What specialty doctors are needed for a pregnant patient at 34-35 weeks gestation who undergoes cardiac arrest in the emergency room?

Multidisciplinary Team Required for Maternal Cardiac Arrest at 34-35 Weeks

A pregnant patient at 34-35 weeks gestation who undergoes cardiac arrest in the emergency room requires immediate activation of a maternal cardiac arrest team that includes: ACLS-trained emergency physicians, an obstetrician capable of performing immediate bedside cesarean delivery, a neonatologist with neonatal resuscitation team, and an anesthesiologist or experienced airway provider. 1

Core Team Composition

The maternal cardiac arrest response must address two critically ill patients simultaneously—the mother and the fetus—requiring a coordinated multidisciplinary approach. 1

Essential Specialists Required:

Emergency Medicine/ACLS Team:

• Emergency physicians or intensivists trained in advanced cardiovascular life support must lead the maternal resuscitation, performing high-quality chest compressions, defibrillation, and medication administration. 1
• A minimum of 4 BLS responders should be present to accomplish all tasks effectively, including chest compressions, airway management, defibrillation, and manual left uterine displacement. 1

Obstetrician/Gynecologist:

• An obstetrician must be immediately available to perform perimortem cesarean delivery (PMCD) at the bedside if return of spontaneous circulation (ROSC) is not achieved within 4 minutes of resuscitative efforts. 1, 2
• At 34-35 weeks gestation, the uterus is well above the umbilicus, making this patient a candidate for emergent PMCD as part of maternal resuscitation. 1
• The obstetrician should not wait for operating room availability—PMCD must be performed at the site of arrest. 2, 3

Anesthesiologist or Experienced Airway Provider:

• An experienced laryngoscopist is essential given the high likelihood of difficult airway in pregnant patients due to airway edema, increased vascularity, and anatomical changes. 1
• Any intubation attempts should be undertaken by an experienced provider, with optimally no more than 2 attempts at laryngoscopy before insertion of a supraglottic airway. 1
• Videolaryngoscopy is preferred when available, and a smaller endotracheal tube (6.0-7.0 mm inner diameter) should be used due to glottic edema. 1

Neonatologist and Neonatal Resuscitation Team:

• A neonatologist or pediatrician with neonatal nurses and respiratory therapists must prepare to receive the infant if PMCD is performed. 1
• At least one team member must be skilled in emergency neonatal endotracheal intubation. 1
• The team should anticipate an advanced resuscitation for a potentially depressed neonate after maternal arrest, including designating a team leader, checking equipment, and preassigning specific roles. 1

Critical Timing Considerations

The 4-Minute Rule:

• If ROSC is not achieved within 4 minutes of maternal cardiac arrest in a patient with uterine size at or above the umbilicus (approximately ≥20 weeks gestation), perimortem cesarean delivery must begin immediately at the bedside. 1, 2, 3
• This procedure is performed primarily to improve maternal resuscitation by relieving aortocaval compression, not solely to save the fetus. 2
• Delays as short as 5 minutes significantly affect both maternal and fetal survivability. 1

Pre-Event Planning Requirements

Hospital Preparedness:

• Each hospital must have a specific method to activate the maternal cardiac arrest team (e.g., "maternal code blue") that simultaneously mobilizes all necessary responders. 1
• Emergency response committees must ensure specialized equipment for PMCD is immediately available, either on the code cart or brought by a designated team member. 1
• All units caring for pregnant patients must have prestocked neonatal crash carts or easy-to-carry bags with comprehensive neonatal resuscitation equipment. 1

Common Pitfalls to Avoid

Do Not:

• Delay calling the obstetric team—activate them simultaneously with the initial code response. 1
• Wait for operating room availability to perform PMCD—it must be done at the bedside. 2
• Assume standard emergency physicians can manage this alone—the complexity requires immediate obstetric and neonatal expertise. 1
• Forget that at 34-35 weeks gestation, this fetus is viable and requires immediate neonatal intensive care capabilities. 1

Critical Point: The maternal cardiac arrest team composition reflects the reality that two critically ill patients must be resuscitated, requiring coordination between emergency medicine, obstetrics, anesthesiology, and neonatology from the moment of arrest recognition. 1