Maternal Resuscitation

Begin basic life support (BLS).

Assess scene safety, check responsiveness and breathing, and call for help (call a code, including alerting the c-section team if at least 20 weeks in gestation).

1. C. (Open airway with hand on forehead and extending neck while) Checking a carotid pulse for circulation assessment, and if no pulse begin chest compressions. If the patient is pregnant and at least 20 weeks in gestation, manually displace the uterus (or place her in a 30° left lateral tilt), and begin chest compressions just above the midline of the sternum, and because of decreased chest wall compliance, increase the amount of pressure used for chest compressions.
2. A. Assess and open the airway, and provide 100% oxygen if available.
3. B. Assess breathing and begin positive pressure ventilation with 100% oxygen.
4. D. Make sure that the defibrillator and crash cart are on their way, with planned early defibrillation as indicated for abnormal rhythm.

Proceed to advanced cardiac life support (ACLS).

Defibrillate early as indicated!

1. A. Secure the airway by intubating if unable to ventilate adequately with bag/mask, prolonged resuscitation, or anticipating perimortem Cesarean section. As this patient is pregnant, intubate with a smaller ET tube, 6-7 mm as opposed to a 7-8 mm ET tube for usual adult intubation.
2. B. Confirm successful intubation and effective ventilation by auscultating both lungs with a stethoscope, placing a CO2 detector on the ET tube and/or using a pulse oximeter, and ordering a post ET tube placement chest x-ray.
3. C. Support the circulation with the placement of 2 large bore (16-18-gauge) IV above diaphragm.
4. D. Determine rhythm and defibrillate “defibrillatable” rhythms, administer ACLS drugs as indicated, consider the potential arrest differential (including the obstetric arrest differential), order appropriate diagnostics (including labs, EKG, ultrasound, and x-ray), and make sure that the 4 T’s/tubes are in place (ET tube, NG tube, IVs, and Foley catheter).

Proceed to the fetal survey.

Assess fundal height and fetal presentation.
Assess fetal heart tones and uterine contractions (with placement of the 2 belts – that need to be removed for any defibrillation).
Vaginal assessment for vaginal bleeding, amniotic fluid, and cervical dilatation.

After completing the maternal and fetal surveys, administering 1-2 rounds of ACLS drugs, 4 minutes will have elapsed, at which time if spontaneous maternal circulation has not been reestablished a perimortem cesarean section should be considered if the fetus is at least 20 weeks in gestation, and facilities and personnel are available for the procedure and post-op care.

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BLS in Brief

Rescue breathing (without compressions) is a single breath every 5-6 seconds (10-12 per minute)
Respirations/minute (with compressions) = 6-10
Compressions/minute = 100-120
Compressions:Respirations ratio = 30:2, and 10:1 once intubated.
Compression depth (inches) = At least 2 inches

Maternal Resuscitation Equipment Sizes

Mask size = 3
ET tube size (mm) = 7-8 (smaller preferable in pregnancy)
Laryngoscope blade size = 3-4
NG/foley = 12+
Nasopharyngeal airway – lubricate & measure size from nostril to tragus.
Oral airway – measure size from mouth to angle of mandible.

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ACLS in Brief

Ventricular Fibrillation and Pulseless Ventricular Tachycardia

Shock at 200-360J (360 if monophasic, 120-200 if biphasic) every 2 minutes.
Epinephrine 1:10,000, 1 mg IV/IO every 3 to 5 minutes.
Amiodarone 300 mg IV/IO, repeat every 10 min at 150 mg if persistent VF/PVT, max of 2.2 gm/24 hrs.  Follow with continuous IV infusion if successful.
Lidocaine 1-1.5 mg/kg IV/IO, repeat every 5-10 minutes at 0.5-0.75 mg/kg if persistent VF/PVT, maximum of 3 mg/kg total.  Follow with continuous IV infusion if successful.
MgSO4 1-2 g in 10 mL D5W IV/IO over 5-20 minutes for torsades or hypomagnesemia.
Bicarbonate 1 mEq/kg for hyperkalemia or tricyclic toxicity.

