Objective
Previous work suggests the potential for suboptimal cardiopulmonary resuscitation (CPR) in the parturient but did not directly assess actual performance.
Study Design
We evaluated 18 videotaped simulations of maternal amniotic fluid embolus and resultant cardiac arrest. A checklist containing 10 current American Heart Association recommendations for advanced cardiac life support (ACLS) in obstetric patients was utilized. We evaluated which tasks were completed correctly and the time required to perform key actions.
Results
Proper compressions were delivered by our teams 56% of the time and ventilations 50% of the time. Critical interventions such as left uterine displacement and placing a firm back support prior to compressions were frequently neglected (in 44% and 22% of cases, respectively). The mean ± SD overall composite score for the tasks was 45 ± 12% (range, 20–60%). The neonatal team was called in a median (interquartile range) of 1:42 (0:44-2:18) minutes:seconds; 15 of 18 (83%) teams called only after the patient was completely unresponsive. Fifty percent of teams did not provide basic information to the neonatal teams as required by neonatal resuscitation provider guidelines.
Conclusion
Multiple deficits were noted in the provision of CPR to parturients during simulated arrests, despite current ACLS certification for all participants. Current requirements for ACLS certification and training for obstetric staff may require revision.
Maternal mortality is likely underreported and continues to occur at an unacceptably high rate. In maternal deaths involving acute cardiac arrest, advanced cardiac life support (ACLS) must be rapidly administered. Recent studies at our institution and elsewhere demonstrate inadequate theoretic knowledge of cardiopulmonary resuscitation (CPR) in pregnant women. However, there is sparse literature on the quality of CPR in actual or simulated obstetric cardiac arrest scenarios.
Obstetric resuscitation is challenging when compared with resuscitation of nonpregnant adults. The anatomic and physiologic changes of pregnancy and the challenges associated with the care of 2 patients (mother and unborn baby) require the coordination of multiple teams and aggressive interventions (ie, perimortem cesarean section for both maternal and fetal benefit if an instrumented vaginal delivery is not possible). For obstetric cardiac arrests, there are additional tasks to perform, and more personnel are required to perform them than in a nonpregnant adult resuscitation.
The aim of this study was to evaluate the quality of obstetric ACLS performed during the management of a simulated cardiac arrest in a term gravid patient. It is unlikely that a randomized, double-blinded, prospective trial evaluating the quality of obstetric resuscitation will ever be published because the logistic and ethical issues preclude it.
The study prospectively reviewed and analyzed preexisting videotapes of high-fidelity, simulated maternal cardiac arrests. The simulated arrests created a setting marked by extreme time pressure but no potential for patient harm.
Materials and Methods
ObSim is the name given to the labor and delivery team training simulation program developed at the Center for Advanced Pediatric and Perinatal Education (CAPE) at Lucile Packard Children’s Hospital (LPCH) (Stanford, CA). The use of ObSim training course videotapes does not meet the definition of human research as defined by the Stanford University Institutional Review Board.
CAPE is located in a separate building across the street from LPCH. Eighteen ObSim courses conducted there over a 25 month period, from August 2005 to September 2007, served as the basis of our investigation.
CAPE contains a high-fidelity labor and delivery suite with working programmable fetal monitors that produce real-time printouts and a continuous audible signal of fetal heart rate (FetalSim Advanced Medical Simulations, Inc, Binghamton, NY), a pelvic model (Simulaids Inc, Saugerties, NY), a patient simulator (SimMan; Laerdal Medical, Wappinger Falls, NY), and digital videotape recording. CAPE also contains video and audio playback capability, and after each scenario a debriefing session took place. During the debriefing (facilitated by trained faculty), the whole team both reviewed and discussed various portions of the scenario.
The study population consisted of teams of labor and delivery nurses, anesthesiologists, and obstetricians. The labor and delivery nurses had experience in obstetric care ranging from 1 to 10 years. The obstetric residents, anesthesiology residents and fellows, and obstetric nurses came from 2 major teaching programs. Obstetric residents were always paired with nurses from their own institutions. Anesthesiologists delivered care at both hospitals and were placed randomly with teams from both institutions.
Each multidisciplinary team studied was comprised of 1-2 obstetricians, 1-2 labor and delivery nurses (1 designated as primary), and 1 anesthesiologist. Neonatologists and code providers were available to respond if requested by the scenario participants. Actions of neonatologists and other requested providers were not evaluated as part of this study. Care delivered and/or tasks performed by these responders were as directed by the study participants as described in previous text.
Participants were not prepared for ObSim with formal lectures prior to the course, nor were they provided with any didactic material. On the day of the course, they were oriented to the simulation room, manikin, and equipment but remained naïve to the scenario.
The simulated scenario was an amniotic fluid embolus (AFE) in a term parturient with a singleton intrauterine pregnancy. The patient had a working lumbar epidural catheter in situ for labor analgesia and an 18-gauge intravenous line in the left antecubital fossa. The fetal vertex was placed in position to allow for an outlet operative vaginal delivery. Required interventions in the scenario included the provision of ACLS after maternal cardiopulmonary collapse from an AFE and operative vaginal delivery of the fetus.
The simulation room contained fully stocked epidural and code carts with expired medications and intravenous fluids, catheters for intravenous access, blood pump tubing, central line kits, arterial line kits, and a live Zoll M Series Biphasic 200J Max defibrillator (Zoll Medical Corp, Chelmsford, MA). This defibrillator model is currently used on our labor and delivery ward.
A simple checklist of 10 basic interventions ( Table ) was developed by 4 of the authors, including a board-certified maternal fetal medicine specialist (M.D.), a general obstetrician (K.I.D.), a clinical nurse specialist in high-risk obstetrics (J.A.), and a fellowship-trained obstetric anesthesiologist (S.S.L.).
| ACLS or pregnancy-appropriate interventions | Teams performing task (%) |
|---|---|
| Removes fetal/uterine monitors before | 0/18 (0) |
| Defibrillation | 1/18 (6) |
| Places firm support under back | 4/18 (22) |
| Switches compressor every 2 minutes | 6/18 (33) |
| Left uterine displacement | 8/18 (44) |
| Correct ventilation rate | 9/18 (50) |
| Correct compression rate | 10/18 (56) |
| Report given to neonatal team | 14/18 (78) |
| Cricoid pressure utilized | 14/18 (78) |
| Correct hand position on the sternum | 15/18 (83) |
| Delivery of fetus in ≤5 minutes | 15/18 (83) |
The checklist was based on expert recommendations for ACLS and obstetric resuscitation from the following 2 definitive consensus publications: (1) American Heart Association (AHA), part 7.2 (Management of Cardiac Arrest ) and (2) AHA, part 10.8 (Cardiac Arrest Associated With Pregnancy ). Neonatal resuscitation provider (NRP) guidelines were based on AHA and the American Academy of Pediatrics NRP guidelines.
The 4 aforementioned individuals reviewed the videotapes using the checklist and determined whether a recommended task was completed. A separate table was used to measure the time required to complete 4 critical actions (delivery, endotracheal intubation, Code Blue activation, and call for a neonatal team). There was complete agreement between the 4 reviewers with respect to whether tasks were completed and the time required to perform them.
Data are presented as mean ± SD, median times (interquartile range), and number of teams (percentage) as appropriate. Time zero for the 4 interventions was taken from the start of a nonperfusing rhythm.
Descriptive data analysis was performed using Microsoft Excel (Richmond, CA) and SPSS version 11 (SPSS, Inc, Chicago, IL). Data were assessed for normal distribution of variance using QQ plots and Kolmogorov-Smirov tests.
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