Resuscitation in Pregnancy

Objectives

To provide up to date guidance on maternal resuscitation whilst deployed on operations.

Scope

This guideline describes the resuscitation of pregnant patients on operations. There are separate guidelines for managing obstetric patients and trauma within CGOs.

Maternal cardiac arrest refers to cardiac arrest that occurs at any stage in pregnancy or within six weeks after birth.

Audience

This guideline is intended for the use by registered healthcare professionals fulfilling a general role in forward medical locations or Emergency Departments on deployed operations.

Initial Assessment & Management

Manage cardiac arrest in pregnancy in-line with adult Advanced Life Support (ALS) principles.

Open airway and call for help

Place the patient supine and displace the uterus to the left, or perform left lateral tilt aiming for 15-30 degrees: manual left uterine displacement is preferred over lateral tilt due to the practicalities of delivering CPR. See here and in accordion content for how to perform manual displacement.

Initiate Advanced Life Support as per standard guidelines. See also ALS (Adult) CGO.

 

Important ALS considerations in pregnancy:

Early iGel, upgraded to ETT early (if skills available)

Site IV or IO access above the diaphragm if possible

Address the '4Hs', '4Ts' and seek pregnancy-specific causes of cardiac arrest: The '4Ps'

  • Pre-eclampsia and eclampsia
  • Puerperal Sepsis
  • Placental and uterine complications
  • Peripartum cardiomyopathy

Consider the 5th P: Prepare for resuscitative hysterotomy (if skills allow) and neonatal life support

Resuscitative hysterotomy (RH) is a time-sensitive intervention that should be performed as soon as possible, at the site of cardiac arrest by a skilled team. RH is indicated in maternal cardiac arrest if patient ≥ 20 weeks gestation (uterus at or above the level of the umbilicus).

 

Separate CGOs exist for Resuscitative Hysterotomy and Newborn Resuscitation.

 

The psychological impact of adverse maternal outcomes should be acknowledged, with support offered to the patient, their family, and the staff involved in their care.

Advanced Assessment & Management

Manage cardiac arrest in pregnancy in-line with adult Advanced Life Support (ALS) principles.

 

In addition to the steps above:

  • Resuscitation in pregnancy requires a multidisciplinary approach to maximise the chances of a good outcome.
  • Prepare early for neonatal resuscitation
  • Point of care ultrasound (POCUS) by a skilled operator can be used to identify reversible causes and evaluate foetal heart rate.

 

In deployed hospital settings perform Resuscitative Hysterotomy (RH):

  • If appropriately trained and environment allows
  • Patient ≥ 20 weeks gestation
  • As soon as possible if maternal cardiac arrest is confirmed on arrival to deployed hospital settings
  • Prepare for and commence newborn resuscitation/supported infant transition.

 

Post-resuscitation care: stabilise mother to stabilise the foetus and prepare for major obstetric haemorrhage.

 

Following maternal resuscitation from haemorrhage:

  • Activate Major Haemorrhage Protocol
  • Consider uterotonic drugs, fibrinogen and tranexamic acid
  • Uterine tamponade / sutures, aortic compression, hysterectomy

 

Extra-corporeal membrane oxygen (ECMO) is unlikely to be available in the deployed environment, but in the unlikely event that ECMO can be accessed then it should be considered for pregnant patients with signs of impending circulatory collapse or in cardiac arrest. See additional detail in accordion content below.

Prolonged Casualty Care

As per Adult ALS and post-ROSC Care - see Advanced Life Support (Adult) CGO

Post resuscitation care in maternal cardiac arrest needs to consider

·       Haemorrhage control and bleeding risk

·       Anaesthetic considerations

·       Available imagining modalities and considerations in pregnancy

·       Neonatal care (if appropriate)

Post-resuscitation care: stabilise mother to stabilise the foetus and prepare for major obstetric haemorrhage.

CPR should be continued until return of spontaneous circulation (ROSC) is achieved or all treatable reversible causes have been addressed/excluded appropriate to the setting.

If ROSC has been achieved, then priority should be for repatriation of the patient into the local healthcare system as it is likely that they will have ongoing medical requirements. If a delay in this process is experienced then an attempt to maintain normal observations (using a maternal assessment chart) including oxygen saturations, glycaemia, blood pressure, temperature and heart rate should be undertaken.

With ROSC the antepartum/postpartum haemorrhage and major haemorrhage CGOs should be considered. In this specific population the use of uterotonics (where available) may be indicated.

If CPR has been unsuccessful then the care of the dead procedure should be carried out.

If a resuscitative hysterotomy has been undertaken then resuscitation of the newborn should be carried out (see separate newborn resuscitation guideline) and the infant kept warm. If available and appropriate the infant could be given to a family member to allow other team members to focus on the ongoing maternal management.

Paediatric Considerations

Refer to the Newborn Resuscitation CGO.