Asystole and Pulseless Electrical Activity (PEA)

Epinephrine 1:10,000, 1 mg IV/IO every 3 to 5 minutes.

Bradycardia

Transcutaneous pacing – especially if high degree A-V block (Type II 2^nd degree or 3^rd degree).
Atropine 0.5 mg IV/IO every 3 to 5 minutes up to a maximum of 3 mg.
Epinephrine drip 2-10 mcg/min.
Dopamine drip 2-10 mcg/min.

Tachycardia (Non-VF/PVT)

If unstable, synchronized cardioversion at 100J (50J for SVT/atrial flutter) up to 360J with successive shocks as needed.

If stable, and wide QRS (≥ 0.12 sec) or irregular rhythm, consult and if single QRS form consider adenosine trial and/or amiodarone or procainamide or sotalol; and for polymorphic QRS, consider synchronized shock and consultation.  (Magnesium 1-2 gm for torsades).

If stable, and narrow QRS, and regular rhythm:
Vagal maneuvers.
Adenosine 6 mg IV push, may repeat x 2, q. 1-2 minutes at 12 mg.
Verapamil 2.5-10 mg or Diltiazem 10-25 mg IV if healthy, and if CHF or LV failure or beta-blocker use consider digoxin or amiadarone or cardioversion in consultation.

Search for cause:

Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/hyperkalemia, Hypoglycemia, Hypothermia.
Toxins, Tamponade, Tension pneumothorax, Thrombosis (PE, MI, CVA), Trauma.

Obstetric cause:

Hemorrhage, Hypertension (Eclampsia/preeclampsia, HELLP), Heart (cardiomyopathy and magnesium toxicity).
Amniotic fluid embolism (or regular PE), Anesthesia complications, Aortic dissection.

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Mnemonic: BE CAREFUL or BEE CCCAAARREEFUL, which is a variation on the ALSO course CAREFULly mnemonic

Bladder empty & IV
Educate patient and your assistant(s), and prepare your Equipment (delivery pack, & Piper forceps)
Cervical dilation, presentation (U/S prn), rule out Cord prolapse, and Call for help (including notifying surgical and neonatal teams)
Await umbilicus and the popliteal area of the knees, Assisting leg delivery (Pinard maneuver) as needed once popliteal fossae visible, loosen umbilical cord, then wrap in blanket/towel and supporting the hips/pelvis ensure sacrum Anterior
Rotate and Remove arms (Loveset’s maneuvers) as needed once tips of scapulae visible
Enter x 2 for Mauriceau-Smellie-Veit (MSV) maneuvers (occiput and cheeks) as needed once nape of neck visible, and Episiotomy as needed
Flex head as part of MSV maneuver
(back) Up (sacrum anterior)
Lift baby onto mother

More detailed description of breech vaginal delivery:

