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Lola Olabode

July 30, 2020 Last Updated: February 23, 2021

Performing CPR and Using an Automated External Defibrillator (AED) on Pregnant Women

Maternal cardiac arrest, when pregnant women suffer from Sudden Cardiac Arrest, is a large and growing problem in the United States. It is important to learn about this issue and the actions that you can take to save potentially two lives at once!

CPR in Pregnancy

If a pregnant woman suffers cardiac arrest, you want to perform the same three life-saving actions that you would for anyone else. Specifically, you need to call 911, perform CPR, and use an AED to restart the heart. These three simple actions are described below and in the Call-Push-Shock guide.

Please note that, while the Call-Push-Shock guide advises performing hands-only CPR on cardiac arrest victims, it is recommended that pregnant women receive traditional CPR with chest compressions and rescue breaths. See below for more information about CPR in pregnancy.

CALL – Step 1: Recognize Maternal Cardiac Arrest & Call 911

Recognizing cardiac arrest in a pregnant person is the same as with anyone else. Check for responsiveness and normal breathing. If they are not responsive and not breathing normally, assume that they are in cardiac arrest. You need to immediately call 911, start CPR, and have someone get an AED. When calling 911, make sure to inform the telecommunicator that the patient is pregnant.

PUSH – Step 2: Perform CPR on Pregnant Women

While 911 is being called, begin performing CPR.

Lay the woman on their back (called the “supine position”) on a flat and hard surface such as the floor
Press hard and fast in the center of their chest. You should push their chest down 2 inches with each compression. Perform compressions at a rate of 100-120 beats per minute. Use the beat of a familiar song, such as Stayin’ Alive by the Bee Gees, to keep the right pace!
After 30 compressions, give 2 rescue breaths
Immediately restart compressions
Continue this sequence until the AED or Emergency Medical Services arrive

SHOCK – Step 3: Use the AED to Restart Their Heart

As soon as the AED unit arrives, power on the device and listen to its instructions. The AED will tell you what to do.

AEDs are designed to read a person’s heart rhythm and determine whether a defibrillation “shock” is needed to restart the heart. If a shock is advised, then the device will charge and deliver the shock. If a shock is not advised, then the AED unit will tell you to continue performing CPR.

Maternal Cardiac Arrest

For expecting mothers – inundated with concerns such as pregnancy loss, preeclampsia, or gestational diabetes – maternal cardiac arrest is probably what they least anticipate. Although many pregnant women may not encounter such a complication, it is still plenty threatening.

What is Cardiac Arrest and Why is it Dangerous?

Cardiac arrest occurs when the heart stops beating properly. Consequently, the heart is no longer able to deliver oxygen-rich blood to the brain and other vital organs.

Without oxygen, a person in cardiac arrest is clinically dead, and will remain so, unless they receive treatment immediately. While high-quality CPR can artificially keep the blood pumping, an AED machine is needed to restart the heart. By delivering a defibrillation “shock” to a person in cardiac arrest, an AED can make the heart start beating normally again. Every minute that a person in sudden cardiac arrest does not receive a shock from an AED defibrillator, their chances of survival decrease by 7-10%.

Pregnant women are particularly vulnerable to oxygen deprivation caused by cardiac arrest. During pregnancy, the fetus requires significant amounts of oxygen from the mother. In fact, women experience a 20% increase in oxygen consumption and a 40% increase in cardiovascular metabolism to accommodate the fetus. Altered levels of hormones like progesterone and estrogen during pregnancy can also restrict air passages and exacerbate the dangers associated with maternal cardiac arrest. These physiological changes, in combination, make cardiac arrest an especially life-threatening condition in pregnant women. Therefore, when pregnant women suffer from sudden cardiac arrest, it is critical to perform high-quality CPR with rescue breaths and use an AED immediately.

