European Journal of Obstetrics & Gynecology and Reproductive Biology 216 (2017) 98–103

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European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Full lenght article

Coronary perfusion pressure and compression quality in maternal

cardiopulmonary resuscitation in supine and left-lateral tilt positions:
A prospective, crossover study using mannequins and swine models
Satoshi Dohia,* , Kiyotake Ichizukaa , Ryu Matsuokab , Kohei Seoa , Masaaki Nagatsukaa ,
Akihiko Sekizawab
a
Department of Obstetrics and Gynecology, Showa University Northern Yokohama Hospital, Kanagawa, Japan
b
Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan

A R T I C L E I N F O A B S T R A C T

Article history: Objective: The risk of maternal and fetal mortality is high if cardiopulmonary arrest occurs during
Received 4 January 2017 pregnancy. To assess the best position for maternal cardiopulmonary resuscitation (CPR), a prospective
Received in revised form 14 June 2017 randomized crossover study was undertaken, involving basic life support mannequin-based simulation
Accepted 12 July 2017
(BLS-MS) and a swine model of pulseless electrical activity (an unstable cardiac state) incorporating a
fetal mannequin (PEA-FM).
Keywords: Study design: The BLS-MS (performed by certified rescuers) served to evaluate the quality of chest
Aortocaval compression
compressions in 30 left lateral tilt (LLT) and supine positions. Based on a 5-point scale, each rescuer
Maternal cardiopulmonary resuscitation
subjectively graded their experience. The PEA-FM model was used to compare coronary perfusion
(CPR)
Supine position pressure readings during CPR in supine, supine with left uterine displacement, 30 LLT, and 30 right
Swine model (LWD strain) lateral tilt positions. Compression rate and correctness of hand position, compression depth, and recoil
Left uterine displacement were measures of compression quality (BLS-MS).
Results: Compared with LLT position, supine position enabled correct hand position (rate: 0.99 vs 0.88;
p < 0.05) and compression depth (rate: 0.76 vs 0.36; p < 0.001) significantly more often. Moreover, BLS-
MS rescuers found chest compressions significantly easier to perform with the mannequin in supine (vs
LLT) position (difficulty score: 1.75 vs 3.95; p < 0.001). In the PEA-FM study arm, supine position with left
uterine displacement and right lateral tilt positions had the highest and lowest recorded coronary
perfusion pressure readings, respectively.
Conclusion: Supine position with left uterine displacement is optimal for maternal CPR.
© 2017 The Author(s). Published by Elsevier Ireland Ltd. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction constitute important challenges for resuscitative efforts during

Cardiopulmonary arrest in pregnant women carries a high risk
of maternal and fetal mortality [1,2], placing the survival of both in
jeopardy. First responders have approximately 4 min to initiate
cardiopulmonary resuscitation (CPR) for maternal cardiac arrest,
thereafter calling for emergency caesarian section [3]. Because of
the toll already exacted on cardiac, respiratory, gastrointestinal,
and reproductive systems in pregnant women, reduced chest
compliance and residual capacity, as well as diminished cardiac
output (owing to uterine compression of the inferior vena cava)
* Corresponding author at: Department of Obstetrics and Gynecology, Showa
University Northern Yokohama Hospital, 35-1 Chigasaki-chuo, Tsuzuki-ku,
Yokohama-city, Kanagawa, Japan.
E-mail address: satoshi.dohi1018@gmail.com (S. Dohi).
pregnancy [1,4].
Other studies of pregnant women have indicated that left
lateral tilt position (LLT) improves maternal hemodynamic
parameters; however, adopting a full lateral position for maternal
CPR may substantially decrease the effectiveness of chest
compressions and affect the feasibility of caesarean delivery [5–
7]. Soar et al. have reported that the ability to provide effective
chest compressions declines as the angle of LLT increases, with
mannequins tending to roll at angles >30 [8]. However, upon
investigating the hemodynamic effects of right lateral tilt (RLT) and
LLT (5 and 10 ) in pregnant women, Ellington et al. discovered no
significant difference in maternal blood flow [9]. Matorras et al.
also saw no obvious benefit for LLT in instances of emergency
caesarean delivery, finding maternal parameters (blood pressure,
heart rate) similar for partial left lateralization and supine position
[10]. Finally, a more recent mannequin study by Butcher et al. has

http://dx.doi.org/10.1016/j.ejogrb.2017.07.019
0301-2115/© 2017 The Author(s). Published by Elsevier Ireland Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-
nd/4.0/).
