To the Editor:—
We report the case of a healthy, multiparous parturient who experienced cardiac arrest in the labor room. Cardiopulmonary resuscitation was not successful; therefore, after approximately 15 min, an emergent cesarean delivery was performed in the labor room, and after delivery of the baby, the mother was successfully resuscitated.
A healthy, 35-yr-old, gravida 5 para 3 woman was admitted to the labor suite in active labor at 8:35 am. The patient was at 39 weeks’ gestational age, and her cervix was dilated 4 cm. At 10:00 am, a lumbar epidural catheter was placed uneventfully. The test dose results were negative, and the catheter was dosed with a mixture of 10 ml bupivacaine, 0.125%, with 120 μg fentanyl. During this time, systolic maternal blood pressure remained greater than 100 mmHg, and fetal heart rate (FHR) was reactive between 130 and 140 beats/min. The patient was comfortable with a T10 dermatome level bilaterally, and a continuous epidural infusion of 0.125% bupivacaine with 2 μg/ml fentanyl was started.
At 11:40 am, the obstetrician uneventfully ruptured the patient's membranes. Eight minutes later, the patient reported nausea and fatigue, and FHR decreased to 90 beats/min. Chest auscultation revealed decreased breath sounds, and oxygen was administered via face mask. Intravenous oxytocin and the continuous epidural infusion were stopped. FHR improved to 140 beats/min with a change of the mother's position. Within minutes, the patient became unresponsive, and FHR decreased to less than 90 beats/min. At 11:58 am, intubation was performed successfully, and breath sounds were confirmed. At 12:00 pm, FHR decreased to 80 beats/min, and the patient experienced a cardiac arrest. A wedge was placed under the patient's hip, and a hard, wooden board was placed underneath the patient's back to facilitate chest compressions. The electrocardiogram revealed a sinus bradycardia, but no pulse was palpable, and 1 mg epinephrine was administered intravenously. With chest compressions, oxygen saturation was measured intermittently at 90%, but no pulse was palpated. At approximately 12:09 pm, a second dose of epinephrine was administered, and FHR remained at 60 beats/min. Because the mother was too unstable for transport, the decision was made to perform an immediate cesarean delivery on the patient's bed. The nursing staff transported the surgical equipment to the labor room, and the fetus was delivered via a classic cesarean delivery at 12:15 pm. Apgar scores at 1 and 5 min were 4 and 5, respectively. After delivery, radial pulse became immediately palpable, maternal blood pressure was 120/80 mmHg, and oxygen saturation improved to 98%. Cardiopulmonary resuscitation was discontinued, and the patient was transferred to the intensive care unit. Postoperatively, the patient experienced severe coagulopathy and was treated for the presumed diagnosis of amniotic fluid embolism.
In the scenario of sudden cardiovascular collapse, regardless of the etiology of the arrest, successful resuscitation in late pregnancy is frequently unsuccessful until after the fetus is delivered. In this case, expedient emergency cesarean delivery in the labor room allowed both mother and baby to survive fully intact.