EDUCATION
Deficits in the provision of cardiopulmonary resuscitation
during simulated obstetric crises
Steven S. Lipman, MD; Kay I. Daniels, MD; Brendan Carvalho, MBBCh, FRCA; Julie Arafeh, RN, MSN; Kimberly Harney, MD; Andrea Puck, RN, MSN; Sheila E. Cohen, MBChB, FRCA; Maurice Druzin, MD
OBJECTIVE:Previous work suggests the potential for suboptimal
car-diopulmonary resuscitation (CPR) in the parturient but did not directly assess actual performance.
STUDY DESIGN:We evaluated 18 videotaped simulations of maternal
amniotic fluid embolus and resultant cardiac arrest. A checklist contain-ing 10 current American Heart Association recommendations for ad-vanced cardiac life support (ACLS) in obstetric patients was utilized. We evaluated which tasks were completed correctly and the time required to perform key actions.
RESULTS:Proper compressions were delivered by our teams 56% of
the time and ventilations 50% of the time. Critical interventions such as left uterine displacement and placing a firm back support prior to com-pressions were frequently neglected (in 44% and 22% of cases,
re-spectively). The mean⫾SD overall composite score for the tasks was 45⫾12% (range, 20 – 60%). The neonatal team was called in a me-dian (interquartile range) of 1:42 (0:44-2:18) minutes:seconds; 15 of 18 (83%) teams called only after the patient was completely unrespon-sive. Fifty percent of teams did not provide basic information to the neo-natal teams as required by neoneo-natal resuscitation provider guidelines.
CONCLUSION:Multiple deficits were noted in the provision of CPR to
parturients during simulated arrests, despite current ACLS certification for all participants. Current requirements for ACLS certification and training for obstetric staff may require revision.
Key words:advanced cardiac life support, amniotic fluid embolus, obstetric crises, simulation
Cite this article as: Lipman SS, Daniels KI, Carvalho B, et al. Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises. Am J Obstet Gynecol 2010;203:179.e1-5.
M
aternal mortality is likely under-reported and continues to occur at an unacceptably high rate.1,2In mater-nal deaths involving acute cardiac arrest, advanced cardiac life support (ACLS) must be rapidly administered.1,3,4 Re-cent studies at our institution and else-where demonstrate inadequate theoretic knowledge of cardiopulmonary resusci-tation (CPR) in pregnant women.5,6 However, there is sparse literature on the quality of CPR in actual or simulated ob-stetric cardiac arrest scenarios.Obstetric resuscitation is challenging when compared with resuscitation of non-pregnant adults.7The anatomic and
phys-iologic changes of pregnancy and the chal-lenges associated with the care of 2 patients (mother and unborn baby) require the co-ordination of multiple teams and aggres-sive interventions (ie, perimortem cesar-ean section for both maternal and fetal benefit if an instrumented vaginal delivery is not possible).7,8For obstetric cardiac ar-rests, there are additional tasks to perform, and more personnel are required to per-form them than in a nonpregnant adult resuscitation.7
The aim of this study was to evaluate the quality of obstetric ACLS performed during the management of a simulated cardiac arrest in a term gravid patient. It
is unlikely that a randomized, double-blinded, prospective trial evaluating the quality of obstetric resuscitation will ever be published because the logistic and ethical issues preclude it.
The study prospectively reviewed and analyzed preexisting videotapes of high-fidelity, simulated maternal cardiac ar-rests. The simulated arrests created a set-ting marked by extreme time pressure but no potential for patient harm.
M
ATERIALS ANDM
ETHODSObSim is the name given to the labor and delivery team training simulation pro-gram developed at the Center for Advanced Pediatric and Perinatal Edu-cation (CAPE) at Lucile Packard Chil-dren’s Hospital (LPCH) (Stanford, CA). The use of ObSim training course video-tapes does not meet the definition of hu-man research as defined by the Stanford University Institutional Review Board.
