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Intrapartum Maternal Cardiac Arrest: A Simulation Case for Multidisciplinary Providers



Introduction Cardiac arrest in pregnancy is rare. Advanced Cardiovascular Life Support courses rarely address interventions specific to obstetric patients, and knowledge gaps are frequent among providers. The Society for Obstetric Anesthesia and Perinatology and American Heart Association have published guidelines regarding management of cardiac arrest in pregnancy, and interdisciplinary simulation training has been advocated to reinforce key management points for this clinical scenario. Methods In situ multidisciplinary simulation training was implemented for anesthesia and maternal fetal medicine fellows and obstetric nurses at our hospital. The case was amniotic fluid embolism in a 35-year-old parturient at term. The patient had a witnessed seizure before cardiovascular collapse. Learners were expected to initiate high-quality cardiopulmonary resuscitation and perform a perimortem cesarean delivery within 5 minutes while demonstrating clear communication with each other. The case required a labor room, high-fidelity mannequin, defibrillator, code cart, cesarean section instruments, and simulated medications and intravenous fluids. Results Participants comprised two obstetric anesthesia fellows, three maternal fetal medicine fellows, and three obstetric nurses. Positive feedback about the training and increased perceptions of self-efficacy were received. Potential systems issues were detected and corrected because of the training, highlighting the value of in situ drills. Discussion We found it challenging to implement more frequent multidisciplinary sessions, but participants found the experience highly rewarding. We hope to expand the training to all physicians and nurses covering the unit on a regular basis. Modified scenario versions are being used for nursing-only and obstetric resident-only simulations during protected teaching time for those services.
Intrapartum Maternal Cardiac Arrest: A Simulation Case
for Multidisciplinary Providers
Allison Lee, MD*, Jean-Ju Sheen, MD, Stacey Richards, MA, RN
*Corresponding author:
Introduction: Cardiac arrest in pregnancy is rare. Advanced Cardiovascular Life Support courses rarely
address interventions specific to obstetric patients, and knowledge gaps are frequent among providers.
The Society for Obstetric Anesthesia and Perinatology and American Heart Association have published
guidelines regarding management of cardiac arrest in pregnancy, and interdisciplinary simulation training
has been advocated to reinforce key management points for this clinical scenario. Methods: In situ
multidisciplinary simulation training was implemented for anesthesia and maternal fetal medicine fellows
and obstetric nurses at our hospital. The case was amniotic fluid embolism in a 35-year-old parturient at
term. The patient had a witnessed seizure before cardiovascular collapse. Learners were expected to
initiate high-quality cardiopulmonary resuscitation and perform a perimortem cesarean delivery within 5
minutes while demonstrating clear communication with each other. The case required a labor room, high-
fidelity mannequin, defibrillator, code cart, cesarean section instruments, and simulated medications and
intravenous fluids. Results: Participants comprised two obstetric anesthesia fellows, three maternal fetal
medicine fellows, and three obstetric nurses. Positive feedback about the training and increased
perceptions of self-efficacy were received. Potential systems issues were detected and corrected because
of the training, highlighting the value of in situ drills. Discussion: We found it challenging to implement
more frequent multidisciplinary sessions, but participants found the experience highly rewarding. We hope
to expand the training to all physicians and nurses covering the unit on a regular basis. Modified scenario
versions are being used for nursing-only and obstetric resident-only simulations during protected teaching
time for those services.
Maternal Cardiac Arrest, Perimortem Cesarean Section, Manual Left Uterine Displacement
Educational Objectives
By the end of this activity, learners will be able to:
1. Perform supportive airway management of the parturient in cardiac arrest.
2. Perform effective chest compressions during cardiopulmonary resuscitation.
3. Perform manual left uterine displacement during cardiopulmonary resuscitation.
4. Initiate timely perimortem cesarean section within 5 minutes of recognized cardiac arrest.
5. Communicate effectively with a multidisciplinary team of anesthesiologists, obstetricians, and nurses
during patient management.
6. Increase their confidence regarding the ability to appropriately manage maternal cardiac arrest in
clinical practice.
Cardiac arrest in pregnancy is a rare event (affecting less than one in 20,000 women) ; however, a
significant proportion of cases have a reversible etiology. Young, critically ill, pregnant women in cardiac
arrest are thus considered to be more salvageable than most patients requiring cardiopulmonary
resuscitation. With the rapid implementation of appropriate treatment, a 50% survival rate has been
reported. Advanced Cardiovascular Life Support courses typically devote little or no attention to
Original Publication OPEN ACCESS
Citation: Lee A, Sheen J-J, R ichards S.
Intrapartum maternal cardiac arrest: a
simulation case for multidisciplinary
providers. MedEdPORTAL.
Copyright: © 2018 Lee et al. This is an
open-access publication distributed
under the terms of the Creative
Commons Attribution-NonCom mercial-
Share Alike license.
A. Simulation Case File.docx
B. Prelearning Slide
C. Simulation Flow Grid.docx
D. Behavior Checklist.docx
E. Learner Feedback Survey
F. Team Follow-up Form.docx
G. Sample Multiple-Choice
All appendices are peer reviewed as
integral parts of the Original
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addressing interventions specific to obstetric patients, and significant gaps in provider knowledge have
been documented in multiple reports. In 2014, the Society for Obstetric Anesthesia and Perinatology
(SOAP) issued a consensus statement in which the need for health care provider education was
emphasized, and in 2015, the American Heart Association (AHA) published its first scientific statement on
maternal cardiac arrest.
