1. Philippines Maternal Mortality rate is 224: 100,000

2. Philippines Maternal Mortality rate is 224: 100,000

3. D’ Angelo R. Anesthesiology 2014;120:1505-12

4. What We Already Know about This Topic
The incidences of serious complications related to
obstetric anesthesia are unknown
What This Article Tells Us That Is New
The Serious Complication Repository Project of the
Society for Obstetric Anesthesia and Perinatology captured
data on approximately 257,000 parturients administered
neuraxial or general anesthesia at 30 institutions between
2004 and 2009
Serious anesthesia related complications were reported
for 85 (1 of 3,000) patients
The most common serious complications were high
neuraxial block, respiratory arrest in labor suite, and
unrecognized spinal catheter
D’ Angelo R. Anesthesiology 2014;120:1505-12

5. What We Already Know about This Topic
The incidences of serious complications related to
obstetric anesthesia are unknown
What This Article Tells Us That Is New
The Serious Complication Repository Project of the
Society for Obstetric Anesthesia and Perinatology captured
data on approximately 257,000 parturients administered
neuraxial or general anesthesia at 30 institutions between
2004 and 2009
Serious anesthesia related complications were reported
for 85 (1 of 3,000) patients
The most common serious complications were high
neuraxial block, respiratory arrest in labor suite, and
unrecognized spinal catheter
D’ Angelo R. Anesthesiology 2014;120:1505-12

6. Resuscitation
in the Parturient
Grace Anne B. Herbosa
Professor in Anesthesiology
University of the Philippines College of Medicine
Philippine General Hospital
Manila

8. REFERENCE
S

9. I. History of CPR in pregnancy

10. II. challenges

11. III. Controversies
of CPR in pregnancy

12. IV. Checklists, drills,
quality improvement

13. 1966^: 1st published AHA guidelines
1974: 2nd AHA guidelines
1980 & 1986*: Adult, Pediatrics, Neonatal Care
^Safar P, Brown T, Holtey W, Wilder R. Ventilation and circulation with closed chest
cardiac massage in man. JAMA 1961;176:574-6
*Katz Obstet Gynecol

14. 1992:
1st to mention pregnancy
4 paragraphs; 8 references
Caval decompression; delivery within 5
minutes

15. 2000: 3 pages (two tables, figure, 9 references)
“The critical point is you will lose both mother
and infant if you cannot restore blood flow to
the mother’s heart.”
“Fetal-centric”: deliver “within 4-5 mins if BLS/
ACLS fail and…some chance…fetus is viable.”

16. 2005: >3 pages (table, 31 references)
Consider emergency cesarean delivery as soon as
woman develops cardiac arrest
Decision making:<20 weeks, 20-23, >24 to 25
“Importance of advance preparation…in
collaboration with obstetric and pediatric services.”

17. 2010

19. “Bundled maternal and neonatal?
Standard team vs “Code OB”
Emergency access barriers?
Lipman et al.Am J Ostet Gynecol 2010;203(2):179.e1-5
Lipman et al. Ostet Gynecol 2011;118(5):1090-4

20. AHA 2010 Guidelines. Circulation2010;122:S829-S861
Cheskes et al. Circulation 2011;124(1):58-66

21.  Depth- 5cm
 100/min (intubated)
 Perishock pause <5 seconds
 No pulse check after defibrillation
 (not intubated) 30 compressions : 2 breaths
 3rd trimester- hand placement 2-3 cm higher on the
sternum vs. non pregnant

22. Eckstein et al. Prehosp Disaster Med 2011;26(3):148-50
Einav et al. Acad Emerg Med. 2011;18(5):468-75
Pokorna et al. J Emerg med. 2010;38(5):614-21

23. >20 weeks gestational size or uterus is palpable or visible
Left uterine Displacement
- 2 Handed Technique
Vanden Hoek. Circulation 2010;122:S861
Left Uterine Displacement
One handed Technique

24. Ueland AJOG 1969 versus McLennan AJOG 1943

25. side
supine
7
Cardiac output
Liters/min
sitting
20-24 28-32 38-40
Gestational age-weeks
Ueland K et al AJOG 1969 july 15: 104(6): 856-64
6
5
Effect of gestational age and maternal posture on cardiac output

26. McLennan CE. Antecubital and femoral venous pressure in normal and toxemic
pregnancy. American Journal of Obstetrics and Gynecology. 1943;45(4):568–591.

27. McLennan CE. Antecubital and femoral venous pressure in normal and toxemic
pregnancy. American Journal of Obstetrics and Gynecology. 1943;45(4):568–591.

