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Clinical review

ABC of Resuscitation
Resuscitation in pregnancy
Stephen Morris, Mark Stacey

Cardiac arrest occurs only about once in every 30 000 late


This article is adapted from the 5th edition of the ABC of
pregnancies, but survival from such an event is exceptional.
Resuscitation, which will be published by BMJ Books in
Most deaths are from acute causes, with many mothers December (www.bmjbooks.com)
receiving some form of resuscitation. However, the number of
indirect deaths—that is, deaths from medical conditions
exacerbated by pregnancy—is greater than that of deaths from
conditions that arise from pregnancy itself. The use of national
guidelines can decrease mortality, as shown by the reduction in Physiological changes in late pregnancy affecting
the number of deaths from pulmonary embolus and sepsis after cardiopulmonary resuscitation
caesarean section. To try to reduce mortality from amniotic
Respiratory
fluid embolism, a national database for suspected cases has x Increased ventilation
been established. x Increased oxygen demand
Factors peculiar to pregnancy that weigh the balance against x Reduced chest compliance
survival include anatomical changes that make it difficult to x Reduced functional residual capacity
maintain a clear airway and perform intubation, pathological Cardiovascular
changes such as laryngeal oedema, physiological factors such as x Incompetent gastroesophageal (cardiac) sphincter
increased oxygen consumption, and an increased likelihood of x Increased intragastric pressure
pulmonary aspiration. In the third trimester the most important x Increased risk of regurgitation
factor is compression of the inferior vena cava and impairment
of venous return by the gravid uterus when the woman lies
supine. These difficulties may be exaggerated by obesity. All staff
directly or indirectly concerned with obstetric care need to be
Specific difficulties in pregnant patients
trained in resuscitation.
A speedy response is essential. Once respiratory or Airway
Patient needs to be inclined laterally for:
cardiac arrest has been diagnosed, the patient must be x Suction or aspiration
positioned appropriately and basic life support started x Removing dentures or foreign bodies
immediately. This must be continued while venous access is x Inserting airways
secured, any obvious causal factors are corrected (for example, Breathing
hypovolaemia), and the necessary equipment, drugs, and staff x Greater oxygen requirement
are assembled. x Reduced chest compliance
x More difficult to see rise and fall of chest
x More risk of regurgitation and aspiration
Circulation
External chest compression difficult because:
Basic life support x Ribs flared
Airway x Diaphragm raised
x Patient obese
A clear airway must be quickly established with the head tilt-jaw
x Breasts hypertrophied
thrust or head tilt-chin lift manoeuvre and then maintained. x Supine position causes inferior vena cava compression by the
Suction should be used to aspirate vomit. Badly fitting dentures gravid uterus
and other foreign bodies should be removed from the mouth,
and an airway should be inserted. These procedures should be
performed with the patient inclined laterally or supine and the
uterus displaced as described below.

Breathing
If the patient is not breathing adequately, intermittent positive
pressure ventilation should be started once the airway has been
cleared; mouth to mouth, mouth to nose, or mouth to airway
ventilation should be carried out until a self inflating bag and
mask are available. Ventilation should then be continued with
100% oxygen and a reservoir bag. Because of the increased risk
of regurgitation and pulmonary aspiration of gastric contents in
late pregnancy, cricoid pressure should be applied until the
airway has been protected by a cuffed tracheal tube. Patient inclined laterally by using Cardiff wedge
Ventilation is made more difficult by the increased oxygen
requirements and reduced chest compliance in pregnancy. The
reduced compliance is due to rib flaring and splinting of the
diaphragm by the abdominal contents. Observing the rise and
fall of the chest in pregnant patients is also more difficult.

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Clinical review

Circulation
Circulatory arrest is diagnosed by the absence of a palpable
pulse in a large artery (carotid or femoral). Chest compressions
are given at the standard rate and ratio of 15:2. Chest
compression on a pregnant woman is made difficult by flared
ribs, raised diaphragm, obesity, and breast hypertrophy. Because
the diaphragm is pushed upwards by the abdominal contents,
the hand position for chest compressions should similarly be
moved up the sternum, although currently no guidelines
suggest exactly how far.
In the supine position an additional factor is compression of
the inferior vena cava by the gravid uterus, which impairs
venous return and reduces cardiac output; all attempts at
resuscitation will be futile unless the compression is relieved.
This is achieved either by placing the patient in an inclined
lateral position by using a wedge or by displacing the uterus
manually. Raising the patient’s legs will improve venous return.
Lateral displacement of the uterus Manual displacement of uterus
Effective forces for chest compression can be generated with
patients inclined at angles of up to 30°, but pregnant women
tend to roll into a full lateral position when inclined at angles
greater than this, making chest compression difficult. The
Cardiff resuscitation wedge is not commercially available, so
other techniques need to be used. One technique is the “human
wedge,” in which the patient is tilted on to a rescuer’s knees to
provide a stable position for basic life support. Alternatively, the
patient can be tilted on to the back of an upturned chair.
Purpose-made wedges are available in maternity units, but any
cushion or pillow can be used to wedge the patient into the left
inclined position. An assistant should, however, move the uterus
further off the inferior vena cava by lifting it with two hands to
the left and towards the patient’s head.

