CLINICAL OBSTETRICS AND GYNECOLOGY

Volume 00, Number 00, 000–000

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Cardiac Arrest:
Obstetric CPR/ACLS
BENJAMIN COBB, MD,* and STEVEN LIPMAN, MDw
*Department of Anesthesiology, University of North Carolina,
Chapel Hill, North Carolina; and w Department of Anesthesia,
Stanford University School of Medicine, Stanford, California

Abstract: In contrast with other high-resource coun- conditions, including cardiomyopathy,

tries, maternal mortality has seen an increase in the
United States. Caring for pregnant women in cardiac
arrest may prove uniquely challenging given the rarity
of the event coupled by the physiological changes of
pregnancy. Optimization of resuscitative efforts war-
rants special attention as described in the 2015
American Heart Association’s ‘‘Scientific Statement
on Maternal Cardiac Arrest.’’ Current recommenda-
tions address a variety of topics ranging from the
basic components of chest compressions and airway
management to some of the logistical complexities
and operational challenges involved in maternal
cardiac arrest.
Key words: obstetrics, resuscitation, cardiac arrest,
cardiopulmonary resuscitation, advanced cardiac
life-support
Maternal Cardiac Arrest
Over the last 30 years, maternal mortality
in high-resource countries has decreased.
In contrast, the United States has seen a
disproportionate increase in maternal
death.1 Hospitalizations complicated by
maternal cardiac arrest may be as high as
1 in 12,000, with survival estimates rang-
ing from 15% to 54%.2–4 Cardiovascular
Correspondence: Steven Lipman, MD, Department of
Anesthesia, Stanford University School of Medicine,
Room H3580, Stanford, CA. E-mail: lipman1@stan
ford.edu
The authors declare that they have nothing to disclose.
have emerged as the number 1 cause of
maternal cardiac arrest (25.8%) in the
United States.2
Data from the California Maternal
Quality Care Collaborative (CMQCC)
collected from 2002 to 2005 suggests the
‘‘preventability of mortality’’ may be
strikingly high in cases of maternal death
(with a good-to-strong chance of prevent-
ability in up to 41% of cases). Possible
contributing factors to causes of reversi-
ble maternal cardiovascular collapse may
include ‘‘delays in seeking care, symptom
recognition, and lack of staff knowl-
edge.’’5 Furthermore, despite national
guidelines advocating a perimortem ce-
sarean delivery (PMCD) during maternal
cardiac arrest, to date, approximately
one third of the women who die during
pregnancy ‘‘remain undelivered at the
time of death.’’6
Maternal resuscitation warrants spe-
cial consideration given the unique
underlying causes, potential reversibility,
and alterations in maternal anatomy and
physiology. In 1992, the American Heart
Association (AHA) first mentioned the
topic of maternal cardiac arrest in ‘‘Part
IV: Special Resuscitation Situations.’’
More recently, national guidelines have

CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 00 / NUMBER 00 / ’’ 2017

www.clinicalobgyn.com | 1
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2 Cobb and Lipman
received considerable additional atten-
tion in the ‘‘Society for Obstetric Anes-
thesia and Perinatology’s (SOAP)
Consensus Statement on the Manage-
ment of Cardiac Arrest in Pregnancy’’
and in the first ‘‘AHA Scientific State-
ment on Cardiac Arrest in Pregnancy’’
(AHA SS) published in 2014 and 2015,
respectively.7,8 These national guidelines
seek to clarify and improve resuscitative
efforts in the setting of maternal cardio-
vascular collapse.
Updates in Maternal
Cardiopulmonary Arrest
Cardiopulmonary Resuscitation (CPR)—
CHEST COMPRESSIONS
In the setting of cardiopulmonary arrest,
there are a variety of modifications to the
standard adult AHA guidelines to opti-
mize resuscitative efforts. Perhaps due to
the rarity of the event, a paucity of data
may contribute to the quality of recom-
mendations and the need for frequent
updates as our understanding of mater-
nal physiology and responses to medical
interventions improves.
Following the immediate initiation of
chest compressions, ‘‘hand placement is no
longer recommended higher on the ster-
num to adjust for the upward incursion of
abdominal contents from the gravid ute-
rus.’’8,9 Consistent with the AHA non-
pregnant basic life support/advanced
cardiac life support (ACLS) protocol for
adults, compressions should be adminis-
tered 100 per minute, 2 inches in depth,
and allowing for full recoil. Interruptions
in compressions should be minimized.8
High-quality CPR should be paired with
uterine displacement, and a firm backboard
should be used. Historically, tilting the
patient to the left has been used even in
healthy parturients in the supine position to
alleviate pressure from the gravid uterus on
the inferior vena cava (IVC) and potentially
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the aorta, which may occur at 20 weeks
gestational age or earlier.10,11 This phenom-
enon was described as early as the 1940s by
McLennan11 and Crawford et al12 in 1972.
More recently, the degree of tilt required to
displace the uterus from the IVC has
generated controversy. Higuchi and col-
leagues prospectively demonstrated that
‘‘15 degrees of lateral tilt did little to relieve
compression on the IVC, and up to 30
degrees of tilt was needed.’’ It has also been
shown that uterine compression of the IVC
can still occur at Z30 degrees of lateral
tilt.13 Conversely, the degree of maternal tilt
was found to compromise the efficacy of
chest compressions as the angle of inclina-
tion was increased.14 The recommendation
for manual uterine displacement rather
than tilt during maternal cardiac arrest
represents an abandonment of the 1992 to
2010 AHA guidelines.15 Although the de-
gree of lateral tilt required in the obstetric
population to relieve compression of the
great vessels remains poorly characterized,
‘‘manual uterine displacement compared
with 15 degrees of lateral tilt resulted in
both less hypotension and a lower ephe-
drine requirement during cesarean deliv-
ery.’’16 In addition to the detrimental effects
of lateral tilt on chest compressions, airway
management may also prove more chal-
lenging. Given these findings, the current
guidelines recommend manual uterine dis-
placement with the patient in the supine
positioning on a hard surface to relieve any
potential compression of the periumbilical
uterus (B20 wk of gestational age) while
maintaining high-quality chest compres-
sions.
An additional recommended step to
ensure the efficacy of chest compressions
includes the utilization of capnography
when available.8,15 Continuous waveform
capnography measures the partial pressure
of carbon dioxide (CO2) in the expired
respiratory gases, and typically displays a
graph of end-tidal CO2 (ETCO2) plotted
against time. Capnography is most fre-
quently used to confirm proper placement
 Cardiac Arrest: Obstetric CPR/ACLS
of an endotracheal tube. Numerous studies
have also shown an association with ET-
CO2 and return of spontaneous circulation
(ROSC) during cardiac arrest.17–19 Eckstein
et al17 concluded, ‘‘an initial ETCO2>10
and the absence of a fall in ETCO2>25%
from baseline were significantly associated
with achieving ROSC’’ in out-of-hospital
cardiac arrest. The current AHA SS for
maternal cardiac arrest states, ‘‘continuous
waveform capnography, in addition to
clinical assessment, is y reasonable to
consider in intubated patients to monitor
CPR quality, to optimize chest compres-
sions, and to detect return of spontaneous
circulation (ROSC).’’8
CPR—AIRWAY BREATHING
Airway management in the parturient has
been reported to be difficult in up to 1 in
280 patients undergoing intubation for
cesarean delivery.20,21 Current guidelines
caution providers about the potential dif-
ficulty associated with airway manage-
ment and seeks to minimize fixation
error.8 In addition to utilizing the most
experienced provider to intubate the tra-
chea during maternal cardiopulmonary
arrest, additional equipment and person-
nel should be made immediately available
in the event a difficult airway is encoun-
tered. To minimize fixation error, fre-
quently pertaining to the increased risk of
aspiration in pregnancy, cricoid pressure is
no longer recommended in general during
cardiac arrest.15 Furthermore, there is a
paucity of data that the application of
cricoid pressure in obstetric patients re-
duces the risk of aspiration.22 Ventilation
remains the priority over intubation in
maternal cardiac arrest, consistent with
adult nonpregnant guidelines.
CPR—DEFIBRILLATION
In the event of maternal cardiac arrest,
early defibrillation of shockable rhythms
is recommended for both adult and ma-
ternal cardiac arrest. Preshock pauses
should be limited to <5 seconds and
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3
postshock rhythm evaluation is no longer
endorsed by the AHA to minimize inter-
ruptions in high-quality CPR. Chest
compressions should be resumed imme-
diately after delivery of the electrical
shock.8,15
Energy requirements for administering
electrical shocks are the same for preg-
nant patients; ‘‘biphasic shock energy of
120 to 200 J y with subsequent escala-
tion of energy output if the first shock is
not effective.’’8 As reported by Einav and
colleagues, shockable rhythms fare bet-
ter, with a ROSC occurring in 60.6% and
about 90% of these survived to hospital
discharge. Two thirds of cardiac arrests
occurred in the hospital in highly moni-
tored areas and 89% were witnessed
[asystole being the most common rhythm
(at 25.5%) followed by ventricular tachy-
cardia/fibrillation (24.3%)].4
The AHA also specifically addressed
the use of automatic external defibrilla-
tors (AEDs) in the 2010 guidelines: ‘‘De-
spite limited evidence, AEDs may be
considered for the hospital setting as a
way to facilitate early defibrillation y
especially in areas where staff have no
rhythm recognition skills or defibrillators
are used infrequently.’’ In many obstetric
settings, use of the AED mode on a
defibrillator may be the most practical
approach for rapid defibrillation (within
3 minutes of cardiopulmonary arrest).7
CPR—PHARMACOLOGY
The AHA recommends that ‘‘drug admin-
istration during ACLS should adhere to
the standard adult guidelines without con-
cern for teratogenicity.’’15 However, more
recently, vasopressin is no longer recom-
mended as an alternative to epinephrine
during CPR in the obstetric patient.8
Given that there does not appear to be
any current evidence of the superiority of
vasopressin in adult cardiac arrest, vaso-
pressin should be deferred at this time
given the potential effects on the uterus.8
www.clinicalobgyn.com
4 Cobb and Lipman
Another pharmacologic consideration
unique to maternal cardiac arrest is the
potential utilization of lipid emulsion ther-
apy. Peripartum labor neuraxial analgesia/
anesthesia may predispose women to high
volumes and concentrations of local anes-
thetic. In severe circumstances, cardiac
arrest may ensue when local anesthetics
reach high systemic levels. The treatment
algorithm for suspected local anesthetic
systemic toxicity that leads to cardiovascu-
lar collapse, in addition to ACLS, includes
the intravenous administration of 20%
lipid emulsion therapy (bolus 1.5 mL/kg
lean body weight over 1 minute followed
by an infusion of 0.25 mL/kg/min or repeat
bolus in the event of persistent cardiovas-
cular collapse). The risks of administering
‘‘lipid rescue’’ appear to be minimal and
may be life-saving in the obstetric patient.23
Furthermore, in patients with refractory
cardiac arrest in the setting of local anes-
thetic toxicity, extracorporeal membranous
oxygenation, or cardiopulmonary bypass
should be considered.8
PMCD
Given the potential for caval compression
and the resultant decrements in preload in
parturients who are 20 weeks or more of
gestational age, the current recommenda-
tion is to perform PMCD in women in
whom there is no hope for survival, and/or
for those who do not respond to initial
resuscitative maneuvers. The PMCD
should be initiated at 4 minutes of cardiac
arrest to deliver the fetus by 5 minutes,
although the decision can be made to
proceed more quickly or delay slightly
based on the specific clinical circumstan-
ces.7,8 In a case series published by Katz
et al24 of 38 cases of maternal cardiac
arrest, 12 of 20 parturients had ROSC
following PMCD. In the large series of
maternal cardiac arrests published by Ei-
nav and colleagues, 76 of 91 cases of
maternal cardiac arrest underwent PMCD.
Up to 32% of these cardiac arrest patients
potentially benefitted from the delivery of
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the fetus. However, the fetus was delivered
within 5 minutes of the onset of cardiac
arrest in only 4 of 76 (7%) of these cases.4
Notably, maternal status did not deterio-
rate with cesarean delivery in any case in
either published series.4,24 In the event of a
PMCD, delivery should occur at the site of
arrest to minimize interruptions in chest
compressions as well as avoiding a poten-
tial delay in delivering the fetus. Delivery of
the fetus may optimize both maternal and
fetal resuscitative efforts. Similarly, efforts
to monitor the fetus during maternal car-
diac arrest should be avoided to prevent
delaying a PMCD.7,8
BUNDLED CODE BLUE
In a study of simulated maternal cardiac
arrest, over 80% of teams delayed calling for
the neonatal intensive care unit team.25
Given the rarity of the event, coupled with
an almost unparalleled need for mutlidisci-
plinary collaboration, the 2015 AHA guide-
lines call for a ‘‘bundled’’ emergency call
system that activates maternal and neonatal
resuscitation teams immediately and simul-
taneously (maternal code blue).8 Included in
the ‘‘maternal code blue’’ activation team
should be the adult cardiac arrest team,
obstetrician, labor and delivery nursing,
obstetric anesthesia/anesthesia, intensive
care unit team, as well as the neonatal
intensive care unit. Team members should
be aware of the location of critical equip-
ment (ie, scalpel, umbilical cord clamps,
maternal and neonatal resuscitation sup-
plies). In addition, unique institutional bar-
riers pertaining to the fastest routes and
access to labor and delivery, the emergency
department, and all intensive care units
should be a part of training emergency
response teams in advance of sentinel
events.7,8,26
Maternal Early Warning Signs
Efforts to provide early identification of
the critically ill parturient have proven
challenging given the variability of he-
modynamics in the peripartum period.

