Management of Maternal Cardiac Arrest in the Third Trimester of Pregnancy: A Simulation-Based Pilot Study

A modified Delphi approach to determine current treatment advances for the development of a resuscitation program for maternal cardiac arrest

OBJECTIVE

Maternal cardiac arrest is a rare and complex process requiring pregnancy-specific responses and techniques. The goals of this study were to (1) identify, evaluate, and determine the most current best practices to treat this patient population and (2) establish a standardized set of guidelines to serve as a foundation for a future educational simulation-based curriculum.

STUDY DESIGN

We used a three-step modified Delphi process to achieve consensus. Twenty-two healthcare experts from across North America agreed to participate in the expert panel. In round 1, 12 pregnancy-specific best practice statements were distributed to the expert panel. Panelists anonymously ranked these using a 7-point Likert scale and provided feedback. Round 2 consisted of a face-to-face consensus meeting where statements that had not already achieved consensus were discussed and then subsequently voted upon by the panelists.

RESULTS

Through two rounds, we achieved consensus on nine evidence-based pregnancy-specific techniques to optimize response to maternal cardiac arrest. Round one resulted in one of the 12 best practice statements achieving consensus. Round two resulted in six of the remaining 12 gaining consensus. Best practice techniques involved use of point-of care ultrasound, resuscitative cesarean delivery, cardiopulmonary resuscitation techniques, and the use of extracorporeal cardiopulmonary resuscitation.

CONCLUSION

The results of this study provide the foundation to develop an optimal, long-term strategy to treat cardiac arrest in pregnancy. We propose these nine priorities for standard practice, curricula, and guidelines to treat maternal cardiac arrest and hope they serve as a foundation for a future educational curriculum.

Simulation for intrapartum care: from training to novel device innovation

Improving maternal and perinatal care is a global priority. Simulation training and novel applications of simulation for intrapartum care may help to reduce preventable deaths worldwide. Evaluation studies have published details of the effectiveness of simulation training for obstetric emergencies, exploring clinical and non-clinical factors as well as the impact on patient outcomes (both maternal and neonatal). This review summarized the many uses of simulation in obstetric emergencies from training to assessment. It also described the adaption of training in low-resource settings and the evidence behind the equipment recommended to support simulation training. The review also discussed novel applications for simulation such as its use in the development of a new device for assisted vaginal birth and its potential role in Cesarean section training. This study analyzed the financial implications of simulation training and how this may impact the delivery of such training packages, considering that simulation should be developed and utilized as a key tool in the development of safe intrapartum care in both emergency and non-emergency settings, in innovation and product development.

Putting the "M" back in maternal-fetal medicine: A 5-year report card on a collaborative effort to address maternal morbidity and mortality in the United States

The Centers for Disease Control and Prevention have demonstrated continuous increased risk for maternal mortality and severe morbidity with racial disparities among non-Hispanic black women an important contributing factor. More than 50,000 women experienced severe maternal morbidity in 2014, with a mortality rate of 18.0 per 100,000, higher than in many other developed countries. In 2012, the first "Putting the 'M' back in Maternal-Fetal Medicine" session was held at the Society for Maternal-Fetal Medicine's (SMFM) Annual Meeting. With the realization that rising risk for severe maternal morbidity and mortality required action, the "M in MFM" meeting identified the following urgent needs: (i) to enhance education and training in maternal care for maternal-fetal medicine (MFM) fellows; (ii) to improve the medical care and management of pregnant women across the country; and (iii) to address critical research gaps in maternal medicine. Since that first meeting, a broad collaborative effort has made a number of major steps forward, including the proliferation of maternal mortality review committees, advances in research, increasing educational focus on maternal critical care, and development of comprehensive clinical strategies to reduce maternal risk. Five years later, the 2017 M in MFM meeting served as a "report card" looking back at progress made but also looking forward to what needs to be done over the next 5 years, given that too many mothers still experience preventable harm and adverse outcomes.

Update: Focus in-hospital maternal cardiac arrest

The incidence of maternal cardiac arrest ranges from 1/55,000 to 1/12,000 births. It is due most frequently to cardiovascular, hemorrhagic, and anesthesia-related causes, as well as to amniotic fluid embolism. The basic principles of resuscitation remain applicable in this situation, but the physiological modifications of pregnancy must be taken into account, in particular, the aortocaval compression syndrome. After 24 weeks of gestation, a salvage cesarean delivery must be performed immediately, without transfer to the operating room, if resuscitation maneuvers have failed 4 min after arrest, because this interval conditions the mother's neurological prognosis and improves neonatal survival.

A novel biosimulation task trainer for the deliberate practice of resuscitative hysterotomy

Resuscitative hysterotomy is a daunting and rarely performed procedure in the emergency department (ED). Given the paucity of clinical exposure to this intervention, resuscitative hysterotomy is an ideal opportunity for simulation-mediated deliberate practice. The authors propose a novel training program using a homegrown, realistic, simulation device as a means to practice resuscitative hysterotomy. Two high-fidelity, tissue-based task-trainer models were constructed and tested on a convenience sample of 14 emergency medicine (EM) residents. The simulated human placenta, bladder, amniotic sac, and uterus were constructed through the use of porcine skin, porcine stomach, transparent plastic bag, Foley tubing, and squid mantle, all secured with nylon sutures. A Gaumard S500 Articulating Newborn was inserted in the simulated uterus, and the entire model was placed into a Gaumard S500 Childbirth Simulator. Each model required less than 1 h for assembly. Emergent hysterotomy was first demonstrated by an EM faculty facilitator, followed by hands-on deliberate practice. Formal feedback on the learners' self-reported confidence and satisfaction levels was solicited at the end of the workshop through a survey previously cited for use with a low-fidelity resuscitative hysterotomy. Quantitative evaluation of the simulated training session was extracted through a 5-item questionnaire using a 5-point Likert-type scale (i.e., from 1, strongly disagree, to 5, strongly agree). Item scores were added for a cumulative total score, with a possible maximum score of 25 and minimum score of 5. Responses were overwhelmingly positive [24.13 (± 1.36)]. Qualitative feedback was extracted from the survey through open-ended questions; these responses highlighted learners' appreciation for hands-on practice and the development of a novel, tissue-based simulation task trainer. All participants recommended the training session be available to future learners. Resuscitative hysterotomy is a high-stakes, low-frequency procedure that demands provider practice and confidence. Our hybrid, tissue-based hysterotomy model represents a feasible opportunity for training. The model is cost conscious, easily reproducible, and portable and allows for ample deliberate practice.