29. Oxygenate and Ventilate
First responders without advanced airway experience
 Jaw thrust, oral airway, bag mask ventilation
Unwavering focus on aspiration prevention= fixation
error
 Cricoid efficacy and effect on ventilation and laryngoscopy
unclear
 AHA 2010 guidelines do not recommend in non pregnant
patients
AHA 2010 Guidelines: Circulation 2010; 122:S829-S861
Fenton et al Int J Obstet Anesth 2009;18(2);106-10
Smith et al. Anesthesiology 2003;99(1);60-4
Boet et al. J Emerg Med. 2010;42(5):606-11

30. Obtaining IV or intraosseous access above the diaphragm
is recommended to avoid the potentially deleterious
effects of vena caval compression  increase time
required for fluids or administered drugs to reach the
heart or even prevent their circulation altogether.

31. Standard resuscitative medications: none
contraindicated & no dose alterations
Lipid emulsion if LA toxicity, consider ECMO or
bypass if refractory
Consider CV effects of oxytocin
AHA 2010 Guidelines:Circulation 2010;122:S829-S861
Bern, Weinberg. Curr Op in Anaesth2011:24(3)262-67
Dyer et al. Curr Opin Anaesthesiol 2011:24(3):255-61

32. Vaginal delivery possible?
Caval compression +4 min since arrest?
No response to ACLS- final pulse check?

33. Katz (38 cases): 12 of 20 cases had ROSC
Einav (76 of 91 cases had CS): 32% benefitted
Delivery within 5 min: only 4 of 76 (7%)
MATERNAL STATUS DID NOT DETERIORATE
WITH CESAREAN DELIVERY IN ANY CASE
Katz et al. Am j Obstet Gynecol 2005; 192(6): 1916-20
Einav et al. Resuscitation 2012; 83(10): 1191-200

34. Milestone Labor Room
(n=7)
OR
( n=7)
P value
CPR
resumed
3: 01
(2:53 – 3:17)
4:20
(3:20- 6:53)
0.030*
Intubation 4: 05
(3:22-4:18)
4:48
(4:19- 5:54)
0.064*
Incision 4:25
(3:59 - 4:50)
7:53
(7:18- 8:57)
0.004*
Values are median (IQR) times in min: sec
Lipman, Daniels, Cohen, Carvalho. Obstet Gynecol 2011;118:1090-4

37. Point of Care Checklist
Adapted from OBSim and OBLS, Center for Advanced Pediatric and Perinatal Education, Stanford University
CALL FOR HELP!
START CHEST COMPRESSIONS
C CIRCULATION
A AIRWAY
B BREATHING
D DEFIBRILLATE
E EXTRACT FETUS
 Call “OB Code”
 Call neonatal team
 Adult Code Cart
 Adult airway equipment
 Scalpel/cesarean pack
 Assign timer/documenter
 Immediate BLS
 Backboard
 Left uterine displacement
 Hands mid-sternum
 100 compressions/min
 PUSH HARD! PUSH FAST!
 Change compressors every 2 min
 Obtain IV access above diaphragm
 100% oxygen
 Chin Lift/ Jaw Thrust
 Oral airway, mask ventilate or
 Intubate early with 6.0 ETT or
 Supraglottic airway (LMA with gastric port)
 DO NOT INTERRUPT CHEST COMPRESSIONS!
 If intubated:10 breaths / min (500-700ml/breath)
 If not intubated: 30 compressions to 2 breaths
 Use self inflating bag
 Administer each breath over 1 second
 Pads front and back
 AED: Analyze/defibrillate every 2 min
 Immediately resume CPR for 2 min
 Prepare for delivery
 Aim for incision by 4 min
 Aim for fetal delivery by 5 min

38. OBLS: ARREST IN A PREGNANT PATIENT
CALL FOR HELP: EMERGENCY CORD/ BUTTON
C
CIRCULATION
 Backboard
 Manual Left uterine
displacemeny
 100 compressions/min
 Push HARD, Push FAST
 Change compressors q i-2 min
A
AIRWAY
Ventilate &Oxygenate
Consider:
Chin lift
Oral Airway
Ambu Bag
Suction
Mask ventilate
Intubate or other device
B
BREATHING
 If intubated- Breathe q 6 sec
(10/min)
 If not intubated- 30
compressions:2 breaths-consider
2 handed mask
ventilation
D
DEFIBRILLATE AND
DELIVER FETUS
- Remove fetal monitors
- Apply pads front and back
- Analyze/defibrillate via AED
- Immediately resume CPR X2min
- Prep for PERIMORTEM
DELIVERY
- DELIVERY within 5 min
Recommended by
AHA 2010. Katz V et al

39.  Different provider?
 Prepare SGA(LMA)
 Continue bag mask PPV
 Place SGA (LMA etc)
 Utilize VA device (glidescope etc)
 Continue with bag mask PPV
AAiirrwwaayy C Coonnttrroolllleedd
 Secure ETT / LMA
 10 breaths per min
 1 breath every 6 seconds
 Delegate PPV to another provider
 Secure ETT / LMA
 10 breaths per min
 1 breath every 6 seconds
 Delegate PPV to another provider

