Most people can recall seeing a “flat line.” Whether one saw it on a television show or witnessed it in real life, the quintessential “beep, beep, beep, silence” comes to mind with the term. Such an event is typically followed by a flurry of activity from medical personnel. Most likely, such a scenario involves a single patient. However, in one particular patient population, a “flat line” simultaneously puts two lives in jeopardy. This article will briefly discuss some of the unique problems and solutions pregnant patients bring into the realm of cardiac arrests.
Pregnancy related complications and deaths have risen over the past 25 years. 1,2According the Centers for Disease Control and Prevention1, the maternal mortality rate for 2011 was 17.8 deaths per 100,000 live births, with 25% of those being attributed to cardiovascular diseases and cardiomyopathies . 1 The exact incidence of cardiac arrest, or illness requiring cardiac intervention, in pregnant patients is not known, but it is estimated to be approximately 1 in every 12,000 pregnancies3.
One must also explore conditions that may lead to cardiac arrest in order to fully appreciate the scope of the problem2-5. Some conditions in pregnancy that can lead to cardiac arrest are hemorrhage, pre-eclampsia/eclampsia, blood clots, amniotic fluid embolism, and sepsis.3,5-7 Perhaps one of the best known, hemorrhage, is estimated to be responsible for 50% of maternal deaths worldwide. 4 In the most recent reports from the United Kingdom and from the United States, sepsis has been the most prevalent cause of non-cardiac related maternal death.1,4 If one considers the conditions identified as increased risk for pregnant patients to develop cardiac arrest in addition to cardiac related causes, one may account for 74 % of pregnancy related deaths in the United States in 2011.1
Some attribute the deterioration of previously healthy patients to the point of cardiac arrest or death to cardiovascular changes that occur during pregnancy 2-6,9, while others surmise that the advancement of healthcare technologies has allowed more complex patients to become pregnant than in previous generations5.As pregnant patients have increased in their complexity, the necessity for healthcare professionals to be able to respond to a cardiac arrest has also risen.1,2 It is widely believed that recognition of a patient’s potential for developing cardiac arrest and rapid intervention are keys to successful resuscitation.2-6,8Early warning checklists are being used with success in identifying patients who are deteriorating.3,8 Training programs are also being utilized to prepare healthcare providers in recognition and management of obstetric emergencies, including cardiac arrest .6,8,10,11 Vital to the success of these training programs is practicing communication and working together as multi-professional teams.4,6,8,10,11
The utilization of training programs is not only a recommendation by the American Heart Association,8 it is an excellent way of ensuring health care teams are using the most current guidelines and practices12. The most current recommendations for successful maternal resuscitation have recently been put forth in official statements by the American Heart Association3,8 as well as the European Resuscitation Council6. These landmark statements addressing the unique requirements of cardiac resuscitation in a pregnant patient echo each other in their key points. As previously discussed, of utmost importance in successful resuscitation is early recognition of a deteriorating patient. 3-6,8-12Nurses, due to their increased contact time with the patient and requirements for monitoring the maternal-fetal dyad, play an integral role in raising alarms before an arrest occurs13. However, not every deteriorating patient is going to be recognized in time to prevent an arrest. Just as with non-pregnant cardiac arrests, an alarm should be raised in the case of maternal arrest. 3,4,6,8 The American Heart Association recommends that each hospital have a code team trained in obstetric emergencies.3,8 The team must assess the mother quickly and be prepared to also care for an infant at the same time; in essence an adult code team, an obstetrics team, and a neonatal team all working together.5,3,8
SEE ALSO: Depression Screening During Pregnancy
In most steps, the resuscitation of a pregnant mother is similar to that of a non-pregnant patient; all American Heart Association steps for Basic or Advanced Life Support apply- with a few additions.5,3,8 In patients who are greater than 20 weeks of gestation, the uterus must be displaced, ideally to the left.2-6,8-10 A rough estimation of 20 weeks gestational age is when the height of the uterine fundus, or the top part of the uterus, is at the level of the mother’s umbilicus. 5,7,8 When the uterus is at the umbilicus, the uterus is heavy enough to compress the mother’s inferior vena cava, thus impeding blood return to the heart.3,5-8 To improve circulation during chest compressions, the health care team must displace the uterus to the left. 3,6,8 Simply put, one team member should stand on the left side of the patient’s abdomen, and gently pull the mother’s uterus up and towards her left side.3,8
The other key item that the team must be aware of is time. Although time is of the essence in all cardiac resuscitations, with maternal arrests the possibility of needing to perform a cesarean section exists.2,3,6,8 The team must make note of the time the resuscitation started, because they need to make a decision to perform a cesarean section by 4 minutes into the process. 2,3,6,8. Maternal and fetal resuscitative efforts are more successful if the fetus is delivered by 5 minutes after cardio-pulmonary resuscitation begins. 2,3,6,8. To avoid delays, the cesarean section should be performed where the arrest occurs, whether that is in the labor room or in the emergency room as the mother arrives by ambulance. 8 It is recommended that areas at high risk of performing peri-mortem cesarean deliveries should, at minimum, include a scalpel in their crash carts3,8.