Maternal cardiac arrest simulation training has been shown to improve learner knowledge and
performance, and multidisciplinary maternal cardiac arrest simulation drills have been recommended to
increase emergency preparedness, to address cognitive knowledge deficits, and to improve behavioral
and communication strategies. It was within this context that it was proposed to launch regular in situ
simulation training for this low-frequency but critical event on our high-risk labor and delivery unit.
Effective teamwork is essential for successful patient management during cardiac arrest, so this learning
activity was designed for a multidisciplinary team of clinical providers including anesthesiologists,
obstetricians, and obstetric nurses. The sessions were geared towards advanced learners at our
institutions—obstetric anesthesia fellows, maternal fetal medicine (MFM) fellows, and obstetric nurses. The
priorities of training were to emphasize clear communication among team members, to initiate early high-
quality chest compressions, to provide manual left uterine displacement, and to perform perimortem
cesarean delivery within 5 minutes. The in situ setting alleviated the pressure of having to schedule
providers to leave the unit, facilitated demonstration of unit-specific educational aspects of training such
as the physical location of the code blue button, and helped to identify latent systems issues.
Despite reports in the literature describing the benefits of maternal cardiac arrest simulation training,
comprehensive scenario details are rarely published. No MedEdPORTAL publications specifically address
the unique issues of management of cardiac arrest in late pregnancy, so we believe this simulation
represents a valuable resource for health care educators.
We developed the learning activity (Appendix A) in 2015 in the context of a busy academic high-risk
obstetric center (with more than 4,000 annual deliveries). In addition to obstetric and anesthesiology
residents, subspecialty trainees in our center include nine MFM fellows and two obstetric anesthesia
fellows. A catalyst for curriculum development had been the 2014 SOAP consensus statement on
management of cardiac arrest in pregnancy and the 2015 AHA scientific statement on cardiac arrest in
pregnancy ; there had also been recent changes to the unit’s code blue emergency alert system that
created a need for educating staff. In 2011, the lead facilitator, Allison Lee, had managed a term parturient
who survived a cardiac arrest due to suspected amniotic fluid embolism and who underwent perimortem
cesarean section. The scenario developed was based on aspects of the real case.
We agreed that the implementation of the simulation training as at least an annual event for advanced
learners (anesthesia and MFM fellows) and nurses was an important initial goal. Fellows were expected to
have been familiarized with the most recently published maternal cardiac arrest guidelines in their didactic
sessions. Nurses were instructed to access prelearning online, which included a 12-slide presentation
(Appendix B) summarizing the key points for management of late-pregnancy cardiac arrest and best
practices for teamwork and communication; supporting reference articles were provided as optional
reading, including the SOAP consensus statement and the AHA scientific statement.
The simulation was conducted in situ in a fully stocked, unused labor room at the NewYork-Presbyterian
Morgan Stanley Children’s Hospital, New York, NY.
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Required equipment included the following:
High-fidelity birthing mannequin, Victoria s2200r (Gaumard Scientific, Miami, FL).
Laptop computer with simulator control software.
Computer monitor for vital signs display.
Prerecorded scripted patient voice responses (“Hi,” “I’m okay,” and “I don’t feel so good”).
Mock patient identification wrist band.
Intravenous infusion giving set with 1L bag of lactated Ringer’s solution attached to mannequin.
30 units/500 ml bag of oxytocin solution with intravenous infusion piggyback giving set.
Two drug infusion pumps.
Spare lactated Ringer’s 1L bag and intravenous infusion giving set.
Epidural catheter (taped to mannequin’s back).
Mock bupivacaine 0.0625%/fentanyl 2 mcg/ml epidural infusion 250 ml solution bag and patient
controlled epidural analgesia (PCEA) tubing.
PCEA pump with bolus dose button.
External cardiotocography sensors and monitor with elastic abdominal straps.
Noninvasive blood pressure cuff and cable.
Pulse oximeter probe and cable.
Nonrebreather oxygen face mask and tubing.
Suction canister, suction tubing, and Yankauer suction tip.
Ambu bag valve mask.
Fully stocked mock code cart (including airway equipment and backboard).
Mock code drug tray, including, at minimum, epinephrine 1mg/10ml (five prefilled syringes), atropine 1
mg/10ml (five prefilled syringes), sodium bicarbonate 8.4% 50 meq/50ml (10 prefilled syringes),
calcium chloride 1 g/10ml (five prefilled syringes).
ZOLL M series (ZOLL Medical Corporation, Chelmsford, MA) biphasic defibrillator with ZOLL Stat Padz
defibrillator electrodes and 3M 2560 Red Dot monitoring electrodes (3M United States, Saint Paul,
Simulation/mock drugs: magnesium sulfate solution 4G/1L bag and intravenous giving set, midazolam
2mg/2ml vials (two vials), phenylephrine 40 mcg/ml 10 ml (two prefilled syringes), ephedrine 5 mg/ml
10 ml (two prefilled syringes).
Mock patient health record summary sheet.
Mock paper anesthesia preoperative assessment with most recent laboratory results and mock
electronic anesthesia record.
Clipboard and code time sheet.
Participant name tags displaying the role in the simulation.
To successfully run the multidisciplinary simulation, the minimum personnel required were two anesthesia
fellows, given roles of anesthesia resident (to be called first to the scene) and attending anesthesiologist;
three MFM fellows, taking the roles of obstetrics resident, MFM fellow, and MFM attending; and three
nurses, with roles of primary labor nurse, secondary labor nurse, and charge nurse. One confederate actor
(Stacey Richards) played a nurse at the end of her shift signing the case over to the primary labor nurse
participant; another confederate actor played the role of the simulated patient’s family member.
