weight of the gravid
uterus on the inferior vena cava impedes blood
return to the maternal heart and decreases systemic blood pressure. Delivering the fetus as
soon as possible when maternal arrest occurs
leads to a more favorable neonatal outcome.32,34,35
If the AFE occurs before delivery, it leads to a
fatal outcome for the fetus in 21% of all cases,
while 50% of the surviving neonates show a
neurologic deficit.19
MATERNAL OXYGENATION AND MONITORING. After delivery has been facilitated and the neonatal team
has assumed care for the baby, all efforts can be
turned to the maternal patient’s resuscitation.
Basic and advanced cardiac life support steps
should already be in place. Oxygenation is the
key to avoiding irreversible neurologic injury
for the patient. Early tracheal intubation and
mechanical ventilation are usually necessary to
maintain normal oxygen saturation.13 Monitoring of the patient with AFE includes continuous
electrocardiographic (ECG) monitoring, pulse
oximetry, and end-tidal carbon dioxide monitoring. Clinicians should monitor the patient’s
blood pressure continuously, if possible.10 These
noninvasive monitors and ventilators are standard in ORs, but may not be immediately available in the obstetric department. If that is the
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TABLE 1
Nursing Care Plan for Patients Who Experience
Amniotic Fluid Embolism [applicable PNDS code]
Diagnosis
Risk for
ineffective
coping [X68];
compromised
family coping
[X14]; interrupted family
processes
[X15]; and
risk for
impaired
parent/
infant/child
attachment
[X39]
•
•
•
•
•
•
•
•
•
•
•
Risk for
body temperature imbalance
[X57]
Outcome
indicator
Outcome
statement
Identifies psychosocial status [I68] and barriers to communication [I134], determines
knowledge level [I135], and notes sensory
impairment [I90].
Assesses readiness to learn [I136] and coping
mechanisms [I137].
Elicits family members’ perceptions of surgery [I32].
Identifies individual values and wishes concerning care [I63].
Verifies consent for the planned procedure
[I124].
Explains expected sequence of events and reinforces teaching about treatment options [I56].
Implements measures to provide psychological support [I147].
Includes the patient and family members in
preoperative teaching [I79] and discharge
planning [I80] and provides time for the patient and family members to ask questions.
Provides status reports to family members
[I109].
Provides information and explains the
Patient Self-Determination Act [I103].
Evaluates psychosocial response to the plan
of care [I147].
The patient,
when applicable,
and family members verbalize understanding of
the procedure,
sequence of
events, and expected outcomes;
demonstrate
knowledge of
emotional responses to surgery and the disease process; and
verbalize decreased anxiety
and an ability to
cope throughout
the perioperative
period.
The patient
or family
members
demonstrate
knowledge
of expected
responses to
the surgical
procedure
[O31].
Assesses risk for inadvertent hypothermia
[I131].
Implements thermoregulation measures [I78]
by:
• ensuring ongoing intraoperative and
postoperative monitoring of core body
temperature with the appropriate method
(eg, tympanic, distal esophagus, nasopharynx, pulmonary artery);
• preheating the OR and postanesthesia
care unit (PACU) to 26° C (78.8° F);
• using effective skin-surface warming methods (eg, forced-air warming, circulatingwater garments, energy transfer pads) preoperatively and intraoperatively and continuing their use in the PACU as needed;
• warming IV and irrigation solutions to
near 37° C (98.6° F) with appropriate
warming equipment according to manufacturers’ instructions; and
• assisting the anesthesia care provider to
humidify and warm the patient’s airway.
Evaluates response to thermoregulation
measures [I55].
The patient’s
temperature is
greater than 36° C
(96.8° F) at the
time of
discharge from
the OR.
Nursing interventions
•
•
•
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The patient
or family
members
participate in
decisions
affecting the
perioperative
plan of care
[O23].
The parent and infant demonstrate
appropriate bonding.
The patient
is at or
returning to
normothermy
at the conclusion of the
immediate
postoperative period
[O12].