Advanced life support


Intubation Use of an upturned chair as wedge
Tracheal intubation should be carried out as soon as facilities
and skill are available. Difficulty in tracheal intubation is more
common in pregnant women, and specialised equipment for
advanced airway management may be required. A short obese
neck and full breasts due to pregnancy may make it difficult to
insert the laryngoscope into the mouth. The use of a short
handled laryngoscope or one with its blade mounted at more
than 90° (polio or adjustable blade) or demounting the blade
from the handle during insertion into the mouth may help.
Mouth to mouth or bag and mask ventilation is best done
without pillows under the head and with the head and neck
fully extended. The position for intubation, however, requires at
least one pillow to flex the neck and extend the head. Any
pillow removed to facilitate initial ventilation must, therefore, be
kept at hand for intubation.
In the event of failure to intubate the trachea or ventilate the
patient’s lungs with a bag and mask, insertion of a laryngeal
mask airway should be attempted. Cricoid pressure must be Cardiff wedge
temporarily removed in order to place the laryngeal mask
airway successfully. Once the airway is in place, cricoid pressure
should be reapplied. Anatomical features relevant to difficult
Defibrillation and drugs intubation or ventilation
Defibrillation and drug administration is in accordance with x Full dentition
advanced life support recommendations. On a practical note, it x Large breasts
is difficult to apply an apical defibrillator paddle with the x Oedema or obesity of neck
patient inclined laterally, and great care must be taken to ensure x Supraglottic oedema
x Flared ribcage
that the dependent breast does not come into contact with the
x Raised diaphragm
hand holding the paddle. This problem is avoided if adhesive
electrodes are used.

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Clinical review

Increasingly, magnesium sulphate is used to treat and prevent


eclampsia. If a high serum magnesium concentration has
contributed to the cardiac arrest, consider giving calcium
chloride. Tachyarrhythmias due to toxicity of the anaesthetic
drug bupivacaine are probably best treated by electrical
cardioversion or with bretylium rather than lidocaine
(lignocaine).
Caesarean section
This is not merely a last ditch attempt to save the life of the
fetus; it plays an important part in the resuscitation of the
mother. Many successful resuscitations have occurred after
prompt surgical intervention. The probable mechanism for the
favourable outcome is that occlusion of the inferior vena cava is
relieved completely by emptying the uterus, whereas it is only
partially relieved by manual uterine displacement or an inclined
position. Delivery also improves thoracic compliance, which will
improve the efficacy of chest compressions and the ability to Paramedics are often the primary responders in obstetric emergency calls and
ventilate the lungs. so must be aware of the problems associated with resuscitation in pregnancy
After cardiac arrest, non-pregnant adults suffer irreversible
brain damage from anoxia within three to four minutes, but
pregnant women become hypoxic more quickly. Although
The timing of caesarean section and the speed with which
evidence shows that the fetus can tolerate prolonged periods of
surgical delivery is carried out is critical in determining
hypoxia, the outlook for the neonate is optimised by immediate the outcome for mother and fetus. Most of the children
caesarean section. and mothers who survive emergency caesarean deliveries
If maternal cardiac arrest occurs in the labour ward, are delivered within five minutes of maternal cardiac
operating theatre, or accident and emergency department, and arrest
basic and advanced life support are not successful within five
minutes, the uterus should be emptied by surgical intervention.
Given the time taken to prepare theatre packs, this procedure is
probably best carried out with just a scalpel. Time passes very
quickly in such a high pressure situation, and it is advisable to Further reading
practise this scenario, particularly in the accident and x Department of Health. Report on the confidential enquiry into maternal
emergency department. deaths in the United Kingdom, 1997-1999. London: Stationery Office,
Cardiopulmonary resuscitation must be continued 2001.
throughout the operation and afterwards because this improves x European Resuscitation Council. Part 8: Advanced challenges in
the prognosis for mother and child. If necessary, resuscitation. Section 3: Special challenges in ECC. 3F: Cardiac
arrest associated with pregnancy. Resuscitation 200:46:293-5
transabdominal open cardiac massage can be performed. After x Goodwin AP, Pearce AJ. The human wedge: a manoeuvre to relieve
successful delivery both mother and infant should be aortocaval compression in resuscitation during late pregnancy.
transferred to their appropriate intensive care units as soon as Anaesthesia 1992;47:433-4
clinical conditions permit. The key factor for successful x Page-Rodriguez A, Gonzalez-Sanchez JA. Perimortem cesarean
resuscitation in late pregnancy is that all midwifery, nursing, and section of twin pregnancy: case report and review of the literature.
medical staff concerned with obstetric care should be trained in Acad Emerg Med 1999;6:1072-4
x Whitten M, Irvine LM. Postmortem and perimorten cesarean
cardiopulmonary resuscitation.
section: what are the indications? J R Soc Med 2000;93:6-9

Training
Retention of cardiopulmonary resuscitation skills is poor,
Stephen Morris and Mark Stacey are consultant obstetric
particularly in midwives and obstetricians who have little anaesthetists at Cardiff and Vale NHS Trust, South Glamorgan.
opportunity to practise them. Regular short periods of practice
on a manikin are therefore essential. The ABC of Resuscitation was edited by Michael Colquhoun,
senior lecturer in prehospital care, Wales Heart Research Institute,
Members of the public and the ambulance service should be
Universtiy of Wales College of Medicine, Cardiff
aware of the additional problems associated with resuscitation (colquhoun@bishopsfrome.u-net.com), Anthony J Handley,
in late pregnancy. The training of ambulance staff is particularly senior research fellow, Prehospital Emergency Research Unit,
important as paramedics are likely to be the primary University of Wales College of Medicine, and Tom Evans,
responders to community obstetric emergency calls. consultant cardiologist, Royal Free Hospital, London

BMJ 2003;327:1277–9 Competing interests: None declared.

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