CAPE is located in a separate building across the street from LPCH. Eighteen ObSim courses conducted there over a 25 month period, from August 2005 to
From the Departments of Anesthesiology (Drs Lipman, Carvalho, and Cohen) and Obstetrics and Gynecology (Drs Daniels, Harney, and Druzin), Stanford University School of Medicine, Stanford, CA; the Center for Advanced Pediatric and Perinatal Education (Ms Arafeh); and the Labor and Delivery Ward, Lucile Packard Children’s Hospital, Palo Alto (Ms Puck).
Presented at the 40th Annual Meeting of the Society for Obstetric Anesthesia and Perinatology, Chicago, IL, April 30-May 4, 2008.
Received July 23, 2009; revised Nov. 23, 2009; accepted Feb. 10, 2010.
Reprints: Steven Lipman, MD, Department of Anesthesiology, MC5640, 300 Pasteur Dr., Stanford, CA [email protected].
This study was supported in part by the Association of Professors of Gynecology and Obstetrics. 0002-9378/$36.00 • © 2010 Mosby, Inc. All rights reserved. • doi: 10.1016/j.ajog.2010.02.022
September 2007, served as the basis of our investigation.
CAPE contains a high-fidelity labor and delivery suite with working pro-grammable fetal monitors that produce real-time printouts and a continuous au-dible signal of fetal heart rate (FetalSim Advanced Medical Simulations, Inc, Binghamton, NY), a pelvic model (Simulaids Inc, Saugerties, NY), a pa-tient simulator (SimMan; Laerdal Med-ical, Wappinger Falls, NY), and digital videotape recording. CAPE also contains video and audio playback capability, and after each scenario a debriefing session took place. During the debriefing (facil-itated by trained faculty), the whole team both reviewed and discussed various portions of the scenario.
The study population consisted of teams of labor and delivery nurses, anesthesiolo-gists, and obstetricians. The labor and de-livery nurses had experience in obstetric care ranging from 1 to 10 years. The obstet-ric residents, anesthesiology residents and fellows, and obstetric nurses came from 2 major teaching programs. Obstetric resi-dents were always paired with nurses from their own institutions. Anesthesiologists delivered care at both hospitals and were placed randomly with teams from both institutions.
Each multidisciplinary team studied was comprised of 1-2 obstetricians, 1-2 labor and delivery nurses (1 designated
as primary), and 1 anesthesiologist. Neo-natologists and code providers were available to respond if requested by the scenario participants. Actions of neona-tologists and other requested providers were not evaluated as part of this study. Care delivered and/or tasks performed by these responders were as directed by the study participants as described in previous text.
Participants were not prepared for ObSim with formal lectures prior to the course, nor were they provided with any didactic material. On the day of the course, they were oriented to the simula-tion room, manikin, and equipment but remained naïve to the scenario.
The simulated scenario was an amni-otic fluid embolus (AFE) in a term par-turient with a singleton intrauterine pregnancy. The patient had a working lumbar epidural catheter in situ for labor analgesia and an 18-gauge intravenous line in the left antecubital fossa. The fetal vertex was placed in position to allow for an outlet operative vaginal delivery. Re-quired interventions in the scenario in-cluded the provision of ACLS after ma-ternal cardiopulmonary collapse from an AFE and operative vaginal delivery of the fetus.
The simulation room contained fully stocked epidural and code carts with ex-pired medications and intravenous flu-ids, catheters for intravenous access,
blood pump tubing, central line kits, ar-terial line kits, and a live Zoll M Series Biphasic 200J Max defibrillator (Zoll Medical Corp, Chelmsford, MA). This defibrillator model is currently used on our labor and delivery ward.
A simple checklist of 10 basic interven-tions (Table) was developed by 4 of the authors, including a board-certified ma-ternal fetal medicine specialist (M.D.), a general obstetrician (K.I.D.), a clinical nurse specialist in high-risk obstetrics (J.A.), and a fellowship-trained obstetric anesthesiologist (S.S.L.).