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TABLE 1 (continued)
Nursing Care Plan for Patients Who Experience
Amniotic Fluid Embolism [applicable PNDS code]
Diagnosis
Decreased
cardiac
output [X8];
risk for
fluid
volume
imbalance
[X20];
impaired
gas
exchange
[X21]; and
ineffective
breathing
pattern [X7]
•
•
•
•
•
•
•
•
•
Risk for
perioperative positioning
injury [X40];
risk for
impaired
skin
integrity
[X51]; and
risk for
infection
[X28]
Outcome
indicator
Outcome
statement
Identifies baseline cardiac status [I59], respiratory
status, and fluid volume status related to the patient’s diagnosis.
Assesses preoperative condition according to
physiological parameters (eg, vital signs, pulses,
skin integrity, cardiac rhythm and dysrhythmias,
breath sounds) and pertinent laboratory studies.
Identifies factors associated with an increased
risk for hemorrhage or fluid and electrolyte loss
[I132].
Uses monitoring equipment to assess cardiac status [I120] and respiratory status [I121].
Recognizes and reports deviations in arterial
blood gas studies [I110] and deviations in diagnostic study results [I111].
Establishes IV access [I34], collaborates in fluid
and electrolyte management [I23], administers
electrolyte therapy as prescribed [I5], and prescribed medications based on arterial blood gas
results [II9].
Implements hemostasis techniques [I133] and administers blood product therapy as prescribed [I2].
Evaluates postoperative cardiac status [I44] and
respiratory status.
Evaluates response to administration of fluids
and electrolytes [I153].
The patient’s
vital signs and
hemodynamic
status are within
the expected
range at transfer
to the PACU and
the patient’s skin
shows adequate
perfusion at
discharge from
the OR.
The patient’s
cardiovascular status
[O15];
respiratory
status [O14];
and fluid,
electrolyte,
and acid-base
balances
[O13] are
consistent
with or
improved
from baseline
levels established preoperatively.
Identifies physical alterations that require additional precautions for procedure-specific positioning [I64].
Verifies presence of prosthetics or corrective devices [I127].
Positions the patient [I96].
Transports the patient according to individual
needs [I42].
Assesses the patient’s susceptibility for infection
[I21].
Implements aseptic technique [I70].
Minimizes the length of the invasive procedure
by planning care efficiently [I85].
Initiates traffic control [I81].
Performs skin preparation [I94].
Classifies the surgical wound [I22] and administers
prescribed prophylactic treatments [I10].
Protects from cross contamination [I98].
Encourages deep breathing and coughing exercises [I33].
Evaluates for signs and symptoms of injury as a
result of positioning [I38] or skin and tissue injury
as a result of transfer or transport [I42].
Monitors for signs and symptoms of infection [I88].
The patient’s skin
remains intact,
non-reddened,
and free of blistering; and motion, sensation,
and circulation
are maintained
or improved during the perioperative period.
The patient is
free from
signs and
symptoms of
injury related
to positioning
[O5].
Nursing interventions
•
•
•
•
•
•
•
•
•
•
•
•
•
•
The patient is
afebrile and has
a clean, primarily
closed surgical
wound that is
free from signs
or symptoms of
infection (eg,
pain, redness,
swelling) at
discharge from
the OR.
The patient is
free of signs
and symptoms of injury related
to transfer/
transport
[O8].
The patient is
free from
signs and
symptoms of
infection
[O10].
