What are the primary steps for maternofetal resuscitation in a pregnant woman experiencing distress?

Maternofetal Resuscitation

In a pregnant woman experiencing cardiac arrest, immediately initiate high-quality CPR with manual left lateral uterine displacement, prioritize early advanced airway management with 100% oxygen, and prepare for perimortem cesarean delivery to be started at 4 minutes if return of spontaneous circulation (ROSC) is not achieved—with the goal of delivery by 5 minutes to optimize both maternal and fetal survival. 1, 2, 3

Immediate Actions: The First 60 Seconds

Activate the maternal cardiac arrest team immediately using a bundled emergency code call (e.g., "maternal code blue") to simultaneously alert obstetric, neonatal, emergency, anesthesiology, intensive care, and cardiac arrest services. 1

Begin high-quality CPR with standard chest compressions and ventilations at a 30:2 ratio until an advanced airway is placed. 1

Apply manual left lateral uterine displacement immediately for any pregnant patient at ≥20 weeks gestation or when the fundal height reaches the umbilicus—this must be maintained continuously throughout all resuscitation efforts to relieve aortocaval compression. 1, 2 This can be performed using either a two-handed pull technique or one-handed push technique to displace the uterus to the patient's left. 1

Designate a timekeeper to call out elapsed time at 1-minute intervals—this is critical for the 4-minute decision point for perimortem cesarean delivery. 3

Airway and Oxygenation: The Highest Priority

Prioritize oxygenation and airway management above other interventions because pregnant patients have increased metabolic demands and decreased functional reserve capacity, making them profoundly susceptible to rapid hypoxia. 1, 2

Assign the most experienced provider available to manage the airway as difficult airways are common in pregnancy due to obesity, sleep apnea, and airway edema. 1, 2

Provide 100% oxygen at ≥15 L/min and follow this airway algorithm: 1

• First intubation attempt with a 6.0-7.0 mm inner diameter endotracheal tube
• If failed, second intubation attempt
• If failed, first supraglottic airway attempt
• If failed, second supraglottic airway attempt
• If failed, return to bag-mask ventilation
• If bag-mask ventilation is inadequate, attempt cricothyrotomy 1

Use two-handed bag-mask ventilation as soon as a second provider is available, as this is more effective than single-handed technique. 1

Once an advanced airway is placed, provide 1 breath every 6 seconds (10 breaths per minute) with continuous chest compressions—do not interrupt compressions for ventilation. 1 Confirm placement with waveform capnography or capnometry. 1

Avoid hyperventilation as it decreases survival likelihood by interrupting chest compressions. 1

The Critical 4-Minute Decision Point

If ROSC is not achieved within 4 minutes of maternal cardiac arrest onset, begin hysterotomy immediately with the goal of completing delivery by 5 minutes. 1, 2, 3 This timing is essential because:

• Maternal benefit: Relieving aortocaval compression by emptying the uterus significantly improves cardiac output and coronary perfusion pressure—in one case series, 12 of 20 women achieved ROSC immediately after delivery. 1, 3

• Fetal benefit: Best fetal survival occurs when delivery happens within 5 minutes, with 24/25 infants surviving when perimortem cesarean delivery occurred within 5 minutes compared to 7/10 when performed after 5 minutes. 1, 3

Perform the procedure at the bedside—do not move to an operating room unless it can be accomplished in 1-2 minutes, as delays are detrimental to both maternal and fetal outcomes. 3

Continue CPR throughout the procedure without interruption. 1, 3

Special Circumstances Requiring Immediate Delivery

In cases of nonsurvivable maternal trauma or prolonged pulselessness where maternal resuscitative efforts are futile, proceed immediately to perimortem cesarean delivery without waiting for the 4-minute mark—there is no reason to delay in these situations. 1, 3

Even if the 5-minute window is missed, still perform perimortem cesarean delivery as maternal survival has been reported up to 39 minutes after arrest onset, and neonatal survival has been documented with delivery up to 30 minutes after arrest. 1

Advanced Cardiovascular Life Support Modifications

Administer standard ACLS medications including epinephrine 1 mg IV/IO every 3-5 minutes, as there is short-term benefit for achieving ROSC despite no difference in long-term survival. 1

Do not perform fetal monitoring during active maternal cardiac arrest as it interferes with maternal resuscitation efforts and carries the risk of delaying critical interventions. 1, 2

If the mother achieves ROSC and is stabilized, then institute fetal heart surveillance when deemed appropriate. 1

Post-Resuscitation Care

Implement targeted temperature management for pregnant women who remain comatose after ROSC, with continuous monitoring of the fetus for bradycardia as a potential complication, and obtain obstetric and neonatal consultation. 1, 2

Critical Pitfalls to Avoid

Do not delay perimortem cesarean delivery for transfer to an operating room—the procedure must be performed at the bedside where the arrest occurred. 3

Do not abandon manual left lateral uterine displacement at any point during resuscitation, even after advanced interventions are initiated. 1

Do not use smaller endotracheal tubes than 6.0-7.0 mm as pregnancy does not require pediatric-sized tubes despite airway edema. 1

Do not prioritize fetal assessment over maternal resuscitation—the mother is the primary patient, and maternal survival is the primary goal of perimortem cesarean delivery. 1, 2, 3