Maternal Mortality is Increasing in the United States

According to an AJOG report, “while the global maternal mortality ratio (maternal deaths/100,000 live births) has decreased in the last 25 years from 281.5- 95.7, the maternal mortality ratio has actually increased from 16.9- 26.4 in the United States.”

As Dr. Carolyn Zelop, a leading maternal-fetal medicine specialist, states, “maternal mortality has gone up by more than 50% since 2000.”

Given this increase in maternal mortality, the AJOG report calls for mandating maternal CPR to improve the survival of pregnant women in hospital settings.

Outside of the hospital, pregnant women who suffer cardiac arrest also need CPR and treatment from an AED machine. Women are already 27% less likely than men to receive CPR outside of the hospital. These known disparities suggest that pregnant women likely receive even less bystander CPR because responders are plausibly concerned about inflicting harm. Therefore, it is critical to stress the importance of both CPR and life-saving shocks from an AED for pregnant women who suffer cardiac arrest.

How Common is Maternal Cardiac Arrest?

Although maternal cardiac arrest is more rare than some pregnancy-related conditions, it still affects a large number of women in the United States and globally.

An American Heart Association report, on which Dr. Zelop is the second author, paints a grim picture. The report details that 1 in 12,000 women admitted for delivery in the United States suffer from sudden cardiac arrest.

The overall number of women affected by this condition is likely larger due to maternal arrests that occur outside the hospital. Additionally, many hospitals in the United States lack systems for reporting maternal cardiac arrest incidents.

Why do Pregnant Women Suffer from Cardiac Arrest?

While there are a variety of factors that place expecting mothers at risk of cardiac arrest, the causes of this condition can be divided into three categories: obstetric, non-obstetric, and iatrogenic.

Obstetric causes include hemorrhage, eclampsia, and amniotic fluid embolism.
Some prominent non-obstetric causes are sepsis, pulmonary embolism, preexisting cardiovascular disease, and stroke.
Iatrogenic causes prominently include anesthetic complications during delivery or testing. According to a UK study, complications due to anesthesia cause one in four cardiac arrests in pregnant women. The 2018 AJOG publication cited anesthesia as one of the leading causes of maternal cardiac arrest.

Given the risks associated with anesthesia, certain guidelines should be followed in the event of maternal cardiac arrest. Specifically, intubation for anesthetic care can hinder timely CPR and resuscitation when pregnant women go into cardiac arrest. Therefore, CPR must be prioritized over intubation.

Important Takeaways

The intention of this report is not to produce fear but rather promote education and preparedness. It is commonly misperceived that pregnant women suffering from sudden cardiac arrest should not receive resuscitation with CPR and defibrillation shocks from an AED. However, the standard protocol for resuscitation remains largely unchanged for pregnant women who suffer cardiac arrest outside of the hospital. It is expected that pregnant women receive the same quality CPR and AED shocks as anyone else. Defibrillation should be administered to pregnant women since it is not known to pose any significant risk to the mother or the fetus. Therefore, upon observing maternal cardiac arrest outside the hospital, a responder should immediately call 911, lay the mother on her back, open her airway, check for the absence of breathing, and perform CPR by alternating between 30 chest compressions and 2 rescue breaths. A responder should also use an AED to restart the heart and continue CPR until emergency medical services arrive.

AHA Algorithm for Advanced Maternal Resuscitation

Maternal cardiac arrest is uniquely complicated because both the mother and fetus are patients. As Dr. Carolyn Zelop, a leading maternal-fetal medicine specialist, explains, “with pregnancy, you have two patients built into one. It’s a very different clinical scenario. Even providers experienced with resuscitation don’t have expertise in maternal cardiac arrest.”

In an AJOG report, Dr. Zelop et al. explain that “resuscitative interventions are concurrent rather than sequential.” Since responding to maternal cardiac arrest is different than with a traditional rescue, it is important that all healthcare providers are prepared for maternal cardiac arrest. Health care providers must act in tandem, simultaneously, to achieve the best possible outcomes for mother and fetus.

