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ACLS-OB. A Maternal Code Are You Ready? Angie Rodriguez ARNP, CS, MSN, CNM, RNC-OB Kerry Foligno RN, BSN, CLC, CPST. ACLS-OB. Advanced Cardiac Life Support with an Obstetric Focus. Why ACLS-OB. Based on AHA guidelines 2010

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acls ob

A Maternal Code

Are You Ready?

Angie Rodriguez ARNP, CS, MSN, CNM, RNC-OB

Kerry Foligno RN, BSN, CLC, CPST

acls ob2

Advanced Cardiac Life Support with an Obstetric Focus

why acls ob
  • Based on AHA guidelines 2010
  • The best hope of fetal survival is maternal survival
why acls ob4
  • Education, preparation and practice are the keys to delivering the safest care for mom and her baby.
  • ACLS-OB includes AHA core cases and algorithms but utilizes specific scenarios that include modifications for pregnant and newly delivered patients.
acls ob5
  • Can lightening strikes be prevented?
  • Rapid response teams
  • Chain of survival
    • Recognition of arrest
    • Activation of EMS/Code Blue
    • BLS
    • AED/ACLS
our journey at mhw
Our Journey at MHW
  • Attended National Convention- booth
  • Requested - Rejected, Persisted
  • 4 staff nurses/CM’s-went to Idaho 2009
  • Magnet journey
  • Brought it back and implemented the program
  • All L&D staff attended from all three facilities
  • Instructor trainer
are arrhythmias serious
Are arrhythmias serious?
  • Arrhythmias may be benign,

symptomatic, life threatening

or even fatal.

acls ob8
  • The most important question is not just

What is the Rhythm …but

How is this rhythm affecting

the patient clinically and how

are we going to treat the


treatable rhythms
Treatable Rhythms

1. Lethal (pulseless) rhythms

  • Shockable
  • Nonshockable

2. Non-lethal (with a pulse) rhythms

lethal rhythms
  • Shockable
    • Ventricular Fibrillation
    • Pulseless Ventricular Tachycardia
  • Non-Shockable
    • Pulseless Electrical Activity
    • Asystole
shockable lethal rhythms
Shockable Lethal Rhythms

Ventricular Tachycardia (Pulseless)

Ventricular Fibrillation

ventricular fibrillation
Ventricular Fibrillation

No organized electrical activity

pharmacologic treatment of ventricular fibrillation ventricular tachycardia pulseless
Pharmacologic Treatment of Ventricular Fibrillation & Ventricular Tachycardia (Pulseless)
  • Vasopressors:
    • Epinephrine
      • 1mg. IVP/IO – 1:10,000 solution
      • Repeat every 3 – 5 minutes
      • Optimizes cardiac and cerebral blood flow
    • Vasopressin
    • To replace 1st or 2nd dose of Epinephrine
      • 40 Units IV/IO
pharmacologic treatment of ventricular fibrillation v tachycardia
Pharmacologic Treatment of Ventricular Fibrillation/V-Tachycardia
  • Antiarrhythmics – Give during CPR (before or after the shock)
    • Amiodarone – 300 mg (recommend dilution in 20 -30 mL D5W) IV/IO push once, then consider additional 150mg IV/IO once , then followed by IV drip

oronly after perimortem delivery

    • Lidocaine – 1 to 1.5 mg/kg first dose, then 0.5 to 0.75 mg/kg IV/IO, maximum 3 doses or 3mg/kg
nonshockable lethal rhythms
NonshockableLethal Rhythms
  • Asystole
  • Pulseless Electrical Activity


pharmacologic treatment of pea and asystole
Pharmacologic Treatment of PEA and Asystole
  • Epinephrine – 1 mg IV/IO