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separation of blood cells from plasma, and recase, caregivers should transport the patient to
turn of these blood cells to the body’s circulathe OR as quickly and safely as possible. Ongotion, diluted with fresh plasma. A transfusion of
ing care should be shared between the perinatal
1.5 times the maternal blood volume may act as
and perioperative nursing staff members. Many
a complete exchange transfusion;41 however,
perinatal units do not require staff members to
cryoprecipitate is particularly useful in AFE
be certified in advanced cardiac life support, so
because it can be used to replenish clotting facthe advanced education and experience of peritors in lieu of fresh frozen plasma in volumeoperative nurses will complement the basic life
restricted patients. In addition, cryoprecipitate
support measures already implemented.
contains both fibrinogen and fibronectin, which
CIRCULATORY SUPPORT. In accordance with the
basics of cardiopulmonary resuscitation, circu- facilitate the removal of cellular and particulate
latory support is the next goal in the resuscitamatter from the blood via the reticuloendothetion of the patient with AFE. Medical and
lial (ie, the mononuclear phagocyte) system.33,42
Thrombocytopenia can be treated with the adnursing staff members should quickly estabministration of platelets.36
lish a large-bore peripheral IV
Arterial lines can be used to
catheter, a central venous
regulate pressures, monitor
pressure catheter, a pulmooxygen saturation, and assist
nary artery catheter, and a
with titration of inotropes.
peripheral arterial line. GathThese patients are
Specific inotropic medications
ering additional resources and
such as dopamine, dobutamanpower from the anesthesia
predisposed to pulmonary
mine, and norepinephrine enand critical care staffs will help
hance hemodynamic stability
support the resuscitation team
edema so their central
by maintaining cardiac output
during this emergency.36,37
Transthoracic or transesophaand blood pressure. Readings
line readings should be
geal echocardiography (TEE) is
from central lines should be
monitored closely to avoid
often necessary to evaluate carmonitored closely to
over-hydration of these padiac function and to guide
tients who are predisposed to
treatment, along with a 12-lead
avoid over-hydration.
pulmonary edema. NoncarECG.3 As time allows and as
diogenic pulmonary edema
equipment is made available,
develops in 70% of AFE pathe TEE may demonstrate the
tients, possibly because of the
acute right ventricular overload, severe pulmonary artery
effect of various mediators of
hypertension, and marked diastolic dysfunction anaphylaxis such as histamine and bradykinins
of the left ventricle secondary to a dilated right
leading to capillary leak syndrome.43 The anes29,38
ventricle.
thesia care provider can draw blood specimens
Use of the peripheral IV catheter should be
from these lines and send them for analysis to
limited to loading with crystalloid, colloid,
assist with interpretation and correction of copacked cells, fresh frozen plasma, and platelets. agulopathy as well as for cytologic analysis for
If profound hemorrhage occurs, a transfusion
amniotic fluid in the maternal patient’s circulaof uncross-matched O-negative packed cells is
tion.33 Rapid assessments may be available
recommended so transfusion is not delayed by
from a point-of-care device, typically accessible
waiting for type-specific and cross-matched
in the perioperative setting.
blood.15 Hemofiltration39 or plasma exchange40
Nursing personnel should see that coagulamay be effective in clearing the maternal plastion studies for prothrombin time, partial
ma of potential fetal debris.10 Hemofiltration is
thromboplastin time, D-dimer, fibrin split prodthe removal of waste product from the blood
ucts, and platelets are sent immediately to the
by passing it through extracorporeal filters.