1. Notify NICU/baby support and C/S staff at standby.
2. Educate patient about options and the imminent event.
3. Prepare two assistants to apply suprapubic pressure, facilitate McRobert’s maneuver, and hold the elevated baby in a towel while applying Piper forceps (the second assistant may also assist in holding/supporting the first/left blade while the second/right blade is being placed).
4. Ensure adequate instrumentation, usual delivery pack & Piper forceps.
5. Lithotomy position.
6. Verify presentation and cervix completely dilated.
7. Bladder catheterization.
8. Allow baby descent until hips and lower back are fully exposed and umbilicus is presenting at introitus, supporting the breech as it presents. If the legs do not deliver spontaneously, perform the Pinard maneuver.  The Pinard maneuver is accomplished by inserting two fingers along the inner aspect of the one thigh sliding down to the knee, which is then pushed/pulled away from the midline (abducting the hip) at the same time as flexing the leg at the hip. This causes spontaneous flexion of the knee and delivery of the foot.  Do not attempt to extract the legs until the popliteal fossae are visible.  Episiotomy may be performed once the hips and genitalia have fully delivered over the perineum.
9. Gently loosen cord if tight.
10. Wrap baby in warm towel.
11. Hold/support the baby by its pelvis/hips with thumbs on the upper buttocks (do not hold the baby by the flanks or abdomen due to risk of intra-abdominal injury) until the scapulae are visible. Maintain flexion of the fetal head by keeping the body below the horizontal plane of the mother.
12. Once scapula tip is visible, deliver anterior shoulder/arm by running finger over the shoulder down to the elbow, and then flexing the elbow to deliver the arm. May use Loveset’s maneuver to facilitate arm delivery by holding onto baby pelvis, applying downward traction and rotating the posterior shoulder anteriorly, delivering the now anterior shoulder, and then rotating the posterior shoulder anteriorly to deliver the second arm (Loveset’s maneuver 2). Loveset’s maneuver 3 is used to deliver a posterior shoulder when an anterior shoulder will not deliver, and it involves holding the baby ankles and elevating the baby up and parallel to the mother’s inner thigh on the opposite side of the posterior shoulder to be delivered, and then deliver the posterior shoulder by again sweeping along the top of the shoulder down to flex the elbow for arm delivery. The baby’s body is then brought back down to deliver the remaining anterior shoulder.
13. Once nape of neck is visible, deliver the head with the Adapted/Modified Mauriceau-Smellie-Veit (MSV) maneuver:

• Lay the baby face down with the length of its body over your arm and hand.
• Place the index and middle fingers of this hand on the baby’s cheek bones, applying pressure to flex the baby’s head.
• Place the other hand on the baby’s upper back such that the index and ring finger go over the top of baby’s shoulders (enabling these fingers to help apply gentle outward traction on the baby), while the middle finger goes up on the baby’s occiput to additionally facilitate neck/head flexion.
• Gentle traction is then applied while raising the whole body of the baby no more than 45 degrees above the mother’s horizontal plane, delivering the face followed by the head and occiput.

Or the Burns-Marshall method where the feet are grasped and with gentle traction swept in a slow arc over the maternal abdomen (avoid extreme elevation of the body, as this may cause hyperextension of the cervical spine), allowing the head to deliver itself as the head and neck are flexed by the process of elevating the baby’s body by its feet.

Or with the use of Piper forceps applied as follows:

–    the baby’s body is elevated to 45 degrees using a warm towel wrapped around the baby’s body (the towel can be held by an assistant) and the left blade (on the mother’s left side) of the forceps is applied to the baby’s head. The left blade is held by the operator’s left hand while the operator’s right hand is placed between the mother’s left vaginal wall and the baby’s head, with the blade then slid inside of the operator’s right hand, and with the blade between the operator’s hand and the baby’s head.
–    right blade is applied with the body still elevated (by one hand of the assistant who may also be asked to hold the handle of the left blade while the right blade is being placed by the operator), with the right shank then sitting above the left shank enabling the locking of the shanks. As with the left blade, the right blade is inserted in a similar fashion, with the operator using their right hand to hold the blade and left hand to guide the vaginal insertion.
–    forceps delivery of the head is completed, with the operator’s one hand pulling the baby’s feet outward at 45 degrees (or the baby’s body may be allowed to rest on the shanks and handle of the forceps), while the other hand pulls and elevates the forceps handles slightly, but not with the handles or blades beyond the horizontal plane

If cervix entrapment of the fetal head is occurring, consider performing a Dührssen cervical incision by cutting the cervix, or to relax the uterus/cervix, sublingual nitroglycerin (400-800 mcg) or intravenous nitroglycerin (50-250 mcg boluses up to a maximum total of 500 mcg) may be administered.

Suprapubic pressure (component of the Bracht maneuver, which is similar to the Burns-Marshall method mentioned above) applied by an assistant with any of the above methods may assist in delivery of the baby’s head.

