Maternal Resuscitation
Aim
To understand and be able to practive resiscitation of the mother and promote the positive outcomes.

Resuscitation of the Mother
The approach to apparently lifeless patient is the cardiopulmonary resiscitation (ABCD) drill: Rapid assessment of the Airway, Breathing, and remedy of the problems with these as they are found (search for and correct reversible causes), moving through to remedy of the absence of Circulation.
1. Ensure a safe environment for patient and rescuer.
2. Shake and Shout, if no response, call for help and return to patient.
3. Turn patient on to her back and place wedge under right side of abdomen to relieve aortocaval compression.
4. Open the Airway:
 Remove any obvious obstruction from mouth.
 Perform chin lift by placing two fingers under the point of the patient’s chin and lifting the chin forward.
 Jaw thrust, performed by placing fingers behind patient’s jaw and lifting jaw forward.
5. Assess Breathing for 10 seconds:
 Look for chest movements.
 Listen for breath sounds.
 Feel for movement of air.
 If the person is breathing, turn her in to the recovery position.
 If there is absence of breathing in the presence of an open airway, take this as an absence of circulation. Give 30 chest compressions followed by two breaths.
 Breaths are delivered by taking a full breath and placing your lips around the mouth and blowing steadily into the mouth. If possible, a facemask and self-inflating bag or pocket mask should be used. Maintain head tilt chin lift when giving breaths. Each breath should last about one second and should make the chest rise as with a normal breath.
 Oxygen should be given as soon as possible.
6. For Chest compression:
 Chest compressions are delivered to the middle of the lower half of the sternum.
 Place the heel of your first hand on top of the other and interlock the fingers of both hands. Keep in midline to ensure that pressure is not applied over the ribs. Do not apply pressure over the abdomen or bottom tip of the sternum.
 Lean well over the woman and, with your arms straight, press down vertically on the sternum to depress it approximately 4-5 cm at a rate of 100 compressions/minute. Change the person delivering the compressions every two minutes but avoid delays in changeover.
7. For Circulation:
 The monitor/defibrillator should be attached when available as soon as possible.
 Gain intravenous access, give adrenergic agent, consider antiarrhythmics, buffer agents, pacing.
 For non-VF/VT patients: Epinephrine 1mg IV, repeat every three to five minutes For VF/VT patients: Vasopressin 40U IV, single dose, one time only OR Epinephrine 1 mg IV, repeat every three to five minutes (if no response after single dose of vasopressin, may resume epinephrine 1 mg IV push, repeat every three to five minutes.
8. Differential Diagnosis: search for and treat reversible causes of cardiopulmonary arrest:
 Four H’s: Hypoxia, Hypovolaemia, Hyperkalaemia and other metabolic disorders, Hypothermia (very unlikely)
 Four T’s: Thromboembolism, Toxicity Tension pneumothorax (very unlikely) Cardiac Tamponade (very unlikely)
9. If CPR unsuccessful after 4-5 minutes (according to the 4 minutes rule, adapt from ALSO provider course), perform caesarean section. This is urgent to reduce the pressure of the pregnant uterus on the maternal vessels. The patient does not need to be moved to the operating theatre.

*The protocol of maternal resuscitation is adopted from the RCOG Life saving Skill Manual (2006) and ALSO course syllabus (2009 version)*

By Tam Chui Yuk, Koo Yuen Yuk (2009)