Thinking About Ob/Gyn
A fresh and evidence-based perspective of all things related to obstetrics and gynecology. Follow us on Instagram @thinkingaboutobgyn or visit thinkingaboutobgyn.com for show notes and more.
Thinking About Ob/Gyn
Episode 9.3 Obstetric Life Support with Jacqueline Vidosh
Join Howard with guest host Jacqueline Vidosh as we explore the challenges of maternal cardiac arrest. This episode emphasizes the urgent need for specialized training in obstetric life support. From discussing causes of maternal mortality to sharing practical tips for first responders, the insights presented aim to enhance awareness and preparedness in critical situations.
• Discussing the alarming rise in maternal mortality rates
• Identifying common causes of maternal cardiac arrest
• The importance of OBLS training and education for healthcare providers
• Emphasizing the need for left uterine displacement during resuscitation
• Addressing healthcare disparities affecting Black women
• Sharing unique physiological adaptations in pregnant patients
• Strategies for improving outcomes in maternal cardiac arrest cases
• Highlighting the value of simulation training for all healthcare personnel
Every healthcare professional plays a role in improving maternal health outcomes. Listen in for tips and insights on how we can enhance readiness for maternal cardiac arrest situations.
00:00:01 Obstetric Life Support
00:03:34 Maternal Mortality and OBLS Training
00:15:23 Maternal Health Disparities and Physiologic Changes
00:27:53 Cesarean Delivery and Post-Delivery Care
00:41:15 History and Implementation of CPR
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Welcome to Thinking About OBGYN. Today's episode features Jacqueline Vidosch and Howard Harrell discussing obstetric life support.
Speaker 2:Howard.
Speaker 3:Jacqueline.
Speaker 2:What are we thinking about on today's episode?
Speaker 3:Oh wow, you do that, just like Antonia.
Speaker 2:Well, we're going to think about, maybe she does it like me.
Speaker 3:Yeah, that's true, you could have done it first. Well, we're going to think about obstetric life support for maternal cardiac arrest.
Speaker 2:Oh, that's one of my favorite topics to discuss. I might know a few things about that.
Speaker 3:Well you better. So welcome to our podcast and, for the listeners, let me introduce my dear friend, Jacqueline Vidal. She was one of the authors editors, whatever you want to call it of the obstetric life support manual, which was published in 2023. And you can get a copy of this book on Amazon, Like I did she hasn't autographed it for me or you can also actually get an open access version of the book and we'll put a link there for the PDF, and, of course, the PDF is going to be harder to get autographed, but it's nice to have a physical book, though with or without autographs.
Speaker 2:Yeah, those old school still likes paper in hand.
Speaker 3:You can highlight it and grab it off the shelf in the middle of the night and it's, it's. I have a lot of books, but OK. Well, when I read your book, one of the first things I noticed was the dedication. So this manual is dedicated to all pregnant and postpartum people who died of maternal cardiac arrest, and Noah.
Speaker 2:So tell the listeners about Noah for just a minute. Yeah Well, it's funny that we're doing it today, because Noah is my third and we just celebrated his fifth birthday today.
Speaker 2:We had a little birthday party, yeah, but a couple of things about him. So he is one of the little Easter eggs throughout the book. So if you see a giant pregnant belly, that was me carrying him and I was pregnant for the majority of the time that we were actually writing the manual and also became the OBLS guinea pig of sorts, because when we were talking about left uterine displacement, I would literally lay flat on my back and get really short of breath and feel like crap, and then we would manually displace my uterus until I felt like I could breathe a little bit again. So it was I became, but we'll talk more about left uterine displacement later and all that good stuff and go from there. But yeah, so that was in part why it was dedicated to Noah Cool yeah.
Speaker 3:Okay. Well, before we get into it, why don't you tell us a little bit about how OBList was started?
Speaker 2:Yeah, this is actually one of my favorite stories. So when I was in the military, my mentor and I had, you know, you have to take BLS and ACLS, of course, every couple of years and you never know when you're going to be on a small base. So you also had to take NRP and all that good stuff. And I was in a BLS class one day and it struck me that I was learning how to take care of men, hairy men, large men, men in a little bit of water, men in a lot of water, babies, children.
Speaker 2:But we were not talking about how to take care of this very special population, particularly to me, which again is the pregnant patient and as obviously we're going to talk a lot more in depth today about, there are very specific and unique changes to resuscitation techniques for these patients and we just didn't cover them at all. So the initial thought between Dr Shields, my mentor, and I was well, maybe we can make like a little video that we can try to pedal to the AHA or ARC and they can play it during their BLS classes. And one thing led to another and we actually were able to get an NIH grant and developed our own resuscitation program called obstetric life support or OBLS Cool, and when we learn about pediatric and neonatal life support, we're always reminded that kids aren't just little people and all the physiologic differences and all that stuff, but honestly, pregnant women are more different than non-pregnant women, I think, than kids are, than adults.
Speaker 3:And we haven't had this, we've had this void.
Speaker 2:Right, and I think one of the things that has been so interesting for us to realize is that when you remove, like, infant death from the pediatric mortality rate, you actually see that the rate of maternal mortality is higher than the rate of pediatric cardiac arrest. So we're obviously it's very important to help a child through cardiac arrest and we learn about that, but we also have this higher rate of maternal cardiac arrest and we're not addressing that need in these basic classes. So, yeah, and you even have PALS and NRP, so you even like further delineate that, and I think it's just striking that we also have this unique patient population with a higher mortality rate and no formalized training, really until OBLS has come around.
Speaker 3:Yeah, well, the other thing regarding OBLS that recently happened is you had a randomized control trial published in JAMA Network Open Access in November of 24. And this was basically, I guess, a validation that obstetric life support education can significantly improve our knowledge and skills and confidence in managing maternal cardiac arrest. So tell us a little bit about what you did in that trial and what you found.
