Maternal Resuscitation and Perimortem Cesarean Delivery

The recommendation for maternal cardiopulmonary resuscitation (CPR) is to adhere to the general guidelines for adult CPR, since few data suggest otherwise. Modifications to the guidelines include lateral displacement of the uterus to decrease aortocaval compression during the second half of pregnancy, and early tracheal intubation, using a tracheal tube 0.5-1 mm smaller than usual, given the likelihood of difficult mask ventilation and reflux. The guidelines promote cricoid pressure, but the potential advantage of preventing regurgitation should be weighed against the risk of a poor glottic view. The importance of effective chest compression is undiminished by pregnancy; it may generate sufficient flow to maintain fetal viability. Both standard and higher than normal hand positions have been recommended for chest compression. Defibrillation and energy doses are unmodified; defibrillation should not be delayed since both mother and fetus may die if treated suboptimally. Fetal monitoring devices should be removed before defibrillation only if this causes no delay. Intravenous lines should be inserted in the upper extremities due to decreased venous return from the lower body. Since rapid maternal resuscitation offers the best chance for survival of both mother and fetus, no medication should be withheld for fear of late effects. If spontaneous circulation returns, monitored care, pharmacological optimization of ventricular function, revascularization when indicated, arrhythmia management (preferably non-medical) and therapeutic hypothermia should all be considered. Indications for perimortem cesarean delivery include failed resuscitation, gestational age >24 weeks and a viable fetus. The chances of fetal survival are higher with early delivery.