The checklist was based on expert rec-ommendations for ACLS and obstetric resuscitation from the following 2 defin-itive consensus publications: (1) Ameri-can Heart Association (AHA), part 7.2 (Management of Cardiac Arrest9 ) and (2) AHA, part 10.8 (Cardiac Arrest Asso-ciated With Pregnancy7). Neonatal re-suscitation provider (NRP) guidelines were based on AHA and the American Academy of Pediatrics NRP guidelines.10 The 4 aforementioned individuals re-viewed the videotapes using the checklist and determined whether a recom-mended task was completed. A separate table was used to measure the time re-quired to complete 4 critical actions (de-livery, endotracheal intubation, Code Blue activation, and call for a neonatal team). There was complete agreement between the 4 reviewers with respect to whether tasks were completed and the time required to perform them.
Data are presented as mean⫾SD, me-dian times (interquartile range), and number of teams (percentage) as appro-priate. Time zero for the 4 interventions was taken from the start of a nonperfus-ing rhythm.
Descriptive data analysis was per-formed using Microsoft Excel (Rich-mond, CA) and SPSS version 11 (SPSS, Inc, Chicago, IL). Data were assessed for normal distribution of variance using QQ plots and Kolmogorov-Smirov tests.
R
ESULTSA total of 18 teams including 69 individ-uals (31 labor and delivery nurses; 15 an-esthesiology residents, fellows, or at-tendings; 23 obstetric postgraduate year TABLE
The proportion of teams performing interventions
ACLS or pregnancy-appropriate interventions Teams performing task (%) Removes fetal/uterine monitors before 0/18 (0)
...
Defibrillation 1/18 (6)
...
Places firm support under back 4/18 (22)
...
Switches compressor every 2 minutes 6/18 (33)
...
Left uterine displacement 8/18 (44)
...
Correct ventilation rate 9/18 (50)
...
Correct compression rate 10/18 (56)
...
Report given to neonatal team 14/18 (78)
...
Cricoid pressure utilized 14/18 (78)
...
Correct hand position on the sternum 15/18 (83)
...
Delivery of fetus inⱕ5 minutes 15/18 (83)
...
ACLS,advanced cardiac life support.
2, 3, and 4 residents, fellows, or attend-ings) participated in the simulated sce-narios. TheFiguresummarizes the expe-rience of the participants.
The Table summarizes the proportion of all teams performing the basic ACLS interventions on the checklist. No team (0/18) performed all of the 10 specified tasks adequately. The mean overall com-posite score⫾SD with respect to perfor-mance of the 10 AHA recommended tasks was 45⫾12% (range, 20 – 60%).
The neonatal team was called in a me-dian (interquartile range [IQR]) of 1:42 (0:44 –2:18) minutes:seconds; 15 of 18 teams (83%) called only after the patient was completely unresponsive. Nine of 18 teams (50%) did not provide basic infor-mation required by the NRP guidelines to the neonatal response teams. Code Blue activation took a median (IQR) of 2:01 (0:57–3:09) minutes:seconds; 3 of 18 teams (17%) did not call a Code Blue. Intubation of the parturient took a median (IQR) of 2:30 (2:07–5:02) min-utes:seconds; 2 of 18 teams (11%) did not intubate, and 2 additional teams did not auscultate for breath sounds after in-tubation. Delivery of the fetus took a me-dian (IQR) of 2:51 (2:23–3:55) minutes: seconds; 3 of 18 teams (17%) did not deliver the fetus within 5 minutes.
C
OMMENTThis study demonstrated striking deficien-cies in the performance of key ACLS tasks critical to the resuscitation of pregnant women during a maternal cardiac arrest. This performance/behavioral study during simulated maternal cardiac arrests con-firms recent reports that demonstrated in-adequate theoretic/cognitive knowledge (as assessed by a written multiple-choice test) of cardiopulmonary resuscitation in pregnant women.5,6
Of the 10 recommended interventions evaluated, the ability to correctly deliver chest compressions is among the most critical.9,11,12 Concerns with regard to the poor quality and number of inter-ruptions in chest compressions resulted in major changes in the 2005 AHA ACLS guidelines.11
Correctly performed compressions are predicated on proper rate and depth
and utilization of a backboard. In preg-nant women, left uterine displacement (LUD) and correct hand position (mid-sternal) are necessary. Based on these 4 criteria, it is notable that 0 of 18 teams (0%) properly administered this most basic intervention.