If the above methods fail to deliver the after-coming head, symphysiotomy or delivery by rapid caesarean section is advised.  Rapid C-section may facilitate vaginal delivery or abdominal delivery if preceded by the Zavanelli maneuver, where the baby’s body is replaced back within the uterus +/- use of a tocolytic (terbutaline or MgSO4).

Assisted Vaginal Delivery, Vacuum vs Forceps

Mid forceps or vacuum – head engaged, but above +2 station.
Low forceps or vacuum – +2 station or lower.
Outlet forceps or vacuum – fetal scalp visible between contractions and sagittal suture within 45° from the AP midline (may be over OA or OP presentation).

These vacuum and forceps mnemonics are from the ALSO course

Vacuum

A – Ask for help, Address the patient, Anesthesia adequate
B – Bladder empty
C – Cervix completely dilated
D – Determine fetal head position, and think shoulder Dystocia (review HELPERR pneumonic)
E – Equipment ready (vacuum and delivery equipment)
F – apply cup 3 cm anterior to the posterior Fontanelle over what is called the “Flexion point”, which places the posterior edge of the cup over the posterior fontanelle.
G – Gentle traction
H – Halt traction between contractions, and reduce vacuum pressure to 100 mm (4 inches) Hg between contractions, and increase pressure to 400-600 mm (15-23 inches) Hg during times of traction.  Halt the procedure if cup disengagement 3 times, no progress after 3 consecutive pulls, no baby within 20 minutes of onset of procedure, any concern about fetal or maternal injury or distress, especially if vaginal delivery not imminent.
I – Incision/consider episiotomy
J – remove the vacuum as the Jaw presents.

Forceps

(Simpson for routine vaginal delivery, Piper for breech)

A – Ask for help, Address the patient, Anesthesia adequate
B – Bladder empty
C – Cervix completely dilated
D – Determine fetal head position, and think shoulder Dystocia (review HELPERR pneumonic)
E – Equipment ready (forceps and delivery equipment)
F – Forceps ready – Position For Safety vs Safety For Position – Sutures (lambdoidal sutures immediately above the upper blade, and the sagittal suture in the midline between the blades), Fenestrations should be just barely palpable and admit no more than one finger tip, Posterior fontanelle should be midway between the shanks and 1 cm above the plane of the shanks (which connect the blades to the handle).
G – Gentle traction
H – Handle manipulated with Pajot’s maneuver (posterior pressure over shanks while pulling on handles) with “J-shape” trajectory.
I – Incision/consider episiotomy
J – remove the forceps as the Jaw presents.

Shoulder Dystocia

Mnemonic: HLPERER(R) is a revised and reordered version of the ALSO course HELPERRRR mnemonic

H – call for help
L – legs (McRoberts maneuver)
P – suprapubic pressure (Rubin’s 1 maneuver)
E – enter/internal rotation maneuvers (single-handed Rubin’s 2 maneuver with pressure behind the anterior shoulder, two-handed Woods screw maneuver goes in the same direction as the Rubin’s 2 maneuver, and/or single-handed Reverse Woods screw maneuver with pressure behind the posterior shoulder.
R – roll the patient onto all fours (remember that delivering the anterior shoulder now requires an elevation of the baby’s head, with the mother on all fours)
E – episiotomy
R– remove the posterior arm

Other:  Repeat any or all of above maneuvers, and consider symphysiotomy, anesthesia +/- vaginal delivery vs Zavanelli maneuver and abdominal delivery.

