Management of Maternal Code

 

VBMC Trauma Algorithm: OB Trauma

 

Management of Maternal Code (OB, Obstetric, Pregnancy)

 

Purpose: To update established guidelines for rapid assessment and treatment of pregnant patients in cardiac arrest

 

Background: Though rare, maternal cardiac arrest can be a challenging clinical scenario. Trauma in pregnancy is a leading cause of non-obstetric maternal death, however other causes include PE, cardiac failure and septic shock. The management of these codes differs and depends upon gestational age (viability) and cause of cardiac arrest.  The age of viability for a fetus/neonate is considered 23 weeks with medical advances. Maternal survival is improved by delivery during medical causes of cardiac arrest, however the evidence is lacking for traumatic/hemorrhagic causes of cardiac arrest. The decision to proceed with perimortem cesarean delivery (PMCD) is best made in consultation with MFM. Team management in any code is therefore crucial with clearly defined roles and protocols. 

Procedure: To effectively manage a maternal code, a multidisciplinary approach is key. Maternal and fetal status are reliant upon one another as are decisions regarding mother and fetus. Maternal status is often reliant upon efficiency of delivery as well. Thus, early recognition of gestational age and fetal status is useful in planning management of the patient.

 

ABCs for potential mechanism of maternal cardiac arrest:

1.     Anesthetic complication:

a.     Hypotension

b.     High neuraxial block

c.     Aspiration

2.     Bleeding:

a.     Obstetric reasons: PPH. atony, abruption, rupture

b.     Surgical

c.     Traumatic - PMCD may or may not be indicated 

3.     Cardiovascular:

a.     Arrhythmia 

b.     MI, aortic dissection, cardiomyopathy

c.     Congenital/acquired cardiac lesions, valvular disease

4.     Drugs:

a.     Magnesium

b.     Illicit drugs

5.     Embolic:

a.     Pulmonary embolus

b.     Amniotic fluid embolus

c.     Air embolism

6.     Fever:

a.     Sepsis

7.     Neurologic:

a.     CVA: embolic or hemorrhagic 

b.     Sinus venous thrombosis 

 

Initial management:

1.     Maternal code near or > 23 weeks, call code, OB, neonatology

2.     Begin ACLS

3.     Displace uterus to the left using 2 hands or a hip bump

4.     Defibrillate if necessary 

5.     Airway management/ventilation

a.     Optimize first attempt at intubation: have difficult airway supplies and a 6-0 ET tube

b.     Second attempt: alternative technique, cricoid pressure changed

c.     Third attempt: insert LMA or surgical airway

6.     IV access: preferably above diaphragm 

7.     No variation in drugs given for ACLS

8.     OB performs PMCD as code team runs code