ACLS – OB: Managing an Obstetric Code

•Angela Walker, MSN, RN-BCLife Support Training Center CoordinatorCenter for Education & Professional Development

&

•Beth Lambertz-Guimarães, MSN, RNC-OBMaternal Outreach Coordinator

The Regional Perinatal Outreach Program at The Medical Center of Central GeorgiaMacon, GA

LEA

RN

ING

O

BJE

CTIV

ES

Upon completion of this session, the learner will be able to:

• List four modifications to ACLS Algorithms (AHA Guidelines2010) for the Obstetric patient.

• Identify three recommendations for peri-mortem cesarean delivery.

• Describe three steps an institution may take to respond effectively to the pregnant woman requiring resuscitative measures based on scientific evidence.

ACLS-OB: MANAGING AN OBSTETRIC CODE

Beth Lambertz-Guimaraes, MSN, RNC-OBMaternal Outreach CoordinatorThe Regional Perinatal Outreach Program atThe Medical Center of Central Georgia

What is A

CLS

– O

B

© ?

ACLS – OB© is…• Authored by a wonderful team at St.

Luke’s Hospital in Boise, Idaho– Teresa Stanfill & Claire Beck

• Provided as adjunct to AHA – ACLS New Provider or Recertification class

• Designed to provide an understanding of modifications of ACLS algorithms to successfully manage a pregnant patient requiring resuscitation.

Th

e S

cop

e o

f the

Pro

ble

m

• Review of CEMACH (Confidential Enquiries into Maternal and Child Health)2007 data set calculates: Maternal Mortality rate @ 13.95 deaths/100,000 GA is 50th out of 50 states for Maternal

deaths!!! Cardiac arrests now 1:20,000 (↑ from 1:30,000) Jeejeebhoy FM, etal. 2011. Management of Cardiac Arrest in Pregnancy: A systematic Review.

Resuscitation, 82, 801-09

• Why is cardiac arrest in pregnancy on rise? More mature gravidas (more morbidity) Childbearing NICU Grads (growing evidence

suggests ↑ rates of hypertension & heart disease in these women)

ART: Assisted Reproductive TechnologiesSchimmelpfennig K, Stanfill T. When Lightning Strikes. AWHONN Lifelines. 10(4): 306-11 Aug /

Sept 2006

Surv

ivin

g C

ard

iac A

rrest in

Pre

gnancy

• Pregnancy & it’s complications ↑ both incidence of & difficulty adapting to life- threatening complications.

• Physiologic changes of pregnancy necessitate an altered response & modifications to improve success.

• Key considerations when pregnant woman experiences cardiac arrest: Where are you? Who and what is available to you? Is the fetus viable?

Com

mon C

ause

s of M

ate

rnal

Morta

lity

• Trauma• Embolic phenomena

(Pulmonary/amniotic fluid) • Hemorrhage• Hypertension• Infection

Datner E, Promes S. Resuscitation in pregnancy. The McGraw-Hill

Co.; 2006. Tintinalli’s emergency medicine; pg. 254

Neufeld J. Trauma in pregnancy. In Marx, editor. Rosen’s

Emergency Medicine 6th Ed. 2006, ch 35.

AH

A G

uid

elin

es2

01

0

Part 12.3: Cardiac Arrest Associated with Pregnancy

• BLS performed perfectly provides 25-33% of

normal cardiac output

• BLS performed in pregnancy w/o

modifications achieves ≤ 10% !!!

• An algorithm to address specifics of

Maternal Cardiac Arrest management was

included in the 2010 guidelines…you will

see that today

“Best hope of fetal survival is maternal survival.”

AHA2010

Vanden Hoek T L et al. Circulation 2010;122:S829-S861

First Resp

on

der

• Modification #1: hand placement at mid-sternum to accommodate the physiologically elevated heart, which is also displaced to the left.