LUD minimizes aortocaval compres-sion by the gravid uterus, improves ve-nous return, and facilitates cardiac out-put. LUD is essential when gestation is greater than 20 weeks. However, two thirds of our ACLS-certified teams ne-glected to perform LUD. Notably, LUD was demonstrated on the manikin to all teams during room orientation.
The majority of teams (83%) were able to deliver the fetus in 5 minutes or less. However, the scenario was written to al-low the obstetrical provider to opt for an operative vaginal delivery. Operative vaginal deliveries are often performed at
the bedside, allow the obstetrician to avoid an abdominal procedure, and may be less detrimental to the ongoing provi-sion of effective chest compresprovi-sions than a perimortem cesarean section (CS). Yet maternal arrests may occur when opera-tive vaginal delivery is not possible. Had a less favorable station and cervical dila-tion been present in our manikin, a peri-mortem CS would have been required.
Simultaneous performance of a peri-mortem CS during CPR may degrade the quality of ongoing compressions or re-quire temporary cessation of compres-sions. Many of our teams indicated they would have moved to the operating room (OR) for CS. Had such transport been initiated, it seems unlikely delivery of the neonate would have occurred within 5 minutes. In addition, expertly performed compressions are thought to generate a cardiac output of only ap-FIGURE
Demographics of team members
A,Physician’s level of training (obstetric and anesthesia residents, fellows, and attendings). Values are presented as percentage distribution.B,Labor and delivery nurse years of practice on labor and delivery. Values are presented as percentage distribution.
PGY, postgraduate year.
proximately 10% of normal in parturi-ents (vs approximately 30% of normal in nonpregnant patients).2,13-15It is there-fore questionable whether effective ma-ternal CPR could even be administered while en route to the OR.
In almost all situations of maternal cardiac arrest, delivery of the neonate should commence when no improve-ment in maternal condition has oc-curred by 4 minutes after the ar-rest.2,7,14,15 Delivery improves maternal venous return and thus cardiac output, reduces additional metabolic demand (increased oxygen consumption and CO2 production) caused by the fetus, and may increase the chance for both in-tact maternal and neonatal survival without neurologic sequelae.
Numerous reports have described suc-cessful maternal resuscitation in preg-nancy only after rapid delivery was per-formed. Delivery of any fetus with gestational age greater than 20 weeks in 5 minutes or less is now considered among the most critical goals in cardiac arrest during pregnancy.2,7,9,14
All participants in this study were cer-tified and current in ACLS. However, it is possible that such certification conferred limited advantage. In a recent study at our institution, Cohen et al5found indi-viduals who had never previously at-tended life support courses to have equivalent knowledge to those who had. Of the 75 subjects in that study, only 15% achieved a passing score of greater than 85% (the passing score used in national AHA ACLS courses).5
These findings agree with other stud-ies suggesting that substantial skill loss occurs over time.10,16Labor and delivery ward staff do not often practice ACLS skills because cardiac arrest is rare in the obstetric setting. Because recertification is currently required only every 2 years, ACLS skills are not often refreshed. Moreover, most ACLS courses do not discuss issues specific to cardiac arrest in pregnant women.
Nine of 18 teams neglected to provide basic NRP recommended information, or even the specific information that the mother had arrested, to the responding neonatal teams in our scenarios.17 Al-though neonatal resuscitation providers
may require several minutes to arrive, 83% of our teams waited nearly 2 minutes after the maternal arrest to call for the neonatal team. In the context of a severely depressed neonate, the resultant delay could have deleterious consequences.
Although we attempted to simulate real-life ACLS resuscitation, simulated scenarios have a number of limitations. The layout of the simulated labor and de-livery room was slightly different from the actual rooms in which our teams ren-der care, and it is possible that the man-ikin did not provide the same cues or en-gender the same responses as an actual patient. Whether our teams would have performed better in their native environ-ment with real patients is unclear.