Speaker 2:Sure, I think, going into the trial, one of the things that we were really intentional about when we were creating the course to begin with was that we wanted something for everyone who might possibly come into contact with a pregnant patient. So essentially we created two main courses. We had one for your pre-hospital responders, so essentially like your paramedics and your EMS firefighters, things like that. And then we also had a course primarily directed for your in-house providers, so your ER physicians, your critical care docs, obviously labor and delivery nurses, obstetricians, anesthesia anybody that could come into contact with a pregnant patient in cardiac arrest. And when we designed the randomized central trial, we had a control group for each of the main courses that ran through the maternal cardiac arrest scenarios. Cold, meaning they had not taken any formalized OBLS training other than we wanted everybody that participated in the trial to have either had BLS or ACLS, whatever your job description would have required. And then we of course graded them on their scenario, and then all of the instructors were blinded to what group they were actually testing and grading. It became pretty apparent as we got into the scenarios which group you were running. But that was our control group. And then we ran our intervention groups through the OBLS course and then put them through the same scenarios and graded them, and it was really amazing to get to see the results. We graded participants on several different aspects. So you had cognitive scores. Everybody had to take a pre-test and we looked at how well they did on, of course, the written portion. And then we had the megacode scenarios, or the simulation portion that everybody got graded on. And then we also asked them how confident they felt within the information and the implementation of it. So, looking at confidence intervals, and not only were all of the scores significantly different between the control and the intervention groups, but the combined assessment pass rates were vastly different. So 90% of our intervention group passed but only 10% did with the control group.
Speaker 2:And again, these were seasoned providers. These were not like we weren't using medical students, we weren't using people with less than a few years of experience, because we really wanted to say okay, if you, if the attendee, or attending, if you will, where we were looking at those things. So, following the initial intervention, when we put the control group through the course, six months later, because we didn't want to leave people without the training, we evaluated the cognitive and competence evaluations of all of the participants again at six and 12 months following the intervention completed. And what we further found was that the cognitive results remained high at six months, but they did start to decrease at 12 months across the groups.
Speaker 2:And I think that's interesting because when you look at resuscitation training programs, they're given at two-year intervals, so your refresher courses are typically at two years. So if we're starting to see a decline, that might be something for future. Research is or just consideration is, instead of a two-year refresher course, should we be looking closer at that 12-month refresher? I don't know. That's all stuff for discussion, I think Right.
Speaker 3:So can I go take this course.
Speaker 2:Yes, caveat, we do have our website. It's oblsorg and you can sign up to host an event. Occasionally we are still hosting some Primarily they've been in San Antonio right now, but we are hoping to make this more national and happy to talk to people to see if they can host a course at their institution and then we follow a train the trainer model. So essentially, if you take it and you pass it at a certain score and you look like you're going to be a great instructor material, then we'll put you through the train the trainer course and then hopefully you can continue to teach people at your institution.
Speaker 3:So All righty, okay. Well, our listeners love practical tips, and we develop these, what we call four tips. For various things we do, various procedures or whatever, and so, by the end of the podcast, I'm going to need you to give me at least four tips. I know you're a long-winded person.
Speaker 2:I don't know what you mean by that.
Speaker 3:But at least four tips for the generalist WGYN like me out in the field in a rural hospital or community hospital or anywhere dealing with maternal cardiac arrest. But again, do that at the end, because for now let's get into some details about the scope of the problem and let's develop some understanding about the things that make this unique for pregnant women. So maybe I can just ask you some questions and let's see what you think. Sure.
Speaker 3:Okay, so first of all, tell us a little bit about the epidemiology and the causes of maternal cardiac arrest.
Speaker 2:Sure, I think you know. First and foremost, we need to discuss the fact that obviously, the United States has had a crisis with maternal mortality in I think it was 2021. We saw a peak at 32.9 deaths per 100,000 live births. That has started to decrease some. It's now 22.3 deaths per 100,000 live births, so elevated but thankfully starting to come down Obviously in 2021, there was a big country, covid exactly contributed a lot to that.
Speaker 2:I think what may be a bit of a moving target is looking at what is the true rate, largely based on the PRMR or the pregnancy-related mortality ratio. It may not be capturing deaths related to trauma et cetera, so I think there's a lot of different ways to look at the data and interpret the data, but by and large, we're still realizing that a lot of these deaths are preventable and that we still have some work to do to take care of the moms in this country.
Speaker 3:And we talk a lot about that on this podcast and the actual numbers honestly, in a way, don't matter. We can admit that we're capturing them maybe better now, and our maternal mortality review committees are doing a better job, but what does come out of them, as you said consistently, is that a lot of them are preventable, and so that's what we need to do Get into some causes for us.
Speaker 2:Yeah, as far as common causes, obviously, worldwide, the most common cause is still hemorrhage, probably followed by infection. What we're noticing now, though, in the United States, is mental health crisis. That is the most frequent cause of maternal mortality. Included in maternal health or maternal mental health is overdose, suicide, homicide. We're also noticing a huge uptick in cardiac disease as a common cause of maternal mortality. So, again, in 2020 and 2021, infection was one of the highest causes in the United States, again most likely driven by COVID, but still again a common cause worldwide.
Speaker 2:The other things that we worry about, of course, hemorrhage, hypertensive disease, things like that. We're still hanging around, unfortunately. I think what is concerning is that, when we look at the maternal cardiac arrest and the maternal mortality disproportionately affecting patients, it really is still the non-Hispanic Black patient population that has the highest increased risk of maternal mortality, so statistics currently are three to four times higher for that population, and this is despite any other demographic factor. So, looking at age or socioeconomic status, things like that, it's just if you are a Black woman in this country, your risk of maternal mortality is higher, which I think is something that we really need to pause and take a look at and do better again for these moms.