Vanden Hoek T L et al. Circulation 2010;122:S829-S861

Su

bse

qu

en

t R

esp

on

ders

• Modification #2: perform bag-mask ventilation with 100% oxygen & consider advanced airway placement ASAP. Physiologic changes of pregnancy result in compensated respiratory alkalosis…therefore periods of apnea / hypoventilation quickly evolve into acidosis

• Modification #3: anticipate difficult airway; experienced provider preferred for advanced airway placement as soon as possible…

• Confirm placement by auscultation @ mid-clavicle & midline of underarm area

“Diffi

cult A

irway”

Incidence of failed intubation 1:280 in normal pregnant population vs. 1:2230 in general surgical population

Physiologic alterations in airway mucosa include hyperemia, edema, friability, & hyper-secretion

If possible, intubation should be managed by experienced providers, w/ smaller (by 0.5 – 1.0 mm) E-T tube (#7 or 6.5) or supra-glottic airway

Airw

ay

Mod

ifica

tion

s

• Use jaw thrust to open airway

• As mentioned,

ventilate w/100% O2

• Expect increased resistance to bag – mask ventilation

• Move to advanced airway placement ASAP

• Cricoid pressure in combination with jaw-thrust to intubate

Wh

at is C

ricoid

Pre

ssure

?

• Cricoid pressure should be used only if the victim is deeply

unconscious; consists of pushing the cricoid cartilage

toward cervical spine… compressing the esophagus, and may prevent gastric inflation and reduce risk of regurgitation and aspiration.

• Application of cricoid pressure is performed by a rescuer who is not responsible for chest compressions or ventilations.

Crico

id P

ressu

re

Vanden Hoek T L et al. Circulation 2010;122:S829-S861

Ob

vio

usly

Gra

vid

W

om

b?

• Once the fundus of the womb reaches the umbilicus it “qualifies” as an obviously gravid womb…Fundal height ↓ level of umbilicus resuscitate as if non-pregnant

• Generally, if the woman is carrying a normal sized singleton, the fundus is @ the umbilicus @ 20 weeks; each additional week the fundus will be 1 cm / 1 fingerbreadth higher.

• Multiple gestations result in an “obviously gravid” womb before 20 weeks…

Su

bse

qu

en

t R

esp

on

ders

• Modification #4: perform manual left uterine displacement (LUD) to relieve aorto-caval compression

• Modification #5: assess femoral pulse for effectiveness of compressions.

LUD

~ 1

-han

d

tech

niq

ue

Vanden Hoek T L et al. Circulation 2010;122:S829-S861

Vanden Hoek T L et al. Circulation 2010;122:S829-S861

LUD

~ 2

-han

d

tech

niq

ue

Vanden Hoek T L et al. Circulation 2010;122:S829-S861

LUD

~3

0º Tilt o

f B

ackb

oard

Peri-M

orte

m

Cesa

rean

• Modification #6: If no ROSC within 4 minutes initiate a

Peri-Mortem Cesarean Delivery (PMCD) with goal to have baby out by 5 minutes.

PM

CD

• Maternal survival in a woman with an “obviously gravid womb” is greatly influenced by presence of fetus

• Mom’s survival is ↑ by maternal modifications to ACLS which include evacuation of the womb within 4 – 5 minutes in the absence of ROSC, once fundal height is ≥ the umbilicus!

• Getting the infant into the hands of the NICU Team quite possibly improves their survival as well

PM

CD

• In a Level III or higher nursery, neonatal survival at ≥ 24 weeks is promising…certainly more promising than remaining in the womb of a momma who is not responding to resuscitative measures.

• >24 wks PMCD ↑ maternal CO & infant survival

• 20-23 wks (1-3 ↑u): better maternal CO; possible fetal survival

• <20 wks (↓ umbilicus): cesarean not likely to improve maternal CO; no fetal survival; proceed w/o modifications to BLS / ACLS algorithms

Wh

o E

mp

ties th

e

Ute

rus?

