Month: May 2025

CPR in Pregnancy: Ohio CORES Series

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Are you prepared for an OB emergency? In this special six-part podcast series, the Ohio CORES team at The Ohio State University explores the management of pregnant and postpartum women in emergency situations. Each episode focuses on a high-stakes obstetrics scenarios, including: 1) maternal morbidity and mortality, 2) postpartum hemorrhage, 3) hypertensive emergencies, 4) cardiac arrest in pregnant patients, 5) peripartum cardiomyopathy, and 6) complicated vaginal deliveries. Whether you’re in the field, ED, ICU, or on L&D, this series equips you with the knowledge to respond when seconds count.

Ohio CORES (Collaborative Obstetric Resuscitation Education and Simulation) is an interdisciplinary team of educators from The Ohio State University dedicated to improving care for pregnant and postpartum women in critical condition  through high-impact education and simulation training. Supported by funding from the Ohio Department of Children and Youth, Ohio CORES delivers obstetric emergency education to healthcare providers across the state.

In this episode of Crash Cart EM, we cover high-quality CPR in pregnancy- a rare emergency with a 7% survival rate. Learn how to adapt your resuscitation approach, avoid common pitfalls, and perform a resuscitative hysterotomy.

Guests: Jennifer Mitzman, MD; Kimberly Bambach, MD
Host: Sheryl Pfeil, MD
Editors: Rashelle Ghanem; Nicole McGarity, MHI, BSN, RN, CEN; Cynthia Shellhaas, MD, MPH; Kim Bambach, MD

1. Common Causes of Maternal Cardiac Arrest

  • Most common: Pulmonary embolism, hemorrhage (including trauma), hypertensive emergencies, infections, peripartum cardiomyopathy, and rare causes like stroke
  • Often occurs during or immediately after delivery
  • Risk factors: Advanced maternal age, African American race, high parity, and lack of prenatal care

2. What Stays the Same in CPR

  • Same compression rate (100–120/min), hand positioning and depth, defibrillation pad placement and energy levels, medication dosing (e.g., 1 mg epinephrine)

3. Key Differences in Pregnant Patients

  • Manual Lateral Uterine Displacement:
    • Displace uterus to the left to relieve IVC compression
    • Must be done manually- lateral tilt is no longer recommended
  • No LUCAS Device: LUCAS device use is not recommended for use in pregnancy due to safety concerns

4. Procedure and Airway Considerations

  • Prefer humeral IO (above diaphragm) over tibial
  • Chest tubes: Place higher (3rd–4th ICS) due to elevated diaphragm
  • Aggressive oxygenation: Avoid borderline sats—aim for 97–99%
  • High aspiration risk: Have readily suction available (two are helpful)
  • Airway edema common: Downsize ETT

5. Resuscitative Hysterotomy

  • Timing: If no ROSC by 4 minutes and >24 weeks gestation (or fundus at umbilicus), proceed
  • Purpose: Increases maternal preload and decreases afterload- improving perfusion. This is a resuscitative procedure for the pregnant patient and will also maximize chances of survival for the fetus. The procedure is still indicated in the case of fetal demise.
  • Steps:
    • Vertical midline incision
    • Dissect to the peritoneal cavity
    • Incise uterus
    • Deliver fetus, clamp/cut cord
    • Deliver placenta, pack uterus
    • Continue high-quality CPR throughout

7. Team Preparation & Simulation

  • The mental barrier is real– similar to performing a cricothyroidotomy
  • Debrief early, assign roles, and have equipment ready
  • Practice with simulation to improve readiness

Resources:

  1. Virtual Obstetric Emergency Simulation Training at The Ohio State University

Podcast: Play in new window | Download

Peripartum Cardiomyopathy: Ohio CORES Series

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Are you prepared for an OB emergency? In this special six-part podcast series, the Ohio CORES team at The Ohio State University explores the management of pregnant and postpartum women in emergency situations. Each episode focuses on a high-stakes obstetrics scenarios, including: 1) maternal morbidity and mortality, 2) postpartum hemorrhage, 3) hypertensive emergencies, 4) cardiac arrest in pregnant patients, 5) peripartum cardiomyopathy, and 6) complicated vaginal deliveries. Whether you’re in the field, ED, ICU, or on L&D, this series equips you with the knowledge to respond when seconds count.

Ohio CORES (Collaborative Obstetric Resuscitation Education and Simulation) is an interdisciplinary team of educators from The Ohio State University dedicated to improving care for pregnant and postpartum women in critical condition  through high-impact education and simulation training. Supported by funding from the Ohio Department of Children and Youth, Ohio CORES delivers obstetric emergency education to healthcare providers across the state.

