Amniotic Fluid Embolism — Interactive Checklist
A running, time-anchored implementation of the Society for Maternal-Fetal Medicine Special Statement checklist for the initial management of amniotic fluid embolism, updated 2026. Every item, threshold and dose is taken from the published statement. Nothing has been added, estimated or extrapolated.
2–6
cases per 100,000 births
SMFM 2026 (ref 1); Clark 2014 (ref 4)
20–40%+
case fatality in “classic” cases with collapse and coagulopathy
SMFM 2026 (ref 1); Mazza 2022 (ref 6)
>80%
of AFE cases accompanied by DIC
Pacheco 2016 (ref 2)
4 min
to initiate delivery if ROSC is not achieved
SMFM 2026 Fig 1 (ref 1); AHA 2015 (ref 7)
1–2
cases per decade at a typical facility — almost no one has done this before
SMFM 2026 introduction (ref 1)
What this is
The SMFM 2026 checklist, executed rather than printed. It merges the text checklist (Figure 1) and the cardiac-arrest flow chart (Figure 2) into one running response, starts the clocks the checklist tells you to keep, calls the minutes the checklist tells you to call, does the weight-based arithmetic the checklist leaves to you, and writes the timed record the debrief will need. Each item carries the figure it came from.
Sections
Why a page of boxes is no longer a checklist
The 2026 statement asks the team to designate a timekeeper calling minutes aloud, to deliver by four minutes, to draw comprehensive labs within five minutes of starting CPR, to abandon transfer to the OR if it will take longer than two minutes, and to titrate four weight-based infusions — all during a resuscitation, on paper, from a pocket on the side of a crash cart. Here is the same content measured against what the response actually requires.
| What the statement asks the team to do | Printed page | This checklist |
|---|---|---|
| Call out elapsed time at 1-minute intervals | A human remembers to, under load | Called automatically, visibly and audibly |
| Deliver by 4 minutes if ROSC is not achieved | A printed sentence | A countdown that turns red and stays red |
| Comprehensive labs within 5 min of CPR | A box in a side branch of a flow chart | Its own clock, anchored to CPR start |
| Transfer to OR only if under 2 minutes | A rule with no way to test it | A 2-minute window you can actually run |
| Norepinephrine 0.05–3.3 mcg/kg/min | Mental arithmetic, times four drugs | Computed from one weight entry |
| Document blood products and timings | Someone writes on a glove | Every action time-stamped as it is checked |
| Distinguish arrest from non-arrest presentation | One linear list for both | Arrest-specific items surface or retire |
| Debrief and revise the checklist afterwards | Recall, hours later | The timed record is the debrief document |
| Measure time to CPR and to delivery as a unit metric | Chart review, retrospectively | Produced as a by-product of use |
The statement itself proposes exactly these measures — time from AFE recognition to CPR initiation and to cesarean delivery, and documentation time during codes before and after implementation. A static file cannot generate them. This one does, without asking anyone to do extra work during the code.
Publications used in this tool
1
PRIMARY SOURCE
Society for Maternal-Fetal Medicine (SMFM), Martinez-King LC, Combs CA, Montgomery DM, Toner LE, Dildy GA; SMFM Patient Safety and Quality Committee. Society for Maternal-Fetal Medicine Special Statement: Checklist for initial management of amniotic fluid embolism—Updated 2026. Pregnancy. 2026;2(5):e70364.
doi:10.1002/pmf2.70364
Every checklist item, time threshold, dose and target on this site comes from Figure 1 (checklist, version July 27, 2026) and Figure 2 (cardiac arrest flow chart) of this statement.
2
GUIDELINE
Pacheco LD, Saade G, Hankins GD, Clark SL; Society for Maternal-Fetal Medicine. Amniotic fluid embolism: diagnosis and management. Am J Obstet Gynecol. 2016;215(2):B16-B24.
doi:10.1016/j.ajog.2016.03.012
SMFM Clinical Guideline No. 9. Diagnostic framing, the >80% DIC figure, and the statement that uterine tone abnormalities may be a consequence of shock rather than the cause.
3
EXPERT REVIEW
Pacheco LD, Clark SL, Klassen M, Hankins GDV. Amniotic fluid embolism: principles of early clinical management. Am J Obstet Gynecol. 2020;222(1):48-52.
doi:10.1016/j.ajog.2019.07.036
Cryoprecipitate in preference to plasma, the vasopressor-inotrope-pulmonary vasodilator strategy, early echocardiography, and ECMO despite coagulopathy.
4
NARRATIVE REVIEW
Clark SL. Amniotic fluid embolism. Obstet Gynecol. 2014;123(2 Pt 1):337-348.
doi:10.1097/AOG.0000000000000107
Clinical Expert Series. Incidence of 2-6 per 100,000, case fatality range, DIC as the confirming finding, and the immune rather than embolic model of the syndrome.
5
CASE DEFINITION
Clark SL, Romero R, Dildy GA, Callaghan WM, Smiley RM, Bracey AW, et al. Proposed diagnostic criteria for the case definition of amniotic fluid embolism in research studies. Am J Obstet Gynecol. 2016;215(4):408-412.
doi:10.1016/j.ajog.2016.06.037
Onset during labour or within 30 minutes of delivery of the placenta; the research case definition underlying the clinical diagnosis.
6
COHORT
Mazza GR, Youssefzadeh AC, Klar M, Kunze M, Matsuzaki S, Mandelbaum RS, et al. Association of pregnancy characteristics and maternal mortality with amniotic fluid embolism. JAMA Netw Open. 2022;5(11):e2242842.
doi:10.1001/jamanetworkopen.2022.42842
Population-level epidemiology and case fatality, cited by the 2026 statement alongside ref 4.
7
GUIDELINE
Jeejeebhoy FM, Zelop CM, Lipman S, Carvalho B, Joglar J, Mhyre JM, et al. Cardiac arrest in pregnancy: a scientific statement from the American Heart Association. Circulation. 2015;132(18):1747-1773.
doi:10.1161/CIR.0000000000000300
The 4-minute rule for initiating delivery during CPR, and the pregnancy-specific cardiac arrest management this checklist deliberately leaves to a separate flowsheet.
9
SYSTEMATIC REVIEW
Trieu NHK, Nguyen NN, Pham HM, Huynh DQ, Mai AT. Extracorporeal membrane oxygenation in amniotic fluid embolism: a systematic review of case reports. ASAIO J. 2025;71(2):143-148.
doi:10.1097/MAT.0000000000002269
79 pooled cases: 72% maternal survival and 6% major neurologic sequelae. Case reports only, so subject to publication bias toward survivors.
10
EXPERT PANEL
Pacheco LD, Clark SM, Fox K, Bauer ME, Clark SL. Use of atropine, ondansetron, and ketorolac in suspected amniotic fluid embolism. Obstet Gynecol. 2026;147(6):780-784.
doi:10.1097/AOG.0000000000006095
Recommends against routine use of the atropine-ondansetron-ketorolac regimen; evidence limited to case reports, with defined potential harms.
11
COHORT
Fitzpatrick KE, van den Akker T, Bloemenkamp KWM, Deneux-Tharaux C, Kristufkova A, Li Z, et al. Risk factors, management, and outcomes of amniotic fluid embolism: a multicountry, population-based cohort and nested case-control study. PLoS Med. 2019;16(11):e1002962.
doi:10.1371/journal.pmed.1002962
INOSS pooled surveillance from five countries. Cited by the 2026 statement for tranexamic acid; also the source of the finding that oxytocin in labour is not significantly associated with AFE while prostaglandin induction is.
Full annotated list of all 28 references on the Evidence page.