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ABC of Resuscitation
Resuscitation in pregnancy
Stephen Morris, Mark Stacey
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.
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.
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