laboratory for analysis. Coagulopathy and hemPlasma exchange consists of removal of blood,
orrhage are common and often occur after the
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pulmonary bypass,45 nitric oxide administraclinical diagnosis of AFE is made.42 Disseminated intravascular coagulation (DIC) is found in
tion under TEE guidance,29,48 administration of
83% of patients with AFE. Half of these patients
recombinant factor VIIa,37,49,50 and placement of
may develop coagulopathy within four hours of a right ventricular assist device to treat pulmonary hypertension.37 Cell salvage with manthe onset of the clinical symptoms.36 Anesthesia
personnel may use low-dose heparin to slow
datory leukocyte depletion filters also may offer
the coagulation cascade and thus treat the con- the ability to clear the maternal vasculature of
sumptive coagulopathy, although this practice is contaminants.51 Hemodialysis for renal failure18
controversial.15
has been used as well. Inhaled prostacycline has
Coexistent hemorrhage may be related to
been used to treat refractory hypoxemia.52
uterine atony; however, the etiology of the
Clark et al30 have suggested that in light of
hemorrhage is obscure, and it is thought that
the similarities of AFE to anaphylaxis, high-dose
consumptive coagulopathy may lead to it.44 In
corticosteroids and epinephrine may be useful
contrast, increased fibrinolysis has been shown adjuvants.30 Administration of hydrocortisone
to occur in AFE, and it has been suggested that sodium succinate will control an inflammatory
response.33 This unique emergency also has been
an elevated plasminogen activator inhibitor-1
antigen in amniotic fluid may become active in termed “anaphylactoid syndrome of pregnancy” because of its similarities to anaphylaxis.36
the maternal blood and contribute to DIC.45
Nursing staff members may implement
After initial resuscitative efforts after AFE,
uterine massage, and the physician may adnurses should focus on longer-term stabilizaminister the traditional oxytocic medications
tion and prevention of side effects from transsuch as oxytocin, methylergonovine maleate,
fusion reactions.15 A vital noninvasive measure
carboprost tromethamine, or misoprostol to
frequently overlooked in an emergency but incorrect uterine atony.34 These medications may herent in perioperative care is patient warmbe given intravenously or directly into the
ing. Use of warmed IV fluids, blood warmers,
uterine musculature during life-saving measand a forced-air patient warming system may
ures to control the uterine atony and bleeding. prevent hypothermia and avoid such detriIf the atony or hemorrhage remains unconmental results as peripheral tissue ischemia,
trolled, many obstetricians attempt other suraltered mentation, and increased hemoglobin
gical interventions such as ligation or emaffinity for oxygen.15
bolization of the inguinal or uterine arteries or
may resort to performing a total abdominal
RECOVERY
hysterectomy to arrest the hemorrhage.33,46
In situations where the maternal patient reNEWER TREATMENT MODALITIES. Newer, breaksponds favorably to these interventions and surthrough, modalities of treatment and supportive vives AFE, postpartum nursing activities will
management with AFE have
shown promise in individual
TABLE 2
case presentations and have
Surgical Treatments and Techniques
demonstrated the uncommon
nature of AFE, in that no two
Valuable in Obstetric Emergencies
patients will respond the same
Cardiopulmonary bypass
way to the insult or to the therCell salvage
apy. Many of these items are
Extracorporeal membrane oxygenation
more easily accessed in the
Intra-aortic balloon counter pulsation
main OR than in the labor and
Invasive cardiac and hemodynamic monitoring
delivery department (Table 2).
Nitric oxide therapy
These items include extracorRapid infusers for blood products
poreal membrane oxygenation,
Transesophageal echocardiography
Ventricular assist device
intra-aortic balloon counter
47
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start directing her recovery; however, nurses
should not wait to implement these actions.
These should be carried out alongside advanced
cardiac life support protocols. Performing and
providing fundal (ie, uterine) massage can indicate the degree of uterine atony and the patient’s
response to therapy. Administration of oxytocin,
a medication familiar to obstetric nurses, will be
required. Programming of IV pumps for oxytocin and the knowledge of its side effects of
water intoxication from large infused volumes53
may be unfamiliar to critical care or perioperative nurses. Keeping the obstetric nurse involved
in the care of this patient after delivery, during
resuscitation, and while providing supportive
care allows the obstetric nurse to share his or her
unique knowledge and expertise. A team approach to this lengthy—sometimes days-long—
resuscitation effort will benefit the patient.
Epidural catheters placed for labor analgesia
should remain in place until the patient has a
platelet count of at least 100,000 per millimeter.5,54
While on bed rest, pneumatic compression devices will help reduce the patient’s risk of other
thromboembolic events.25 The ongoing task of
inspecting the patient’s episiotomy may require
that the obstetric nurse educate OR, PACU, and
critical care nurses about how best to perform
this task. Continual monitoring of postpartum
blood loss can be done by weighing sanitary
pads (1 g = 1 mL). Frequent patient care visits to
the PACU and critical care unit (CCU) by obstetric nursing staff members will ensure appropriate evaluation of the patient for breastfeeding,
routine breast pumping, or general breast care.