Speaker 3:Yeah, and also, as you were talking about those other causes, especially now, as you said, suicides, homicides, things like that, overdoses. This information is not just. The problem is, if we get this information in this course out for OB providers, well, that's a drop in the bucket, because it's ER docs, trauma surgeons, people like that, who are also encountering and are part of the solution for maternal mortality, where those patients may often see end up first before we ever see them.
Speaker 2:A hundred percent, and I think that is another really great place where we can make positive change and positive impact is including those other providers, and again, that was one of the things that we were really trying to be intentional about when we created the courses we got to. You got to get everybody involved for everything to improve Okay.
Speaker 3:And then what are some of the things that we can think about to prevent maternal cardiac arrest? We're going to get into the situation, but obviously an ounce of prevention is worth a pound of cure. So what can we do to prevent, or at least be prepared and ready to go if it should happen?
Speaker 2:Right. I think it is perhaps the single biggest thing that we can do is actually train for it. So when you have these high risk, low volume problems, simulation is going to be one of your best tools in your toolkit. When we were doing our initial literature review for the manual and even when we were doing our randomized control trial, it's that even when you have providers and experienced providers who are very well versed in BLS and ACLS and all of these things, it didn't improve their initial response to maternal cardiac arrest really until they had specialized training specific to maternal cardiac arrest. So spending that time doing the SIMS, doing that team training, that's going to be huge. I think that we have these AIM bundles and all of these things that are also trying to address the problem before you actually get into the code. So continuing to do the SIMS for your common ideologies that can ultimately end up in maternal cardiac arrest is going to be helpful. So hopefully, stopping that process before the patient actually codes Again, that ounce of prevention is worth a pound of cure, I think is going to be super helpful. And developing that muscle memory as a unit and that team response has that will also impact change Like from a practical standpoint, I think implementing some form of maternal warning sign system within your hospital is helpful.
Speaker 2:There are multiple to pick from. Some of them have, like, a higher alarm fatigue associated with it. So it really is going to have to be dependent on what your hospital institution is going to benefit from and they you will know best what you guys need. But using systems such as a MUSE score or the MUTE score can be helpful in identifying those patients that are pending some kind of morbidity. Another I think it's the only validated score is the sepsis scoring or the SOS scoring system. That can be used in the setting of infection and identifying those patients that have a higher likelihood to end up in the ICU or in shock. Things like that are also really important to help implement in your department.
Speaker 2:I think another one of the increasing problems we have in the United States are these maternal deserts or maternity care deserts. So making sure that patients have equal and close access to maternal care is huge. So when we're talking about maternal deserts, we're talking about counties that don't have access to some form of birth place for these patients to either get care and or deliver their baby, and what we're seeing an alarming rate is more and more of these deserts occurring. So I think in 2024, we saw greater than 35% of the counties in the United States have they're considered maternity care deserts and when you look at the map it's really right down the center of the United States. So I think it makes sense that if you aren't getting care and timely care and then you are struggling to get to a place to deliver, we're losing all of these potential points to impact, change and hopefully decrease the morbidity of problems. So I think that's going to be a bigger topic and a bigger discussion and again, I think you guys had a podcast last year about that.
Speaker 3:Yeah, it's an increasing problem and lots of different reasons and we actually had some specific calls to action about what to do about some of these issues. But yeah, increasing maternity care deserts fewer and fewer docs per patient. The ratios are going up and up. Training programs closing Texas just had a residency training program close, really just for financial reasons, not because the need's not there.
Speaker 3:So, we're in trouble in a lot of regards and we also know, as you mentioned, that there is this disparity between black and white women in the United States in terms of these outcomes, and the disparity is across multiple gaps, including cardiac outcomes, which tend to affect patients after they've gone home. So what are your thoughts about the role of bias or other reasons why this disparity exists?
Speaker 2:Yeah, I think that we absolutely know that bias exists in healthcare. To ignore that or avoid that is careless on our part. So I think, when we review some of the different minorities your American Indian, alaska Native population have a PRMR of 63.4 deaths per 100,000 live births in 2020. That is followed by 55.9 deaths per 100,000 live births for your Black population and then 22.6 deaths per 100,000 live births for Hispanic patients, and then all compared to your white population, that had only 18.1 deaths per 100,000. So the only major population less than the white population was Asian, which was 14.2 deaths per 100,000 live births. So, absolutely, when we look at race, we are seeing a disparity. The disparity within the races also worsens as age increases but interestingly, remained stable across education and income levels.
Speaker 2:I think when we're looking at disparity and the problem that it comes with, it's very complex. It's related to multiple factors. I don't think you get to peg it all on one specific thing. Everything plays into itself and each other, but certainly, again, access to care is a big driver of the disparity. Access to insurance is another. So if you look at your Black and your AIAN patients, approximately two-thirds of their births were covered by Medicaid, with many of these previously uninsured prior to their pregnancy. Again, when we're talking about access to care, if you don't have a way to pay for it, you're not going to be coming until you do so if there was ways that we could have impacted change prior to pregnancy, we're missing a large subset of patients because health care is just too expensive without insurance.
Speaker 3:Yeah, I'll throw in there that I've seen the Tennessee data coming out that we're going to talk about in the next couple of episodes. That shows that Medicaid to commercial disparity is basically the same ratio as the black to white disparity in Tennessee. It follows the lines.
Speaker 2:That makes total sense to me. We talked about maternal care deserts, that those are really going to disproportionately affect your rural and your medically underserved communities. I think that we also need to spend a minute talking about racism. Approximately 30% of minority mothers reported some form of mistreatment by their providers during their maternity care. So when they were doing this research, they gave examples such as violations of privacy, verbal abuse and that kind of incorporated whether they felt ignored if they asked for help and then it was refused, or just non-responsiveness from their team, being shouted at or scolded.