 S. Dohi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 216 (2017) 98–103
shown comparable effectiveness of chest compressions in both
supine/uterine displacement and lateral tilt positions, suggesting
that either method may be suitable for maternal CPR [11]. These
studies demonstrate the lack of a definitive protocol for CPR in an
obstetric setting. Because related clinical trials involve ethical and
practical concerns, development of suitable preclinical models of
maternal cardiac arrest and resuscitation is essential for instituting
effective CPR interventions in pregnant women.
The present study entailed use of a basic life support
mannequin simulation (BLS-MS) to evaluate CPR effectiveness,
comparing 30 LLT tilt and supine positions. A 5-point question-
naire then served to score the ease of performing CPR. Position-
dependent changes in coronary perfusion pressure (CPP), a major
indicator of CPR effectiveness [12], were also assessed. For this
purpose, a novel swine model of maternal CPR was devised,
incorporating pulseless electrical activity (PEA) cardiac arrest and a
fetal mannequin (PEA-FM).
Materials and methods
Study design
This prospective randomized crossover study was conducted at
Yokohama Advanced Cardiovascular Life Support (BLS-MS arm)
and Kobe Medical Device Development Center (PEA-FM arm)
between 2008 and 2012. To measure CPR parameters such as
compression rate and hand position, certified rescuers performed
chest compressions on a mannequin placed in either supine or 30
LLT position, using an adjustable bed (comparable to an operating
room table) as platform. The degree of tilt was protractor-verified
in each instance. Participants provided their own assessments of
the difficulty encountered during each procedure. The medical
Fig. 1. Preparation of swine model for maternal CPR.
A–C: Fetal mannequin placed intra-abdominally in sedated pig and positioned against inferior vena cava, inserting a Swan-Ganz catheter to monitor arterial and central
venous pressures; D: Fetal mannequin, consisting of full-body pregnancy simulation fetus with amnion (LM-105; Koken Co Ltd, Tokyo, Japan). Abbreviations: CPR,
cardiopulmonary resuscitation.
99
ethical review board of Kanazawa University approved the study
protocol.
To measure CPP at different positions, fetal mannequins were
placed within abdominal cavities of four pigs, subsequently
inducing PEA cardiac arrest in these animals. The Animal
Experiment Committee of the Intervention Technical Center for
the use of laboratory animals in the Kobe Medical Device
Development Center granted approval for this aspect of the study.
BLS-MS participants, protocol, and outcome measures
Twenty rescuers  18 years old and certified as competent in
American Heart Association (AHA) basic life support (BLS)
volunteered for this investigation. All participants provided
written informed consent, and all completed the study success-
fully.
On a random assignment basis, each BLS rescuer performed
simulated chest compressions on a mannequin (Resusci Anne
Simulator; Laerdal Medical, Stavanger, Norway) placed in either
supine or 30 LLT position, continuing for 2 min in the position first
assigned, resting for 10 min, and then repositioning the mannequin
and repeating CPR for 2 min in the second assigned position. The 2-
min intervals for CPR conformed to AHA BLS guidelines of 2005
and 2010. To avoid potential bias, rescuers were blinded to the
monitor screen displaying compression rate or hand position.
Analysis of all collected data involved proprietary methods (PC
Skill Reporting System; Laerdal Medical).
The primary outcome measure was chest compression quality
(stipulated as a compression depth of 50–60 mm, hand positioned
on the lower half of the sternum, and recoil to within 5 mm of
baseline chest height) and rate (number of compressions executed
in 1 min). As a secondary outcome, rescuers scored the ease of
100 S. Dohi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 216 (2017) 98–103
performing CPR with the mannequin in a given position. The
questionnaires were completed after BLS-MS execution, applying a
5-point Likert-like scale (1, very easy; 2, easy; 3, normal; 4,
difficult; 5, very difficult) [13]. The average values of self-reported
ratings were termed difficulty scores.
PEA-FM model, CPR protocol, and outcome measures
Four female swine (LWD strain: Landrace  Large White 
Duroc three-way cross breeds; age, 3 months; weight, 35–37 kg)
were used to develop the PEA-FM model. The swine were
purchased from a pathogen-free farm in Japan and kept at the
Intervention Technical Center under controlled conditions (tem-
perature, 23  3  C; humidity, 55  10%), implementing a 12-h
light-dark cycle (lights on, 7:00–19:00; lights off, 19:00–7:00) and
direct-expansion air conditioning, with a medium-quality air filter.