• Someone with “scalpel privileges”

OB is so privileged…

No OB?...any physician on staff with

scalpel privileges may empty womb…

Check with Medical Staff Office /

Credentialing Department to see who

might “fit the bill” if you represent a

hospital without obstetric service

provision

Loca

tion

?

• Scientific evidence supports PMCD at point of entry / location of arrest…

• Movement to OR costs valuable life saving time

• Have PMCD “Kit” available in ER and readily accessible to any labor room

PM

CD

“Packs” o

r “K

its”

• Knife handle (1) with #10 blade (2)• Kelly clamps (4)• Mayo scissors (1)• Bandage scissors (1)• Tooth forceps (2)• Needle holders (2)• Uterine closure sutures (4) • Laparotomy sponges (2 packs of 5

each)• Adhesive clear plastic abdominal

drape (1)• 1 ml/10 units pitocin vials (2)• 10 ml normal saline vials (2)• 10 ml syringe with intramuscular

needle (1)

Katz, 1986, reported by Luppi. AWHONN Lifelines. 1999

Birth

Weig

ht a

nd

Outco

me

Westg

ren a

nd

Paul’s re

vie

w o

f 25

1 ca

ses

Birth Weight (grams)

Number Surviving

Percent Surviving

< 500 0 0%

501 - 750 20 43%

751 - 1000 32 65%

1001 - 1250 43 88%

1251 - 1500 73 92%

Wh

at D

oesn

’t C

han

ge?

Wh

at D

oesn

’t C

han

ge

• Don’t delay defibrillation…joules as per AHA ACLS Algorithms If electronic fetal monitor in use, disconnect the

cables Pads preferable to paddles…if paddles = only

option – ↑ pressure on paddles (normal 25#)

• Administer ACLS drugs & doses per AHA ACLS Algorithms

• Note: Amiodarone (FDA Category “D”); 40 day ½ life; use in pregnancy associated w/fetal hypothyroidism

• At point it appears in Cardiac arrest algorithm…if PMCD indicated should have baby out by then or lidocaine = alternative

AH

A M

nem

onic “B

EA

U-

CH

OPS”

• Bleeding/DIC• Embolism

Coronary / Pulmonary / Amniotic fluid

• Anesthesia- complications• Uterine atony

• Cardiac disease

MI / cardio-myopathy / congenital defects ~ repaired / aortic dissection

• Hypertension

Chronic / Preeclampsia / Eclampsia

• Other usual “H’s” & “T’s” • Placenta ~ previa / accreta / increta /

percreta / abruptio • Sepsis

Wh

at D

oesn

’t C

han

ge

• Review the Reversible Causes:

Hypovolemia

Hypoxia

Hydrogen Ion

Hypo-/hyperkalemia

Hypothermia

Tension pnuemothorax

Tamponade, cardiac

Toxins

Thrombosis, pulmonary

Thrombosis, coronary

ACLS – OB / INSTITUTIONAL PREPARATION

Angela Walker, MSN, RN-BC•Nurse Educator Specialist•Training Center Coordinator•Center for Education & Professional Development at•The Medical Center of Central Georgia

Wh

y A

CLS

-OB

?

Outreach education & support to all providers in the region is a requirement of the contracts.

Beth Lambertz-Guimaraes is the Maternal Outreach Coordinator for MCCG.

Wh

y A

CLS

-OB

?

• MCCG receives Maternal (& Neonatal) transports from hospitals in our region.

• The moms are often extremely complex, at very high risk for life-threatening complications…not all life-threatening complications have waited to get to MCCG to occur!!!

Ou

r Jou

rney a

t M

CC

G

• In March of 2012, Beth invited the ACLS-OB authors Teresa Stanfill and Claire Beck to come from St. Luke’s Hospital in Boise, Idaho, to MCCG for three days of intensive training.

Log

istics, Logistics,

Logistics…

..

Get a ROOM! Set

Up

Agendas

Paperwor

k

Clean UpBreak

it Down!

