In-Hospital Cardiac Arrest in Pregnancy Algorithm

The video below provides a comprehensive visual walkthrough of the In-Hospital Cardiac Arrest in Pregnancy algorithm. Watching this breakdown helps bridge the gap between written steps and real-time clinical application during high-stress resuscitations.

Goals for the Management of Cardiac Arrest in Pregnant Patients

In terms of effective management cardiac arrest in a pregnant patient requires unique physiological considerations. The primary rationale involves relieving aortocaval compression (which impedes blood return to the heart) and executing rapid team planning to potentially deliver the fetus, thereby saving the mother’s life (AHA Guidelines). The responder must succeed in the following goals to successfully manage cardiac arrest in pregnant patients:

• Recognizing the rhythms of cardiac arrest: ventricular fibrillation, ventricular tachycardia, Pulseless Electrical Activity (PEA), and asystole (flatline).
• Recognizing the Hs and Ts (reversible causes) as possible causes of cardiac arrest.
• Appropriately intervening in the cardiac arrest, depending on the cardiac arrest rhythm.
• Remembering that there are two lives involved in this scenario—both mother and unborn child.

Cardiac Arrest in a Pregnant Patient Algorithm Explained

This algorithm was created to present the steps for assessing and managing pregnant patients presenting with cardiac arrest symptoms. The following breakdown guides you from initial emergency response (Box 1) through potential perimortem cesarean delivery and neonatal care (Box 8).

Note: This algorithm walkthrough is intended as an educational reference for emergency cardiovascular care. Clinical practice should always align with your specific institutional protocols and the latest American Heart Association (AHA) guidelines.

A pregnant patient experiencing cardiac arrest has two lives at stake.

Box 1: Initial BLS and ACLS Actions

The team provides high-quality cardiopulmonary resuscitation (CPR) and rapid defibrillation, using an automated external defibrillator (AED) or manual defibrillator, to resuscitate the pregnant patient in cardiac arrest and follows other ACLS interventions as appropriate. These rapid initial actions stabilize the patient and lead directly into the critical decision point: determining if the cardiac rhythm is shockable or non-shockable.

Box 2: Notifying Resuscitation Teams

The critical difference in this maternal resuscitation is that maternal and neonatal teams are simultaneously present to care for the mother and newborn. A comprehensive maternal cardiac arrest team roster should include:

• Code Team Leader
• Anesthesiologist (specializing in obstetric anesthesia)
• Physicians from obstetrics gynecology
• Neonatologist
• Emergency department (ED) nurses, ICU nurses, and Obstetric Nurses (along with prehospital emergency medical services if the arrest occurred outside the hospital setting)
• Pharmacists and Respiratory Therapists

Box 3: Determining Etiology of Arrest

During the arrest, the team attempts to identify and treat the cause[cite: 208, 209].

Possibilities follow the A to H framework:

• Anesthesia complications
• Bleeding / Blood loss
• Cardiovascular issues (e.g., an acute myocardial infarction or a prior history of myocardial infarction)
• Drugs
• Embolus (e.g., amniotic fluid embolism or pulmonary embolism)
• Fever
• General causes (the standard Hs and Ts)
• Hypertension (e.g., severe preeclampsia or eclampsia)

A potential cause for cardiac arrest could be anesthesia complications.

Box 4: ACLS Interventions for the Mother

Airway: The team provides 100% oxygen to the mother through a patent airway. Because physiological changes in pregnancy, such as a relaxed lower esophageal sphincter (which makes the esophageal sphincter less competent and increases the risk of aspiration), create a high risk for a difficult airway, the most experienced team member must obtain and maintain the airway.

IV Access: A skilled member initiates an IV above the level of the mother’s diaphragm. This is crucial because aortocaval compression from the gravid uterus can block venous return from the lower extremities, rendering lower-extremity IV lines ineffective during arrest (AHA Guidelines).

Medication Reversal: If the mother is receiving magnesium sulfate (commonly used for eclampsia) and magnesium toxicity is the suspected cause of the arrest, the team discontinues that infusion and administers calcium chloride or calcium gluconate to reverse the toxicity.

Because magnesium toxicity is a specific reversible cause of maternal cardiac arrest (especially in patients treated for preeclampsia), understanding its administration and reversal is vital. The video below reviews Magnesium as an ACLS medication.

Box 5: Ongoing CPR and Rhythm-Based ACLS

Unlike the initial actions in Box 1, this phase represents the continuous loop of assessment. The team continues to provide high-quality CPR and other ACLS interventions as appropriate, cycling through rhythm checks, shocks (if indicated), and medication administration.

Box 6: Obstetric Interventions

As team members are providing ACLS interventions, the obstetrics team detaches any fetal monitors, maintains left uterine displacement (LUD) to ensure manual aortocaval decompression, and prepares for the infant’s delivery by emergent cesarean section.

Box 7: Cesarean Section Delivery

If the mother does not achieve ROSC, the team leader must prepare for an immediate perimortem cesarean delivery (PMCD), with the strict goal of delivering the infant within 5 minutes of maternal arrest (AHA Guidelines). Feasibility depends on the immediate availability of the obstetric/surgical team and appropriate equipment.

Box 8: Transferring Care of Neonate to Neonatal Team

Following delivery, the neonatal team assumes care of the infant. The code leader should ensure a rapid handoff is completed, allowing the maternal team to resume focus on stabilizing the mother while the neonatal team initiates independent neonatal resuscitation efforts.

Once the infant is delivered, resuscitation protocols drastically shift. The video below covers the essentials of Neonatal BLS, which the specialized neonatal team will utilize immediately upon handoff. If you are part of a team responding to maternal codes, completing your NRP Certification is highly recommended.

Frequently Asked Questions

Why perform a Perimortem Cesarean Delivery (PMCD) or perimortem cesarean section in maternal cardiac arrest?

The primary goal of a PMCD is not solely to save the infant, but to relieve aortocaval compression caused by the gravid uterus. Emptying the uterus significantly improves maternal venous return, making CPR more effective and increasing the mother’s chances of achieving ROSC.

What defines a gravid uterus likely to cause aortocaval compression?

Aortocaval compression generally becomes clinically significant when the uterus reaches the level of the umbilicus, which typically occurs around 20 weeks of gestation.

Does defibrillation change in pregnancy?

No, defibrillation doses and pad placement remain the same for pregnant patients. It is a safe and critical intervention for shockable rhythms. Ensure fetal monitors are removed prior to shocking to avoid electrical arching.

What is the epinephrine timing in nonshockable rhythms?

For nonshockable rhythms (PEA/asystole), epinephrine should be administered as early as possible, and repeated every 3 to 5 minutes, following standard ACLS protocols.

Summary

Responding to maternal cardiac arrest demands speed, clear communication, and concurrent team workflows. Additionally, if the arrest was triggered by extreme cold exposure (hypothermia cardiac arrest), or if the mother achieves ROSC and requires targeted temperature management (therapeutic hypothermia), specialized protocols must be enacted carefully to protect the fetus. Your top priorities remain initiating high-quality CPR with LUD, establishing an airway, identifying the rhythm, and preparing for delivery by the 5-minute mark. Use the algorithm graphic, video assets, and PDF links on this page to train your multidisciplinary teams and refine your in-hospital code protocols.

Other Pregnancy Emergencies

Not all maternal emergencies lead to cardiac arrest. The following video covers the 2020 AHA/ILCOR guidelines for treating a choking pregnant woman, highlighting the shift from abdominal thrusts to chest thrusts.