The animals consumed a commercial solid diet (MP-A, Oriental
Yeast, Tokyo, Japan; maximum limit, 800 g/day).
The pigs were sedated using intramuscular ketamine (Ketalar,
2 mg/kg) and xylazine (10 mg/kg) as well as inhalatory isoflurane
(2–3%) in oxygen (2–3 L/min). Subsequently, a 3.5-g fetal manne-
quin consisting of a full-body pregnancy-simulating fetus with
amnion (LM-105; Koken, Tokyo, Japan) was positioned within the
abdominal cavity of each pig, placed against the inferior vena cava
(Fig. 1). PEA cardiac arrest [14], an unstable cardiac condition
marked by sustained electrical activity and absence of a palpable
pulse, was induced by administering a bolus of potassium chloride
(0.9 mEq/kg) in normal saline (20 mL) intravenously. Precordial
electrodes continuously monitored electrocardiographic activity.
All four pigs ultimately experienced cardiac arrest, signaled by
ventricular fibrillation on electrocardiogram and loss of arterial
blood pressure waveforms.
Subsequently, 2-min sets of chest compressions were delivered
to the animals positioned as follows: supine, supine with left
uterine displacement (LUD), 30 LLT, and 30 RLT. In addition to
constant monitoring of heart rate, Swan-Ganz catheter placement
enabled ongoing recording of arterial and central venous
pressures. The primary outcome in the PEA-FM arm was CPP,
defined as aortic diastolic pressure minus left ventricular end-
diastolic pressure, with readings taken at 0.5, 1.0, 1.5, and 2.0 min
after starting CPR.
Statistical analysis
Mean differences in percentage of compressions performed at
stipulated depth, hand position, and recoil, as well as differences in
chest compression rates, were analyzed via Student’s two-tailed t-
test, applying Kruskal-Wallis and Dunn’s post-hoc tests to assess
CPP differences in the animal model. All computations relied on
standard software (SAS JMP Pro 11.0; SAS Institute, Cary, NC),
setting significance at p  0.05.
Results
Demographics
Among the BLS-MS participants (women, 35%), age was
40.8  7.2 years, and median BLS experience was 3 years. Thirteen
(65%) of the rescuers were registered nurses (Table 1).
CPR parameters and ease of performing the mannequin CPR
simulation (BLS-MS)
Relative to total number of compressions executed, the ratio of
compressions executed at stipulated depth was significantly
higher for supine than for 30 LLT position (114.5/150 vs 53.8/
Table 1
Characteristics of the participants involved in the mannequin-based CPR simulation
(N = 20).
Variable Value
Age, years 40.8  7.2
Sex Male 7 (35)
Female 13 (65)
Specialty
Registered nurse 13 (65)
Anesthesiologist 1 (5)
Obstetrician 1 (5)
EMS technician 3 (15)
ER physician 1 (5)
Neurosurgeon 1 (5)
Professional experience, years 16.5 (13.5–20.2)
Experience with BLS, years 3 (2–4.2)
Values expressed as number (percentage), median (interquartile range), or
mean  standard deviation.
CPR, cardiopulmonary resuscitation; ER, emergency room; EMS, emergency
medicine service; BLS, basic life support.
150; p < 0.001), as was the ratio of compressions performed using
correct hand position (149.5/150 vs 131.7/150; p < 0.05). However,
our analysis showed no position-specific differences in chest
compression rate or ratio of compressions that recoiled correctly to
total number of compressions (Table 2). Questionnaire scores also
revealed that the participants found chest compressions signifi-
cantly easier to perform with the mannequin in supine (vs LLT)
position (difficulty score, 1.75 [95% confidence interval, 1.31–2.19]
vs 3.95 [95% confidence interval, 3.68–4.22]; p < 0.001).
CPP variation in the swine model (PEA-FM)
In the swine model, animal position during CPR significantly
affected CPP values at 1.0 and 1.5 min, but not those at 0.5 and
2.0 min (Dunn’s post-hoc test: p < 0.001, p = 0.02, p = 0.10, and
p = 0.14, respectively; Fig. 2, Supplementary Fig. 1). At all four
evaluated time points, supine position with LUD and 30 RLT
position generated the highest and lowest CPP values, respectively
(Dunn’s post-hoc test: p < 0.05).
