What is the recommended maternal position and immediate interventions for fetal resuscitation in a pregnant patient?

Maternal Positioning During Resuscitation in Pregnancy

For maternal cardiac arrest or resuscitation in pregnancy ≥20 weeks gestation, position the patient fully supine on a firm surface while a dedicated team member provides continuous manual left uterine displacement—do NOT use left lateral tilt positioning as it significantly compromises chest compression quality and coronary perfusion. 1, 2, 3

Critical Positioning Strategy

The Supine Position with Manual Left Uterine Displacement is Superior

• Place the patient completely supine on a firm surface to optimize chest compression effectiveness. 1, 2, 3

• Assign a dedicated team member to perform continuous two-handed manual left uterine displacement throughout resuscitation, pulling the gravid uterus leftward without pushing it toward the pubis or the patient's back. 1, 2, 3

• Animal model data demonstrates coronary perfusion pressures of 20 mm Hg with supine positioning plus manual left uterine displacement versus only 5 mm Hg with left-lateral tilt positioning (P<0.05). 1, 4

Why Left Lateral Tilt is Contraindicated During CPR

• Left lateral tilt (27-30°) reduces correct compression depth rate by 19% and correct hand position rate by 9% compared to supine positioning. 5

• The left lateral position during cardiac massage yields only 10% of the cardiac output recorded during normal pregnancy, making it inadequate for effective resuscitation. 1

• Rescuers find chest compressions significantly more difficult to perform in left lateral tilt versus supine position (difficulty score 3.95 vs 1.75, p<0.001). 4

When Manual Uterine Displacement is Required

• Perform manual left uterine displacement if the uterine fundus is palpable at or above the umbilicus, which corresponds to approximately ≥20 weeks gestation. 1, 2, 3

• The gravid uterus compresses the inferior vena cava in supine position, reducing venous return by up to 30% and potentially causing complete cardiovascular collapse. 3

Context-Specific Positioning Guidelines

For Conscious Pregnant Patients (Non-Arrest Situations)

• Fully conscious pregnant women without cardiovascular compromise may be managed in sitting position or full left lateral decubitus position. 1

• For intrauterine fetal resuscitation during labor (non-arrest), initial positioning should be left lateral recumbent, followed by right lateral or knee-elbow position if necessary. 6

For Pregnant Trauma Patients

• Pregnant trauma patients should be kept in left lateral decubitus position during transport and evaluation to avoid inferior vena cava compression and resultant hypotension. 7

• For pregnant patients >20 weeks gestation at risk of cardiovascular compromise (trauma, bleeding), use left lateral tilt, manual uterine displacement, or full left lateral position. 1

Critical Distinction: Arrest vs Non-Arrest

• The positioning recommendations differ fundamentally between cardiac arrest (supine with manual displacement) and non-arrest situations (left lateral positioning acceptable). 1, 3

Additional Resuscitation Priorities

High-Quality Chest Compressions

• Perform chest compressions at depth of at least 2 inches with rate of 100-120 compressions per minute, allowing complete chest recoil between compressions. 2

• Switch compressors every 2 minutes to prevent fatigue and maintain compression quality. 2

The 4-Minute Decision Point

• If return of spontaneous circulation (ROSC) is not achieved within 4 minutes of cardiac arrest onset in patients ≥20 weeks gestation, begin perimortem cesarean delivery immediately at the bedside to achieve delivery by 5 minutes. 1, 2, 3

• The primary goal of perimortem cesarean delivery is maternal resuscitation by relieving aortocaval compression, not just fetal salvage. 2, 3

• Continue all maternal resuscitative efforts during and after cesarean delivery. 8, 2, 3

Vascular Access Considerations

• Establish intravenous access above the diaphragm immediately, as inferior vena cava compression renders lower extremity access ineffective during resuscitation. 3

Common Pitfalls to Avoid

• Never use left lateral tilt during active CPR—this is the single most important positioning error that compromises resuscitation effectiveness. 1, 5, 4

• Do not delay perimortem cesarean delivery waiting for operating room availability—perform at bedside. 3

• Do not waste time transporting the patient to different positions or locations during active resuscitation. 1

• Avoid the misconception that left lateral positioning is always optimal in pregnancy—context determines the appropriate position. 1, 3