40. A Anesthetic complications (high block; loss of airway; aspiration; respiratory
depression, hypotension, local anesthetic toxicity)
B Bleeding* (DIC or coagulopathy, uterine atony, placenta accreta, abruption,
previa, uterine rupture, trauma, transfusion reaction
C Cardiac cause (cardiomyopathy, myocardial infarction, aortic dissection,
arrhythmias)
D Drugs (illicit; drug error, magnesium, narcotic, insulin or oxytocin overdose,
anaphylaxis)
E Embolic (pulmonary embolus, amniotic fluid (AFE); air)
F Fever* (Infection, Sepsis)
G General non obstetric causes of cardiac arrest (Hs and Ts)**
H Hypertension* (preeclampsia/eclampsia/HELLP, intracranial bleed)
*Often diagnosis is apparent or predicted from pre-arrest condition

44. Refractory to resuscitation interventions (no ROSC), the
use of ECMO/cardiac bypass
 Correct reversible etiologies of arrest
Manage uterine bleeding in the post-arrest patient
?Therapeutic hypothermia has been reported in several
women who had a cardiac arrest during the first half of
pregnancy. No adverse fetal effects resulted, except in
one case. (stillbirth) birth.

45.  98 deaths reviewed
 77% related to healthcare professional
Delays or inadequacies in dx/ tx
Ineffective treatment
Misdiagnosis
The California Pregnancy Associated Mortality Review. Report from 2002 and 2003 Maternal Death reviews
Sacramento:California Department of Public Health, Maternal Child and Adolescent Health Division;2011

46. Institutional preparedness
Periodic emergency drills or simulations
Debrief to analyze individual (behavioral,
cognitive, technical) and systems issues;
operationalize solutions
Hui. Obstet Gynecol Can 2011;33:858-63
Cohen. Int J Obstet Anesth 2008;17:20-25
Lipman. Semin Perinatol 2011;35(2):74-9
Dijkman. BJOG 2010;117:282-87

47. Q&A: CAB or ABC?
 C-A-B sequence (AHA)
 Note: respiratory maternal collapse (e.g., Mg/ opioid
overdose, high neuraxial block, hypoventilation after
eclamptic seizure, failed intubation/ventilation), cardiac
arrhythmias may develop
 Parturients develop hypoxia/ acidosis rapidly during
apnea (high basal metabolic rate, decreased FRC, and
fetal O2 requirements.

48. Q&A: CAB or ABC?
 C-A-B sequence (AHA)
 Note: respiratory maternal collapse (e.g., Mg/ opioid
overdose, high neuraxial block, hypoventilation after eclamptic
seizure, failed intubation/ventilation), cardiac arrhythmias may
develop
 Parturients develop hypoxia/ acidosis rapidly during apnea
(high basal metabolic rate, decreased FRC, and fetal O2
requirements.
✓Prompt provision of high quality chest compressions with
minimal interruptions+ Adequate ventilation initiated ASAP, in
parallel with defibrillation.

49. Q&A:Manual Left Uterine Displacement vs Tilt?
 Tilt has mechanical disadvantage for chest compression-transmission
forces are no longer perpendicular to the
thorax.
 A study in healthy pregnant women undergoing CS :
manual LUD decreased spinal hypotension compared to
use of a 15° L table tilt.

50. Q&A:Manual Left Uterine Displacement vs Tilt?
 Tilt has mechanical disadvantage for chest compression-transmission
forces are no longer perpendicular to the
thorax.
 A study in healthy pregnant women undergoing CS :
manual LUD decreased spinal hypotension compared to
use of a 15° L table tilt.
✓Effective LUD best achieved with manual displacement.
Kundra P, Khanna S, Habeebullah S, Ravishankar M. Anesthesia 2007;62:460–5

51. Q&A: PMCD - Transport to OR?
Simulation studies on maternal cardiac arrest and
PMCD: transport from LR to the OR delayed uterine
incision. Median times from maternal arrest to
“incision” were 4 and 8 min (LR vs OR)
Transport- more interruptions and degradation in the
quality of chest compressions.
Lipman S, Daniels K, Cohen SE, Carvalho B. Obstet Gynecol
2011;118:1090–4

52. Q&A: PMCD - Transport to OR?
 Simulation studies on maternal cardiac arrest and
PMCD: transport from LR to the OR delayed uterine
incision. Median times from maternal arrest to “incision”
were 4 and 8 min (LR vs OR)
 Transport- more interruptions and degradation in the
quality of chest compressions.
✓PMCD be performed at the bedside whenever
possible in any pregnant patient >20 weeks’
gestation who sustains a cardiac arrest.
Lipman S, Daniels K, Cohen SE, Carvalho B. Obstet Gynecol 2011;118:1090–4

53. Case Scenario Q&A
Laboring patient found in cardiac arrest 7 min after the last recording of a
low BP. Immediate chest compressions started upon discovering the
patient. The code team arrived shortly thereafter. When should the baby
be delivered?

