A 32-year-old woman at 38 weeks gestation suddenly develops severe dyspnea, hypotension, and altered mental status during labor. The fetal heart rate shows severe bradycardia. Anaphylactoid syndrome of pregnancy (ASP) is suspected. What is the nurse's priority intervention?

Immediate cesarean delivery is the priority to remove the source of amniotic fluid embolism and allow effective maternal resuscitation. Other interventions like oxygen or fluid resuscitation are important but do not address the underlying cause.

Understanding Anaphylactoid Syndrome of Pregnancy (ASP)
Anaphylactoid syndrome of pregnancy, historically referred to as amniotic fluid embolism (AFE), is a rare, catastrophic obstetric emergency. The classic triad involves sudden onset of respiratory distress, cardiovascular collapse (hypotension, cardiac arrest), and coagulopathy. The underlying mechanism is not a true embolic event, but rather an anaphylactoid reaction to fetal antigens entering the maternal circulation, triggering a massive systemic inflammatory response. This leads to pulmonary vasospasm, right heart failure, and left ventricular dysfunction, rapidly progressing to cardiorespiratory arrest. The case reports you see in the provided literature consistently highlight this abrupt presentation of severe dyspnea, hypotension, and altered mental status during labor or immediately postpartum [1,3,4].

Prioritizing Immediate Intervention
In a maternal cardiac arrest scenario, especially when fetal bradycardia is present, the guiding principle is maternal resuscitation. The pregnant uterus compresses the aorta and inferior vena cava, significantly impeding venous return and reducing the effectiveness of chest compressions. Therefore, the single most critical, time-sensitive intervention that directly impacts both maternal and fetal survival is to relieve this aortocaval compression while simultaneously initiating high-quality cardiopulmonary resuscitation (CPR). This is achieved by preparing for an immediate cesarean delivery, also known as a perimortem cesarean section. The literature underscores that in cases of AFE leading to cardiac arrest, prompt delivery is integral to the resuscitation effort, as it removes the source of the anaphylactoid trigger and optimizes maternal hemodynamics for CPR [3,4]. A case report explicitly describes a patient who developed cardiac arrest during emergency cesarean section for AFE, illustrating that surgical intervention is not a separate step but a concurrent, life-saving component of the resuscitation algorithm ^[4].

Analysis of Other Options
While the other options represent important aspects of care, they are not the immediate priority in the context of cardiac arrest with fetal bradycardia.
- Administering high-flow oxygen and establishing IV access is a critical component of initial stabilization for a patient in respiratory distress, but it is insufficient and delays definitive action once cardiac arrest has occurred or is imminent. The case reports detail that these patients rapidly deteriorate, and supportive measures alone do not reverse the underlying crisis [1,2].
- Positioning in left lateral decubitus is a standard intervention to relieve aortocaval compression in a conscious, hypotensive pregnant patient. However, in a full cardiac arrest scenario, this position makes effective chest compressions impossible. The definitive way to relieve compression during CPR is to empty the uterus.
- Obtaining coagulation studies and preparing for transfusion addresses the disseminated intravascular coagulation (DIC) that frequently complicates AFE, as noted in the case reports where massive hemorrhage followed the initial event [1,4]. However, managing DIC is a secondary priority; the immediate threat to life is the cessation of cardiac output and oxygenation, which must be corrected first to give any subsequent interventions a chance to succeed.