After two face-to-face meetings to discuss the design of the simulation, the facilitators met with the
simulation technician in the simulation center to review the flow of the scenario (Appendix C), rehearse
expected vital signs changes, and plan strategies to move the scenario forward if participants failed to
recognize key events.
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Sessions were scheduled to be conducted over 1 hour, starting at 8:00 a.m. on a Monday morning around
the midpoint of the academic year, during the usual protected teaching time slot for the MFM fellows. The
anesthesia fellows were given nonclinical assignments that day. Nurses were selected for participation in
the simulation at the discretion of the perinatal safety nurse and patient care director. The labor room was
set up for the simulation by the three multidisciplinary facilitators and two simulation technicians 1 hour in
advance of the start of the session.
Prior to the start of the activity, participants were assembled in the labor room, and a 10-minute prebriefing
was conducted by Allison Lee. During the prebriefing, participants were welcomed and attendees asked
to individually introduce themselves by giving their name and their title. Reassurance was provided to
encourage a sense of psychological safety and emphasize the confidentiality of the learning activity.
Participants were oriented to the mannequin, room setup, and location of equipment. Participants were
asked not to actually press the code blue button, which would initiate the notification calls throughout the
hospital, but instead to verbalize that they would like to press the code blue button. A brief description of
the setting and patient history (35-year-old G3 P1 woman, with gestational age 40 weeks, in active labor,
receiving PCEA) were provided, the roles for the scenario were assigned, and the primary nurse was
asked to remain in the room while other participants waited outside.
Stacey Richards, the facilitator playing the role of a labor nurse at the end of her shift, gave a sign-out to
the primary labor nurse participant. As part of the report, it was disclosed that the patient had recently
received an epidural top-up dose for breakthrough pain. After 1-2 minutes of interaction, the patient
complained of not feeling well and then had a generalized seizure lasting 10 seconds. The confederate
playing the role of the patient’s sister became alarmed.
The nurse called for help from the obstetric and anesthesia residents and charge nurse (Stacey Richards
stepped outside the room to call in the other participants). The first responders initially performed
immediate postseizure management before the patient developed complete cardiorespiratory arrest. The
primary nurse indicated that she would like to press the code blue button, which would notify the hospital
code team, composed of internal medicine physicians and respiratory therapists. Cardiopulmonary
resuscitation maneuvers, including chest compression and bag-mask ventilation, were begun, and the
other participants and code cart were brought to the room. Along with tracheal intubation, other actions
were medication administration and electrocardiogram rhythm analysis and defibrillation for ventricular
fibrillation; perimortem cesarean delivery was performed within 5 minutes, upon which return to
spontaneous circulation occurred. Following the simulation, which lasted about 15 minutes, a 30-minute
debriefing was conducted by the three co-debriefers.
The critical action checklist (Appendix D) was developed for the domain Management of Cardiac Arrest in
Late Pregnancy, based on the input of content experts, Allison Lee, Jean-Ju Sheen, and Stacey Richards.
The guidelines provided in the SOAP consensus statement and AHA scientific statement were used as
the primary reference material for development of behavior checklist items.
The effectiveness of the simulation at achieving the educational objectives was determined by verbal
feedback during the debrief, when participants were invited to share their perceptions of the session. At
the end of the activity, learners were asked to each state one thing they had learned from the activity. An
example of a shared response by some learners was that they had not known about the bed lever that
instantaneously flattens the labor bed to the horizontal position and facilitates rapid initiation of
cardiopulmonary resuscitation efforts. An anonymous paper survey was also completed by participants in
2018 (survey template, Appendix E).
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The preview advocacy-inquiry debriefing model was utilized at the conclusion of the simulation. The
structure involving multidisciplinary co-debriefers (an anesthesiologist, MFM obstetrician, and perinatal
safety nurse educator) contributing differing perspectives, targeted at the different types of learners, was
believed to be highly valuable. The content of the debriefing was geared to achieving the stated learning
objectives and guided by learner adherence to actions on the behavior checklist. Outcomes and summary
points of the debriefing, systems issues that were identified, and plans for follow-up were documented
(Appendix F).
The debriefing began with a reactions phase, in which Allison Lee asked participants to share their
emotional response to the simulation. The simulation’s purpose and learning objectives were made clear
to the learners, and they were asked to describe their perceptions of how the scenario had unfolded. The
co-debriefers took turns commenting on aspects of the simulation that had gone well and discussed
observed performance gaps, taking the approach of having sincere curiosity about the learners’ frames.
By conducting a conversational formative assessment, facilitators were able to address performance gaps
on the spot. Participants were specifically asked about their perception of team communication and
whether or not a leader had been established during the event. Because the number of MFM fellows
exceeded the number required for the scenario, the more senior fellows (particularly any who had
experienced the simulation previously) were asked to be peer observers and were provided with copies of
the behavior checklist. They were invited to make any additional comments towards the end of the
This multidisciplinary in situ simulation has been conducted on an annual basis since 2015, and the
experiences have been highly valued by the labor and delivery unit staff. The facilitators are simulation
educators with almost 2 decades of experience combined; Allison Lee and Stacey Richards have received
formal instructor training from the Center for Medical Simulation. For each session, active participants
included two obstetric anesthesia fellows, three to four MFM fellows, and three to four obstetric nurses.
