In which I clarify a few things about resuscitation of pregnant folk

Yeah, I get cranky at stories like this one: Tracy Hermanstorfer: Christmas Miracle Mom and Baby Die, Revive

I’m thrilled for the family that they both survived this event. I hope they go on to a happy, loving, long life together. It’s hard to imagine how terrifying an experience this must have been.

What’s cheesing me off is the media/theocon wankfest about what a “mystery” it all is, and about how doctors are “stunned” that Hermanstorfer “miraculously” regained a pulse after the baby was delivered. Blah blah impossible Christmas miracle HandoftheLawd yadda yadda *snore*

The short story is, she went into cardiac arrest. No one, apparently, knows why. One site said it happened shortly after an epidural; that’s unusual as an adverse effect, but it can happen. Or perhaps she had an amniotic fluid embolus, or an unexplainable cardiac arrhythmia or something else. Whatever the cause, her heart stopped, an extremely rare event.

CPR was performed for a few minutes – four or five – without success before the medical team decided to deliver the baby by crash C section. There’s nothing strange about this; it’s standard operating procedure. After the C section, resuscitation of the mother succeeded, and she was revived.

The crash section is not just to save the baby, and that’s where the news reports go horribly wrong. It’s also where outraged bloggy diatribes from the feminist side of the fence about how they should be concentrating on saving the mother, not the baby (which I haven’t seen about this case yet, but I have seen in similar situations) get up my nose.

Because one of the bog standard fundamentals of advanced cardiac life support in late pregnancy, when the opening gambits of airway/a few breaths and compressions/a shock or two/a squirt of adrenaline don’t succeed, is EMPTY THE UTERUS. Resuscitation in complete arrest is doomed to failure most of the time, it’s true, but it’s way, way more doomed to failure in the presence of a term or near-term fetus. The uterine pressure makes it difficult to ventilate a person in arrest, because chest compliance is poor and the upward pressure means it’s hard to expand the lungs. Perhaps more importantly, the uterus sits on the large vessels and stops blood returning to the heart. Tilt or manual displacement of the uterus is standard, but this doesn’t completely solve the problem.

A few cites:

Circulation 2000;102:I-229: ECC Guidelines Part 8: Advanced Challenges in Resuscitation

If standard application of BLS and ACLS fail and there is some chance that the fetus is viable, consider immediate perimortem cesarean section. The goal is to deliver the fetus within 4 to 5 minutes after the onset of arrest. If at all possible involve obstetric and neonatal personnel.8F

Why Reduce the Size and Weight of the Uterus?
With the mother in cardiac arrest, the blood supply to the fetus rapidly becomes hypoxic and acidotic, causing adverse effects in the fetus. Return of blood to the mother’s heart, blocked by the uterus pressing against the inferior vena cava, must be restored. Consequently the key to resuscitation of the child is resuscitation of the mother. The mother cannot be resuscitated until blood flow to her right ventricle is restored.

This results in the familiar admonition to immediately begin cesarean section and remove the baby and placenta when arrest occurs in a near-term pregnant woman. That single act allows access to the infant so that newborn resuscitation can be started. Cesarean section also immediately corrects much of the abnormal physiology of the full-term mother. The critical point to remember is that you will lose both mother and infant if you cannot restore blood flow to the mother’s heart.

BMJ: ABC of Resuscitation: Resuscitation in pregnancy

Caesarean section
This is not merely a last ditch attempt to save the life of the fetus; it plays an important part in the resuscitation of the mother. Many successful resuscitations have occurred after prompt surgical intervention. The probable mechanism for the favourable outcome is that occlusion of the inferior vena cava is relieved completely by emptying the uterus, whereas it is only partially relieved by manual uterine displacement or an inclined position. Delivery also improves thoracic compliance, which will improve the efficacy of chest compressions and the ability to ventilate the lungs.? Cardiac Arrest in Labor and Delivery: A Current Review

It is now recommended that cesarean section be performed within 4-5 minutes of the arrest (3) It has been shown that the shorter the interval between the onset of maternal cardiac arrest and commencement of CPR, and the shorter the time taken to deliver the fetus once CPR commences, the more likely that the mother will survive and the fetus will be neurologically intact. Timing is the most crucial factor when performing CPR in late pregnancy. Cesarean section, performed in a patient’s room within 10 minutes after arrest, was essential in the successful resuscitation of a full term parturient and her fetus during an amniotic fluid embolism (9). In that case, because of the rapid delivery of the fetus leading to immediate restoration of maternal circulation, both patients survived neurologically intact.

You get the baby out, and you get it out fast. Saving the baby is a (rather nice) bonus; the main reason you do this is to have more than a snowflake’s chance in Perth of of saving the mother.

