Maternal Health Nursing

1. Prepared by:
Anju Bista
M.Sc.Nursing 2nd year

2. Objectives
• At the end of this session participants will be
able to know life saving skills.

3. Life support Measures
Procedures and techniques performed to save
the life and improve the chances of survival
and recovery.
 Two life support measures: Basic life support,
Advanced life support

4. Life support Measures
BSL/ASLS are the approaches of chain of
survival system care established by American
heart association.

5. Importance
• Almost 90% who suffer out of hospital die
due to cardiac arrests.
• CPR in few minutes of cardiac arrest, can
double and triple a person’s chance of survival.
• Missed minute of defibrillation(with in 1- 2
min can decrease the survival rate by 7%-
10%(AHA) if done timely resuscitation and
defibrillation can result more than 60%
survival.

6. Approach for Management
 Basic Life Support (BLS)
 Advanced Life Support (ALS)

7. Chain of Survival:
 The key to the patient‘s survival is ensuring
the Cardiac Chain of Survival
 Cardiac Chain of Survival gives a patient in
cardiac arrest the greatest chance of survival

9. The AHA adult Chain of Survival
has separated into 2 chains:
one for in-hospital
one for out-of-hospital systems of care

10. Out of hospital chain of survival

11. In-Hospital chain of survival:

12. BASIC LIFE SUPPORT (BLS)
• Basic life support (BLS) is a level of medical
care which is used for victims of life-
threatening illnesses or injuries until they can
be given full medical care at a hospital.
• It can be provided by trained medical
personnel, including emergency medical
technicians, paramedics, and by qualified
bystanders.

13. BASIC LIFE SUPPORT (BLS)
Sequence of care provided to patients with
respiratory arrest, cardiac arrest or airway
obstruction.
Performed by Anyone, Anywhere,
Immediately, Without any other Equipment
and Protective devices.

14. BASIC LIFE SUPPORT (BLS)
It provides 15 to 20% of normal cardiac output
and should be regarded as ―buying time until
the commencement of ALS.
 It includes considerations of patient transport
such as the protection of the cervical spine and
avoiding additional injuries through splinting
and immobilization

15. Remember Flow chart of BLS
Danger
Responsiveness
Shout for help
Compression
Airway
Breathing

16. Overview of Initial Basic Life Support
Steps:
• The first rescuer who arrives at the side of a
potential cardiac arrest victim should quickly
perform the following steps:

17. Step 1: Assessment and scene safety
Verify that the scene is safe
for you and the victim. You
do not want to become a
victim yourself.
 Check for responsiveness.
Tap the victim‘s shoulder and
shout, ―Are you OK?‖
 If the victim is not
responsive, shout for nearby
help.

18. Step 2: Activate the Emergency
Response System and get AED
 Activate the emergency response system as
appropriate to the setting & local protocol.
Depending on work situation, call local
emergency number from phone, mobilize the
code team, or notify advanced life support.
 If you are alone, get AED/defibrillator &
emergency equipment. If someone else is
available, send that person to get it.

19. Step 3: Assess for breathing & pulse
To minimize delay in starting CPR, assess
breathing at the same time as we check the
pulse.
 This should take no more than 10 seconds.

20. Breathing

21. Check pulse
To perform a pulse check in an adult, palpate a
carotid pulse.
If you do not definitely feel a pulse within 10
seconds, begin high-quality CPR, starting with
chest compressions

22. Locating the carotid pulse
Locate trachea, using 2-3 fingers.
Slide these 2-3 fingers into the
groove between the trachea and the
muscles at the side of the neck, where
carotid pulse can be felt.
Feel the pulse for at least 5 but not
more than 10 seconds. If pulse is not
felt within 10 seconds, begin CPR,
starting with chest compression

23. Step 4: Chest Compressions:
Foundation of CPR
• Each time you stop chest compression, blood
flow to heart & brain decreases significantly.
Once you resume compressions, it takes
several compressions to increase blood flow to
heart & brain back to the levels present before
interruption.
• Thus, the more often chest compressions are
interrupted & the longer the interruptions are,
the lower the blood supply to heart & brain is

24. • High quality chest compression
Single rescuers should use the compression to
ventilation ratio of 30 compressions to 2
breaths when giving CPR to victims.

25. chest compressions, it is important to:
Place the victim on a firm surface to make
compressions as effective as possible allows
compression of chest & heart to create blood flow.
Start compression within 10 second of recognition of
cardiac arrest.
Push hard, push fast: Compress @ 100 to 120/min. with
a depth of
 At least 5 cm for adults.
 Chest compression no more than 6 cm in adults.
Research suggests that compression depth greater than
6 cm in adults may cause injuries.

27. Chest compressions
 Place the casualty on a firm
surface on their back. If
possible, wedge padding
such as a cushion, towel or
similar object under their
right hip to tilt the hips about
15°-30°while leaving their
shoulders flat to the ground.
Kneel beside them.
 Place the heel of one hand on
the lower half of the sternum.
Place your other hand on top.