Uterine Displacement & Aortocaval Compression

Aortocaval compression (compression of the inferior vena cava and the aorta by the gravid uterus) usually manifests by the 20th week of gestation. This reduces venous return and  cardiac output.

In healthy pregnant patients with preserved intrinsic compensatory mechanisms, the effects of aortocaval compression may be absent or minimal. However, in critically ill or hypotensive patients, aortocaval compression may precipitate cardiac arrest and limit the effectiveness of cardiopulmonary resuscitation.

Aortocaval compression can be relieved by manual left uterine displacement or left lateral tilt (although supporting data are derived from non-cardiac arrest and simulation studies).

European and UK Resuscitation guidelines suggest performing manual left uterine displacement in maternal cardiac arrest. This can be achieved by placing one or both hands below the uterus, on the patient’s right side, and pushing upwards and to the left. If standing on the patient’s left, reaching across to cup the uterus from below and lifting upward and leftward.

 

 

2-Handed Uterine Displacement from Patient's RHS

 

 

1-Handed Uterine Displacement from Patient's RHS

 

 

2-Handed Uterine Displacement from Patient's LHS

 

Resuscitative Hysterotomy (RH)

Resuscitative hysterotomy should be performed by a skilled team at the site of cardiac arrest to achieve ROSC by relieving aortocaval compression.

Previous guidelines recommended starting the procedure at 4 min and completing uterine evacuation by 5 min. The maternal cardiac arrest supplement to European and UK ALS guidelines shifts the focus to preparing for resuscitative hysterotomy, highlighting the time-sensitive nature of the intervention.

The 2025 ILCOR review found insufficient evidence to support a specific time for initiating resuscitative hysterotomy.

Time-sensitive resuscitative hysterotomy depends on clearly designated team competences, rapid system activation, and equipment readiness, all requiring training and rehearsal.

If arrest results from hypotension despite optimal resuscitation, it is suggested that resuscitative hysterotomy be performed as soon as possible.

The procedure should not be considered futile beyond 5 min, however, the benefit declines steadily the longer emptying the uterus is delayed.

In exceptional cases, ECPR may be initiated immediately, with uterine evacuation postponed due to anticoagulation-related bleeding risks.609,610

In the prehospital setting, the procedure requires adequate access to the patient and a trained clinician, otherwise prioritise time-critical transport to hospital.

 

Suggested pre-prepared equipment to perform Resuscitative Hysterotomy.

For staff:

  • Sterile gloves (non-latex)
  • Gown
  • Masks

For mother:

  • Skin preparation solution
  • 3 scalpels (1: incision, 2: umbilical cord, 3: backup)
  • Dissection scissors
  • Laparotomy sponges
  • 4 haemostat clamps
  • Retractor
  • Gauze (ideally haemostatic)

For baby:

  • 3 cord clamps
  • Hat
  • Towels
  • Heated incubator
  • Equipment to resuscitate the neonate

Causes of Maternal Cardiac Arrest

Systematically address the 4Hs and 4Ts and seek pregnancy-specific causes of cardiac arrest, including the the 4Ps: Pre-eclampsia and eclampsia, Puerperal sepsis, Placental and uterine complications, and Peripartum cardiomyopathy.

 

Potential Causes of Maternal Cardiac Arrest

 

Modifications to ALS in Pregnant Patients

Airway Management

Early airway management should be considered and if in a setting where intubation is available then early insertion of an endotracheal (ET) tube will help prevent regurgitation of stomach contents and possible aspiration.

If intubation is not possible then use of a LMA with a suction/drain port will allow for best available airway protection and passage of an NG tube through the suction port should help decompress the stomach.  

Aspiration and failed intubation risk are both increased. 

Try to achieve a ramped position. Intubation should be performed by an experienced operator.

Equipment considerations:

  • Short-handled laryngoscope for large breasts
  • Video laryngoscope as standard for intubation
  • Smaller tracheal tube with guidance.

 

Defibrillation − Shock energy

No change to standard ALS

Ensure defibrillation pads are placed under, not over, enlarged breast tissue.

 

Extracorporeal Life Support (ECMO)

A retrospective analysis of peripartum patients requiring ECPR from the International Registry of Extracorporeal Life Support Organization, identified 280 patients, with 70 % survival. Survival rates were higher when extracorporeal membranous oxygenation (ECMO) was initiated prior to cardiac arrest.

Last reviewed: 24/03/2026

Next review date: 24/03/2027

Related resources

Resuscitation Council UK Guidelines 2025: Adult Advanced Life Support

Resuscitation Council UK Guidelines 2025: Newborn resuscitation and support of transition of infants at birth

References

Resuscitation Council UK Guidelines 2025. Obstetric Cardiac Arrest.

European Resuscitation Guidelines 2025: Special Circumstances in Resuscitation

Evidence method

Consensus guideline