Obstetric critical care

Maternal cardiac arrest and amniotic fluid embolism

Reviewed Nov 2026·3 references
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High-quality CPR with left uterine displacement, early airway, resuscitative hysterotomy by 5 minutes, and the reversible causes specific to pregnancy.

Definition
Maternal arrest needs two patients' teams (obstetric, anaesthetic, neonatal). After about 20 weeks (fundus at or above umbilicus) the gravid uterus compresses the aorta and IVC; delivery improves maternal resuscitation.

At the bedside

Timed steps
  1. 1

    Start CPR and call

    0 min

    Call obstetric arrest team and neonatology; CPR with standard hand position; defibrillate with standard energies (remove fetal monitors).

  2. 2

    Manual left uterine displacement

    0 min

    Continuous manual displacement to the left (or 15-30° left tilt if on firm surface) when fundus is at or above the umbilicus.

  3. 3

    Airway and access

    Early airway by experienced operator (difficult airway, aspiration risk; smaller tube); IV/IO access above the diaphragm.

  4. 4

    Resuscitative hysterotomy

    4-5 min

    If no ROSC by 4 minutes, perform perimortem caesarean delivery at the site of arrest, aiming delivery within 5 minutes of arrest.

  5. 5

    Reversible causes (BEAU-CHOPS)

    Bleeding/DIC, Embolism (PE, AFE), Anaesthetic complications (high block, LAST - lipid), Uterine atony, Cardiac disease (PPCM, MI, dissection), Hypertension/eclampsia/stroke, Others (Hs and Ts), Placenta, Sepsis. Magnesium toxicity: calcium gluconate.

  6. 6

    Amniotic fluid embolism

    Sudden hypoxia, hypotension/arrest and DIC during labour or shortly after: high-quality CPR, early delivery, aggressive correction of coagulopathy (MTP, fibrinogen), RV support (avoid fluid overload, inhaled vasodilators, noradrenaline/dobutamine/milrinone), ECMO where available.

  7. 7

    Post-arrest

    ICU; targeted temperature control avoiding fever; treat cause; neonatal resuscitation team.

Arrest on magnesium infusion

Calcium gluconate 10%

IV
Dose
1 g (10 mL 10%)
Red flag · call your senior now
Collapse with hypoxia and bleeding/DIC during or just after delivery: amniotic fluid embolism.
Pitfall
Waiting to transfer to theatre for perimortem caesarean: perform it where the arrest occurs.
Pitfall
Stopping CPR to tilt the patient: use manual uterine displacement instead.
Pearl
Keep a perimortem caesarean kit (scalpel) on every labour ward and emergency resuscitation trolley.

References

  1. 1

    Lott C, et al. European Resuscitation Council Guidelines 2025: Special Circumstances in Resuscitation. Resuscitation 2025;215:110753.

  2. 2

    Jeejeebhoy FM, Zelop CM, Lipman S, et al. Cardiac arrest in pregnancy: a scientific statement from the American Heart Association. Circulation 2015;132:1747-73.

  3. 3

    Society for Maternal-Fetal Medicine; Pacheco LD, Clark SL, Klassen M, Hankins GDV. Amniotic fluid embolism: principles of early clinical management. Am J Obstet Gynecol 2020;222:48-52.

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