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Where should we place the hands during chest compressions in parturients? A pilot study on trans-thoracic echocardiographic localization of the left ventricle.
Abstract Number: T1D-321
Abstract Type: Original Research
Background: Effective chest compression is one of the few interventions that affects the outcome of cardiopulmonary resuscitation (CPR)(1). AHA guidelines recommend the hands be placed on the lower third of the sternum for compressions during pregnancy(2). Additionally, manual uterine displacement is endorsed to alleviate vena cava compression(3). In pregnant women, the heart is rotated to the left(4), although there is no imaging evidence of vertical displacement(5). We sought to evaluate the effect of the gravid uterus and left uterine displacement on the position of the maternal left ventricle (LV) using trans-thoracic echocardiography (TTE).
Methods: Twenty women in the 3rd trimester of a singleton pregnancy (>28 weeks gestational age) were prospectively enrolled (12/2017-12/2018). Demographic and obstetric data were obtained. A registered diagnostic cardiac sonographer performed imaging. The following TTE images were acquired in the supine and left lateral decubitus position using a 30° wedge: parasternal long (PLAX) and short axis (PSAX) at the lower third of the sternum; and PLAX and PSAX of the LV position using each patient’s ideal imaging window (showing the best image of mid-LV at 90°degree transducer orientation so as not to under- or overestimate LV location). The primary outcome was the distance (cm) between images from the lower third of sternum, suggested location for CPR hand placement, and the ideal imaging window.
Results: Demographic variables are included in Table 1. Mean cranial displacement of the LV in relationship the lower third of the sternum was 5.8 (±2) cm in the supine position and 6.1 (±2) cm in the lateral (wedge) position (p=0.6). No evidence of lateral cardiac displacement was observed in either the supine or the wedge position (Table 2).
Conclusions: This is the first study using TTE to document the position of the LV during the third trimester of pregnancy. The maternal LV was consistently located 6cm cranial to the lower third of the sternum. There may be justification for reinstating the recommendation for more cranial hand placement during chest compressions in maternal cardiac arrest, but further validation is required.
1. Ristagno G, et al. Chest. 2007;132(1):70-5.
2. Jeejeebhoy FM, et al. Circulation. 2015;132(18):1747-73.
3. Ryo E, et al. Int J Gynaecol Obstet. 1996;55(3):213-8.
4. Regitz-Zagrosek V, et al. Eur Heart J. 2011;32:3147–3197.
5. Holmes S, et al. Am J Obstet Gynecol 2015;213:401.e1-5.