28. Chest compressions
 Straighten your arms and
position yourself over the
casualty’s chest.
Use the weight of your
body to press straight
down onto their chest by
⅓ the depth of the chest,
which is generally more
than 5 cm.

29. Chest compressions
Release the pressure. Allow for a full chest recoil
by lifting your hands slightly off the chest
between each compression. Pressing down and
releasing comprises one compression. The time
spent on chest compressions and release phases
should be equal.
 Perform 30 chest compressions hard and fast, at a
rate of almost 2 compressions per second or 100-
120 per minute. It is helpful to count aloud.

30. Rescue breaths (mouth-to-mouth)
After the 30 compressions,
give 2 rescue breaths.
Open the casualty’s
airway.
 Ensure the head is tilted
back and the chin is
lifted by placing one
hand on their forehead
and the other hand under
their chin to tilt the head
back.

31. Rescue breaths (mouth-to-mouth)
Use your index finger
and thumb to pinch
closed the soft part of
the casualty’s nose.
Use your other hand
to open the casualty’s
mouth.

32. Rescue breaths
Take a breath and with
your mouth form a
tight seal over the
casualty’s mouth.
Blow at a steady rate
for about 1 second,
and look for the chest
to rise. Now look for
the chest to fall.
Repeat and give a
second rescue breath.

33. Bag and mask breath

34. If the chest does not rise, make sure:
 The casualty is positioned properly.
 The airway is not obstructed by a foreign body - if it is -
remove it.
 The nose is pinched closed to prevent any air from
escaping and you maintain a tight seal with the casualty’s
mouth.
• One cycle of CPR consists of 30 compressions + 2 rescue
breaths.
• Keep repeating this process and aim to do 5 cycles of CPR in
roughly 2 minutes.
• Giving life-saving CPR is tiring. If you have another person
to help you, swap with minimal interruption, so they give
compressions and rescue breaths every 5 cycles.

37. Using an AED
(Automated External Defibrillator)
• Portable electronic devices that automatically
analyze the patient‘s heart rhythm and
provide an electrical shock that help the heart
to re-establish a perusing rhythm.
• Where an AED is available, turn it on and
attach pads or have a bystander attach them
so you can continue doing compressions.

38. • Follow the AED’s
instructions.
• An AED will analyze
heart rhythm every 2
minutes. It may or
may not give a
shock. Continue to
give CPR in between
each analysis cycle.

39. Continue performing CPR until:
the person responds or resumes breathing
normally
it is impossible to continue e.g. due to
exhaustion
a health care professional takes over or directs
that CPR be ceased (don't stop until they tell
you)
Declaration of patient deceased.

40. Advanced cardiac life support
It is a life support with the use of special
equipment's. (e.g.: Airway, endotracheal tube,
defibrillation).
ALS is a set of life-saving protocols and skills
that extend Basic Life Support to further
support the circulation and provide an open
airway and adequate ventilation (breathing)
• Good ACLS starts with good BLS.

41. • Advanced Life Support in Obstetrics (ALSO)
is an evidence-based, interprofessional, and
multidisciplinary training program that equips
the entire maternity care team with skills to
effectively manage obstetric emergencies.

42. ACLS
• Advanced cardiac life support (ACLS)
guidelines have been developed with a focus
on sudden death from ischemic heart disease.
Although acute myocardial infarction can
occur during pregnancy, arrest in a previously
healthy woman is more likely related to acute
events such as pulmonary embolism or
hemorrhage

44. Adult ACLS Algorithm
1. Activate ER Response Team
2. Circulation by cardiac massage(continue
High Quality CPR)
3. Airway management by Equipment's/Give
Oxygen
4. Breathing by advanced techniques
5. Defibrillation by manual defibrillator
6. Drugs.

45. ALS treatment algorithm:
1. Continue Chest Compressions:
High quality CPR
Push Hard and Fast
Allow complete chest recoil
Minimize interruptions
Give effective breaths
Avoid Excessive ventilation

46. 2. Rhythm Recognition
Put the patient on monitor
Recognize cardiac rhythm
–Shockable rhythms (ventricular fibrillation/
pulseless ventricular tachycardia (VF/ pVT))
–Non-shockable rhythms (Asystole and
pulseless electrical activity (PEA))

47. Cardiac Monitoring & Rhythm
Recognition
• Normal ECG Rhythm

48. Rhythm Recognition- Shockable

49. Rhythm Recognition- Shockable

50. Rhythm Recognition- NonShockable
Pulseless Electrical Activity

51. 3. Defibrillation
• Treatment of choice for VF and Pulseless VT.
• Sooner the defibrillator is used, the better the
survival rate.
• Defibrillation depolarizes a critical mass of
myocardial cells all at once, when they
repolarize the sinus node usually recaptures its
role as a pacemaker.