Eclampsia/Pre-eclampsia

Mnemonic:  C BAVILCUS DDT

Call for Help (baby & delivery support)
Baby gestation and FHT (and tocometer)
Airway support, position, suction, protection
Vitals, frequent BP & Pulse, consider O2 need
IV and IV meds* (Mg, BP med prn, +/- additional seizure med), and foley
Labs: Preeclamptic and metabolic labs (CBC with platelets, AST, U/A, 24hr urine protein and creatinine or spot urine protein/creatinine ratio (if pt normally active, should be <0.19), creatinine, BUN, uric acid, (if suspect HELLP, acute fatty liver, severe preeclampsia features, or if bleeding, peripheral smear, bili, LDH, albumin, fibrinogen, FSP, PT/PTT, & D-dimer) and consider urine toxicology/drug screen, Mg level, and brain imaging
Cervix check for delivery assessment
U/S prn
Diagnosis/differential: Eclampsia/preeclampsia, Trauma, Primary Seizure disorder, Metabolic disorder, Infection, other Brain pathology
Delivery need and mode
Transfer prn

*Initial medication doses:
Magnesium sulfate 4-6 gm IV bolus over 10 minutes, then maintenance rate of 2 gm/hour (add 2 gm bolus for second seizure.
Initial dose of labetalol 20 mg IV (10-80 mg IV q 10-20 min to max of 300 mg total IV dose; 100-400 mg po bid/tid to max 2400 mg/24 hrs).
Initial dose of hydralazine is 5 mg IV (2.5-10 mg IV q 20 min to max 50 mg total IV dose; 10-50 po q 6 hrs to max 200 mg/24 hrs)
or
Initial dose of nifedipine 10-20 mg SL/p.o. q 20 min up to max 40 mg; or 30-40 mg po q 8 hrs up to max 120 mg/24 hrs (risk of hypotension with MgSO4!)
Goal to maintain D.B.P.<100. Avoid rapid BP drops!

Post-Partum Hemorrhage

Active management of the third stage of labor

Oxytocin with delivery of anterior shoulder
(Delay cord clamping if baby does not need immediate assistance)
Gentle umbilical cord traction
Uterine massage before and after placental delivery

Postpartum hemorrhage – >500 ml in vaginal delivery

Mnemonic: See MILK, spelled CEMMIILC

Call for help (nursing to surgeon/obstetrician and anesthesia), follow vitals (BP, pulse, & O2 sat), record blood loss, & keep patient warm
Etiology – 4 Ts (Tone, Trauma, Tissue, and Thrombin) from the ALSO course refers to uterine atony, tissue injury, retained tissue, and coagulopathy
Massage – (uterine) progressing rapidly to bimanual uterine massage
Medications –  oxytocin, methylergonovine, carboprost, misoprostol, & tranexamic acid
IV – placement of 2 large bore IVs, fluids vs transfusion (massive transfusion protocol if blood loss >1500 ml, bleeding is ongoing and patient is symptomatic), & foley prn
Interventions – inspect & explore genitals, vagina, cervix, & uterus (and placenta) and repair, replace (for uterine inversion), and/or remove (manual uterine exploration vs uterine U/S for POC), then stop bleeding with uterine tamponade balloon vs packing, surgical interventions (D&C, B-Lynch/compression sutures, uterine artery ligation, hysterectomy) vs uterine artery embolization, and ICU or tertiary transfer +/- MAST suit
Labs – hemoglobin, type and screen/crossmatch, and coagulation studies
Communication – with family & other team members, & post event documentation

Post-Partum Hemorrhage Medications

(If the table below is not easily viewed upright, try turning your device sideways!)

Umbilical Cord Prolapse

Mnemonic:  C BAVILCUS DDT

Call for Help (baby & delivery support)
Baby gestation and FHT (and tocometer) – if contracting, consider terbutaline/tocolytic administration.
Amniotic fluid clear?
Vitals, frequent BP & Pulse, consider O2 need
IV early, and foley (consider placing 500 ml, begin draining just prior to or when initiating C/S incision)
Labs: Hgb, T & S
Cervix check – keep examining hand in place with fetal head elevation until C/S ready for baby removal, and consider Trendelenberg or maternal hands & knees position if unable to easily restore fetal heart tones with baby head elevation in lithotomy position
U/S not needed
Diagnosis cord prolapse
Delivery needed by C/S
Transfer to OR