54. Case Scenario- Timing of delivery?
2010 AHA: (1)”Emergency cesarean section may be
considered at 4 minutes after onset of cardiac arrest if
there is no ROSC,” and (2) “if no ROSC by 4 minutes of
resuscitative efforts, consider immediate emergency CS:
Aim for delivery within 5 minutes of onset of resuscitative
efforts”
✓In the above scenario, chest compressions/ BLS/ACLS
continued while preparations are made for an immediate
delivery in the LR, but not necessary to wait additional 4
min before delivery.

55. Q&A: Why are AEDs recommended over manual
defibrillators?
AHA 2010: “Despite limited evidence, AEDs may
be considered for the hospital setting, especially
in areas where staff have no rhythm recognition
skills or defibrillators are used infrequently.”

56. Q&A: Should family members stay in the room
during maternal CPR?
Some favor escorting family members out
of the room during CPR,
 medico-legal liability
family members becoming
traumatized/distressed
disrupting/delaying critical, life-saving
interventions.
Jabre P, et al. N Engl J Med 2013;368:1008–18

57. Q&A: Should family members stay in the room
during maternal CPR?
✓AHA, the Emergency Nurses Association and public
opinion- favor allowing family members to remain close
to the patient during CPR.
 Family members view it as a right rather than a
privilege to be with a loved one during their last
moments..
facilitate the grieving process
 study found that relatives who did not witness CPR
experienced symptoms of post- traumatic stress disorder,
anxiety and depression more frequently than those who
did witness CPR.
Jabre P, et al. N Engl J Med 2013;368:1008–18

58. Q&A: Is it important to remove fetal monitors before
delivery of shock?
 Fetal monitors are electrical contact points – If present during
maternal defibrillation, there is the potential for arcing or electrical
burns. (risk is theoretical and defibrillation should never be delayed)
 2 types of monitors of fetal heart rate: external and internal(FSE)
Katz VL, Dotters DJ, Droegemueller W.Obstet Gynecol 1986;68:571–6
Katz V, Balderston K, DeFreest M. Am J Obstet Gynecol 2005;192:1916–20

59. Q&A: Is it important to remove fetal monitors before
delivery of shock?
 Fetal monitors are electrical contact points – If present
during maternal defibrillation, there is the potential for
arcing or electrical burns. (risk is theoretical and
defibrillation should never be delayed)
 2 types of monitors of FHR: external and internal (FSE)
✓Removal of either external/ internal fetal monitors is
recommended if the situation permits but should never
delay defibrillation.
Katz VL, Dotters DJ, Droegemueller W.Obstet Gynecol 1986;68:571–6
Katz V, Balderston K, DeFreest M. Am J Obstet Gynecol 2005;192:1916–20

60. Q&A: Where do you place the hands higher on the
sternum during chest compressions ?
gravid uterus displace the contents of the
thorax cephalad shift in pregnant patients
who are near term.
✓To be effective- hands should be placed 2-3 cm
above usual sternal level under which the heart
is likely to be located.

61. Q&A: If one suspects LA-induced cardiac arrest should lipid
emulsion be administered, as in a nonpregnant patient?
Pregnancy -enhanced sensitivity to LAST, and cardiac
toxicity resulting from high LA plasma concentrations.
Dosing/ timing of lipid emulsion during resuscitation of
pregnant patients follow standard algorithms used in
nonpregnant patients
Bern S, Weinberg G. Curr Opin Anaesthesiol 2011;24:262–7
Neal JM, Mulroy MF, Weinberg GL; ASRA checklist for managing local anesthetic systemic toxicity: 2012
version. Reg Anesth Pain Med 2012;37:16–8

62. Q&A: Use of checklists to improve team performance during a
maternal cardiac arrest is recommended. Why?
Checklists - integral part of the culture of safety
in other highly dynamic, high-stakes domains.
Ex. aviation industry- pre-flight safety checklist,
and emergent situations
preprocedure/preincision surgical time-outs
Simulation studies suggest checklists help
medical teams perform optimally during
emergencies; periodic training is necessary.
Marshall S. The use of cognitive aids during emergencies in anesthesia:
a review of the literature. Anesth Analg 2013;117:1162–71

63. BEAUCHOPS
*Institutional preparedness, implementaion strategies before event!

64. REFERENCE
S

65. Thank you!