Discussion
Main findings
The present study indicates that rescuers perform higher-
quality chest compressions if subjects are in supine position, and
that CPP normalization proceeds most effectively in supine
position with LUD.
Interpretation
In an obstetric setting, optimal patient positioning during CPR
remains controversial. A mannequin simulation study previously
performed by Kim et al. has confirmed that even inexperienced
first responders can execute high-quality chest compressions with
subjects in 30 LLT position [15]. Furthermore, although neither
hand position nor other measures of chest compression technique
(rate, depth, or recoil) showed significant position-specific differ-
ences, performing chest compressions proved easier in supine (vs
LLT) position. All BLS rescuers participating in the present study,
each AHA-certified, also stated preferring supine mannequin
position during simulated CPR. Indeed, the stipulated chest
compression depth and hand position were achieved by rescuers
more often when performing simulated CPR supine.
Upon investigating various methods for producing lateral tilt, Ip
et al. found dedicated foam or hard wedges, rather than pillows or
 S. Dohi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 216 (2017) 98–103
Table 2
Quality of chest compressions in the mannequin-based simulation.
Parameter Supine position
(n = 20)
Correct hand position 0.99
Correct chest compression depth 0.76
Correct recoil 1.0
Chest compression rate* 120.4
Unless otherwise specified, all values are provided as ratios between number of compressions performed in correct capacity and total number of compressions.
NS, not significant.
*
Compressions/min.
Fig. 2. Measurement of CPP during resuscitative chest compressions, executed with animals in different positions.
A–D: CPP readings at 0.5, 1.0, 1.5, and 2.0 min after pulseless cardiac arrest.
Abbreviations: CPP, coronary perfusion pressure; LLT, left lateral tilt; LUD, supine position with left uterine displacement; RLT, right lateral tilt; SP, supine position.
human wedge, superior in conferring lateral tilt during CPR [16].
On the other hand, the mannequin study of Butcher et al.
demonstrated that chest compressions were equally effective in
both supine/uterine displacement and lateral tilt positions,
maintaining that either method is suitable for CPR [11]. Such
observations are perhaps attributable to differences in experience
levels of rescuers recruited for these studies, and to subtle
differences in the models used or study protocols applied. For
example, unlike the relatively inexperienced first responders
involved in the study by Kim et al. [15], the AHA-certified BLS
rescuers enlisted in this investigation were highly experienced, and
therefore more apt to achieve better outcomes. Present findings
thus underscore the importance of rescue experience in achieving
superior CPR outcomes, and support the contention that supine
position, rather than LLT, yields better-quality chest compressions.
Data acquired from the swine model of maternal CPR also
corroborated that chest compressions are most effective if
performed on the animal positioned supine with LUD, while
conversely suggesting that 30 RLT position may be harmful, given
the very low CPPs generated. Maximal CPP has emerged as one of
the best parameters in predicting return of spontaneous circula-
tion, and CPP measurements are generally more predictive than
aortic pressure alone [17,18]. Lateral positioning also appeared to
improve left atrial wedge pressure correlation in a positive-
pressure ventilation pig model [19], although another study using
LLT to relieve presumptive aortocaval compression by pregnant
101
Left lateral tilt position p-value
(n = 20)
0.88 < 0.05
0.36 < 0.001
1.0 NS
123.1 NS
uteri indicated that 15 of LLT was ineffective in reducing inferior
vena cava compression [20]. It is therefore prudent for healthcare
providers to perform maternal CPR using uterine displacement and
not lateral tilt.
Aortocaval compression is a key contributor to supine maternal
hypotension. The PEA-FM model we devised simulates the
condition of aortocaval compression, so the low CPPs recorded
in LLT attest to the inadequacy of lateral tilt in alleviating aortocaval
compression. Such inference stems from the fact that aortocaval
compression may persist, despite high lateral tilt, if the gravid
uterus is immobile and sags over the abdomen [21].
Armstrong et al. analyzed cardiac indices of term pregnant
women in sitting, lateral, and supine positions and found that
maternal stroke volume index, heart rate, and systolic blood
pressure were higher in lateral position [22]. Although body
position may be critical in exacerbating cardiorespiratory stress
during pregnancy, deficits in delivery of maternal CPR in simulated
obstetric settings have been conspicuous in several studies. One
such investigation revealed that compressions were carried out
correctly in just 56% of cases, and ventilations in 50% [23].