For example, the following actions should be simultaneously performed by healthcare providers when a woman is found to be unresponsive and not breathing properly

Call for help – maternal “code blue”
One person should immediately start high-quality CPR at a rate of 30 compressions to 2 breaths
One person should manage her airway (provide ventilation with a bag-valve-mask and intubation)
And someone should apply manual left uterine displacement to help ensure proper blood flow to the heart
- One-handed technique: With patient flat on her back and the responder standing on the woman’s right side, the responder pushes the women’s uterus away (toward the patient’s left side)
- Two-handed technique: With the patient on her back, the responder standing on the woman’s left side, the responder uses two hands to pull the women’s uterus towards (toward the patient’s left side)

The 2020 AHA CPR and ECC Guidelines outline the following algorithm for maternal resuscitation by ACLS professionals in the hospital.

2020 AHA maternal cardiac arrest algorithm

2020 AHA Recommendations and protocols for in-hospital maternal cardiac arrest now include the following:

Priorities for pregnant women in cardiac arrest should be high-quality CPR and relief of aortocaval compressions with lateral uterine displacement.
The onset of cardiac arrest in a pregnant mother inevitably places the fetus in danger. Fetuses that are beyond 23 weeks in gestation are considered viable and doctors can, therefore, consider a perimortem cesarean section. In many cases, the delivery of the fetus through this method will result in the stabilization of the mother because arteriovenous compression caused by a gravid uterus stops.
Perimortem cesarean section should be conducted in 5 minutes of cardiac arrest depending on the resources and skill sets of the providers.
A difficult airway is common in pregnancy, so use the most experienced provider to provide endotracheal intubation or supraglottic advanced airway.
Perform waveform capnography or capnography to confirm and monitor ET tube placement.
Once advanced airway is in place, give 1 breath every 6 seconds with continuous chest compressions.

Frequently Asked Questions

Can I perform CPR (on someone else) while I’m pregnant?

In most cases, it’s perfectly safe to perform CPR while pregnant. Consider this: many physicians and other healthcare professionals work while they’re pregnant and may perform CPR regularly while working.

Of course, if you have any specific questions or if you’re experiencing a high-risk pregnancy, check with your doctor for more information about your specific situation.

Another way to think about this question might be “what is your role in a cardiac arrest rescue if you’re pregnant?”

For instance, if you’re responding to someone and you’re alone, you might not have another option besides performing compressions and delivering a shock with an AED. But, if there is more than one rescuer, your role in the emergency might be different. Instead of performing compressions, you can be the person to call 911, grab the AED unit, or guide the EMTs to the victim when they arrive on scene. All roles are important for achieving a successful outcome!

Can I take CPR training while pregnant?

It depends. Practicing and delivering CPR requires vigorous exercise. Pregnant students should ask their physician what types of activities they can participate in and if CPR classes are ok for their situation.

No matter what, if pregnant students experience pain or discomfort during a CPR training class, they should stop training immediately and contact their physician.

If a pregnant student and their physician decide that it’s OK to participate in CPR training, reasonable accommodations should be made, such as resting between scenarios. Or, in other cases, it may make sense for the student to watch and then practice compressions another time in the future.

Can an AED be used on a pregnant woman?

Absolutely! The use of AED units is encouraged on pregnant women who might be in cardiac arrest (not responsive and not breathing properly). The AED machine will walk rescuers through the process, analyze the woman’s heart rhythm, and determine if a “shock” is required or not. Begin CPR and apply the AED as soon as possible to maximize the chances of survival.

Where do you place the AED pads on a pregnant woman?

If you’re outside of the hospital, the AED’s pads are placed in the same location on a pregnant woman as on any other adult patient. Look at the diagrams on your AED or the electrode pads for proper placement.

If you’re in the hospital, remove the fetal monitors if present. See the AHA algorithm for maternal resuscitation above for more information.

Maternal-Cardiac-Arrest-Infographic-(For-Web)

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