ACLS Guide to First Aid Series: First Aid for Pregnant Women
Two lives are at stake when a pregnant woman goes into cardiac arrest or is choking. By understanding the physical changes brought about by pregnancy you can respond appropriately to maternal emergencies.
Here is a quick reference guide to first aid modifications for the mother-to-be. Be sure and take a glimpse at the resources under each section if you are interested in the research that defines the problem and outlines the many things that bystanders, emergency medical services (EMS), first responders, and healthcare professionals need to know when a pregnant woman experiences a possibly deadly event.
Maternal Cardiopulmonary Resuscitation (CPR)
Although most characteristics of maternal resuscitation are similar to the standard adult resuscitation, several aspects are uniquely different.
- Call 9-1-1 (or EMS) or direct someone else to call. Tell the operator that there is a pregnant woman in cardiac arrest. This alerts the EMS to take specific measures, such as sending additional providers. Immediate perimortem cesarean delivery (PMCD), or resuscitative hysterotomy, should be anticipated, at the site of the cardiac arrest, within four to five minutes of the arrest.
- Start CPR with the woman flat on her back in a supine position. According to the scientific statement by the American Heart Association (AHA), high-quality chest compressions occur when the pregnant woman is supine on a hard surface. If a backboard is used, care should be taken to avoid delays in the initiation of CPR, reduce interruptions during CPR, and prevent line or tube displacement (2015;132, Issue 18).
- One-person CPR as a bystander: Follow the basic life support (BLS) sequence —C-A-B (chest compressions-airway-breathing)—push hard and fast in the center of the chest at a rate of at least 100 compressions per minute with a depth of 2 in (5 cm). Perform this in cycles of 30 compressions and two breaths. Deliver the chest compressions same way for a pregnant woman as for a non-pregnant woman. (See two-person CPR for information regarding left uterine displacement)1
- Two-person CPR: Use C-A-B-U (chest compressions-airway-breathing-uterine displacement) if two or more rescuers are at hand. Continuously perform manual left uterine displacement (LUD) when the uterus is felt at or above the umbilicus (approximately 20 weeks pregnant) to help restore blood flow to the heart by reducing aortocaval compression, which is the compression of the inferior vena cava and abdominal aorta by the gravid (pregnant) uterus. Historically, a left lateral tilt of 30° has been used to displace the uterus; however, the AHA reports that a tilt of her body may shift the heart laterally and impact the force of the chest compressions. Therefore,the AHA recommend the left lateral tilt if manual LUD is unsuccessful (see footnote 1). Furthermore, a manikin study found that the left lateral tilt and manual uterine displacement are equally effective during chest compressions. The researchers of this study also mention that the compressions were easier to perform in the supine position. As a bystander performing one-person CPR, high-quality chest compressions are critical. Nevertheless, if you have a wedge immediately available (or other article that can act as a wedge, such as a stiff pillow), you can place this under the woman’s right hip to attempt LUD.
- If recovered, the pregnant woman should be placed on her left side to increase blood flow to the heart and baby.
2015 AHA Statement on Cardiac Arrest in Pregnancy – key points to remember about cardiac arrest in pregnancy derived from the 2015 AHA statement on cardiac arrest in pregnancy.
Frequent Causes of Maternal Cardiac Arrest in the US – this article discusses the common causes of cardiac arrest in a pregnant woman; these include heart failure, bleeding, amniotic fluid embolism, and infection.
Data on Pregnancy Complications – these figures show trends from 1993 through 2014 of three serious pregnancy complications.
Pregnancy Mortality Surveillance System – information about the pregnancy-related mortality ratio.
Cardiac Arrest in Pregnancy: Out-of-Hospital Basic Life Support (BLS) – a one-page algorithm for healthcare providers.
Cardiac Arrest in Pregnancy: In-Hospital Basic Life Support (BLS) – a one-page algorithm for healthcare providers.
How to Determine Fundal Height – this resource explains the significance of fundal height measurement.
Physiological Changes in Pregnancy – this review highlights the important changes in the cardiovascular system during pregnancy, this includes the normal findings on an ECG.
Cardiac Disease and Pregnancy – outlines the general guidelines for the management of heart disease in pregnant women.
John Hopkins OB Critical Care Training: Amniotic Fluid Embolism, Massive Transfusion Protocol, and Cesarean Delivery – John Hopkins in-hospital training video.
Healthy Pregnancy – this article takes you through a healthy pregnancy week by week.