So no, they didn’t write the woman off as dead, decide to save the baby, and stand around twiddling their thumbs and feeling sad while the Hand of God came down from the sky and miraculously raised her from the dead. They followed standard resuscitation protocol, and it worked as designed.

Nothing miraculous about it.

Categories: medicine, Science, skepticism

Tags: , , ,

8 replies

  1. Wow, that was something I didn’t know. Would CPR have to be stopped during a crash C-section? I am assuming so, as things not moving would be helpful and CPR moves the belly a lot that I’ve seen. How fast could an experienced doc get the baby out under those circumstances? If the mother’s in full arrest then there’s no need for anesthesia, presumably, it seems like it could be done a really short amount of time (minute or two?) if you don’t count closing up – and given the circumstances presumably any non-haemoraging uterus would just be left open until they knew if the resus had succeeded, if there’s no circulation it’s not going to bleed enough to impede the CPR is it?
    Now I’m all curious! But thank you – I’d seen that “Christmas Miracle!” headline and actually hadn’t read the full report since it smelled like bullshit just from the headline. Nice to know my detectors still work 🙂
    .-= Ricky Buchanan´s last blog ..2009 New Year’s Eve Gifts =-.

  2. How fast could an experienced doc get the baby out under those circumstances?

    Real, real fast. I’ve only been around for one true NOW C section, and that wasn’t a CPR situation. It was knife-to-skin to baby-out in around 30 seconds – and since things weren’t drastic, that was with a lower segment incision, which is traditionally considered slower than classical (vertical incision) section. Meticulous haemostasis (bleeding control) and sewing-up can wait. Even a bit of a bowel perforation or bladder or ureter damage could be inspected for and repaired later in the surgery once the person is more stable; they’re not immediately threatening. I think opening the instrument packages probably takes longer than baby-extraction, and in a CPR situation with enough people around I’d hope the packs would be opened when compressions started. Though all you’d really need to get started is a scalpel and some blood-absorbing packs.
    There’s no need to stop ventilation during C section of course, and though I haven’t tried it, I reckon at least some compressions could continue through the baby-extraction stage. Maybe someone here has been involved in something like this and could comment?

  3. I half-suspected that something was up when I saw the “miracle” headlines, thanks for addressing this!

  4. Thanks for this, Lauredhel. I was looking at all the headlines and read the story and thought that there must surely be some standard physiological explanation for what happened.

  5. What’s getting me about this is the massaged and whispered stories that state outright that they had given the mother up for dead, yoinked the baby out with “no signs of life”, decided instantly he was dead too, and thrown him at the Dad whereupon he miraculously revived in the Dad’s arms.
    No. If you read the more reputable sources, it’s absolutely clear that they pulled the child out with a slow heartbeat and low tone, which are exactly what you would expect in that situation, and resuscitated the baby, which is again completely to be expected after only around four minutes down – newborns are amazingly resilient.
    A lot of parents are surprised at the condition of perfectly healthy babies straight after perfectly normal births – purply-blue and not breathing. It takes a few seconds to a few minutes to breathe and switch from fetal to mature circulation at the best of times. Babies aren’t born looking like the little round things on Hallmark cards and nappy advertisements. Add in a baby who isn’t in great condition, and I guess it’s understandable that the father thought the baby was dead.
    They also kept resuscitating the mother, which was the plan all along (only one article I’ve read actually mentions this, per the doctor). Seriously, who believes that resus attempts will only be made for 4-5 minutes on a young healthy person, with no DNR order, and a witnessed in-hospital arrest? Seriously? Has no one so much as seen E.R.? You can work over these people for maybe an hour, maybe longer. The miracle-mongers are writing it as though the doctors threw up their hands in despair after five minutes, yanked a dead baby out, and sat around twiddling their thumbs and making the sign of the cross while the power of prayer brought these people back from the dead.
    The fallout is generally only made public if there’s a death or a lawsuit, but I gotta wonder if the M&M review in this case is going to show more clearly that this was an epidural adverse effect, because it sure sounds like it – that she passed out straight after the epi – but of course the media articles could be distorting. It would perhaps explain a little more why some folk seem so keen to call it a “mystery”.

  6. Yes, the Lamaze blog has an excellent write-up about how it sounds like an epidural adverse effect. That post and this one provide an excellent counterbalance to the mainstream media beat-up.

  7. Bravo. Lets hope this information gets to those who believe it was a Christmas Miracle.

    You know this will be the plot line to tv drama series next Christmas, right? *sigh*

  8. thank you for this post. my son was born vaginally (a surprise footling breech) and was blue and not breathing right away either. his apgar was low. i imagine it was something similar with this baby. although i understand why things would be way more tense in their situation, the fact is many babies are born not breathing.
    anyway, i wrote about this story on my blog too. i think there was a whole heck of a lot of sensational journalism involved.

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