Furthermore, critical interventions such as LUD or engaging a firm
back support prior to initiating compressions were frequently
neglected [23]. Poor pregnancy-specific CPR was also reported in
another study [24]. Finally, Einav et al. have noted that obstetric
specialty clinicians in a hospital setting possessed limited
knowledge of current recommendations for treating maternal
102 S. Dohi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 216 (2017) 98–103
cardiac arrest [25]. All these sources highlight the need for
awareness, standardization, continued education, and further
studies in this high-risk and complex field.
Strengths and limitations
Clinical trials in obstetric settings involve ethical and practical
concerns. Studies/guidelines for CPR in pregnancy therefore
generally rely on case series, extrapolating from cardiac arrest
data in non-pregnant patients and from mannequin studies.
Unfortunately, these approaches are inherently limited in terms of
reflecting real maternal CPR conditions. The major strength of the
present study is the use of a novel PEA-FM model that perhaps
more closely mimics maternal CPR. In non-obstetric settings,
porcine models of cardiac arrest and resuscitation are relatively
well understood [26]. The swine model has several important
advantages over other animal models, and outcomes in the swine
model seemingly translate well to clinical circumstances [27].
Especially relevant to CPR is the fact that the large chests of pigs
can accommodate appropriately forceful precordial chest com-
pressions and electrical transthoracic counter shocks applied
during defibrillation. In addition, this large mammal will tolerate
extensive manipulations, especially sampling of blood and
intravascular or intracardiac pressure measurements; moreover,
the serum chemistries of pigs and humans are quite similar [27,28].
The animal model used here also incorporated a fetal mannequin,
an important feature closely simulating aortocaval compression in
pregnant women. Hence, the three study arms conducted (BLS-MS,
PEA-FM, and rescuer questionnaire) all generated data to support
the superiority of supine position for better-quality outcomes in
maternal CPR.
The present study has several acknowledged limitations.
Although the PEA-FM model of maternity embodies certain CPR-
relevant anatomic features, its applicability to pregnant women
cannot be completely conceded. Specifically, the fetal mannequin
was not secured in place, creating a potential for excessive
mobility. Another major limitation is that CPP was the sole index of
CPR effectiveness in the animal model. Cerebral perfusion pressure
is an equally important measure and would be an appropriate
addition to similar future investigations. More recently, near-
infrared spectroscopic cerebral oximetry has also emerged as a
noninvasive means of predicting return of spontaneous circulation
following CPR. Finally, although the lack of statistically significant
differences in CPP values at 0.5 and 2.0 min remains unexplained, it
may reflect insufficient chest compression soon after initiating CPR
and fatigue before terminating CPR [29,30]. As determined by
Ashton et al., rotating rescuers at 1-min intervals is advisable, due
to fatigue that develops within 3 min of uninterrupted CPR.
However, further research is needed to clarify such issues.
Conclusions
Although maternal chest compression is feasible in 30 LLT
position, correct compression depth may be more difficult to
achieve, due in part to the surface used. Using mannequin-based
simulations, we found that chest compressions were much more
effective if performed with the subject positioned supine on a firm
surface, preferably with lateral uterine displacement. Our limited
animal model also registered consistently lower CPP readings
during CPR in supine and in LLT or RLT positions at 30 , compared
with CPP readings in supine position plus LUD. RLT position
seemed especially inadequate for maintaining CPP during chest
compressions.
Funding
None.
Conflict of interest
The author reports no conflict of interest.
Acknowledgements
I am deeply grateful to Prof. Takayuki Kosuge (Teikyo
University), Prof. Hiroshi Saito (Showa University Northern
Yokohama Hospital), Dr. Yasuo Takegoshi (Fukui Saiseikai Hospi-
tal), Mr. Yasuo Hara (IVTec), and Ms. Kazue Nara (Yokohama
Advanced Cardiovascular Life Support [ACLS]), whose related
comments and suggestions were of immeasurable value. I also
extend my gratitude to the BLS rescuers of Yokohama ACLS. Cactus
Communications provided editorial support, assisting in medical
writing, table creation, production of high-resolution images (per
author’s detailed specifications), collating the author’s comments,
copyediting, fact checking, and referencing.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at http://dx.doi.org/10.1016/j.
ejogrb.2017.07.019.
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