52. Defibrillators can be classified as:
Monophasic (delivers current of one polarity)
Biphasic (deliver current of 2 polarity)
• Recommendation for shock protocol
Previous:3 successive shock (200,300,360 J)
Recent: only single shock
360J monophasic, 150-200J-biphasic

54. 5. Use of Life saving Drugs

57. Drugs used for
VT/VF
• Epinephrine
• Vasopressin
• Amiodarone
• Lidocaine
• Magnesium.
Drugs used for
Asystole/PEA.
• Epinephrine
• Vasopressin
• Atropine (removed from
algorithm per
2010 ACLS Guidelines)

58. Recovery position

59. Nursing role during life support
measures
Post-resuscitation care is meant:
• To optimize ventilation and circulation
• To preserve organ/tissue function, and
• To maintain recommended blood glucose
levels.

60. Post- Resuscitation Care
a. Continuous Monitoring
• ECG monitoring: 12-lead ECG should be
obtained as soon as possible
• Intra-arterial blood pressure monitoring
– Acid-Base Status, Electrolytes
– Waveform Capnography

61. Post- Resuscitation Care
b. Maintaining Hemodynamics
• Reliable intravenous access
• Aim for SBP >100 mm of Hg
• For hypotension, norepinephrine and
dobutamine may be used.
• Control body temperature to optimize survival
and neurological recovery:Target temperature
between 32°C and 36°C

62. Post- Resuscitation Care
c. Blood sugar
• Hyperglycemia and hypoglycemia should be
avoided
d. Ventilation
• Hyperventilation should be avoided.
SpO2 should be maintained at 95-98 %
e. Adequate sedation

63. Nursing care:
• Team leader/ code leader: Team leader
coordinates or instruct team to act as per
algorithm. He gives direct instruction to specific
person
• Record keeper: writes each and every on the care
and medication on the arrest sheet
• Resuscitation nurse: performs chest compression
• Airway: nurse, doctor, anesthetist whoever is
available shall take care of the airway
• Drug nurse: one nurse should be giving the
medications as ordered by the team leader

64. Nursing care:
• Assistant/floor nurse: another nurse shall be helping the
team in preparing medications and equipment's for
resuscitation.
• Monitor that patient stay in converted rhythm.
• Keep patient well oxygenated. (SPO2 >98%)
• Check serum K+ & Mg+ levels.
• Maintain acid base balance.
• Get 12 lead ECG after procedure.
• Check for chest pain & access.
• Get CPK & Troponin done.
• Assess patients‘ skin.

65. Nurses role while performing
defibrillation:
• Apply conducting jelly between the paddle and
the skin.
• Place the paddle so that they don‘t touch
patient‘s clothing and bed linen and are not
near medication and direct oxygen flow.
• Don‘t charge the device until ready to shock;
then keep the thumbs and fingers off discharge
button until paddle are on the chest.

66. Before pressing the discharge button
call ― all clear 3 times
1. 1st clear: Ensures you aren‘t touching patient, bed,
equipment
2. 2nd clear: Ensures no one is touching patient, bed,
equipment
3. 3rd clear: Ensures you and everyone else are clear off
the patient and anything touching the patient.
Record the delivered energy and the results (cardiac
rhythm and pulse).
After the event is complete inspect the skin under the
pads and paddles for burns, and if any detected consult
about the treatment

67. Research articles:
• Casereport on effective cardiopulmonary
resuscitation in a pregnant woman
• Management of cardiac arrest in pregnancy is an
important task for the emergency physicians.
Some reasons for cardiac arrest are reversible and
should be recognized and managed promptly.
Cardiopulmonary resuscitation follows general
advanced cardiac life support guidelines with
several modifications for pregnant women, taking
into account the lives of both mother and fetus..

68. Research articles:
• The case of 23-year-old pregnant patient who came to Guru
Nanak Dev Hospital, Amritsar; in shock, had a cardiac arrest.
• As the patient was being shifted from the stretcher to bed, the
patient had a sudden cardiac arrest in labor room itself.
• Immediately, wedge was kept under the right hip, and chest
compressions were started as per advanced cardiac life support
(ACLS) guidelines that are, 100 compressions/min.
• The simultaneously patient was intubated with endotracheal
tube number 7 fixed by another rescuer and tube was secured.
Rescue breaths were given with AMBU at 12/min. Injection
adrenaline 1 mg i.v was given twice and all others resuscitative
measures were taken.(Radhesaran, 2019)

69. References:
• Cardiopulmonary resuscitation [online]. Available from:
https://eccguidelines.heart.org/wp-
content/uploads/2021/10/2021Focused-
Updates_Highlights.pdf
https://www.nationalcprassociation.com/free-cpr-study-
guide https://www.mayoclinic.org/first-aid/first-aid-
cpr/basics/art-20056600 [Accessed on 24th Sept, 2021]
• Andrew Randazzo. 4 Criteria for When to Stop CPR[online].
Available from:
https://www.primemedicaltraining.com/when-to-stop-cpr/
[Accessed on 24th Sept 2021]
• Amanda Barrell.CPR steps: A visual guide [online]. Available
from: https://www.medicalnewstoday.com/articles/324712
[Accessed on 27th Sept, 2021]