Cardiac arrest is a rare event, and the drills uncovered important latent systems hazards and staff training
Systems Issues Revealed
At the initial event, it was discovered that the universal cable on the defibrillator (which connects the unit
to the disposable electrodes) had been cinched with plastic zip ties, leading to a delay in defibrillation
since the ties had to be cut in order to release the cable for use. This issue has since been corrected. Also
at the initial event, a participant had to rush to the operating room area to obtain surgical instruments,
resulting in a delay in making the incision. A scalpel is now stored in a lockable cart in each labor room.
The third event revealed that nursing staff had difficulty opening the lowest compartment on the code cart
and that there had been a decay in knowledge regarding the use of the defibrillator. This prompted a
modified version of the scenario for nursing-only drills in which multiple nurses, utilizing an empty labor
room, received training; the goal was to reach all nurses on staff. Obstetric resident-only drills, also using a
modified version of the scenario, are being conducted at the medical school simulation center during the
residents’ scheduled didactic time.
Learner performance was assessed using a behavior checklist, with actions rated as not done, partially
done, or done well. The checklists were helpful for formative assessment and keeping track of
performance gaps that needed to be addressed in the debriefing. The anesthesia fellows consistently
initiated prompt bag-mask ventilation with equipment located at the bedside; however, the first time the
scenario was conducted, there was a delay in intubation of the trachea due to uncertainty about where
the nearest airway equipment was located. In the debrief, participants were shown the exact location of
invasive airway equipment in the mock code cart and were informed about a portable airway equipment
bag stored in the anesthesia work room. Participants performed early and vigorous chest compressions
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but failed to use the backboard in all sessions except the last one in 2018. In the first session, participants
incorrectly performed chest compressions at the mid-sternum level and were taught in the debrief that
hand placement at the level of the lower sternum is recommended for pregnant women. Teamwork has
been consistently strong in the simulation sessions, and participants have called for help early in every
case. There has been inconsistent use of closed-loop communication and poor role clarity at times. In the
debrief, strategies such as closed-loop communication and readback have been encouraged. The
importance of identifying a team leader and of team members assuming specific roles, such as being a
scribe or timekeeper, has been reinforced at each session.
In 2018, learners were asked to provide anonymous feedback about their perceptions of the simulation
and level of confidence after training in managing this situation. Widely positive responses were received,
with all nine respondents reporting that they agreed (slightly or strongly) that the simulation was a valuable
learning experience and that they were likely to apply what had been learned to patient care. Eight of nine
respondents agreed (slightly or strongly) that the simulation increased their confidence in managing
cardiac arrest in pregnancy; only one respondent selected a neutral rating for the latter ( Table).
Table. Feedback Survey Responses (N = 9)
Slightly Neutral
This simulation was a valuable learning experience. 0 0 0 1 8
This simulation would be worth repeating. 0 0 0 1 8
The time allotted for this simulation was appropriate. 0 0 0 2 7
The simulation was realistic and applicable to clinical practice. 0 0 0 1 8
This simulation increased my confidence. 0 0 1 3 5
The learning environment was nonthreatening. 0 0 0 0 9
Facilitation, feedback, and instruction stations w ere helpful to
my learning.
0 0 0 2 7
How likely are you to apply what you have learned today to
patient care?
0 0 0 2 7
This report provides a detailed description of the design and implementation of multidisciplinary
simulation training in maternal intrapartum cardiac arrest for advanced learners (fellows) and nurses. We
consider this to be a core learning activity for our physicians and labor nursing staff, and indeed for any
labor and delivery unit. Because of the natural decay in knowledge over time, regularly scheduled training
in this rare but critical event is imperative to ensure preparedness.
Our evaluation was limited to participant self-report of perceptions of the training session. The behavior
checklist was developed for formative evaluation of the participants overall and to help guide debriefing.
Facilitator checklist notes were not preserved as the session was designed for teaching purposes and it
was not anticipated that a formal report would be made in the future. The absence of such data is a
limitation of this report. Sample multiple-choice questions that may be utilized as a pre- and/or
postsimulation knowledge assessment are provided (Appendix G).
With repeated trainings, our drills have become more seamless. The scenario has been slightly simplified
since the initial session. The initial narrative included recent penicillin administration prior to the collapse,
complicating the potential differential diagnosis to include anaphylaxis. This aspect is now seen as adding
unnecessary complexity and does not necessarily aid in achieving the learning objectives. It was desirable
to have staff physically complete management steps to mimic a real-life situation; however, we wanted to
avoid the potential risk of mixing real drugs with simulated drugs. No simulated drugs were placed in the
automated drug dispenser; instead, clearly labeled simulated medications were to be accessed in a
bucket left in the locked room with the drug-dispensing machines.
The major limitation of this multidisciplinary training activity has been the difficulty with scheduling more
frequent sessions among three services; we received feedback from learners that they wished the
trainings occurred more often. With in situ training, the risk of not securing a free room at the time of the
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training and/or the staff being too busy to participate in the training always exists. For this reason, we
prepared a backup plan of moving the drill to the simulation center, if needed. With a 3-year MFM
fellowship, it is inevitable that some fellows will have experienced the simulation in the past. To increase
the challenge of the simulation, we have experimented with blindfolding the team leader to emphasize the
importance of clear, closed-loop communication among the participants.
Based on the in-person feedback during the debrief, where each participant was asked to convey what
new information had been learned during the simulation, and on anonymous survey responses to date
(Table), we conclude that the sessions have been very effective in meeting the learning objectives. We will
continue to collect feedback via surveys with future sessions. The sessions have been successful in
identifying systems issues, resulting in important system changes geared toward improving patient safety.
