What is the next intervention for a pulseless, apneic patient with ventricular fibrillation and a gravid uterus after endotracheal intubation, chest compressions, and intravenous (IV) access have been established?

Immediate Defibrillation is the Next Intervention

For a pregnant patient in ventricular fibrillation cardiac arrest who has been intubated with chest compressions ongoing and IV access established, immediate defibrillation must occur without delay. 1

Rationale for Immediate Defibrillation

The presence of ventricular fibrillation is an absolute indication for immediate defibrillation, and this takes priority over all other interventions including perimortem cesarean section. 1

• Defibrillation is the only rhythm-specific therapy proven to increase survival to hospital discharge in VF/pulseless VT cardiac arrest. 1
• The probability of successful defibrillation decreases by approximately 10% with each minute of delay. 2
• Over 80% of patients who will be successfully defibrillated achieve return of spontaneous circulation (ROSC) with one of the first three shocks. 1

Defibrillation Protocol in Pregnancy

Standard ACLS defibrillation doses should be used without modification in pregnant patients. 1

• Deliver the first shock at 120-200 J for biphasic defibrillators (or manufacturer recommendation), or 360 J for monophasic devices. 1
• Resume chest compressions immediately after shock delivery without pausing for rhythm or pulse check. 1
• Continue CPR for 2 minutes before the next rhythm assessment. 1, 3
• If VF persists, deliver subsequent shocks at equivalent or higher energy levels. 1

Pregnancy-Specific Modifications During Resuscitation

While defibrillation is the immediate priority, the following modifications should be implemented during ongoing CPR:

• Perform manual left lateral uterine displacement to relieve aortocaval compression and improve venous return. 1
• Position chest compressions slightly higher on the sternum to account for diaphragm elevation from the gravid uterus. 1
• Prepare for potential airway difficulties due to pregnancy-related airway edema and anatomical changes. 1

When to Consider Perimortem Cesarean Section

Perimortem cesarean section should be considered only if ROSC is not achieved after initial resuscitation efforts, not as the immediate next step. 1

• If the fundus is at or above the umbilicus and ROSC has not been achieved with standard resuscitation plus manual left lateral uterine displacement, prepare to evacuate the uterus. 1
• The decision for perimortem cesarean delivery should occur within 4-5 minutes of maternal cardiac arrest to optimize both maternal and fetal outcomes, but only after initial defibrillation attempts. 1

Why Other Options Are Incorrect

• Magnesium IV (Option B): Has no role in the immediate management of ventricular fibrillation and would delay life-saving defibrillation. 1
• Perimortem cesarean section (Option C): While important in refractory cardiac arrest in pregnancy, it is not the immediate next step when VF is present and the patient has not yet received defibrillation. 1
• Thrombolytics IV (Option D): Not indicated as immediate therapy for VF and should only be considered if pulmonary embolism is suspected as the underlying cause, which would be addressed after initial defibrillation attempts. 1

Critical Pitfall to Avoid

Do not delay defibrillation to perform perimortem cesarean section or administer medications. The gravid uterus does not contraindicate defibrillation, and there are no modifications needed to standard defibrillation energy levels or technique in pregnancy. 1 The best outcome for both mother and fetus is achieved through successful maternal resuscitation, which requires immediate defibrillation for VF. 1