Automated External Defibrillator (AED) in Maternal Resuscitation
The best way to save the baby is to save the mother. Rapid defibrillation, when indicated, can be life-saving. Use the AED as per standard protocol. The guidelines are the same for the pregnant patient as they are for the non-pregnant patient.
Resume compressions immediately after the delivery of the electric shock.
ACLS Guide to Defibrillation – an online guide to the history and types of defibrillation.
How and When to Use an AED – a step-by-step explanation from the National Health Institute of how and when to use an AED.
Overview of AEDs – the Occupational Safety and Health Administration provides a list of resources related to AEDs.
Choking When Pregnant
The universal sign of choking is the hands clenched around the throat; however, this signal may not be present. Other immediate indications include not being able to talk or difficulty breathing or wheezing.
If the pregnant woman can cough forcefully, then she should keep coughing. If the woman cannot talk, cry, or laugh, then initiate a modified Heimlich maneuver. In this situation, you protect the developing fetus by using chest thrusts versus abdominal thrusts to dislodge the object.
- If you are the only rescuer, initiate chest thrusts before calling 9-1-1 or emergency services. If another person is available, have that person call for help while you begin first aid.
- For stability, position yourself behind the pregnant woman with one leg in between theirs.
- Place your arms underneath each of the woman's armpits.
- Place your fist—thumb side towards the woman with your knuckles pointing towards the sky—in the center of the chest between the breasts.
- Deliver repeated chest thrusts to the woman, straight inward in a quick, sharp manner to compress the lungs.
- Continue chest thrusts until the object is relieved or the woman becomes unconscious.
If the woman becomes unconscious, follow the next steps.
- Lower her to a supine position and make sure to call emergency services if not already done.
- Perform 30 chest compressions, do a head tilt/chin lift, check for the object, and sweep it out if possible. *Do not* attempt a finger sweep if you *cannot* see the foreign body.
- Attempt a rescue breath. If no rise and fall of the chest, reposition the airway and attempt a second breath.
- If air does not fill the lungs, perform 30 chest compressions, check for the object again, and sweep it out if possible.
- Attempt another rescue breath. If you do not see a rise and fall of the chest, reposition the airway and attempt the breath again. Repeat this process until the airway is open.
- At this point, check for a pulse for a maximum of 10 seconds.
- If the pulse is present in the absence of normal breathing, continue rescue breathing for one breath every five seconds for two minutes.
- After two minutes, reassess the pulse and check for normal breathing.
- If no palpable pulse, begin full CPR until: (a) an EMS arrives, (b) an AED arrives, or (c) the woman revives.
- Once revived, the pregnant woman should be placed on her left side to increase blood flow to the heart and baby.
- The pregnant woman should see her healthcare provider as soon as possible; internal injuries can occur.
More resources on choking when pregnant
Clearing the Airway of a Pregnant Woman – video tutorial of the modified Heimlich maneuver performed on a pregnant woman.
Causes of Choking – learn the causes and symptoms of choking.
Signals of Someone Choking – a guide that reviews the signs of choking and detailed information about how to handle the emergency.
Blockage of the Upper Airway – a summary of upper airway obstruction and its possible complications if not promptly treated.
Standard Heimlich Maneuver – this resource provides a review of the standard abdominal Heimlich maneuver for someone (not pregnant) that is choking, including infants.
Note: A quick reference guide is not a replacement for CPR and first aid training—get trained today and save a life!
Other Potential Pregnancy Complications and Emergencies
Spot the Signs of Early Labor – review the signs of false labor, stages of labor, and management of labor pain.
Emergency Childbirth – this article guides you through anatomy and physiology, prehospital care, field delivery, neonatal care, and postpartum care.
Vaginal Bleeding in Early Pregnancy – know the difference between spotting and bleeding, when to worry, and what causes vaginal bleeding.
Premature Rupture of Membranes (PROM) – a review of what causes the “water to break” prematurely and how a healthcare provider manages the rupture.
Seizure – a summary of preeclampsia and eclampsia.
Gestational Diabetes – a thorough review of the causes, symptoms, risk factors, and complications of gestational diabetes.
Chronic Disease in Pregnancy – a glance into the risk behaviors and chronic disease of the mother-to-be.
Abdominal Pain in Early Pregnancy – case study and commentary of a 34-year-old-woman who was 14 weeks pregnant that presents to the emergency department with five days of nonspecific abdominal pain, nausea, and vomiting.
1. [Jeejeebhoy FM, Zelop CM, Lipman S, et al. Cardiac arrest in pregnancy: a scientific statement from the American Heart Association. Circulation. 2015;132:1747-1773. doi: 10.1161/CIR.0000000000000300]↩
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