Routinely scheduled application of a breast
pump every four hours for 15 minutes also may
help with uterine involution and decrease the
need for long-term oxytocin use.
FAMILY SUPPORT. Unlimited family visitation in
the PACU and CCU is instrumental in the maternal patient’s recovery, especially if the neonate is unable to visit or has died. Despite
neonatal outcome, facilitation of maternal-infant
bonding should occur. This may mean having
support persons in the PACU and working with
the perinatal nursing staff members to safely
transfer the neonate for visitation. Pictures of the
deceased neonate or family viewing and holding of the neonate’s body has been shown to aid
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Keeping the obstetric nurse involved in
the care of the patient after delivery,
during resuscitation, and while
providing supportive care allows the
obstetric nurse to share his or her
unique knowledge and expertise
to benefit the patient.
in grief resolution.55 Viewing should be encouraged throughout the patient’s hospitalization,
and trips to the morgue to retrieve the neonate
should be conducted with respect and modesty.
Allowing unlimited viewing of the deceased
infant as well as unsupervised family time with
the mother is helpful. Family members may
want to take pictures of the infant, mother, or
both, which may seem morbid to someone unfamiliar with perinatal loss, yet families express
deep gratitude for any memento they have of
this time.55 The opportunity for such activity
may need to occur in the OR or PACU setting
when there is little time or little hope of survival
of the maternal patient, the neonate, or both.
Nursing staff members should anticipate a wide
range of family members’ emotions, particularly
if the mother dies and the neonate survives.33
Many obstetric units have dedicated memory
boxes to hold copies of footprints, locks of hair,
identification bands, receiving blankets, and pictures. Maternal patients and surviving family
members may need counseling after such a traumatic event. In some instances, the counseling
may include reproductive counseling for survivors wishing to undertake another pregnancy.
Although this may seem daunting or ill-advised,
there are six case reports of successful pregnancies after AFE with no recurrence.56
STAFF MEMBER SUPPORT. Care and support offered
to patients and family members is a natural re-
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Dobbenga-Rhodes
JUNE 2009, VOL 89, NO 6
sponse, yet care and support also must be offered to the nursing and medical staff members
involved in this event.57 Opportunities to debrief
should be provided as soon as possible after the
event and with as many personnel involved as
possible to make it effective and to allow staff
members to generate a meaningful action plan
for future AFE emergencies. The action plan
should include an outline of specific responsibilities and locations of necessary equipment. Grief
counseling should be offered via pastoral care or
through employee assistance programs.33 Initial
and ongoing education of nurses about maternal
and perinatal bereavement care is needed. Effective strategies for coping during and after providing care to these families supports nurses in
meeting the emotional challenge of providing
high-quality maternal and perinatal bereavement care.57
CONCLUSION
Responding to AFE is a team effort. Each
team member brings his or her skill set and expertise. Supportive management of the maternal patient experiencing this uncommon and
unpredictable event is central to her survival,
and the emotional support of team members is
crucial to ongoing quality patient care.
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46. Stanten RD, Iverson LI, Daugharty TM, Lovett
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factor VIIa after amniotic fluid embolism and disseminated intravascular coagulopathy. Int J Gynaecol
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50. Prosper SC, Goudge CS, Lupo VR. Recombinant
factor VIIa to successfully manage disseminated intravascular coagulation from amniotic fluid embolism. Obstet Gynecol. 2007;109(2 Pt2):524-525.
51. Allam J, Cox M, Yentis SM. Cell salvage in obstetrics. Int J Obstet Anesth. 2008;17(1):37-45.
52. Van Heerden PV, Webb SA, Hee G, Corkeron M,
Thompson WR. Inhaled aerosolized prostacyclin as
a selective pulmonary vasodilator for the treatment
of severe hypoxaemia. Anaesth Intensive Care. 1996;
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53. Ophir E, Solt I, Odeh M, Bornstein J. Water intoxication—a dangerous condition in labor and delivery
rooms. Obstet Gynecol Surv. 2007;62(11):731-738.