‘‘These challenges are highlighted by a
series of maternal death case reviews that
show delays in recognition/treatment of
the critically ill parturient.’’27 Given these
findings, there is a growing body of
literature seeking to standardize and val-
idate ‘‘maternal early warning signs.’’
Class I level C evidence currently sup-
ports the use of a ‘‘validated obstetric
early warning score in pregnant women
who become ill for additional risk strat-
ification.’’8 The maternal early warning
criteria is a composite scoring system of
blood pressure, heart rate, respiratory
rate, oxygen saturation, oliguria, and/or
signs of maternal cognitive dysfunction
or end organ dysfunction.27 These early
warning scores aim to identify critically
ill parturients to facilitate early assess-
ment and potentially therapies to prevent
further decline/decompensation.
DRILLS/SIMULATION
Although maternal cardiac arrest is a rare
event, the literature suggests a significant
portion of these cases are preventable.5 In
the most recent AHA guidelines for ma-
ternal cardiac arrest, there is a heightened
emphasis on the need for team training/
drills and protocolization of crisis manage-
ment in the setting of a rare and potentially
chaotic event. The ‘‘logistical complexities
and operational challenges’’ should not be
underestimated and may vary by institu-
tion. Furthermore, there is a call for ‘‘the
development of local and national curric-
ula to enhance maternal resuscitative skills
for multi-disciplinary healthcare teams’’ to
optimize patient safety in the event of
maternal cardiac arrest.7,8
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