Finally, the sessions have identified performance gaps that illuminated a need for additional staff training.
The template provided has detailed instructions for implementation and should be easily generalizable to
other institutions. In the future, we hope to find opportunities to expand the learning activity to include
anesthesiology and obstetric residents, as the scenario could also be generalized to less experienced
learners. We intend to implement pre- and posttesting for participants to objectively document the
increments in learning following the training.
Allison Lee, MD: Assistant Professor, Division of Obstetric Anesthesia, Department of Anesthesiology, Columbia University; Medical
Director, Margaret Wood Center for Simulation and Education, Division of Obstetric Anesthesia, Department of Anesthesiology,
Columbia University
Jean-Ju Sheen, MD: Assistant Professor, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia
University; Medical Director of Labor and Delivery, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology,
Columbia University
Stacey Richards, MA, RN: Perinatal Patient Safety Coordinator, NewYork-Presbyterian Hospital
We would like to acknowledge Branden Ford and Woojin Shim for preparing and operating the simulator for our education sessions.
None to report.
None to report.
Informed Consent
All identifiable persons in this resource have granted their permission.
Ethical Approval
Reported as not applicable.
1. Lipman S, Cohen S, Einav S, et al. The Society for Obstetric Anesthesia and Perinatology consensus statement on the
management of cardiac arrest in pregnancy. Anesth Analg. 2014;118(5):1003-1016.
2. Zelop CM, Einav S, Mhyre JM, Martin S. Cardiac arrest during pregnancy: ongoing clinical conundrum. Am J Obstet Gynecol.
3. Cohen SE, Andes LC, Carvalho B. Assessment of knowledge regarding cardiopulmonary resuscitation of pregnant women. Int J
Obstet Anesth. 2008;17(1):20-25.
4. Einav S, Matot I, Berkenstadt H, Bromiker R, Weiniger CF. A survey of labour ward clinicians’ knowledge of maternal cardiac
arrest and resuscitation. Int J Obstet Anesth. 2008;17(3):238-242.
5. Berkenstadt H, Ben-Menachem E, Dach R, et al. Deficits in the provision of cardiopulmonary resuscitation during simulated
obstetric crises: results from the Israeli Board of Anesthesiologists. Anesth Analg. 2012;115(5):1122-1126.
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6. Lipman SS, Daniels KI, Carvalho B, et al. Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric
crises. Am J Obstet Gynecol. 2010;203(2):179.e1-179.e5.
7. Jeejeebhoy FM, Zelop CM, Lipman S, et al; for American Heart Association Emergency Cardiovascular Care Committee, Council
on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Cardiovascular Diseases in the Young, and
Council on Clinical Cardiology. Cardiac arrest in pregnancy: a scientific statement from the American Heart Association.
Circulation. 2015;132(18):1747-1773.
8. Fisher N, Eisen LA, Bayya JV, et al. Improved performance of maternal-fetal medicine staff after maternal cardiac arrest
simulation-based training. Am J Obstet Gynecol. 2011;205(3):239.e1-239.e5.
9. Abdel-Rahim R, Burrough B, Lee A. A case of intrapartum cardiac arrest and perimortem cesarean section. Presented at:
Society for Obstetric Anesthesia and Perinatology Annual Meeting; May 2-5, 2012; Monterey, CA.
10. Rudolph JW, Simon R, Dufresne RL, Raemer DB. There’s no such thing as “nonjudgmental” debriefing: a theory and method for
debriefing with good judgment. Simul Healthc . 2006;1(1):49-55.
Received: May 30, 2018 | Accepted: September 24, 2018 | Published: October 26, 2018
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Supplementary resource (1)

... Simulation is a well-established and effective means of education for code blue training, 13 particularly in preparing for situational variations with which health care teams may have less experience. [14][15][16][17] At the start of the COVID-19 pandemic, several groups successfully used high-fidelity simulation to train staff for airborne isolation code blue. [18][19][20] Unfortunately, this method of simulation requires significant resources, including personnel, time, and expensive equipment, that are limited in many institutions. ...
... Our learner-reported improvements are similar to those seen in prior cardiac arrest simulation literature, 26,27 and they add to a growing body of evidence supporting the utility of simulation programs to prepare for COVID-19 cardiac arrest and other rare resuscitation events. [13][14][15][16][17][18][19][20]28 Unlike previous work, however, our talk-through walk-through structure and scripted simulation is far simpler to implement in time-, personnel-, and resourceconstrained settings such as those with current outbreaks due to low vaccination rates. While we cannot directly compare our outcomes to a traditional high-fidelity simulation structure, some of our highest-risk communities are less likely to have a dedicated simulation lab. ...
Introduction: In-hospital cardiac arrest in patients with COVID-19 presents significant challenges to health care teams. Airborne precautions can delay patient care, place providers at high risk of virus exposure, and exacerbate an already stressful environment. Within the constraints of an ongoing pandemic, an efficient educational program is required to prepare health care teams for airborne isolation code blue. Methods: This simulation was conducted in a room on the target unit using a CPR manikin to represent the patient. A "talk-through walk-through" scripted simulation directed learners (internal medicine residents, unit nurses, and other code blue responders) through a resuscitation using an airborne isolation code blue protocol. Key scripted events prompted role identification, communication, and item transfer. Learners self-assessed their airborne isolation code blue knowledge and skills and their confidence in providing quality care while maintaining safety using a pre-/posttraining 5-point Likert-scale survey. Results: We trained 100 participants over a 5-month period, with 65 participants surveyed (43 respondents; 16 residents, 22 nurses). Following training, participants had a statistically significant (p < .001) increase in percentage selecting agree/strongly agree for all statements related to knowledge and skills specific to airborne isolation code blue protocol, as well as confidence in providing care while keeping themselves and their colleagues safe. Discussion: Our simulation program allowed a small number of educators to feasibly train a large number of learners, let learners practice required skills, and improved learners' self-assessed knowledge, skills, and confidence regarding quality and safety of care.