In this special episode of Crash Cart EM, we explore peripartum cardiomyopathy- a rare but serious cause of heart failure in late pregnancy and the postpartum period. We’ll review key risk factors, clinical features, and strategies for recognition and early management.

Guests: Jennifer Mitzman, MD; Kimberly Bambach, MD
Host: Sheryl Pfeil, MD
Editors: Katie Connell, RN, BSN, C-EFM, CLC; Pallavi Jonnalagadda, PhD; Jennifer Mitzman, MD; Cynthia Shellhaas, MD, MPH; Kim Bambach, MD

1. Definitions and Risk Factors

  • Peripartum cardiomyopathy is a form of dilated cardiomyopathy causing heart failure.
    It occurs in the last month of pregnancy or within five months postpartum.
  • Risk factors include:
    • Hypertensive disorders (e.g., preeclampsia)
    • Advanced maternal age
    • Obesity
    • Multiparity
    • Cardiomyopathy is 4x more likely in black women and black women are 2x more likely to have persistently impaired cardiac function

2. Recognition

  • Often presents as acute heart failure: dyspnea, orthopnea, peripheral edema, or chest pain.
  • Watch for signs of volume overload, pulmonary edema, JVD, new murmurs, and wheezing (which may mimic asthma). Wheezing may be due to cardiogenic pulmonary edema, not asthma. New adult-onset “asthma” should raise suspicion for cardiac etiology. This diagnosis is often missed due to overlapping symptoms with normal pregnancy changes or obesity bias.
  • Always ask about recent pregnancy– especially in the case of the young female patient with unexplained respiratory symptoms.

3. Initial Management

  • ABCs (Airway, Breathing, Circulation) come first.
  • Support breathing with oxygen or early BiPAP– this may avoid risky intubation.
  • Initial workup includes ordering an EKG, troponin, BNP, chest X-ray, echocardiogram (or performing POCUS).
  • Judicious use of diuretics and inotropes may be needed.
  • Consult Cardiology and Maternal FM when appropriate. Consider transport to advanced OB/cardiac centers for definitive care.

Resources:

  1. Virtual Obstetric Emergency Simulation Training at The Ohio State University

Podcast: Play in new window | Download

Postpartum Hemorrhage: Ohio CORES Series

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Are you prepared for an OB emergency? In this special six-part podcast series, the Ohio CORES team at The Ohio State University explores the management of pregnant and postpartum women in emergency situations. Each episode focuses on a high-stakes obstetrics scenarios, including: 1) maternal morbidity and mortality, 2) postpartum hemorrhage, 3) hypertensive emergencies, 4) cardiac arrest in pregnant patients, 5) peripartum cardiomyopathy, and 6) complicated vaginal deliveries. Whether you’re in the field, ED, ICU, or on L&D, this series equips you with the knowledge to respond when seconds count.

Ohio CORES (Collaborative Obstetric Resuscitation Education and Simulation) is an interdisciplinary team of educators from The Ohio State University dedicated to improving care for pregnant and postpartum women in critical condition  through high-impact education and simulation training. Supported by funding from the Ohio Department of Children and Youth, Ohio CORES delivers obstetric emergency education to healthcare providers across the state.

In this special episode of Crash Cart EM, we dive into postpartum hemorrhage, a leading cause of pregnancy-related deaths in Ohio and globally. We’ll discuss definitions, common causes, and clinical signs. You’ll also learn key management strategies, including assessing blood loss, fundal massage, medications, and advanced interventions like Bakri balloons and surgical options.

Guests: Katie Connell, RN, BSN, C-EFM, CLC; Nicole McGarity, MHI, BSN, RN, CEN
Host: Jennifer Mitzman, MD
Editors: Cynthia Shellhaas, MD, MPH; Kim Bambach, MD

1. Definition & Timing

  • PPH is defined as blood loss greater than 1000 mL after vaginal or cesarean delivery.
  • It can occur immediately or be delayed up to 12 weeks postpartum.

2. Causes: The 4 T’s

  • Tone (uterine atony, the most common cause)
  • Tissue (retained placenta or products of conception)
  • Trauma (lacerations)
  • Thrombin (coagulopathies)

3. Recognition

  • Look for signs of hypovolemia such as tachycardia, pallor, and restlessness.
  • Vital signs may remain normal until significant blood loss has already occured. Use additional tools for assessment.