Repeat every 3 to 5 minutes


  • Vasopressin – 40 Units
    • to replace 1st or 2nd dose of epinephrine
treat the patient not the monitor
Treat the patient, not the monitor
  • Signs and symptoms such as:
      • Low blood pressure
      • Altered mental status
      • Shortness of breath
      • Chest pain or angina
      • Signs of shock
non lethal arrhythmias with a pulse
Non-Lethal Arrhythmias (With a pulse)
  • Tachyarrhythmias
    • Sinus Tachycardia
    • Supraventricular Tachycardia
    • Ventricular tachycardia

(with a pulse)

  • Bradyarrhythmias
    • Sinus Bradycardia
    • Blocks
too fast
Too Fast
  • More than 100 beats per minute

Stable or Unstable ??????????

pharmacologic treatment of svt
Pharmacologic Treatment of SVT

Narrow Complex – Regular

  • Vagal Manuevers
  • Adenosine 6mg IV rapid push.

If no conversion then give

Adenosine 12 mg IV rapid push,

  • Synchronized Cardioversion-50-100 joules
ventricular tachycardia30
Ventricular Tachycardia
  • Question- is there a pulse
    • Yes- synchronized cardioversion
    • No-
      • start CPR, Airway management, defibrillate and or meds
sinus bradycardia
Sinus Bradycardia

Rhythm Regular

pharmacologic treatment of non lethal bradyarrhythmias
Pharmacologic Treatment of Non-Lethal Bradyarrhythmias
  • Symptomatic??
    • YES – Altered mental status, chest pain, hypotension, other signs of shock
      • Atropine 0.5 mg IV. May repeat to a total dose of 3 mg.
      • Prepare for transvenous pacing
        • Set rate
        • Set current-(MA) increase by 5 or 10 until capture
h s and t s
H’s and T’s


Review for most frequent causes

  • Hypovolemia
  • Hypoxia
  • Hydrogen ion —acidosis
  • Hyper-/hypokalemia
  • Hypothermia
  • Tablets” (drug OD, accidents)
  • Tamponade, cardiac
  • Tension pneumothorax
  • Thrombosis, coronary (ACS)
  • Thrombosis, pulmonary (embolism)
perimortem cesarean kit
Perimortem Cesarean Kit
  • Knife handle with #10 blade
  • Kelly clamos
  • Mayo scissors
  • Bandage scissors
  • Tooth forceps
  • Needle holders
  • Sutures
  • Laparotomy sponges
  • Clear plastic abdominal drape
  • IV pitocin
  • Normal saline vials
  • Syringes with needle
highest risk of cardiopulmonary arrest
Highest Risk of Cardiopulmonary Arrest
  • Tocolytic therapy
  • Infection
  • Anesthesia
  • Gestational HTN
  • Substance abuse
  • Thyroid storm
  • Surgery and tissue trauma
  • Cardiac anomalies Polyhydramnios
  • Multiple gestation
  • Prior uterine surgery
  • Hemorrhage
maternal cardiopulmonary arrest
Maternal Cardiopulmonary Arrest
  • Preexisting medical conditions
    • Asthma
    • Hypertension
    • Diabetes
    • Lupus
    • etc
  • Cardiac issues
    • MVP
    • Status post MI
    • Atherosclerosis
    • Preexisting structural defects
maternal cardiopulmonary arrest38
Maternal Cardiopulmonary Arrest
  • Accidents/Trauma
    • MVA, Stabbings, Gunshot
    • Domestic Violence
    • Drug use/ Overdose
  • Pregnancy related issues
    • Preeclampsia/eclampsia
    • Uterine placental emergencies resulting in hemorrhage
    • Uterine atony
    • Alterations in clotting
    • Cardiomyopathy
    • Anaphylactoid syndrome of pregnancy
maternal cardiopulmonary arrest39
Maternal Cardiopulmonary Arrest
  • Anesthesia incidents
  • Intubation complications
  • Suicidal attempts
  • Medication issue
maternal contributing factors beau chops
Maternal Contributing FactorsBEAU-CHOPS
  • B-leeding/DIC
  • E-mbolism:
    • coronary/pulmonary/amniotic fluid
  • A-nesthesia- complications
  • U-terineatony
  • C-ardiac disease-
    • MI. cardiomyopathy/ischemia/aortic
  • H-ypertension- preeclampsia/eclampsia
  • O-ther: usual differential diagnosis
  • P-lacenta: abruption/previa
  • S-epsis
acls ob contributing factors a cub hopes
ACLS OB Contributing factors (A CUB HOPES)
  • A-nesthesia
  • C-ardiac disease
  • U-terineatony
  • B-leeding
  • H-ypertension
  • O-ther
  • P-lacenta
  • E-mbolism
  • S-epsis
ob considerations
OB Considerations
  • Search for pregnancy specific
    • H’s and T’s
  • Defibrillation
    • Remove fetal monitors
ob considerations43
OB Considerations
  • Meds
    • Vasopressors
      • Epi
      • Vaso
    • Antiarrhythmics
      • Amiodarone-class D
      • Lidocaine-class B
      • Mag Sulfate-class A
ob considerations44
OB Considerations