54. Bernstein K, Baer A, Pollack M, Sebrow D, Elstein
D, Ioscovich A. Retrospective audit of outcome of regional anesthesia for delivery in women with thrombocytopenia. J Perinat Med. 2008;36(2):120-123.
55. Kobler K, Limbo R, Kavanaugh K. Meaningful
moments. MCN Am J Matern Child Nurs. 2007;32
(5):288-295.
56. Stiller RJ, Siddiqui D, Laifer SA, Tiakowski RL,
Whetham JC. Successful pregnancy after suspected
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Caring for families coping with perinatal loss. J Obstet
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Yvonne A. Dobbenga-Rhodes, RNC-OB,
MS, CNS, is a maternal-child health clinical
nurse specialist at Washington Hospital
Healthcare System, Fremont, CA. Ms
Dobbenga-Rhodes has no declared affiliation
that could be perceived as a potential conflict of
interest in publishing this article.
p1079-1092_06_09:Layout 1 5/13/2009 3:27 PM Page 1089
Examination
2.1
Responding to Amniotic Fluid Embolism
PURPOSE/GOAL
To educate perioperative nurses about caring for patients with amniotic fluid embolisms (AFEs).
BEHAVIORAL OBJECTIVES
After reading and studying the article on responding to AFEs, nurses will be able to
1. explain theories regarding the pathophysiologic process that leads to AFE,
2. describe the risk factors for AFE,
3. discuss the treatment of AFE, and
4. describe supportive care for patients and their family members after an AFE occurrence.
QUESTIONS
1. According to a study of 3 million births,
AFE occurs in 7.7 per 100,000 births and
has a fatality rate of
a. 10.9%.
b. 15.5%.
c. 21.6%.
d. 31.5%.
2. In 1941, a published report of autopsy
findings for eight pregnant women with
sudden shock and pulmonary edema described finding ______________________
in the patients’ pulmonary vasculature.
a. fetal squamous or mucin cells
b. fetal white blood cells
c. viral cells
d. fetal red blood cells
3. Risk factors for AFE include
1. cesarean birth or instrumented vaginal
delivery.
2. eclampsia.
3. maternal age younger than 35
years.
4. multiparity.
5. rapid and intense labor.
a. 1, 2,and 3
b. 3, 4, and 5
c. 1, 2, 4, and 5
© AORN, Inc, 2009
d. 1, 2, 3, 4, and 5
4. One current theory about the pathophysiology of AFE is that it is a biphasic cardiac
failure that includes
1. initial acute pulmonary hypertension.
2. right heart failure with hypoxia.
3. left ventricular failure with systemic
hypotension.
a. 2
b. 1 and 3
c. 1 and 2
d. 1, 2, and 3
5. Another theory identifies left ventricular
dysfunction, acute lung injury, and clotting factor activation as the root causes of
AFE, leading to
a. initial acute pulmonary hypertension.
b. multi-organ collapse.
c. right heart failure with hypoxia.
d. left heart failure with systemic hypotension.
6. Early ___________ for the still-pregnant
woman is the key to her survival.
a. circulatory support
b. diagnosis of AFE
c. fundal massage
d. induction of labor
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Examination
JUNE 2009, VOL 89, NO 6
7. _________________ is/are the key to
avoiding irreversible neurologic injury for
the maternal patient.
a. Coagulation studies
b. Epidural anesthesia
c. Oxygenation
8. Researchers have suggested that AFE is
similar to anaphylaxis and suggest treating it with high-dose corticosteroids and
epinephrine.
a. true
b. false
9. A crucial nursing intervention that may
be overlooked during this emergency is
a. breast care.
The behavioral objectives and examination for this program were prepared
by Helen Starbuck Pashley, RN, MA,
CNOR, with consultation from Susan
Bakewell, RN, MS, BC, director, Center for Perioperative Education. Ms
Pashley and Ms Bakewell have no declared affiliations that could be perceived as potential conflicts of interest
in publishing this article.