Schedule

Instructors

Talk to Boise team

Juggle Concur

rent Classes

Sit in on ACLS-

OB Class

Ou

r Jou

rney a

t M

CC

G

• The original training class included

eight nurses: Beth, our Maternal Outreach nurse.

Nurses from MCCG, including a

department-based educator, a staff nurse,

and the assistant director of Labor &

Delivery.

Nurses from Dodge County Hospital and

Fairview Park Hospital, both in Middle

Georgia and Level I providers.

Nurses from Tift Regional Medical Center,

in Tifton, Georgia and a Level II provider.

Ou

r Jou

rney a

t M

CC

G

• Program of Study:ACLS Provider ClassACLS Instructor ClassACLS-OB Provider Class

• Results:All nurses enrolled completed and

passed all stations and examinations.All MCCG nurses completed the

process to become ACLS instructors.Beth also completed the process to

become an ACLS instructor.

AC

LS &

OB

– A G

ood

Fit • ACLS-OB content is provided as an adjunct to

AHA ACLS:

Taught prior to or after ACLS

Standard AHA Provider card

Standard AHA ACLS written exam

Skills tests utilize AHA Algorithms with OB-focused

scenarios.

Ou

r Jou

rney a

t M

CC

G

• Roles of the Educator:EducatorFacilitatorConsultantResearcher LeaderChange Agent

• A change agent initiates needed change, and assists others in adopting and adapting to change.

O’Shea, Kristen L. (2002). Staff Development Nursing Secrets. Philadelphia, PA: Hanley & Belfus, Inc.

Ou

r Jou

rney a

t M

CC

G

• Working Within the System to Affect Change:

Barriers

Buy-in

Cost

Time

Champions

Cham

pio

ns in

Change

• Adding this course to our Life Support Training Center Schedule on a regular basis involved the commitment and dedication of many individuals and teams. Administration – especially Betty Casey,

MSN, AVP of Surgical, Women’s & Outpatient Services

The Center for Education & Professional Development at MCCG

The Code Blue Committee at MCCGAnd many others….

Oth

er C

han

ges…

• Codes We Call at MCCG:

CODE BLU

E

CODE STORK

Both codes called for the same

location means:ACLS-

OB

Inaugura

l AC

LS O

B P

rovid

er

Cla

ss

The first ACLS-OB Provider Class held at MCCG took place on January 30th and 31st 2014. MCCG is the only hospital in Georgia that teaches this class. This initiative was spear-headed by the Maternal Outreach nurse, Beth Lambertz-Guimaraes, who brought the authors of the program from Boise, Idaho, to train our team of instructors, Jennifer Boland and Lisa Suggs. Pictured from left to right (back row) is Jane Holik, Jennifer Boland, Lisa Suggs, Beth Lambertz-Guimaraes, Kristen Spotts, and left to right (front row) Rita Little, Heather Staley, Phyllis Gresham, and Kayla Blount.

Team

Appro

ach

(Krueger, 2004)

OB/Maternal Team

BLSUterine displacementAssessment of fetal

viabilityMedical history

Perimortem Cesarean

Neonatal Team

Maternal historyResuscitation history

Gestational age of fetusDisposition of neonate

Code Team

ACLSIntubate-IVs-MedicationsInternal cardiac massage

(Krueger, 2004)

Wh

at’s N

ext?

• Continue to offer ACLS-OB at MCCG for:

All Labor & Delivery NursesAll Medical Residents Interested Healthcare Providers in

the Community and StateExpand program to include the

Emergency Center Nurses and Physicians at MCCG

Expand program to include the Intensive Care Unit Nurses and Physicians at MCCG

Con

sidera

tion

s

• Unit-Specific Criteria for Instructors

• Hospital Budget

• Target Audience

• Administrative /Management Challenges

• Equipment, Supplies

• Funding

• Startup Investment/Regulatory Issues

Don

’t Miss T

his!

• Reduced tuition for conference attendees for the ACLS-OB Provider Class on

• October 16th and 17th, 2014 and • January 29th and 30th, 2015.