Newborn Resuscitation

1. Prior to birth: Gestation/Term, Meconium, Risk factors (Maternal, pregnancy, and labor), Umbilical cord management plan?
2. Review Neonatal Resuscitation Preparation and therefore ensure needed equipment, using mnemonic: WISPIE for Warmer on (include blankets/towels, baby hat, bulb suction, cardiac monitor, pulse oximeter, temperature sensor, stethoscope, plastic bag/wrap or thermal mattress if <32 weeks, and turn up room temperature prn – 22 deg C or 72 deg F for term babies, and 23-25 deg C or 74-77 deg F if preterm, with temperature sensor baby goal temp of 36-36.5 C or 97-98 F) , Intubation equipment (ET size and length, stylet, laryngoscope blade size, ET suction tube size, CO2 detector, tape, scissors, and size 1 supraglottic airway (LMA or i-gel for >32-34 wks or >1.5-2 kg)), Suction on and at 80-100 mg Hg (bulb suction, ET suction tube, 10 or 12 F suction tube for mouth and nose, orogastric 8F suction tube with 20 ml syringe, and meconium aspirator), Positive pressure ventilation (PPV set-up, including mask size, initial PIP, PEEP, and pop-off pressure settings, and O2 blender and flowmeter settings – FIO2 of 21% if >=35 weeks, and 21-30% if <35 weeks at 10 L/min), IV (set up including umbilical catheter size to be used, tubing and calculated 10 ml fluid/kg), Epinephrine (dose calculated with easy syringe and medication access) and Naloxone prn.
3. At birth: Gestation/Term appearance, Tone, Breathing?
4. If non-vigorous baby (poor respiratory effort, poor muscle tone, or heart rate <100): Warm, Dry, Stimulate, Position, and Suction prn; then if persistently non-vigorous begin PPV:

PPV at 40-60 breaths/min (“breathe, 2, 3, breathe . . . “) x 15-30 seconds, then pulse check.

PPV first breath 25 cm H2O (20 cm if preterm), then 15-20 cm H2O for normal lungs or 20-40 cm H2O for diseased lungs.

When starting PPV: 

Add 2^nd person (call for help) for resuscitation

• Use stethoscope to auscultate lungs to verify successful ventilation
• Place pulse oximeter
• Place ECG to follow heart rate

If no chest movement or failed ventilation with PPV or HR not increasing:  Mr. SOPA mnemonic from NELS

• M = Mask adjustment, R = Reposition airway, then PPV attempt
• S = Suction mouth then nose, O = Open mouth to ventilate, then PPV attempt
• P = Pressure increase, then PPV attempt
• A = Airway alternate, ET vs LMA

PPV before naloxone use in maternal narcotic dependency, as risk of inducing withdrawal seizures.

After PPV, consider CPAP 5 cm H2O (esp. if labored breathing) and OG tube for stomach suctioning.

5. Intubate or supraglottic airway

After 30 seconds of good PPV

• And HR<100 and not increasing
• And/or when initiating chest compressions

– 30 sec per intubation attempt

After intubating or supraglottic airway (ET)

• Use stethoscope to auscultate lungs and stomach
• Secure ET with tape at lip-to-tip cm
• Place CO2 detector, pulse oximeter, & ECG
• Order post-placement CXR

6. Chest compressions

after 30-60 sec of PPV and HR<60

• 90/min (ventilations 30/min)
• “1 and 2 and 3 and breathe . . . “
• For 60 seconds, then pulse check

When starting chest compressions: 

Add 3^rd person (call for help) for resuscitation

• Increase O2 to 100%
• Intubate or supraglottic airway if not already done
• Place UVC and/or IV

7. Epinephrine 1:10,000 – given rapidly

• if HR<60 after 60 seconds of compressions
• UVC/IV/Intraosseous 0.2 ml/kg
• ET 1 ml/kg
• Repeat every 3-5 minutes
• Dilute/follow epi with 3 ml NS
• Pause compressions for heart rate check 1 minute after epi administration