The unique needs of pregnant patients experiencing cardiac arrest require multiple disciplines to cooperate, learn, and prepare together. The American Heart Association’s82015 guidelines support the use of training programs and specialty teams to care for this population of patients. With knowledge, planning, and practice, perhaps the maternal mortality rates in the United States may be reduced.
- Centers for Disease Control and Prevention. Pregnancy and mortality surveillance system. Sept 2015 [cited 2016 Jan 14]. Available from http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html
- Lavecchia, M. & Abenhaim HA. Cardiopulmonary resuscitation of pregnant women in the emergency department. Resuscitation. 2015;91:104-107.
- Jeejeebehoy F. & Windrim R. Management of cardiac arrest in pregnancy. Best Practice & Research Clinical Obstetrics and Gynaecology. 2014;28:607-618.
- O’Gormann N. & Penna L. Maternal collapse. Obstetrics, Gynaecology, and Reproductive Medicine. 2015; 25(5):115-122.
- McGregor AJ; Barron R; & Rosene-Montella K. The pregnant heart: Cardiac emergencies during pregnancy. American Journal of Emergency Medicine. 2015; 33: 573-579.
- Truhlar A, Deakon CD, Soar J, Khalifa GEA, Alfonso A, Bierens JJLM, et al. European Resuscitation Council guidelines for resuscitation 2015 section 4; Cardiac arrest in special circumstances. Resuscitation. 2015;95:148-201.
- Cunningham, F. Gary, et al. Williams Obstetrics, Twenty-Fourth Edition. Eds. F. Gary Cunningham, et al. New York, NY: McGraw-Hill, 2013. n. pag. AccessMedicine. Web. 25 Jan. 2016. http://accessmedicine.mhmedical.com/content.aspx?bookid=1057&Sectionid=59789139.
- Jeejeebhoy F, Zelop CM, Lipman S,Carvalho B,Joglar J, Mhyre JM, et al. Cardiac arrest in pregnancy: A scientific statement from the American Heart Association. Circulation. 2015;132:00-00. DOI: 10.1161/CIR.0000000000000300.
- Mhyre JM, Tsen LC, Einav S, Kuklina EV, Leffert LR, & Bateman BT. Cardiac arrest during hospitalization for delivery in the United States, 1998-2011. Anesthesiology. 2014; 120:810-818.
- Haeri S & Marcozzi D. Emergency preparedness in obstetrics. Obstetrics & Gynecology. 2015;125(4):959-970.
- Weiner CP, Collins L, Bentley S, Dong Y, & Satterwhite CL. Multi-professional training for obstetric emergencies in a US hospital over a 7-year interval: an observational study. Journal of Perinatology. 2016; 36: 19-24.
- Merriel A, van der Nelson H, Merriel S, Bennett J, Donald F, Draycott T, et al. Identifying deteriorating patients through multi-disciplinary team training. American Journal of Medical Quality. 2015. 20 January 2016. ajmq.sagepub.com DOI: 10.1177/1062860615598573
- Pak KM & Hardasmalani M. A multi-disciplinary obstetric trauma resuscitation using in situ high-fidelity simulation. Advanced Emergency Nursing Journal. 2015; 37(1):51-57.
Elisa M. van Daalen is a clinical nurse educator at the University of Kansas Medical Center.