Amniotic fluid embolism with arrest during vacuum delivery38-year-old woman, 72 kg, para 4, at 40 weeks in oxytocin-augmented labour with a working epidural
Amniotic fluid embolism: maternal arrest, uterine displacement, delivery and DIC
From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.
Know this first
- Resuscitative delivery begins at recognition of arrest, completed by 5 minutes, at the bedside.
- Uterus at the umbilicus or higher: displace it manually to the left.
- Shock energies unchanged by pregnancy; access in the arms, above the diaphragm.
- AFE: massive transfusion with balanced products, tranexamic acid, early fibrinogen.
- Atropine is not given in AFE unless she is bradycardic.
The patient
The examiner asks
Answer aloud, then press Show.
Consider
What risks do you see as she delivers?
Show the answerHide the answer
- A 38-year-old para 4 at term, augmented labour, epidural, now having a vacuum delivery. Patient
- At term: caval compression, difficult airway and aspiration risk if she deteriorates.
- High parity, augmented labour and oxytocin all raise her atony risk. Disease
- Fully dilated with an epidural: a failed vacuum means a fast caesarean under that block. Surgery
Plan
The obstetrician wants a trial of vacuum in the delivery room. What is your plan?
Show the answerHide the answer
- Epidural topped up to cover the vacuum, with extension drugs ready if a caesarean follows. Surgery
- Left uterine displacement, a large cannula, group and screen, uterotonics drawn up. Patient
- If she collapses, my differential: AFE, haemorrhage, high block, LAST, embolism, aspiration. Disease
- Neonatal team aware; arrest trolley and resuscitative delivery kit checked in the room. After surgery
Crisis
During the vacuum she becomes agitated, says she can't breathe, and goes grey; SpO2 70%, BP 60/30, then no pulse; the monitor shows a rhythm at 40/min. What do you do?
Show the answerHide the answer
- Maternal arrest, PEA: call the obstetric arrest and neonatal teams, start compressions. (Crisis)
- Fundus above her umbilicus: manual left uterine displacement throughout CPR.
- Airway early: bag-mask with 100% oxygen, then a smaller tube by the most skilled person.
- Adrenaline 1 mg every 3–5 minutes via an arm vein, as PEA isn't shockable; standard shocks if VF.
- Fully dilated with the vacuum on: deliver vaginally now; otherwise hysterotomy here, done by 5 minutes.
- Her causes: amniotic fluid embolism first; also bleeding, high block or LAST from the epidural.
- Fetal monitors off; they only distract and delay.
Crisis
Circulation returns after delivery at 4 minutes. Now blood pours from the vagina and every cannula site; BP 78/40, HR 140, SpO2 92% on 100%. What do you do?
Show the answerHide the answer
- AFE with DIC: massive transfusion protocol, balanced red cells, plasma and platelets. Crisis
- Fibrinogen early, kept at 150–200 mg/dL; viscoelastic tests to steer products.
- Give tranexamic acid 1 g, run in over 10 minutes.
- Oxytocin for atony; carboprost avoided because it raises her pulmonary pressures.
- Echo for RV failure: noradrenaline 0.1–1 mcg/kg/min and inhaled nitric oxide 10–40 ppm.
- No atropine unless she's bradycardic; VA-ECMO if she stays unstable.
- ICU post-arrest care afterwards, then a team debrief. After surgery
Fatal mistakes
- Moving her to theatre during the arrest.
- Compressions without uterine displacement.
- Delivery left beyond 5 minutes of arrest.
- Fibrinogen replacement delayed in AFE bleeding.
Checked against: AHA guidelines: special circumstances of resuscitation (2025) · Miller 10e
Report a problem with this case
Mark Got it only if you said every point. Again brings the case back tomorrow; Got it brings it back in 3, then 7, 14 and 30 days.