Speaker 2:A percent of minority mothers also reported some form of discrimination during their pregnancy. 45% of these mothers reported holding back some form of communication to their providers because they didn't know if they were either going to be heard or if they were going to be judged. So I think I have talked at length with my residents about the words that we use and our tone and all that stuff. It just matters in so many different aspects. But again, if we have almost half of our minority patients saying that they have felt some kind of discrimination or verbal abuse or things like that, then this is another huge area where we can change and make positive impact, because I think this is a huge missed opportunity, and programs such as the Hear Her campaign all of those things originated as a result to try to address this specific problem. So I think it absolutely plays into maternal health.
Speaker 3:And if patients are worried to tell us things, those could be key things that affect their outcomes.
Speaker 2:Exactly. So if you're scared to tell me that you have a raging worst case headache of your whole life, I'm not going to know to get that CT scan and make sure things are okay, stuff like that. But I think, just to wrap up this topic for now, one of the concepts that I really want to bring people's attention to is the concept of maternal weathering and how that speaks to the problem. And basically it was a concept that was defined and really studied by Dr Arlene Geronimus and it suggests that the constant stressful environment of marginalized populations and what they're living in whether it's due to discrimination, poverty etc. It physically damages the body and it can lead to worsening health problems.
Speaker 2:And correct me if I'm wrong, but I think it actually originated with looking into preterm birth and we know that preterm birth disproportionately affects women of color. And when you look at populations from like Africa coming over to the United States and delivering, they were not having the same rate as Black women that had lived in this country. Further, and we see that in the Hispanic population with other chronic health diseases where you know they, it worsens the longer that they're living here. So again, that's called maternal weathering and I think that it does. It speaks to being a minority in this country and just another area that we need to look at ourselves and how we can impact positive change.
Speaker 3:All right, well, changing gears a bit. So obviously pregnancy is a unique condition physiologically, so there's many adaptations and physiologic anatomic changes. So what are some of the key anatomic and physiologic adaptations of pregnancy that we need to be aware of, especially as it relates to maternal cardiac arrest and preventing or really managing this condition?
Speaker 2:Yeah, obviously pregnancy impacts every single system. So lots of changes happening during those nine months. But I think if we're going to really try to like hammer down a couple of things, I think we need to focus on the cardiopulmonary changes and let's talk about those first. So the cardiac system has lots of different things. We're looking at a gradual increase in heart rate over the course of the pregnancy. We have an increase in cardiac output.
Speaker 2:The blood pressure changes, so initially it drops due to that hormonal mediation of the peripheral resistance. You'll see the nadir of blood pressure in that second trimester but then it's naturally going to start rising again in the third, not quite to pre-pregnancy levels, but it gets almost there. And then, going back to cardiac output, 60 to 80, there's a 60 to 80% increase in cardiac output, particularly during labor. So that's just, it's huge. When we look at the uterus and as it grows, particularly after it gets to the level of the umbilicus, it starts to impinge on the great vessels so that of course, can inhibit blood flow.
Speaker 2:Return to the heart. This definitely comes into play when we start performing chest compressions and we can discuss that again later when we get into the nuts and bolts of MCA resuscitation, but, yeah, lots of different physical and physiologic changes in pregnancy. From a pulmonary standpoint, pregnancy induces a mild respiratory alkalosis. So you're seeing, ph is closer to 7.40 and 7.45 during pregnancy and this is really because there's a mild hyperventilation that is associated with pregnancy, I think. While we're on the topic of acid-base levels, it's very rousing conversation.
Speaker 3:You're popular at parties, okay.
Speaker 2:I really am. I really am the life of the party. Let's talk about some PaCO2. But it does. It drops naturally to 27 to 32 millimeters of mercury and again your normal non-pregnant patient is going to have one that's closer to 35 to 40. Your bicarb drops naturally in pregnancy, so it's going to be closer to 17 to 19 millimeters of mercury and this is basically to create a compensatory metabolic acidosis to the respiratory changes. No-transcript patients, because I think there's a lot of confusion even within the hospital for what are normal values of pregnancy, what's normal for non-pregnant and what's the comparison. So that's where we can step in and be that voice, I think.
Speaker 2:Other pulmonary changes that we see the tidal volume is going to increase but your functional residual capacity, or FRC, decreases and we see that in part due to the diaphragm elevation. We also see a decreased chest wall recoil and then we have decreased downward tension of the abdomen. So all of that is going to translate into a decreased respiratory reserve, particularly at term. So again, you're going to need to preload her with oxygen before an intubation. You need to be looking at those different levels of PaCO2 and stuff like that. It's all going to come into play with these things. The diaphragm moves upward, the chest wall expands. Lots of other changes from different systems come into play, such as delayed GI motility. You have changes in the GFR and the way that we filter things. But I think again, for today's purpose, let's focus on the cardiopulmonary changes and how we can keep those in mind as we do CPR.
Speaker 3:We don't have to talk about hair and skin changes for the purpose of this.
Speaker 2:Okay, your hair looks fabulous.
Speaker 3:What hair I have left. Okay. So all right. Well, we traditionally divide life support into basic and advanced life support, and you all do that in the book as well, so run through some of the basic life support principles that are different, or modified, at least during, for pregnant patients compared to non-pregnant patients.
Speaker 2:Sure, I think from a basic life support standpoint, essentially you're talking about high quality CPR. You're not doing your advanced airway or meds with BLS. So what you're really focusing on from a respiratory standpoint is you're ventilating with a bag valve mask or BBM and performing high quality chest compressions. And the big takeaway from OBLS that I want people to walk away with is that you are not doing high quality chest compressions if you are not incorporating continuous left uterine displacement simultaneously. So if you're not pushing the uterus off of those great vessels to allow for the blood to return from all of your excellent chest compressions, you are not doing excellent chest compressions.
Speaker 2:And that's really probably the biggest change, things that remain the same that I think are important to highlight. Your rate of chest compression is going to be the same. It's still 100 to 120 beats per minute. You can still sing whatever Taylor Swift song you want to do with that and it'll work. The depth of your compressions are still going to be the same. So two inches or two thirds the chest wall, chest with recoil.