Financial and logistic challenges pre-cluded studying larger numbers of sub-jects, and comparisons of performances among teams and level of training were not possible. However, all participants routinely provided high-risk obstetric care, and the study teams’ composition was very similar to teams responding to actual maternal arrests in our institu-tions. We therefore believe our findings are highly relevant to our 2 programs (combined delivery rate of 12,000/year) and may be relevant to other tertiary care academic centers and community hospitals.
There are other limitations to our study. Although a team of experienced physicians developed the checklist, it did not undergo validation testing. How-ever, the checklist was derived from cur-rent, published AHA guidelines on this subject. We believe that it addresses areas critical to the proper performance of ACLS in the parturient. Lastly, our teams knew the purpose of the ObSim course was to practice obstetric crises.
We extensively reviewed the operation of the Zoll defibrillator during orienta-tion, and it is likely that participants an-ticipated the need to perform CPR. Our teams therefore had certain advantages relative to individual providers or teams in actual events: (1) they expected some-thing bad to happen, and hence, their level of vigilance and reaction to slight physiologic aberrations was likely en-hanced; (2) the cervix was completely di-lated with the fetal vertex at the
peri-neum, so an operative vaginal operative delivery was possible; (3) the courses were conducted during normal working hours between 8 and 11:30AM, so decre-ments in human performance secondary to diurnal variation and fatigue were presumably not factors;18(4) our partic-ipants had no other patients to care for, were on-site, and were immediately available when called into the simula-tion; (5) all of our participants were ACLS certified and worked on busy labor and delivery units in large teaching hos-pitals that serve as referral centers for high-acuity patients; (6) some of the physician participants were fellow or at-tending level providers; (7) our partici-pants received a hands-on in-service of the Zoll defibrillator during orientation, so they were familiar with the operation of the device, and (8) some of the anes-thesiologists and all of the nurses were volunteers. Because of self-selection bias, volunteers may be more confident or skilled than the general population.
Despite these multiple advantages, our study teams made multiple errors in the performance of basic physical and cogni-tive tasks. Yet in actual maternal cardiac arrests occurring in the field, emergency rooms, or small hospitals with few or no in-house obstetricians or anesthesiolo-gists, team performance is likely to be worse.
Our findings support previous studies that assessed fund of knowledge only.5,6 Such data suggest biennial ACLS re-certification alone is not adequate for obstetric staff. In the top 10 recommen-dations from the report, Saving Mothers Lives 2003-2005, The Confidential En-quires into Maternal and Child Health (CEMACH) specifically recommends “the improvement of basic, immediate, and advanced life support skills” on an annual basis.3,19However, whether an-nual (or even more frequent recertifica-tion) would result in better performance is untested.
Possible measures to improve perfor-mance of maternal CPR include the fol-lowing: (1) creation of immersive
learn-ing environments with simulation
training; (2) frequent clinical multidisci-plinary obstetric team drills as recom-mended by the Joint Commission and
CEMACH;3,19,20 (3) more frequent re-certification and/or the development of an AHA obstetric life support (ObLS) course certification; and (4) inclusion of didactic modules specific to resuscita-tion of pregnant women in ACLS
courses. f
ACKNOWLEDGMENTS
The development of AFE/cardiac arrest sce-nario was done by K.I.D., J.A., S.S.L., M.D., and K.H. The faculty and staff for ObSim courses at CAPE were K.I.D., J.A., S.S.L., M.D., K.H., and A.P. The study conception and design was by J.A. and M.D. The acquisition of data was done by K.I.D., J.A., M.D., and S.S.L. Analysis and interpretation of data was done by B.C. and S.S.L. Draft and revisions of manuscript was done by S.S.L. Manuscript edits, tables, and statistics were done by B.C., K.I.D., S.E.C., and M.D. Critical analysis and major revisions of manuscript were done by S.S.L. and S.E.C.
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