... Exposure to high-fidelity simulation in conjunction with traditional lecture-based learning has been shown to enhance trainee performance in emergency management of an obstetric emergency requiring general anesthesia to the competency normally only seen in a fully trained faculty member utilizing a previously validated scoring system with significant retention 8 months following the initial assessment. 13,14 A large volume of scenarios for anesthesia training for obstetric emergencies has been published for educators, including high spinal anesthetic level, 15 maternal cardiac arrest, 16 and a variety of other conditions. 5,17,18 Clinton and Minehart provided a roadmap in 2020 for the development of comprehensive simulation curriculum for advancing clinical skills with the inclusion of sample scenarios ( Table 1). ...
Simulation has played a critical role in medicine for decades as a pedagogical and assessment tool. The labor and delivery unit provides an ideal setting for the use of simulation technology. Prior reviews of this topic have focused on simulation for individual and team training and assessment. The COVID-19 pandemic has provided an opportunity for educators and leaders in obstetric anesthesiology to rapidly train health care providers and develop new protocols for patient care with simulation. This review surveys new developments in simulation for obstetric anesthesiology with an emphasis on simulation use during the COVID-19 pandemic.
We report and discuss the case of a 29-year-old tercigravida with intrapartum cardiorespiratory arrest due to a massive amniotic fluid embolism and disseminated intravascular coagulopathy. Perimortem caesarean section with B-Lynch compression uterine suture with simultaneous fetal and maternal resuscitation were performed with a favorable outcome for both the mother and the child.
Background The incidence of maternal cardiac arrest is rising in recent years. Medical staff generally lack the experience of performing resuscitation on pregnant patients. Maternal cardiac arrest and perimortem caesarean section simulation training was newly introduced in the Advanced Life Support in Obstetrics provider courses in Hong Kong since April 2021. Objective To evaluate the course participants’ opinions on maternal cardiac arrest simulation training. Methods A questionnaire survey was conducted for all participants in the Advanced Life Support in Obstetrics provider course in April 2021 to assess their opinions on the usefulness of this training. Results There were four Advanced Life Support in Obstetrics provider courses in April 2021 with 36 participants in each course, and 137 questionnaires were received at the end of the course. The response rate was 137/144 (95.1%). After excluding the questionnaires with incomplete information, 134 questionnaires were included for final analysis. Almost all of the participants agreed that the maternal cardiac arrest simulation training could help them in their work (97.8%), could improve their knowledge and skill (98.5%) and could improve team training and co-ordination (97.0%). The majority of them (97.0%) felt more confident in managing maternal cardiac arrest after the training, and 97.8% of participants felt that the perimortem caesarean section model was useful for training. Around 80% of the participants would recommend this course to their colleagues. There were no significant differences in opinions on the usefulness of this training among participants with regard to their specialty, whether they were doctors or nurses, their years of experience and the specific hospital settings. Conclusions Maternal cardiac arrest simulation training was highly valued by all levels of obstetric, emergency medicine and anaesthesia staff in both public and private hospitals.
Objective: Evaluate simulation-based training (SBT) in low-and-middle-income countries (LMIC) and the long-term retention of knowledge and self-efficacy. Methods: We conducted a SBT course on the management of post-partum hemorrhage (PPH), shoulder dystocia (SD), and maternal cardiac arrest (MCA) in three governmental teaching hospitals in Guatemala. We evaluated changes in knowledge and self-efficacy using a multiple-choice questionnaire (MCQ) for 46 OB/GYN residents. A paired Student t-test was used to analyze changes at one week and six months after the SBT. Results: There was an increase in scores in clinical knowledge of MCA, P <0. 001, 95% CI [0.81, 1.49], and SD, P<0.001, 95% CI [0.41, 1.02] one week following SBT and a statistically insignificant increase in PPH scores, P= 0.617, 95% CI [-0.96, 0.60]. This increase in scores was maintained after six months, for MCA, P< 0.001, 95% CI [0.69, 1.53], SD, P= 0.02 95% CI [0.07-0.85] and PPH, P=0.04 95% CI [0.01, 1.26]. For MCA and SD levels of self-efficacy were increased one-week following training, P<0.001 95% CI [0.83, 2.30] and P= 0.008 95% CI [0.60, 3.92], respectively, and at six-months P<0.001 95% CI [0.79, 2.42] and P= 0.006 95% CI [0.66, 3.81], respectively. There was a slight increase in PPH self-efficacy scores one-week after SBT, P=0.73, 95% CI [-6.05, 4.41], maintained after six-months P= 0.38 95% CI [-6.85, 2.85]. Conclusion: SBT was found to be an effective and feasible method to increase short and long-term clinical knowledge and self-efficacy of obstetric emergencies in LMIC.
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This is the first scientific statement from the American Heart Association on maternal resuscitation. This document will provide readers with up-to-date and comprehensive information, guidelines, and recommendations for all aspects of maternal resuscitation. Maternal resuscitation is an acute event that involves many subspecialties and allied health providers; this document will be relevant to all healthcare providers who are involved in resuscitation and specifically maternal resuscitation.