Speaker 2:You're going to again manage the airway, the same in BLS. So using the bag valve mask at a rate of 30 to 2, all of that's the same. You're going to shock the same. Honestly, if you're in a shockable rhythm, you need to do that immediately, whether they're pregnant or not, and you're going to do that at the same frequency and at the same electricity, same joules. What you are not going to do in BLS and ACLS, however, is try to find a fetal heartbeat and focus on fetal status. So we're really recommending that you remove any kind of fetal monitoring altogether, other than if you are doing some kind of ultrasound to confirm a pregnancy status, like is she 20 weeks or not to keep your focus on the mom and saving the mom's life, because if you don't save mom, you're definitely not saving baby.
Speaker 3:Yeah, and it's amazing for people when you think about. You kept talking about the effects of the uterus on the great vessels, but there are a lot of normally, physiologically normal pregnant women who have complete occlusion of the vena cava during pregnancy. But that means they're getting all this collateral perfusion through the vertebrals and that's just. That's just not what you need. During a chest compression, during a cardiopulmonary resuscitation, you talk you've mentioned several times about displacement but practically the patient's laying on the floor. I'm starting chest compressions. Tell me what to do.
Speaker 2:Yeah. So first things first. You want to keep your patient supine, like completely supine. So what we have found if you do any kind of like leftward tilt or anything like that, your chest compression quality is going to go down significantly. So keeping her completely flat is key and then you can either do the push or the pull technique. So if you're on the patient's right, you are going to do the push technique and you're going to, essentially you can kind of like create L's with your thumb and your forefinger. You're going to find the ASIS and you're going to scoop the uterus up with your thumbs and forefingers up and over to the left and then you're just going to continue doing that throughout compressions until you get to the RCD, which again we'll talk about with the ACLS changes. If you are on the patient's left side, you are going to do the pull technique. So again, you're going to bounce off of that ASIS and you're going to lift up and over toward the left with the uterus.
Speaker 2:And going back to my funny little story about Noah and being pregnant and being the guinea pig, I can tell you almost 90, we'll say 90, because you never say 100% or zero in medicine, right? 90% of the time people didn't do it hard enough the first time. The uterus is mobile. It's meant to be mobile. You're not going to hurt, don't like punch it obviously, but slow, steady pressure is going to move the uterus. You are not going to hurt her. You're not going to hurt the baby. You will in fact make her feel better if she's awake and make your compressions much higher quality if you have that off. So just that's. Another little anecdote is you probably aren't doing it hard enough for over, far enough the first time. So go further than you think.
Speaker 3:All right, excellent, okay. Well, what about advanced life support changes then?
Speaker 2:Yeah, I think again, let's talk about some of the things that remain the same. So any medications you're going to use in ACLS you're going to use at the same frequency, at the same dosage. So epinephrine is a great example. That's still going to be one milligram every three to five minutes, as indicated Amiodarone all those other things you can use at the same dose and same frequency that you otherwise would in your non-pregnant population.
Speaker 2:Things that become a little bit more unique and nuanced are things like how are you going to manage her advanced airway? The pregnant patient's airway, particularly a pregnant patient in labor has probably the most complex airway in the hospital. So it is really important to use the most experienced laryngoscopist to perform the advanced airway just because there's so much more edema in the airway, especially if we're talking about a patient who's got preeclampsia or something that's going to predispose them to even further edema. Anyway, the attempts at advanced airway are limited to two tries per method, and I think that's really important to highlight because I don't think that when we're looking at ACLS algorithms in the non-pregnant patients, they don't specify that as significantly as we do in our patients.
Speaker 2:So just to give a, for instance, if you're trying to place an intubation tube or an ET tube and you fail twice, then you need to move to something different.
Speaker 2:So, like your iGel or your LMA, or vice versa, if you do the LMA and that doesn't work, then you need to go to the tube and if that fails, then probably you're going to be moving more toward that surgical airway and ideally you're not getting to that point because you've got your experienced laryngoscopist who can do that. If you are waiting for them to get there, then if you're moving air with a bag, then probably you just need to continue doing BBM until you get them there, if at all feasible Other things that are unique and nuanced. So we have found that by evacuating the uterus, if it's at or above the level of the umbilicus, you are much more likely to achieve ROSC or return of spontaneous circulation. So for this reason, recommendations are to move toward that resuscitative cesarean delivery at four minutes within the code. If you haven't achieved ROSC already with the intent to deliver the fetus by five minutes, oh, go ahead.
Speaker 3:Well, I was going to say before you go on for the recessive cesarean delivery do you have? Any tips there? Vertical incision does it matter?
Speaker 2:Yeah, I think that's a really great question and we actually get this a lot in our OBLS courses. So I think, ideally, like Cliff Notes version, your vertical incision is technically your fastest incision. Okay, you, I think that's really helpful from if it's a general surgeon or a trauma surgeon or somebody kind of responding to the code if there's not an obstetrician there. From an obstetric standpoint, I know I do far more fan and steel incisions than I do vertical. So if you're in a labor and delivery scenario and you're going to be able to do a fan and steel, I think that's reasonable to consider as an obstetrician.
Speaker 2:That being said, though, if there's any kind of concern for trauma or if there's any part, any reason at all that you would need to explore the abdomen, you absolutely need to go vertical and you can always extend. A low vertical underneath the umbilicus is really great access entry, it's very quick to get in, and the other benefit of doing vertical as opposed to fan and steel is, while the initial procedure is going to be bloodless, it won't be when you get ROSC and the likelihood of getting into any of the epigastrics are going to be significantly lower. Obviously, with a vertical incision as opposed to a phan and steel both through the skin and the fascia. So vertical on the skin again, I think a term uterus and an obstetrician you could consider your horizontal hysterotomy, but otherwise I would say a vertical incision.
