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
• The best hope of fetal
survival is maternal survival
Why ACLS-OB
• 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-OB
• Can lightening strikes be prevented?
• Rapid response teams
• Chain of survival
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Recognition of arrest
Activation of EMS/Code Blue
BLS
AED/ACLS
Our Journey at MHW
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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?
• Arrhythmias may be benign,
symptomatic, life threatening
or even fatal.
ACLS-OB
• 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
rhythm??
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
Ventricular Tachycardia (Pulseless)
Ventricular Fibrillation
Ventricular Tachycardia
Pulseless
Ventricular Tachycardia
Ventricular Fibrillation
No organized electrical
activity
Ventricular Fibrillation
• Coarse
Ventricular Fibrillation
• Fine
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
• 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
or only 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
• Asystole
• Pulseless Electrical Activity
Asystole
CHECK LEADS, CHECK PULSE
Pulseless Electrical Activity
Pharmacologic Treatment of
PEA and Asystole
• Epinephrine – 1 mg IV/IO
Repeat every 3 to 5 minutes
OR
• Vasopressin – 40 Units
• to replace 1st or 2nd dose of epinephrine
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)
• Tachyarrhythmias
• Sinus Tachycardia
• Supraventricular Tachycardia
• Ventricular tachycardia
(with a pulse)
• Bradyarrhythmias
• Sinus Bradycardia
• Blocks
Too Fast
• More than 100 beats per minute
Stable or Unstable
??????????
Sinus Tachycardia
Supraventricular Tachycardia
(SVT)
• Symptomatic?
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 Tachycardia
Ventricular Tachycardia
• Question- is there a pulse
• Yes- synchronized cardioversion
• No• start CPR, Airway management, defibrillate
and or meds
Too Slow
Sinus Bradycardia
Rhythm Regular
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
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)
1
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
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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
• Preexisting medical
conditions
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Asthma
Hypertension
Diabetes
Lupus
etc
• Cardiac issues
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MVP
Status post MI
Atherosclerosis
Preexisting
structural defects
Maternal Cardiopulmonary
Arrest
• Accidents/Trauma
• MVA, Stabbings,
Gunshot
• Domestic Violence
• Drug use/ Overdose
• Pregnancy related
issues
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Preeclampsia/eclampsia
Uterine placental emergencies
resulting in hemorrhage
Uterine atony
Alterations in clotting
Cardiomyopathy
Anaphylactoid syndrome of
pregnancy
Maternal Cardiopulmonary
Arrest
• Anesthesia
incidents
• Intubation
complications
• Suicidal attempts
• Medication issue
Maternal Contributing Factors
BEAU-CHOPS
• B-leeding/DIC
• E-mbolism:
• coronary/pulmonary/amniotic fluid
• A-nesthesia- complications
• U-terine atony
• 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)
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A-nesthesia
C-ardiac disease
U-terine atony
B-leeding
H-ypertension
O-ther
P-lacenta
E-mbolism
S-epsis
OB Considerations
• Search for pregnancy specific
• H’s and T’s
• Defibrillation
• Remove fetal monitors
OB Considerations
• Meds
• Vasopressors
• Epi
• Vaso
• Antiarrhythmics
• Amiodarone-class D
• Lidocaine-class B
• Mag Sulfate-class A
OB Considerations
Fibrinolytics
relative contraindications-pregnancy and
immediate postpartum due to increased risk
of bleeding
Amiodarone
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
• 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 Pregnancy
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Early advanced airway
Complicated intubation
Jaw thrust
Cricoid pressure/Sellick maneuver
Smaller ETT if needed
Altered location of confirmatory lung
sounds
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
• Hemorrhagic stroke
• Ischemic stroke
• Hypertensive
encephalopathy
• Preeclampsia or
eclampsia
• Intracranial mass
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Meningitis/encephalitis
Seizure
Migraine
Craniocerebral/cervical
trauma
• Metabolic conditions
• Hypo, hyperglycemia,
drug overdose
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 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 megacode scenarios
• 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.
Considerations
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Unit specific criteria for instructors
Hospital Budget
Target audience
Administrative /Management
challenges
• Supplies, Equipment- Funding???
• Startup investment/regulatory issues
Hope you don’t feel like this
ANY
QUESTIONS?