relative contraindications-pregnancy and immediate postpartum due to increased risk of bleeding


Half life- 40 days

Avoid in pregnancy- fetal hypothyroidism

Use lidocaine- if 24-42 weeks

Ok for gestational age less than 24 weeks or postpartum

modifications for pregnancy
Modifications for Pregnancy
  • Higher hand placement of chest
  • Use pulse checks to confirm efficacy of compressions
  • Uterine displacement
  • Timing -for perimortem C/S delivery
  • No fibrinolytics
  • Amiodarone- less than 24 weeks or after delivery of fetus
modifications for pregnancy46
Modifications for Pregnancy
  • Early advanced airway
  • Complicated intubation
  • Jaw thrust
  • Cricoid pressure/Sellick maneuver
  • Smaller ETT if needed
  • Altered location of confirmatory lung sounds
modifications for pregnancy47
Modifications for Pregnancy
  • Increased resistance with bag mask ventilation
  • Remove fetal monitors prior to cardioversion, defibrillation
  • Increase paddle pressure if using paddles- use hands free is preferred
  • Maternal Tilt
potential causes for stroke
Potential Causes for Stroke
  • Hemorrhagic stroke
  • Ischemic stroke
  • Hypertensive encephalopathy
  • Preeclampsia or eclampsia
  • Intracranial mass
  • Meningitis/encephalitis
  • Seizure
  • Migraine
  • Craniocerebral/cervical trauma
  • Metabolic conditions
    • Hypo, hyperglycemia, drug overdose
pulseless vt vf
Pulseless VT /VF
  • CPR and defibrillation
  • Vasopressor and 2nd defibrillation
  • Antiarrhythmic and 3rd defibrillation
how do i become an acls ob instructor
How do I become an ACLS-OB Instructor

Become an ACLS instructor in your area

  • Take the on-line Core Instructors course from AHA- (manual purchased from AHA)
  • Attend a one day ACLS instructor class
  • Attend two day ACLS-OB provider class 
  • Do teachback class in your area
  • Set up program with your Organizational Development department- CEU’s etc
  • Offer first class for managers, charge staff
implementing acls ob program at your facility
Implementing ACLS-OB program at your facility
  • Two day provider course- initially
    • Followed by one day renewal
  • Train ACLS instructors
    • Anesthesia, ED, other educators
  • Mock simulations on the units
implementing acls ob program at your facility54
Implementing ACLS-OB program at your facility
  • Limit class size to 6 participants per 2 instructors
    • Read scenario/run simulator
    • Grade and debrief
  • Organize paperwork into a file box
    • Laminate practice and megacodescenarios
  • ECG simulator- $1700.00 x 2
  • Mannequin, Sample meds, Ambu bag, ETT, Stethescope, IV bag/tubing, O2 mask, Monitor belts, Internal Monitors, Airway, CO2 detector, bathing suit with low transverse incision, baby, placenta.
  • Unit specific criteria for instructors
  • Hospital Budget
  • Target audience
  • Administrative /Management challenges
  • Supplies, Equipment- Funding???
  • Startup investment/regulatory issues