Speaker 3:Get what you need to do but the horizontal hysterotomy will bleed less when you get ROSC as well.
Speaker 2:Exactly, but again, I think, from your non-obstetric providers that may be called into doing something like this, then you need to be definitive, so vertical.
Speaker 3:Trauma surgeon yeah.
Speaker 2:Exactly, you can always towel, clamp the uterus closed until more definitive care can be done.
Speaker 3:Okay.
Speaker 2:Yeah, okay, so we talked about RCD. I think a couple of other things that maybe make sense, but it's really important to highlight and point out is if you're in the hospital, then you're going to keep a stay and play mentality. So if she codes in her labor room, you are not going to take extra time to move her to the operating room to do the RCD, you're going to do it at her bedside. So bringing the scalpel to you as opposed to you going to the operating room with the patient is really important. Where stay in play mentality does not work is in the field. So in that pre-hospital environment, we actually are seeing this stay in play mentality for your non-pregnant patients, where they will actually run the code at the patient's house or wherever that happened. But we do not want that from a maternal standpoint, so they need to be getting them loaded and headed to the hospital as quickly as possible. So those are some of the things that are different in ACLS for opiates.
Speaker 3:The other question I had about RCD was well, that's a new name for it Forever. We've called this perimortem cesarean or something like that. So why have we changed the name of it?
Speaker 2:We know that uterine evacuation can increase the chances of ROSC. When we were developing OBLS, we wanted again to keep this very intentionally mom-focused, and perimortem terminology originally rose out of the attempt to salvage the baby. In changing some of the terminology, it really does become more mom-focused. One of the next steps was to call it a resuscitative hysterotomy, which of course, is the technical term for opening the uterus. But it's not something that perhaps non-obstetricians are going to immediately think of like oh, I need to open the uterus, and by changing it to resuscitative cesarean delivery, it's mom focused, it's friendly terminology. Everybody knows what a C-section is and it also is like leaving life in the definition, which is, I think, important.
Speaker 3:Yeah, yeah, and the whole emphasis about this is not focused on the newborn or the neonate or the fetus is really important. This happens a lot and people get ahead of their skis and the best thing you can do for the fetus is save the mother. So, okay, well, the baby's delivered, we've done a recessive cesarean and now you've got ROSC. So what's next?
Speaker 2:Yeah, this is also going to be similar to your non-pregnant patient. So the American Heart Association uses the alphabet it's like ABCDEFGHI to approach their post-arrest care and OBLS follows that. There are a couple of differences. So if ROSC is achieved and this is a big one actually so if ROSC is achieved prior to performing a resuscitative cesarean delivery, you are undergoing post-ROSC treatment with a pregnant patient. Depending on their gestational age, you may or may not want to consider steroids. You may need to consider monitoring. Again, that's going to be determinate on gestational age. If she can tolerate full left lateral positioning, that is the time that you would consider putting her in that left lateral tilt.
Speaker 2:Your etiologies for maternal cardiac arrest are also going to be slightly different than the traditional H's and T's that the AHA talks about. So, depending on that etiology, you're going to have to address the underlying cause. Targeted temperature management can also be considered on case-by-case basis for a pregnant patient. I don't think that would be a decision you're going to be making in a vacuum. That's going to be a huge multidisciplinary discussion, but it can absolutely be used following an RCD and ROSC. So I think maybe one caveat to that is if you're in the setting of a hemorrhagic shock, then that would need to be a discussion, because obviously cooling could make DIC and clotting issues and things like that worse.
Speaker 3:But otherwise Okay, so we talked a little bit about some of the causes, the etiologies earlier. So how does OBLS address this aspect of maternal cardiac arrest, the obstetric specific sort of things?
Speaker 2:Sure, we like to think that we were a little clever when we came up with our mnemonic. So instead of using every letter, we made the mnemonic back to life. So B-A-A-C-C to life. One of the things again that we were really intentional about while we were creating the course was how can we make this as relevant as possible for maternal cardiac arrest and for those that are going to encounter it. So H's and T's awesome, but only get to a certain point and they miss a lot of things that are unique to pregnancy. So, taking ACLS and BLS for a long time now and please don't ask me because I'm a woman of a certain age, I think other things that are really important in those like your WinkyBock and bradycardia and ACS.
Speaker 2:It's just not as immediately relevant in our pregnant population. Even looking at stroke as a, for instance, is different in pregnancy and postpartum, because the etiology of stroke is much more likely to be hemorrhagic as opposed to ischemic. So in your pregnant and recently postpartum patients, it's about 50-50 whether it's hemorrhagic or ischemic, and it is much higher skewed toward ischemic in your older patients. So just things to keep in mind and as we were developing OBLS and going over these etiologies, we try to highlight those differences and nuances. So, of course, when you're thinking about stroke or even like pulmonary embolisms and things like that, the management of these in your pregnant patients are going to be different, because things like TPA and things that you would give as a clot buster to your older non-pregnant patients are a much more significant discussion because, of course, if you think she is pending an RCD, that's an absolute contraindication to giving these medications.
Speaker 2:So we go over all of that in the book and in the course. And labor and delivery nurses again, they don't need to be doing codes on these 70 year old patients in the ER. They need to be. How can I apply ACLS to these pregnant patients that we're going to be taking care of? So what's it going to look like circulating and recovering a patient from a C-section? And, yes, they need to be familiar with ACLS algorithms and drugs and things like that. But again, how do we apply it so that they retain it and that it's using?
Speaker 3:And so, for the listener, the back to life. It really is good. This is something that people should be able to, I think, to reproduce and remember. But it's B, double A, double C to life. So bleeding, anesthesia, afe, cardiovascular cardiomyopathic causes, clot or CVA causes trauma, overdose, and think magnesium, think opioids or other substances, lung injuries or ARDS ions. So think glucose, potassium, et cetera, fever or sepsis, and then emergency hypertension or eclampsia. You get two things for the E there. So that's a very easy differential to remember and help focus you when you're quickly going through looking at a patient and wondering what's wrong. A great place to start. So, okay, well, do you have your four tips ready? If you've got four things, what would they be?