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This consensus statement was commissioned in 2012 by the Board of Directors of the Society for Obstetric Anesthesia and Perinatology to improve maternal resuscitation by providing health care providers critical information (including point-of-care checklists) and operational strategies relevant to maternal cardiac arrest. The recommendations in this statement were designed to address the challenges of an actual event by emphasizing health care provider education, behavioral/communication strategies, latent systems errors, and periodic testing of performance. This statement also expands on, interprets, and discusses controversial aspects of material covered in the American Heart Association 2010 guidelines.
While global maternal mortality has decreased in the last 25 years, the maternal mortality ratio in the United States has actually increased. Maternal mortality is a complex phenomenon involving multifaceted socioeconomic and clinical parameters including inequalities in access to health care, racial and ethnic disparities, maternal comorbidities and epidemiologic ascertainment bias. Escalating maternal mortality underscores the importance of clinician preparedness to respond to maternal cardiac arrest that may occur in any maternal health care setting. Management of maternal cardiac arrest requires an interdisciplinary team familiar with the physiologic changes of pregnancy and the maternal resuscitation algorithm. Interventions intended to mitigate obstacles such as aortocaval compression which may undermine the success of resuscitation interventions must be performed concurrent to standard basic and advanced cardiac life support maneuvers. High quality chest compressions and oxygenation must be performed along with manual left lateral uterine displacement when the uterine size is greater than or equal to 20 weeks. While deciphering the etiology of maternal cardiac arrest, diagnoses unique to pregnancy and those of the nonpregnant state should be considered at the same time. If initial basic life support and advanced cardiac life support interventions fail to restore maternal circulation within four minutes of cardiac arrest, perimortem delivery is advised provided the uterus is greater than or equal to 20 weeks’ size. Preparations for perimortem delivery are best anticipated by the resuscitation team in order for the procedure to be executed opportunely. Following delivery, intraabdominal examination may reveal a vascular catastrophe, hematoma or both. If return of spontaneous circulation has not been achieved, additional interventions may include cardiopulmonary bypass and/ or extracorporeal membrane oxygenation. Simulation and team training enhance institution readiness for maternal cardiac arrest. Knowledge gaps are significant in the science of maternal resuscitation. Further research is required to fully optimize: relief of aortocaval compression during the resuscitation process, gestational age and timing of perimortem delivery and other interventions that deviate from non-pregnant standard resuscitation protocol to achieve successful maternal resuscitation. A robust detailed national and international prospective database was recommended by the International Liaison Committee on Resuscitation in 2015 to facilitate further research unique to cardiac arrest during pregnancy that will produce optimal resuscitation techniques for maternal cardiac arrest.
Background: Cardiac arrest in the parturient is often fatal, but appropriate resuscitation in this special situation may save the lives of the mother and/or unborn baby. Concern has arisen as to application of recommended techniques for resuscitation in the obstetric patient. The Israel Board of Anesthesiology has incorporated simulation assessment into accreditation examinations. The candidates represent a unique national cohort in which we were able to assess competence in the simulated scenario of cardiorespiratory arrest in the parturient. METHODS A simulated scenario of preeclampsia with magnesium toxicity leading to cardiac arrest in a pregnant patient was performed by 25 senior anesthesiology residents. A unique two-stage simulation examination consisting of high fidelity simulation followed immediately by oral debriefing was conducted. The assessment was scored using a predetermined checklist of key actions and answers to clarifying questions. Simulation performance was compared to debriefing performance. RESULTS During the board examination, resuscitation not specific to the pregnant patient was performed well (commencing chest compressions, bag-mask ventilation, cardiac defibrillation); however actions specific to the parturient were performed poorly. Left uterine displacement, cricoid pressure during bag-mask ventilation, and instructing preparations to be made for perimortem cesarean delivery within 5 minutes were performed by 68%, 48%, and 40% of candidates respectively (lower 99% confidence limit 42%, 25%, and 19%, respectively). Cricoid pressure during bag-mask ventilation was performed by 48% (25%) but described in debriefing by 80% of candidates (53%) (P = 0.08), and time setting for perimortem cesarean delivery was performed by 40% (29%) but described by 80% (53%) (P = 0.05) of examinees. CONCLUSIONS Senior anesthesiology residents have poor knowledge of resuscitation of the pregnant patient. The results suggest 2-stage simulation including an oral component may reveal disparities in knowledge not assessed by simulation alone, but definitive conclusions require further study.
To determine the impact of simulation-based maternal cardiac arrest training on performance, knowledge, and confidence among Maternal-Fetal Medicine staff. Maternal-Fetal Medicine staff (n = 19) participated in a maternal arrest simulation program. Based on evaluation of performance during initial simulations, an intervention was designed including: basic life support course, advanced cardiac life support pregnancy modification lecture, and simulation practice. Postintervention evaluative simulations were performed. All simulations included a knowledge test, confidence survey, and debriefing. A checklist with 9 pregnancy modification (maternal) and 16 critical care (25 total) tasks was used for scoring. Postintervention scores reflected statistically significant improvement. Maternal-Fetal Medicine staff demonstrated statistically significant improvement in timely initiation of cardiopulmonary resuscitation (120 vs 32 seconds, P = .042) and cesarean delivery (240 vs 159 seconds, P = .017). Prompt cardiopulmonary resuscitation initiation and pregnancy modifications application are critical in maternal and fetal survival during cardiac arrest. Simulation is a useful tool for Maternal-Fetal Medicine staff to improve skills, knowledge, and confidence in the management of this catastrophic event.
