MONTEREY, CALIF. – The quality of cardiopulmonary resuscitation deteriorates when women experiencing cardiac arrest during labor and delivery are transported to the operating room for emergent cesarean section, suggests a randomized trial using simulation.
Results of the trial, conducted by investigators at Stanford (Calif.) University involving 26 multidisciplinary obstetric teams using mannequins, were reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.
Main findings showed that teams that stayed put, starting and continuing CPR in the labor room, administered most chest compressions correctly. In contrast, teams that transported their mannequins on a gurney to the operating room had a marked drop-off in CPR performance, administering only a third of compressions correctly while in motion.
The transport group almost universally experienced interruptions in CPR, whereas the stationary group seldom did. In addition, ventilatory tidal volume fell sharply in the transport group during transport, whereas it remained stable in the stationary group.
"The quality of CPR definitely decreases when you move patients," commented presenting author Dr. Brendan Carvalho, an anesthesiologist at Lucile Packard Children’s Hospital at Stanford. He noted that a similar earlier study, also using simulation, found that the average time to incision for perimortem cesarean was almost doubled by transport to the operating room, from 4:25 minutes to 7:53 minutes (Obstet. Gynecol. 2011;118:1090-4).
Taken together, the studies’ results "would suggest strongly that we would recommend you to perform perimortem cesarean delivery at the site where the arrest occurs, either in labor & delivery or in the operating room, but not to move the patient if they are not in the operating room," he maintained.
Dr. Vilma E. Ortiz, session moderator and an anesthesiologist at the Massachusetts General Hospital in Boston, said, "In general, the overall quality of resuscitation – line placement, intubation, fluids – seems to be better in the operating room. Do you think that in practice, that might offset perhaps the poorer chest compressions [during transport]?"
The earlier study also found that other important tasks were forgotten or performed more poorly under conditions of transport, Dr. Carvalho replied. "Now clearly, it would be easier to do the cesarean in an operating room setting, but these patients are often dead and they are not going to bleed. Once you get the baby out, you can then move them later on if you want to. So I think the importance is getting the delivery, and moving the patient to the operating room will pretty much guarantee you will not be able to do this within 5 minutes [of the arrest], which is the recommendation from the guidelines."
A session attendee noted, "If we are going to do these emergent C-sections in the labor room, one of the advantages to being in the operating room is all the equipment for surgery exists. Do you have some special equipment on your code carts or somewhere else that would help facilitate that cesarean delivery? Can you make recommendations about what we all should have if we are going to do these sections in the delivery room?"
"That’s a very good point," Dr. Carvalho remarked. "If you propose this at your institution, it’s important that you get the surgical pack there so in an arrest situation, when a code comes up, someone’s job is to get the pack there." He noted that his own institution had to deal with logistics to ensure that scalpels for performing cesareans were always available in the labor room. "So you have to work through this and make those logistic changes, whatever works at your institution – each institution is different. But you must think out the scenario before just proposing it as the right scenario."
Institutions should also be aware that changing the place of delivery may change behaviors, he added. For example, in the earlier study, "when the cesareans were done in the labor & delivery room, the vast majority were vertical incisions, as the [obstetricians] have been taught to do in a perimortem section. In the group that moved to the operating room, the majority did Pfannenstiel incisions, because they sort of went back to old habits from the operating room days. So there are behavior changes based on whether you move or don’t move."
In the new study, the investigators created 26 obstetric teams, each having two staff members (obstetricians, nurses, and/or anesthesiologists). The teams were randomly assigned to stationary or transport groups.
The study period had three phases. During phase I, lasting 4 minutes, teams in both groups performed stationary CPR in the labor room. During phase II, lasting 2 minutes, the stationary teams continued with CPR there, whereas the transport teams performed CPR while transporting their mannequin to the operating room. During phase III, lasting 4 minutes, teams in both groups performed stationary CPR at their respective location.