🔴 Obstetric ACLS – AHA Guidelines (2020 Update, reaffirmed in 2022)

⚡ Why Special Considerations Are Needed:

• Pregnancy induces physiological changes (↑ blood volume, ↓ SVR, ↑ cardiac output, ↑ oxygen consumption, etc.)
• Gravid uterus can compress major vessels → supine hypotension → reduced preload
• Fetal viability adds a dual-patient complexity—resuscitative efforts must consider both maternal and fetal survival
• Most maternal arrests are due to reversible causes (e.g., hemorrhage, eclampsia, embolism, sepsis)

🩺 Key Principles of Obstetric ACLS

1. Team Preparation

• Clearly defined roles
• Ensure PPE, especially for COVID-19 scenarios
• Immediate notification of obstetric and neonatal teams
• Uterine displacement and early perimortem cesarean are part of the initial algorithm

2. Recognize Cardiac Arrest in Pregnancy

• Sudden collapse, pulselessness
• Loss of consciousness
• Respiratory or cardiac arrest
• Always assess circulation, airway, and breathing (CAB)

3. Perform High-Quality CPR

• Chest Compressions:
• Depth: at least 2 inches (5 cm)
• Rate: 100–120/min
• Full chest recoil, minimal interruptions
• Hand placement is slightly higher on the sternum due to diaphragm displacement
• Airway and Breathing:
• 30:2 ratio until airway secured
• Prefer early advanced airway (ETT) if trained
• Use 100% O₂, avoid hyperventilation

4. Left Uterine Displacement (LUD)

• Crucial from 20 weeks onward to prevent aortocaval compression
• Methods:
• Manual displacement (preferred): Push uterus to the left
• Or tilt the patient (wedge under right hip or 15–30° tilt)
• Avoid placing in pure left lateral position → ineffective CPR

5. Defibrillation

• Use standard energy levels (no dose modification)
• Pads may need repositioning (anterior-posterior is preferred)
• Fetal monitoring should not delay maternal defibrillation

6. Medications

• Standard ACLS drugs used at standard doses:
• Epinephrine 1 mg IV every 3–5 min
• Amiodarone, lidocaine if needed
• Magnesium sulfate if torsades de pointes or eclampsia
• No pregnancy-specific dose changes

7. Identify and Treat Reversible Causes (4Hs + 4Ts)

Special pregnancy-related additions:

• Hemorrhage (PPH, uterine rupture)
• Hypertensive disorders (eclampsia)
• Sepsis
• Amniotic fluid embolism

🚨 Perimortem Cesarean Delivery (PMCD)

➤ Indication:

• No ROSC after 5 minutes of CPR
• Fetus is ≥20 weeks (uterus palpable at or above umbilicus)

➤ Why?

• Relieves aortocaval compression
• Improves maternal venous return
• Improves oxygenation and ventilation
• May improve chance of fetal survival if <5 minutes from arrest

➤ How?

• Done at bedside—don’t wait for OR
• Incision: midline vertical → faster access
• Neonatal team should be ready to receive neonate

🧠 Special Situations

🟠 Maternal Trauma:

• CPR modifications may be needed
• Consider hemorrhage, pelvic fracture

🟠 Eclampsia:

• Use magnesium sulfate cautiously
• Seizure control is priority

🟠 Anesthetic Complications:

• High spinal, local anesthetic systemic toxicity (LAST)
• Airway complications → rapid sequence intubation

🟣 Post-Resuscitation Care

• ICU admission
• Maintain oxygenation, hemodynamic stability
• Consider targeted temperature management (case-by-case)
• Monitor for multi-organ dysfunction
• Initiate appropriate OB and neonatal follow-up

📚 Summary: OB ACLS vs Standard ACLS