Speaker 2:I think, first and foremost, high quality chest compressions are not high quality without continuous left uterine displacement and we talked about that again, but I think it's worth repeating. So that's number one. Number two RCD saves lives, hopefully plural. If you can't complete it right at the four minute mark, that's okay. There's still case reports that show even after like well, after missing that mark, there can be, there can be ROSC and people can walk out of the hospital. So do it anyway. Also, I'm still keeping this as number two because it's about RCD. You want to prepare for a bloodless procedure until after delivery and ROSC. So that can be weird, but prepare for that.
Speaker 2:Number three I would say simulation training is critical for success. So training should be for everyone again who can contact or who could come into contact with a pregnant patient. So not only should this be labor and delivery and all of its providers, but your ER nurses and docs, your ICU nurses and docs, anesthesia, ems. It's critical along that entire chain of success to successfully resuscitating a pregnant patient. And I think. Number four, I would say pregnant patients are remarkable. So again, there are multiple reports of patients that have had prolonged CPR or even eCPR, which is like ECMO leaving the hospital and I'll never forget there was like one report that talked about the only residual problem she had was she couldn't move her little pinky and had CPR for like 45 minutes or something just otherwise unheard of. And for your providers in the rural setting this could mean continuing that CPR and transferring to a larger facility or waiting for that unit to get to you. And then I think because I, as Howard, I'm a little extra I have a fifth one and.
Speaker 2:I would say that if your patient isn't telling you something, or if excuse me, if your patient is telling you that something doesn't feel right, it probably isn't and you need we need to, as providers, do a better job listening and investigating. So if upwards of 80% of maternal mortality can be prevented, then this is one big step and one piece of that pie into correcting that. So hear her.
Speaker 3:Yeah, and I love how Noah was a part of the book but also this podcast. So if anybody's heard any playful sounds or pets or anything else, that just know that we have real lives and Noah's a real person who's playing with some toys right now.
Speaker 2:So yeah, that's in clacky slugs. That's his favorite.
Speaker 3:That's great. That's great. People don't mind too much. Antonia's children have made guest appearances many times over the years. The astute listener will remember we usually do every other episode. When Stuart was on, we talked about the history of cesarean hysterectomy, and so every other episode we do a little bit of a history section and it is interesting really the modern era of just cardiopulmonary resuscitation is not that old Really.
Speaker 3:The foundations of even closed chest compressions for the most part are just in the 50s and even ventilation and stuff really in the 60s. But there has been lots of ideas over time. I looked at a couple of articles to look at the history of some of this stuff and lots of things People will point to things in the Bible, for example, where Elijah is described as reviving a child through what might be interpreted as mouth-to-mouth resuscitation. And folks did lots of interesting things In older books. People would take newborns for resuscitation and they would sling them, just pound on them or put them on a horse and make the horse trot fast and things like that. And there's even ideas that some of these things did lead to spontaneous restarting of the heart, probably accidentally or coincidentally, but people really believed in a lot of these things.
Speaker 3:In 1555, Vesalius actually wrote about using a reed inserted into the trachea, at least of animals. We don't know that this was done to humans, but as a way of maintaining respiration, and he would do this well during vivisections. But they understood the concept about basically creating artificial inlet to the trachea and then using that to respirate, using that to respirate. And then in 1732, a guy named Tosic reported the first successful resuscitation of a coal miner using what today I think we would call mouth-to-mouth techniques. And it's also interesting about back then. We believe that the errors that people had were bad. We had all these theories of medicine that dealt with the dark errors and stuff. So people were actually resistant to that because what we thought the exhaled air from a sick or dying person might do to the person who was given the mouth to mouth and so that, if anything, stymied some of that concept for a long time with mouth to mouth resuscitation. But and there's lots of reports too about when we started doing some sort of cardiac massage or resuscitation In 1880, a guy named Niehaus attempted what we would call the first closed chest cardiac massage. It didn't work but the ideas were there. And then there was a time of open chest cardiac massage, which still occurs in some traumas and things like that.
Speaker 3:But the idea about doing this completely and successfully through what we would call modern CPR really dates to, I think, 1960 for chest compressions, and 1958 is when we saw the modern ideas and cadences of mouth-to-mouth resuscitation. And also in the late 50s is when we started seeing defibrillation and other things like that. So the modern era of cardiopulmonary resuscitation really starts in around 1958. And then, of course, our professional societies, like the American Heart Association, have become more and more advanced over time with the different kinds of protocols that you've mentioned since then. But a lot of interesting things.
Speaker 3:And now we need to take it, the next step, as we've done already with the neonates and pediatricians and those special populations to pregnant women. Well, before we finish, let's wrap all this together, and I will say one of the nice things in the book is you have these cases in the back where you go through scenarios. Putting it all together is the name of that chapter and try to integrate everything that you've learned. So I'm going to put you on the spot, though, and just give you a scenario and we can see what we've, what we've learned and what the response would be. So a pregnant woman is found, comes to the hospital, she's 35, 36 weeks pregnant, she's been bleeding some, and that's why she came to the hospital, and as she's walking up to the labor floor, she collapses and is in the hallway and it's collapsed, and and then the staff go and attend to her, and she's found to be in cardiac arrest.
Speaker 2:Okay, so first thing you're going to do, obviously you called your code right, so you need to get all hands on deck, and then you're going to check for a pulse. Do I have a pulse?
Speaker 3:You don't have a pulse.
Speaker 2:Okay, so you're going to immediately start your chest compressions and we know, since she's got a belly bigger than like higher than her umbilicus, you need to do your left uterine displacement and then, hopefully, somebody is getting a CART or an AED or something and you, while you're getting the AED set up and putting the pads on and I guess that's one thing that we didn't talk about earlier so when you put pads on a pregnant patient, we have found that, like doing antero, posterior pad placement is probably more effective.
