Cardiopulmonary arrest is defined as the sudden cessation of cardiac activity resulting in unresponsiveness, abnormal or absent breathing, and no signs of circulation. In a review of more than 50 million hospitalizations for delivery in the United States from 1998 to 2011, cardiac arrest occurred in approximately 1 in 12,000 patients with a survival rate of 58.4%.[1] The most frequent causes of cardiac arrest in pregnancy include pulmonary embolism, hemorrhage, sepsis, peripartum cardiomyopathy, stroke, preeclampsia, amniotic fluid embolism, and complications related to anesthesia.[1] Cardiopulmonary collapse during pregnancy presents unique clinical challenges and requires timely and multidisciplinary management to optimize outcomes for both the patient and fetus. Modifications to basic and advanced cardiac life support, such as left uterine displacement and intravenous access above the diaphragm are necessary for high-quality resuscitation, and expeditious delivery may be indicated to improve survival of both the patient and neonate. In the event that a pregnant or postpartum patient experiences cardiac arrest, OB/GYN hospitalists are likely to be first responders and therefore should be able to promptly initiate advanced cardiac life support and perform a resuscitative hysterotomy. Additionally, OB/GYN hospitalists can provide leadership to ensure that adequate educational programs, systems, and processes are in place to support and prepare the health care team for this rare, high-acuity clinical situation.

Knowledge

OB/GYN hospitalists should be able to:

• Define maternal mortality and the most common causes of death in the obstetric population.
• List risk factors for sudden cardiac arrest in pregnancy or the postpartum period.
• List the common causes of sudden cardiac arrest in pregnancy and the postpartum period.
• List medications commonly used in obstetrics and gynecology that confer a high risk for contributing to cardiac arrest and discuss their antidotes.
• Discuss clinical signs and symptoms that herald impending cardiopulmonary collapse.
• Describe the anatomic and physiologic changes in pregnancy that are pertinent to cardiac arrest and to resuscitation.
• Discuss the American Heart Association key principles and algorithm for management of cardiac arrest in pregnancy.
• Explain the features of high-quality cardiopulmonary resuscitation (CPR) and the modifications for CPR in pregnant patients.
• Discuss the indications, contraindications, and recommended timing for initiating a resuscitative hysterotomy.
• Discuss the recommendations regarding fetal heart rate monitoring in the setting of cardiac arrest.
• Identify the commonly cited reasons treatment is delayed during a cardiac arrest.
• List the recommended equipment for high-risk cardiac arrest areas of the hospital such as cardiac monitor and defibrillator, medications for resuscitation, scalpel, etc.
• Describe the general principles of management of pregnant and nonpregnant patients after return of spontaneous circulation.

Skills

OB/GYN hospitalists should be able to:

• Elicit a thorough and relevant medical history and stratify patients according to cardiopulmonary risk.
• Diagnose and actively manage prearrest conditions (eg, sepsis, hypertensive emergency, hemorrhage, respiratory distress).
• Diagnose cardiopulmonary collapse.
• Activate adult and neonatal emergency response teams.
• Assess gestational age by fundal height.
• Initiate advanced cardiac life support and provide high-quality CPR with appropriate modifications for the pregnant patient.
• Perform manual uterine displacement with 1- and 2-handed techniques.
• Lead a team in the management of cardiac arrest until the hospital’s code team arrives.
• Perform a resuscitative hysterotomy, optimally within 5 minutes of maternal asystole.
• Assess for and address factors causing or contributing to arrest such as bleeding, pulmonary embolus, or medication toxicity.
• Stabilize the surgical site after restoration of spontaneous circulation.
• Engage consultants and coordinate a multidisciplinary approach,including the patient, those who support the patient, anesthesiologists, critical care specialists, nursing staff, and other specialists when indicated.
• Conduct end-of-life discussions and maintain an open dialogue with family members.
• Debrief with team members and ensure documentation in the medical record is consistent and complete.

Self-Awareness and Collaborative Attitudes

OB/GYN hospitalists should be able to:

• Demonstrate the principles of crew resource management and team communication.
• Apply a multidisciplinary approach that focuses both on resuscitation of the patient, regardless of gestational age, and the fetus at or beyond periviability.
• Collaborate and communicate effectively within a multidisciplinary team, including the patient, those who support the patient, anesthesiologists, critical care specialists, nursing staff, and other specialists.
• Maintain awareness of the common barriers to care and avoid delays in initiating CPR and resuscitative hysterotomy.
• Adhere to the American Heart Association guidelines and expert recommendations for basic life support and advanced cardiac life support.

System Organization and Improvement

OB/GYN hospitalists should be able to:

• Lead, coordinate, and/or participate in efforts to ensure certification and training of staff, including OB/GYN hospitalists, in basic life support and advanced cardiac life support for pregnant and nonpregnant patients.
• Lead, coordinate, and/or participate in educational programs regarding cardiopulmonary arrest, including in-situ simulation, in all clinical areas caring for women during pregnancy and the postpartum period.
• Lead, coordinate, and/or participate in the development and implementation of safety protocols for prearrest conditions to decrease the risk of cardiac arrest (eg, sepsis, hemorrhage, hypertensive emergency).
• Implement systems to ensure availability of equipment for emergent cesarean deliveries in all high-risk areas of the hospital.
• Lead, coordinate, and/or participate in research to better characterize at-risk populations and responses to safety protocols with regard to maternal mortality.
• Champion efforts to improve the health of vulnerable populations to reduce the overall incidence of cardiac arrest in the obstetric population.
• Conduct multidisciplinary reviews of all cases of maternal mortality or significant maternal morbidity, including cases of maternal cardiac arrest.

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