Shock

Shock is characterized by failure of the circulatory system to maintain adequate perfusion of the vital organs. Shock is a life-threatening condition that requires immediate and intensive treatment.

Suspect or anticipate shock if at least one of the following is present:

• bleeding in early pregnancy (e.g. abortion, ectopic or molar pregnancy);

• bleeding in late pregnancy or labour (e.g. placenta praevia, abruptio placentae, ruptured uterus);

• bleeding after childbirth (e.g. ruptured uterus, uterine atony, tears of genital tract, retained placenta or placental fragments);

• infection (e.g. unsafe or septic abortion, amnionitis, metritis, pyelonephritis);

• trauma (e.g. injury to uterus or bowel during abortion, ruptured uterus, tears of genital tract).

SYMPTOMS AND SIGNS

Diagnose shock if the following symptoms and signs are present:

• fast, weak pulse (110 per minute or more);

• low blood pressure (systolic less than 90 mm Hg).

Other symptoms and signs of shock include:

• pallor (especially of inner eyelid, palms or around mouth);

• sweatiness or cold clammy skin;

• rapid breathing (rate of 30 breaths per minute or more);

• anxiousness, confusion or unconsciousness;

• scanty urine output (less than 30 mL per hour).

MANAGEMENT

Immediate management

• SHOUT FOR HELP. Urgently mobilize all available personnel.

• Monitor vital signs (pulse, blood pressure, respiration, temperature).

• Turn the woman onto her side to minimize the risk of aspiration if she vomits and to ensure that an airway is open.

• Keep the woman warm but do not overheat her as this will increase peripheral circulation and reduce blood supply to the vital centres.

• Elevate the legs to increase return of blood to the heart (if possible, raise the foot end of the bed).

SPECIFIC MANAGEMENT

• Start an IV infusion (two if possible) using a large-bore (16-gauge or largest available) cannula or needle. Collect blood for estimation of haemoglobin, immediate cross-match and bedside clotting (see below), just before infusion of fluids:

- Rapidly infuse IV fluids (normal saline or Ringer’s lactate) initially at the rate of 1 L in 15-20 minutes;

Note: Avoid using plasma substitutes (e.g. dextran). There is no evidence that plasma substitutes are superior to normal saline in the resuscitation of a shocked woman and dextran can be harmful in large doses.

- Give at least 2 L of these fluids in the first hour. This is over and above fluid replacement for ongoing losses.

Note: A more rapid rate of infusion is required in the management of shock resulting from bleeding. Aim to replace 2-3 times the estimated fluid loss. 

 Do not give fluids by mouth to a woman in shock. 

• If a peripheral vein cannot be cannulated, perform a venous cut-down (Fig S-1).

• Continue to monitor vital signs (every 15 minutes) and blood loss.

• Catheterize the bladder and monitor fluid intake and urine output.

• Give oxygen at 6-8 L per minute by mask or nasal cannulae.

Bedside clotting test

• Assess clotting status using this bedside clotting test: 

- Take 2 mL of venous blood into a small, dry, clean, plain glass test tube (approximately 10 mm x 75 mm);

- Hold the tube in your closed fist to keep it warm (+ 37�C);

- After 4 minutes, tip the tube slowly to see if a clot is forming. Then tip it again every minute until the blood clots and the tube can be turned upside down;

- Failure of a clot to form after 7 minutes or a soft clot that breaks down easily suggests coagulopathy.

Figure S-1

 Venous cut-down 

DETERMINING AND MANAGING THE CAUSE OF SHOCK

Determine the cause of shock after the woman is stabilized.

• If heavy bleeding is suspected as the cause of shock:

- Take steps simultaneously to stop bleeding (e.g. oxytocics, uterine massage, bimanual compression, aortic compression, preparations for surgical intervention);

- Transfuse as soon as possible to replace blood loss;

- Determine the cause of bleeding and manage:

- If bleeding occurs during first 22 weeks of pregnancy, suspect abortion, ectopic or molar pregnancy;

- If bleeding occurs after 22 weeks or during labour but before delivery, suspect placenta praevia, abruptio placentae or ruptured uterus;

- If bleeding occurs after childbirth, suspect ruptured uterus, uterine atony, tears of genital tract, retained placenta or placental fragments.

- Reassess the woman’s condition for signs of improvement.

• If infection is suspected as the cause of shock:

- Collect appropriate samples (blood, urine, pus) for microbial culture before starting antibiotics, if facilities are available;

- Give the woman a combination of antibiotics to cover aerobic and anaerobic infections and continue until she is fever-free for 48 hours:

- penicillin G 2 million units OR ampicillin 2 g IV every 6 hours; 

-PLUS gentamicin 5 mg/kg body weight IV every 24 hours;

- PLUS metronidazole 500 mg IV every 8 hours. 

 Do not give antibiotics by mouth to a woman in shock. 

- Reassess the woman’s condition for signs of improvement.

• If  trauma is suspected as the cause of shock, prepare for surgical intervention.

REASSESSMENT

• Reassess the woman’s response to fluids within 30 minutes to determine if her condition is improving. Signs of improvement include:

- stabilizing pulse (rate of 90 per minute or less);

- increasing blood pressure (systolic 100 mm Hg or more);

- improving mental status (less confusion or anxiety);

- increasing urine output (30 mL per hour or more).

• If the woman’s condition improves:

- Adjust the rate of infusion of IV fluids to 1 L in 6 hours;

- Continue management for the underlying cause of shock.

• If the woman’s condition fails to improve or stabilize, she requires further management (see below).

FURTHER MANAGEMENT

• Continue to infuse IV fluids, adjusting the rate of infusion to 1 L in 6 hours and maintain oxygen at 6-8 L per minute.

• Closely monitor the woman’s condition.

• Perform laboratory tests including haematocrit, blood grouping and Rh typing and cross-match.  If facilities are available, check serum electrolytes, serum creatinine and blood pH.

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