Maternal collapse and CPR

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Common Causes of Maternal Cardiac Arrest

  • Mnemonic: BEAU‑CHOPS + H’s and T’s
  • B—Bleeding: Obstetric haemorrhage (placental abruption, uterine rupture, postpartum haemorrhage, disseminated intravascular coagulation).
  • E—Embolism: Amniotic fluid embolism; pulmonary thromboembolism; air or fat embolism.
  • A—Anesthetic complications: High spinal block, local anaesthetic systemic toxicity, failed airway, aspiration.
  • U—Uterine atony: Severe hypotension from atonic uterus and haemorrhage.
  • C—Cardiovascular disease: Peripartum cardiomyopathy, ischaemic heart disease, aortic dissection.
  • H—Hypertension: Severe pre‑eclampsia/eclampsia with intracranial haemorrhage or cardiac dysfunction.
  • O—Other obstetric causes: Placenta previa, vasa praevia.
  • P—Pulmonary causes: Tension pneumothorax, cardiac tamponade (pericardial tamponade), massive pulmonary embolism.
  • S—Sepsis: Septic shock from chorioamnionitis or other infection.
  • H’s and T’s (General reversible causes): Hypoxia, hypovolaemia, hypo/hyperkalaemia, hypothermia, acidosis; tension pneumothorax, tamponade, toxins.

Initial Management Steps

  1. Immediate recognition (unresponsiveness, absent or abnormal breathing; fundal height ≥ umbilicus indicating ≥ 20 weeks gestation).
  2. Call for help: Activate maternal arrest protocol; summon ≥ 3 additional trained responders, crash cart, defibrillator.
  3. High‑quality CPR:
    • Start chest compressions within 10 s of arrest; rate 100–120 min⁻¹, depth 5–6 cm, full recoil.
    • Continue uninterrupted, minimise pauses (< 10 s).
    • Manual left uterine displacement throughout compressions.
  4. Airway and breathing:
    • 100 % O₂ via bag‑mask (two‑person, two‑handed hold), 10 breaths min⁻¹.
    • Early endotracheal intubation by experienced operator; confirm with waveform capnography.
  5. Circulation:
    • IV/intraosseous access above diaphragm.
    • Defibrillation as per standard ACLS; epinephrine 1 mg IV every 3–5 min.
    • Identify and treat reversible causes (BEAU‑CHOPS, H’s and T’s).

Perimortem Caesarean Section (PMCS)

  • Indication: Gestation ≥ 20 weeks or uterine fundus at or above the umbilicus.
  • Timing: Decision at 4 min of unsuccessful resuscitation; delivery by 5 min (“4‑to‑5‑min rule”)
  • Personnel: Earliest available operator (obstetric surgeon if possible); neonatal team pre‑alerted.
  • Objective: Decompress aortocaval vessels to improve maternal haemodynamics and optimise fetal salvage.

Modifications to Standard ACLS in Pregnancy

  • Position: Supine on firm surface with 15–30° left lateral tilt or continuous manual uterine displacement.
  • Compressions: Hands 2 cm higher on sternum compared to non‑pregnant position.
  • Airway: Prepare for difficult intubation; use rapid‑sequence induction modifications if needed post‑ROSC.
  • Drug considerations: Avoid drugs harmful to fetus if viable; calcium for magnesium toxicity; early transfusion for haemorrhage.
  • Team roles: Assign specific roles (compressions, airway, drug administration, PMCS preparation).

Gestational Age and Decision‑making

  • < 20 weeks (< fundus at umbilicus): Uterine size unlikely to impede compressions; PMCS not routinely indicated for fetal salvage.
  • 20–24 weeks: Consider PMCS primarily for maternal haemodynamic benefit, with minimal fetal viability.
  • ≥ 24 weeks: PMCS aims for both maternal resuscitation and neonatal survival; coordinate neonatal intensive care.

Links

References:

1. American Heart Association. (2006). Algorithm for Advanced Cardiovascular Life Support in Pregnancy – In-Hospital. Retrieved from https://cpr.heart.org/-/media/CPR-Files/CPR-Guidelines-Files/Algorithms/AlgorithmACLS_CA_in_Pregnancy_InHospital_200612.pdf
2. World Federation of Societies of Anaesthesiologists. (n.d.). _Emergency management of maternal collapse and arrest_. Retrieved from https://resources.wfsahq.org/wp-content/uploads/uia34-Emergency-management-of-maternal-collapse-and-arrest.pdf
3. American Heart Association. 2020 AHA guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 5: Special circumstances. _Circulation_. 2020;142(Suppl 2):S541–S563. Available from: https://doi.org/10.1161/CIR.0000000000000916
4. International Liaison Committee on Resuscitation. Part 7.1: Adult basic life support, automated external defibrillation, and maternal resuscitation. _Resuscitation_. 2021;161:357–372. Available from: https://doi.org/10.1016/j.resuscitation.2020.12.017
5. Einav S, Rashwan C, Seidman D, et al. Maternal cardiac arrest: Consensus statement of the Obstetric Life Support Training group. _Resuscitation_. 2018;132:465–472. Available from: https://doi.org/10.1016/j.resuscitation.2018.09.002
6. Perkins GD, Travers AH, Berg RA, et al. European Resuscitation Council guidelines for resuscitation 2021: Section 4—Adult advanced life support. _Resuscitation_. 2021;161:115–151. Available from: https://doi.org/10.1016/j.resuscitation.2021.01.015
7. Society for Obstetric Anesthesia and Perinatology. Guideline for perimortem caesarean delivery. _Anesth Analg_. 2021;132(2):474–484. Available from: https://journals.lww.com/anesthesia-analgesia/Fulltext/2021/02000/Guideline_for_Perimortem_Cesarean_Delivery.20.aspx

Summaries:
Obstetric emergencies

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© 2025 Francois Uys. All Rights Reserved.

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