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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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A Maternal Code

Are You Ready?

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

Kerry Foligno RN, BSN, CLC, CPST

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Advanced Cardiac Life Support with an Obstetric Focus

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  • Based on AHA guidelines 2010

  • The best hope of fetal survival is maternal survival

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  • 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.

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  • Can lightening strikes be prevented?

  • Rapid response teams

  • Chain of survival

    • Recognition of arrest

    • Activation of EMS/Code Blue

    • BLS

    • AED/ACLS

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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

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Are arrhythmias serious?

  • Arrhythmias may be benign,

    symptomatic, life threatening

    or even fatal.

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  • 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


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Treatable Rhythms

1. Lethal (pulseless) rhythms

  • Shockable

  • Nonshockable

    2. Non-lethal (with a pulse) rhythms

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  • Shockable

    • Ventricular Fibrillation

    • Pulseless Ventricular Tachycardia

  • Non-Shockable

    • Pulseless Electrical Activity

    • Asystole

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Shockable Lethal Rhythms

Ventricular Tachycardia (Pulseless)

Ventricular Fibrillation

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Ventricular Fibrillation

No organized electrical activity

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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

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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

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Nonshockable Fibrillation/V-Tachycardia Lethal Rhythms

  • Asystole

  • Pulseless Electrical Activity

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Asystole Fibrillation/V-Tachycardia


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Pulseless Electrical Activity Fibrillation/V-Tachycardia

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Pharmacologic Treatment of PEA and Asystole Fibrillation/V-Tachycardia

  • Epinephrine – 1 mg IV/IO

    Repeat every 3 to 5 minutes


  • Vasopressin – 40 Units

    • to replace 1st or 2nd dose of epinephrine

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Treat the patient, not the monitor Fibrillation/V-Tachycardia

  • Signs and symptoms such as:

    • Low blood pressure

    • Altered mental status

    • Shortness of breath

    • Chest pain or angina

    • Signs of shock

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Non-Lethal Arrhythmias Fibrillation/V-Tachycardia (With a pulse)

  • Tachyarrhythmias

    • Sinus Tachycardia

    • Supraventricular Tachycardia

    • Ventricular tachycardia

      (with a pulse)

  • Bradyarrhythmias

    • Sinus Bradycardia

    • Blocks

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Too Fast Fibrillation/V-Tachycardia

  • More than 100 beats per minute

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

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Sinus Tachycardia Fibrillation/V-Tachycardia

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Supraventricular Tachycardia Fibrillation/V-Tachycardia (SVT)

  • Symptomatic?

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Pharmacologic Treatment of SVT Fibrillation/V-Tachycardia

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

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Ventricular Tachycardia Fibrillation/V-Tachycardia

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Ventricular Tachycardia Fibrillation/V-Tachycardia

  • Question- is there a pulse

    • Yes- synchronized cardioversion

    • No-

      • start CPR, Airway management, defibrillate and or meds

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Too Slow Fibrillation/V-Tachycardia

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Sinus Bradycardia Fibrillation/V-Tachycardia

Rhythm Regular

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Pharmacologic Treatment of Non-Lethal Bradyarrhythmias Fibrillation/V-Tachycardia

  • 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

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H’s and T’s Fibrillation/V-Tachycardia


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)

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Perimortem Fibrillation/V-Tachycardia 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

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Highest Risk of Cardiopulmonary Arrest Fibrillation/V-Tachycardia

  • Tocolytic therapy

  • Infection

  • Anesthesia

  • Gestational HTN

  • Substance abuse

  • Thyroid storm

  • Surgery and tissue trauma

  • Cardiac anomalies Polyhydramnios

  • Multiple gestation

  • Prior uterine surgery

  • Hemorrhage

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Maternal Cardiopulmonary Arrest Fibrillation/V-Tachycardia

  • Preexisting medical conditions

    • Asthma

    • Hypertension

    • Diabetes

    • Lupus

    • etc

  • Cardiac issues

    • MVP

    • Status post MI

    • Atherosclerosis

    • Preexisting structural defects

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Maternal Cardiopulmonary Arrest Fibrillation/V-Tachycardia

  • 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

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Maternal Cardiopulmonary Arrest Fibrillation/V-Tachycardia

  • Anesthesia incidents

  • Intubation complications

  • Suicidal attempts

  • Medication issue

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Maternal Contributing Factors Fibrillation/V-Tachycardia BEAU-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

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ACLS OB Contributing factors Fibrillation/V-Tachycardia (A CUB HOPES)

  • A-nesthesia

  • C-ardiac disease

  • U-terineatony

  • B-leeding

  • H-ypertension

  • O-ther

  • P-lacenta

  • E-mbolism

  • S-epsis

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OB Considerations Fibrillation/V-Tachycardia

  • Search for pregnancy specific

    • H’s and T’s

  • Defibrillation

    • Remove fetal monitors

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OB Considerations Fibrillation/V-Tachycardia

  • Meds

    • Vasopressors

      • Epi

      • Vaso

    • Antiarrhythmics

      • Amiodarone-class D

      • Lidocaine-class B

      • Mag Sulfate-class A

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OB Considerations Fibrillation/V-Tachycardia


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

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Modifications for Pregnancy Fibrillation/V-Tachycardia

  • 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

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Modifications for Pregnancy Fibrillation/V-Tachycardia

  • Early advanced airway

  • Complicated intubation

  • Jaw thrust

  • Cricoid pressure/Sellick maneuver

  • Smaller ETT if needed

  • Altered location of confirmatory lung sounds

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Modifications for Pregnancy Fibrillation/V-Tachycardia

  • 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

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Potential Causes for Stroke Fibrillation/V-Tachycardia

  • Hemorrhagic stroke

  • Ischemic stroke

  • Hypertensive encephalopathy

  • Preeclampsia or eclampsia

  • Intracranial mass

  • Meningitis/encephalitis

  • Seizure

  • Migraine

  • Craniocerebral/cervical trauma

  • Metabolic conditions

    • Hypo, hyperglycemia, drug overdose

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Pulseless Fibrillation/V-Tachycardia VT /VF

  • CPR and defibrillation

  • Vasopressor and 2nd defibrillation

  • Antiarrhythmic and 3rd defibrillation

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How do I become an ACLS-OB Instructor Fibrillation/V-Tachycardia

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

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  • Implementing Fibrillation/V-Tachycardia ACLS-OB program at your facility

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Implementing Fibrillation/V-Tachycardia 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

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Implementing Fibrillation/V-Tachycardia 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.

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Considerations Fibrillation/V-Tachycardia

  • Unit specific criteria for instructors

  • Hospital Budget

  • Target audience

  • Administrative /Management challenges

  • Supplies, Equipment- Funding???

  • Startup investment/regulatory issues

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Hope you don’t feel like this Fibrillation/V-Tachycardia