1090 • AORN JOURNAL
b. patient warming.
c. uterine massage.
10. Support of patients and their family members after an AFE emergency can include
1. unlimited family visitation in the
postanesthesia care unit and critical
care unit.
2. facilitation of mother-infant bonding
despite the neonatal outcome.
3. unlimited viewing of the infant if the
infant is deceased.
4. counseling.
a. 1 and 2
b. 3 and 4
c. 2, 3, and 4
d. 1, 2, 3, and 4
This program meets criteria for CNOR and CRNFA recertification, as well as
other continuing education requirements.
AORN is accredited as a provider of continuing nursing education by the
American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as continuing education for registered
nurses. This recognition does not imply that AORN or the American
Nurses Credentialing Center approves or endorses products mentioned
in the activity.
AORN is provider-approved by the California Board of Registered Nursing,
Provider Number CEP 13019. Check with your state board of nursing for
acceptance of this activity for relicensure.
p1079-1092_06_09:Layout 1 5/13/2009 3:27 PM Page 1091
Answer Sheet
Responding to Amniotic Fluid Embolism
2.1
Event #09110
Session #1079
lease fill out the application and answer form
on this page and the evaluation form on the back
of this page. Tear the page out of the Journal or make
photocopies and mail with appropriate fee to:
P
AORN Customer Service
c/o AORN Journal Continuing Education
2170 S Parker Rd, Suite 300
Denver, CO 80231-5711
or fax with credit card information to
(303) 750-3212.
Additionally, please verify by signature that you
have reviewed the objectives and read the
article, or you will not receive credit.
Signature ______________________________________
1. Record your AORN member identification number in
the appropriate section below. (See your member
card.)
2. Completely darken the spaces that indicate your answers to examination questions 1 through 10. Use blue
or black ink only.
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© AORN, Inc, 2009
A score of 70% correct on the examination is
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JUNE 2009, VOL 89, NO 6 • AORN JOURNAL •
1091
p1079-1092_06_09:Layout 1 5/13/2009 3:27 PM Page 1092
2.1
Learner Evaluation
Responding to Amniotic Fluid Embolism
his evaluation is used to determine the
extent to which this continuing education
program met your learning needs. Rate these
items on a scale of 1 to 5.
T
PURPOSE/GOAL
To educate perioperative nurses about caring
for patients with amniotic fluid embolisms
(AFEs).
OBJECTIVES
To what extent were the following objectives of
this continuing education program achieved?
1. Explain theories regarding the pathophysiologic process that leads to AFE.
2. Describe the risk factors for AFE.
3. Discuss the treatment of AFE.
4. Describe supportive care for patients and
their family members after an AFE occurrence.
CONTENT
To what extent
5. did this article increase your knowledge
of the subject matter?
6. was the content clear and organized?
7. did this article facilitate learning?
8. were your individual objectives met?
9. did the objectives relate to the overall
purpose/goal?
TEST QUESTIONS/ANSWERS
To what extent
10. were they reflective of the content?
11. were they easy to understand?
12. did they address important points?
LEARNER INPUT
13. Will you be able to use the information
from this article in your work setting?
a. yes
b. no
14. I learned of this article via
a. the AORN Journal I receive as an AORN
member.
b. an AORN Journal I obtained elsewhere.
c. the AORN Journal web site.
1092 • AORN JOURNAL • JUNE 2009, VOL 89, NO 6
15. What factor most affects whether you take
an AORN Journal continuing education
examination?
a. need for continuing education contact
hours
b. price
c. subject matter relevant to current position
d. number of continuing education contact
hours offered
What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know
someone who would be interested in writing
an article on this topic?
Topic(s): __________________________________
__________________________________________
__________________________________________
Author names and addresses: _______________
__________________________________________
__________________________________________
__________________________________________
© AORN, Inc, 2009