Speaker 2:Obviously, if you have a concern for like some kind of like neck injury or spinal cord injury, then you would do anterolateral, with care being taken to really avoid any kind of breast tissue underneath the pad. So, okay, so you're putting the pads on AP placement and you need to assess for a rhythm as soon as you get the pads on, and the most common rhythm that you're going to find in maternal cardiac arrest is probably going to be PEA, or pulseless electrical activity, in which case your answer is high quality CPR with your chest compressions and left uterine displacement and then epi as soon as you get your cart.
Speaker 3:Okay.
Speaker 2:So you put me into a little bit of a corner by having her pass out in a hallway. So I probably would put her on a gurney and get her to an ER, whatever bay is going to be closest.
Speaker 3:She's outside your labor and delivery.
Speaker 2:She's just down the hallway, okay, so I would get her on a bed in a room and then move toward getting the crash cart and doing the RCD.
Speaker 3:Okay, so you're doing high quality chest compressions and you've got their left lateral displacement of the uterus and you do, in fact, have pulseless electrical activity and you've given epinephrine and it's been four minutes and you still don't have a return to spontaneous circulation.
Speaker 2:Sure, I, hopefully you have called for your scalpel and you've activated your hospital response. So again in OBLS we call it the MCAT or the maternal cardiac arrest team, and that's going to have your anesthesiologist and NICU and everybody, so they should hopefully all be a bedside and you're going to do your RCD and deliver.
Speaker 3:And if we, what have we done with your airway by this point, are we?
Speaker 2:Yeah, so if you have your laryngoscopist, then if you haven't intubated, then you probably need to be establishing that advanced airway. You don't have to do your RCD but again, ideally you're securing that but otherwise ventilating with a bag valve mask until you have that person there to establish the advanced airway.
Speaker 3:Okay, so we do the recessive cesarean, and now we have ROSC.
Speaker 2:Great, hopefully. One thing we didn't highlight but hopefully you're doing and one of your nurses has done, is you've established two IVs above the diaphragm. So again, that's going to be anywhere in the arm. What you don't want to be doing is putting an IV in the femoral because again, you worry about decreased return to the heart in a pregnant patient. But you are going to probably have some bleeding at that point and my concern for her if she'd already had some bleeding would be she was abrupting it for some reason and we're going to be at a higher, increased risk for DIC.
Speaker 2:So if you haven't activated your massive transfusion protocol prior to the RCD, then my guess is you're probably going to need it now. So activating that and getting the team responding to the blood loss I think from a wound standpoint assuming that you can either whip, stitch, close the uterus you really want to just manage immediate bleeding. You don't necessarily need to close the abdomen yet. In fact we probably would favor packing until things are fully stabilized, but absolutely getting antibiotics after ROSC and stuff like that to help prevent any kind of wound infection, and things like that are key. And then, depending on where she is clinically, whether or not you close is. I think you could probably favor moving to the OR for that and getting more sterilized equipment.
Speaker 3:And everything we've talked about so far in this acute rapid stabilization process hasn't really focused too much on the differential diagnosis. But you know well I was going to say are there things that where the differential matters right now, like if this is amniotic fluid embolism and that's higher on our differential? Are there other things? We need to be doing that, or do we just need to do the standard resuscitation and worry about the differential in a minute?
Speaker 2:I think it goes hand in hand. So I think if we're talking about AFE as a specific etiology, again, that follows really strict criteria to be considered as an AFE. So you must have like a respiratory arrest phase and that is then followed by the hemorrhagic phase. So perhaps she had come in because it was respiratory arrest and she was like feeling very short of breath from that. The likelihood of AFE outside of her water being broken, I don't. So we have like other pieces of history that we don't know for sure.
Speaker 2:If she had come in, bleeding again, is she abrupting? And then secondary questions are well, why is she abrupting? Was she, is she in a hypertensive emergency or something like that that's causing an abruption? Was she in trauma? So hopefully we've got a family member that we can be asking questions and help guide us down the etiology trail. Obviously bleeding is going to be fixed by products like blood products and delivery AFE. I would anticipate her ventilation pressures are going to be like much. She's going to require significantly more pressure to move air because again that kind of falls into this ARDS type picture and she's going to need a lot of support and that way DIC is going to. That's a major risk factor for either of these etiologies, honestly depending on her blood loss.
Speaker 3:So and it's not going to be a big secret at this point.
Speaker 2:If she's in DIC, we're seeing it and we're responding yeah, exactly so.
Speaker 3:No, and I guess the other thing I was thinking about is even Narcan. Where's where's Narcan in this? We found her on the floor. Where do we just give Narcan empirically, or things like that?
Speaker 2:I think that's a good question. I honestly, if she was bleeding, I don't know if I would necessarily give Narcan first that may be like. So I work in a military facility. Overdose is not something that I encounter commonly, so it's not something that is going to be immediately higher on my differential. But I think that's different for whatever your patient population is and that may need to be something that you consider You're not gonna be wrong giving Narcan. It just may not fix the problem.
Speaker 3:Yeah, yeah, yeah. Well good, any parting thoughts or parting shots?
Speaker 2:No, I just want to say thank you for having me and letting me be a part of this and talk about some. My fourth kid, as I have called it, yeah.
Speaker 3:Well, we're going to have you on again later this year, hopefully so.
Speaker 2:I agree.
Speaker 3:Send us questions if you have questions for her, and we can get her to answer those questions before she's back on, if folks have anything that they'd like to see, and we'll be back in a couple of weeks with something new.
Speaker 2:Awesome. Thank you so much.
Speaker 1:Thanks for listening. Be sure to check out thinkingaboutobgyncom for more information and be sure to follow us on Instagram. We'll be back in two weeks.