Table 6 Rankings and Standard Deviations for Statements before and after Expert Panel Meeting using the modified RAM process (pre = ranking + SD after first round, prior to Expert Panel meeting, post = ranking +SD after second face-to-face consensus round at Expert Panel Meeting)

Training emergency department physicians in perimortem cesarean delivery (PMCD) is recommended so that PMCD can be immediately performed upon arrival to the hospital for out-of-hospital maternal cardiac arrest without return of spontaneous circulation (ROSC).

5.17

5.74

1.03

0.45

PMCD should be immediately performed in a pregnant patient with a fundus height at or above the umbilicus with a non-shockable rhythm (versus proceeding with standard ACLS then PMCD after 4 minutes as would be recommended in pregnant patients with a shockable rhythm).

4.78

5.35

1.13

0.80

The term “perimortem cesarean delivery” should be replaced with the term “resuscitative hysterotomy” to more correctly describe the purpose/indication and increase the sense of urgency for performing this procedure.

4.87

5.18

0.97

1.39

First responders should initiate and maintain bag-mask-valve (BMV) techniques until arrival at a hospital with a more experienced laryngoscopist arrives

4.57

1.92

1.59

1.29

EMS should deploy highly specialized paramedics in addition to regular EMS crew in cases of suspected maternal cardiac arrest.

4.87

2.52

1.32

0.98

The use of a ketamine-based anesthesia package should be considered for patients with return of spontaneous circulation (ROSC) who have undergone PMCD in settings without immediate anesthesia availability.

4.22

3.56

1.17

1.45

The use of extracorporeal life support (ELS, or eCPR) should be strongly considered for management of maternal cardiac arrest complicated by refractory cardiopulmonary resuscitation (CPR) in an extracorporeal membrane oxygenation (ECMO) center with capacity to care for critically ill pregnant patients.

4.86

5.40

0.94

0.76

The use of ELS or eCPR should be considered for organ procurement in pregnant patients post-arrest with circulatory determination of death.

4.33

4.53

0.97

0.77

Where available, point-of-care ultrasound (POC-US) should be used in the management of maternal cardiac arrest for identification of an intrauterine pregnancy and quick determination of gestational age to guide decision making on PMCD.

4.26

4.96

1.29

0.75

POC-US should be considered for use during maternal cardiac arrest in emergency protocols for identification of potentially reversible causes of cardiac arrest, identification of cardiac contractility activity without palpable pulse for clinical reclassification of pulseless electrical activity, and identification of the absence of cardiac contractility where further attempts at resuscitation may be unsuccessful.

4.90

4.78

0.89

0.85

The use of POC-US by prehospital providers for diagnosis and management of maternal cardiac arrest should only be utilized in research protocols.

3.87

4.30

1.46

1.02