4. Estimating Blood Loss

  • Visual estimation is unreliable. Use scales or graduated drapes.
  • One gram of soaked material equals one mL of blood.

5. Initial Management

  • Start with fundal massage, establish two large-bore IVs, and give uterotonics (Pitocin, Methylergonovine, Hemabate, Cytotec, TXA).
  • Know contraindications such as avoiding Methylergonovine in hypertension and Hemabate in asthma.

6. Escalation

  • Use uterine tamponade devices like the Bakri balloon or Jada device.
  • If not available, consider Foley catheters or gauze packing.
  • Prepare early for surgery or transfer if bleeding continues.

7. Special Considerations

  • Always ask about recent pregnancy or delivery in reproductive-age patients with unexplained bleeding.
  • Early recognition and prompt action are critical.

Resources:

  1. Virtual Obstetric Emergency Simulation Training at The Ohio State University

Podcast: Play in new window | Download

Maternal Morbidity and Mortality: Ohio CORES Series

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Are you prepared for an OB emergency? In this special six-part podcast series, the Ohio CORES team at The Ohio State University explores the management of pregnant and postpartum women in emergency situations. Each episode focuses on a high-stakes obstetrics scenarios, including: 1) maternal morbidity and mortality, 2) postpartum hemorrhage, 3) hypertensive emergencies, 4) cardiac arrest in pregnant patients, 5) peripartum cardiomyopathy, and 6) complicated vaginal deliveries. Whether you’re in the field, ED, ICU, or on L&D, this series equips you with the knowledge to respond when seconds count.

Ohio CORES (Collaborative Obstetric Resuscitation Education and Simulation) is an interdisciplinary team of educators from The Ohio State University dedicated to improving care for pregnant and postpartum women in critical condition  through high-impact education and simulation training. Supported by funding from the Ohio Department of Children and Youth, Ohio CORES delivers obstetric emergency education to healthcare providers across the state.

In this special edition of Crash Cart EM, Dr. Sheryl Pfeil is joined by Dr. Cynthia Shellhaas and Nicole McGarity, RN, to kick off our new podcast series on obstetric emergency care. This episode explores the landscape of maternal mortality in Ohio, unpacking key definitions, concerning trends, preventable causes, and persistent health disparities. The conversation underscores the urgency of this issue across all healthcare settings- from academic hospitals to rural EDs and prehospital care.
Tune in to learn how simulation-based training is helping providers build the skills needed to improve maternal outcomes.

Guests: Cynthia Shellhaas, MD, MPH; Nicole McGarity, MHI, BSN, RN, CEN
Host: Sheryl Pfeil, MD
Editors: Katie Connell, RN, BSN, C-EFM, CLC; Rashelle Ghanem; Anneleise Sinclair; Kim Bambach, MD

Key Learning Points

1. Definitions and Trends

  • Pregnancy-associated death = death during pregnancy or within a year postpartum, regardless of cause.
  • Pregnancy-related death = death caused or aggravated by the pregnancy or its management. 61% are preventable.
  • U.S. maternal mortality rates have risen over the past decades.
  • Most deaths occur in the postpartum period. 67% occur after delivery- often weeks to months later.
  • Black women have a 3–4× higher mortality risk.

2. Recognition

  • Recognition is key, as many deaths occur outside of labor & delivery: EMS cares for ~30% of patients with pregnancy-related deaths. This is a touch-point where we can potentially intervene and help. 
  • Always ask: “Have you been pregnant in the past year?”. This is especially important for postpartum patients, where signs may be subtle.

3. Key Causes and Contributing Factors

  • Causes in the immediate postpartum period: infection/sepsis and hypertension.
    • Hypertension in pregnancy/postpartum patients is a medical emergency if BP ≥160/110 for 15+ minutes.
    • Sepsis risks include endometritis, retained products after pregnancy loss, and even breast infections.
  • Causes in the late postpartum period: Hemorrhage, thromboembolism, cardiomyopathy.
  • Mental health conditions, substance use, and lack of care coordination are common contributors.

4. System-Level Interventions

  • Data awareness: Institutions should examine their own data to identify clinical outcome disparities.
  • Effective handoffs and continuity of care are essential- especially across EMS, ED, OB, and inpatient teams.
  • Simulation training offers a safe, impactful way to prepare for high-risk, low-frequency events like eclampsia.

Resources:

  1. Ohio Maternal Health Data and Reports
  2. Ohio Pregnancy-Associated Mortality Review
  3. Virtual Obstetric Emergency Simulation Training at The Ohio State University

Podcast: Play in new window | Download