Cardiac arrest in pregnancy: New CPR recommendations for expectant moms

When a pregnant woman’s heart stops, two lives are threatened. Yet few caregivers know how to modify their cardiopulmonary resuscitation (CPR) technique for the expectant mom and her fetus, and few hospitals are optimally prepared for such an event.

To fill the knowledge gap, the Society for Obstetric Anesthesia and Perinatology commissioned a Stanford-led team of experts from several medical disciplines to write a consensus statement of expert recommendations, published in the May issue of Anesthesia & Analgesia, that describes best practices for CPR on a pregnant patient. The new statement is one of many examples of Stanford leadership in helping to save the lives of pregnant women around the world; our experts have also helped to develop widely-adopted protocols for dealing with massive bleeding (hemorrhage) during delivery and for treatment of preeclampsia, for example.

I asked two Stanford scientists who helped prepare the statement, lead author Steven Lipman, MD, and senior author Brendan Carvalho, MD, for their perspectives on the challenges of resuscitation in pregnancy. Both are obstetric anesthesiologists at Lucile Packard Children’s Hospital Stanford, where Carvalho is chief of obstetric anesthesia.

“The good news is that cardiac arrest in pregnancy is very rare, and also that rates of survival are higher than for the non-pregnant population,” Lipman said. Only about one in every 20,000 women with access to modern obstetric care experiences cardiac arrest while pregnant. Higher survival among pregnant patients may be partly due, he said, to the fact that many maternal cardiac arrests are witnessed: They tend to occur during labor or delivery, when the woman is already in a hospital and being closely monitored by trained medical staff who can begin CPR right away.

But rarity creates challenges. Because maternal cardiac arrests happen infrequently, obstetric caregivers nationally have less experience in performing resuscitation than people who work in other parts of the hospital, such as the emergency room or intensive care unit. And it’s impossible to conduct randomized clinical trials – usually considered the gold standard for evidence-based medicine – on these emergencies to determine what works best.

The consensus statement provides specific details for best positioning of the mother during CPR and the need for rapid C-section delivery, ideally within five minutes, to save both mother and baby. It also encourages obstetric care provider teams to hone their resuscitation skills with detailed simulations, an approach that has been well studied at the Center for Advanced Pediatric and Perinatal Education at Lucile Packard Children’s Hospital Stanford. Drills conducted in the labor and delivery unit, with caregivers responding exactly as they would in a real emergency in the same location, are especially valuable ways to allow all team members to learn their roles without real patients’ lives on the line. “With carefully studied simulations and drills, we’ve learned a lot of life lessons that have prepared us for the rare real scenarios,” Carvalho said.