What is the recommended management of cardiac arrest in a pregnant patient?

Management of Cardiac Arrest in Pregnancy

Immediately initiate high-quality CPR with continuous manual left lateral uterine displacement (LUD) for any pregnant patient whose uterus reaches or exceeds the umbilicus (≥20 weeks gestation), and if return of spontaneous circulation (ROSC) is not achieved within 4 minutes, begin hysterotomy at the bedside with the goal of completing delivery by 5 minutes. 1

Immediate Positioning and Compressions

• Keep the patient supine on a firm backboard—do NOT use left lateral tilt positioning. 1 Left lateral tilt >30° causes the patient to slide and shifts the heart laterally, markedly reducing chest compression effectiveness. 1

• Apply continuous manual left lateral uterine displacement throughout the entire resuscitation for any pregnant patient at ≥20 weeks gestation or when the fundal height reaches the umbilicus. 1 This can be performed from either side:

  • From the left side: cup and lift the uterus upward and leftward off the maternal vessels
  • From the right side: push the uterus upward and leftward off the maternal vessels 1

• Avoid any downward force on the uterus, which worsens inferior vena cava compression. 1 Manual LUD yields significantly higher coronary perfusion pressures (≈20 mmHg) compared with left lateral tilt (≈5 mmHg). 1

• Place hands in the center of the chest, identical to non-pregnant patients. 1 Compress at a rate of ≥100 compressions per minute with a depth of ≥2 inches (5 cm). 1

• Allow complete chest recoil after each compression and minimize interruptions, keeping peri-shock pauses <10 seconds. 1

Airway Management and Oxygenation—The Highest Priority

Airway management is the highest priority because pregnancy increases metabolic demand and reduces functional reserve, making rapid hypoxia likely. 1 Hypoxemia develops more rapidly in pregnant versus non-pregnant patients. 2

• Assign the most experienced provider available to manage the airway, as pregnant patients frequently present difficult airways due to obesity, sleep apnea, and airway edema. 1

• Provide 100% oxygen at ≥15 L/min immediately via bag-mask ventilation. 2, 1

• Use a two-handed bag-mask technique with a proper seal to prevent leaks. 1 Deliver each rescue breath over 1 second with enough tidal volume to produce visible chest rise. 1

• Give 2 breaths for every 30 compressions before placement of an advanced airway. 1

• After endotracheal intubation, confirm tube placement with waveform capnography or capnometry. 1 Once an advanced airway is secured, provide 1 breath every 6 seconds (≈10 breaths/min) while maintaining continuous compressions. 1

• Avoid excessive ventilation to prevent increased intrathoracic pressure. 1

Defibrillation Protocol

• Use the same defibrillation protocol as in non-pregnant patients—there is no modification of the recommended application of electric shock during pregnancy. 2

• Defibrillate with biphasic shock energy of 120 to 200 J with subsequent escalation of energy output if the first shock is not effective and the device allows this option. 2

• Resume compressions immediately after delivery of the electric shock. 2

• Use anterolateral defibrillator pad placement as the default, with the lateral pad placed under the breast tissue. 2

• Use adhesive shock electrodes to allow consistent electrode placement. 2

Medications—Standard ACLS Without Modification

• Administer standard ACLS medications without dose adjustments for pregnancy. 2, 1 Medication doses do not require alteration to accommodate the physiological changes of pregnancy. 2

• Epinephrine 1 mg IV/IO every 3 to 5 minutes is reasonable to administer, as it improves ROSC despite no difference in long-term survival. 2, 1

• For refractory ventricular fibrillation and tachycardia, administer amiodarone 300 mg rapid infusion with 150-mg doses repeated as needed. 2

• In the setting of cardiac arrest, no medication should be withheld because of concerns about fetal teratogenicity. 2

The Critical 4-Minute Decision Point for Perimortem Cesarean Delivery (PMCD)

If ROSC is not achieved within 4 minutes of cardiac arrest onset, immediately begin hysterotomy at the bedside with the goal of completing delivery by 5 minutes. 1 This is the single most critical intervention that distinguishes maternal cardiac arrest management from standard resuscitation.

• Fetal survival is 96% when PMCD is performed within 5 minutes versus 70% when performed later. 1

• Maternal survival benefit is clear: PMCD led to maternal survival in 19 of 60 cases (31.7%), with no cases where PMCD was deleterious to maternal survival. 2

• Relieving aortocaval compression by emptying the uterus significantly improves resuscitative efforts by restoring cardiac output. 2

• Median time from arrest to delivery was 9 minutes in surviving mothers compared with 20 minutes in non-survivors. 1

• The 2024 International Consensus recommends PMCD for women in cardiac arrest during the second half of pregnancy. 1

Team Activation and Coordination

• Immediately activate a maternal cardiac arrest team using a bundled emergency code (e.g., "maternal code blue") that simultaneously alerts obstetric, anesthesiology, neonatal, and intensive care services. 1, 3

• The team must include: ACLS-trained emergency physicians, an obstetrician capable of performing immediate bedside cesarean delivery, a neonatologist with neonatal resuscitation team, and an experienced airway provider. 3

• Ensure at least three additional staff are present for basic life support response, together with a code cart and automated external defibrillator. 1

• Each hospital must have a specific method to activate the maternal cardiac arrest team and ensure specialized equipment for PMCD is immediately available at the bedside. 3

Fetal Monitoring—Do NOT Perform During Active CPR

Do not perform fetal monitoring during active maternal cardiac arrest, as it diverts critical time from maternal resuscitation efforts and carries the risk of delaying critical interventions. 2, 1 The focus should remain on maternal resuscitation and restoration of maternal pulse and blood pressure with adequate oxygenation. 2

Once the mother achieves ROSC and her condition is stabilized, fetal heart surveillance may be instituted when deemed appropriate. 2

Common Pitfalls to Avoid

• Do not use left lateral tilt instead of manual LUD: tilt reduces compression effectiveness and still allows inferior vena cava compression at angles >30°. 1

• Do not delay PMCD beyond 5 minutes: this markedly worsens both maternal and fetal outcomes. 1

• Do not underestimate airway difficulty: pregnancy predisposes to airway edema and reduced functional reserve. 1

• Do not change hand position for chest compressions: maintain standard center-chest placement. 1

• Do not transport the patient: management should occur at the site of the arrest unless transport to a facility capable of cesarean delivery is required for out-of-hospital cardiac arrest. 2