Previous work suggests the potential for suboptimal cardiopulmonary resuscitation (CPR) in the parturient but did not directly assess actual performance. 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. 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. 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.
We report on our experience with an approach to debriefing that emphasizes disclosing instructors' judgments and eliciting trainees' assumptions about the situation and their reasons for acting as they did. To highlight the importance of instructors disclosing their judgment skillfully, we call the approach "debriefing with good judgment." The approach draws on theory and empirical findings from a 35-year research program in the behavioral sciences on how to improve professional effectiveness through "reflective practice." This approach specifies a rigorous self-reflection process that helps trainees recognize and resolve pressing clinical and behavioral dilemmas raised by the simulation and the judgment of the instructor. The "debriefing with good judgment" approach is comprised of three elements. The first element is a conceptual model drawn from cognitive science. It stipulates that the trainees' "frames"--comprised of such things as knowledge, assumptions, and feelings--drive their actions. The actions, in turn, produce clinical results in a scenario. By uncovering the trainee's internal frame, the instructor can help the learner reframe internal assumptions and feelings and take action to achieve better results in the future. The second element is a stance of genuine curiosity about the trainee's frames. Presuming that the trainee's actions are an inevitable result of their frames, the instructor's job is that of a "cognitive detective" who tries to discover, through inquiry, what those frames are. The instructor establishes a "stance of curiosity" in which the trainees' mistakes are puzzles to be solved rather than simply erroneous. Finally, the approach includes a conversational technique designed to bring the judgment of the instructor and the frames of the trainee to light. The technique pairs advocacy and inquiry. Advocacy is a type of speech that includes an objective observation about and subjective judgment of the trainees' actions. Inquiry is a genuinely curious question that attempts to illuminate the trainee's frame in relation to the action described in the instructor's advocacy. We find that the approach helps instructors manage the apparent tension between sharing critical, evaluative judgments while maintaining a trusting relationship with trainees.
The 2000-2002 triennial UK Report on Confidential Enquiries into Maternal Deaths concluded that over 50% of maternal deaths involved substandard care and that many could have been prevented. Catastrophic events leading to cardio-respiratory arrest may necessitate the resuscitation of pregnant women in various hospital locations. This study was designed to evaluate knowledge about resuscitation of parturients among anesthesiologists, obstetricians and emergency physicians. A 12-question survey was distributed anonymously to residents and faculty in the anesthesia (ANES), obstetrics (OB), and emergency medicine (EM) departments at Stanford University Medical Center/Lucile Packard Children's Hospital, Stanford, California. Questions were designed to elicit knowledge deficiencies in four critical areas: need for left uterine displacement (LUD), advanced cardiac life support algorithms (ACLS), physiologic changes of pregnancy (PHYS), and the recommendation to perform cesarean delivery in parturients (>20 weeks gestation) after 4-5 min of unsuccessful resuscitation for cardiac arrest (5CD). In total, 74/75 physicians (43% ANES, 37% OB, and 20% EM) completed the test. ANES scored highest in overall test scores, and in knowledge of PHYS (P<0.05). Scores for LUD and 5CD were similar among groups, but 25-40% of these questions were answered incorrectly. In the ACLS category, the EM group scored highest (93%). We conclude that knowledge of important basic concepts, including the need for LUD and the potential benefit of early cesarean delivery during cardiac arrest, is inadequate among all three specialties. All three departments should provide ACLS physician training with emphasis on the special considerations for parturients.
Guidelines for the management of cardiac arrest during pregnancy exist but they are based on little research. The study hypothesis was that experienced medical clinicians who specialise in obstetric care would not follow current International Liaison Committee on Resuscitation/American Heart Association recommendations in this situation. Following waiver of informed consent by the institutional review board, an anonymous structured scenario questionnaire survey was conducted among relevant hospital clinicians. Demographic details included field of expertise and resuscitation experience. A single case vignette of maternal cardiac arrest was presented, followed by nine questions to examine knowledge of existing recommendations for maternal cardiopulmonary resuscitation. Statistical analyses were performed using SPSS version 12 software (SPSS Inc, Chicago, IL). The overall response rate was 67% (30/45 questionnaires). Specialist obstetricians, midwives and anaesthetists from 17 hospitals participated. Forty-three percent (n=13) claimed broad experience, 50% (n=15) claimed some experience and 6.7% (n=2) claimed no experience in adult resuscitation. Participants were divided in their opinions regarding every choice of action: positioning, need to administer cricoid pressure during mask ventilation, timing of intubation, location of external chest compression, location of paddle placement for delivery of shock during ventricular fibrillation, the timing of defibrillation versus fetal delivery, medication doses and the need to rupture the membranes at an early phase of the resuscitation. Specialist clinicians who treat pregnant women in hospital on a daily basis possess a limited knowledge of the recommendations for treating maternal cardiac arrest.
A case of intrapartum cardiac arrest and perimortem cesarean section. Presented at: Society for Obstetric Anesthesia and Perinatology Annual Meeting
  • R Abdel-Rahim
  • B Burrough
  • A Lee
Abdel-Rahim R, Burrough B, Lee A. A case of intrapartum cardiac arrest and perimortem cesarean section. Presented at: Society for Obstetric Anesthesia and Perinatology Annual Meeting; May 2-5, 2012; Monterey, CA.