Perimortem C-Section Summary

Purpose

  • Performed during maternal cardiac arrest
  • Improves maternal resuscitation chances
  • Enables neonatal resuscitation

Gestational Age

  • <20 weeks: Not indicated
  • 20-23 weeks: For maternal rescue only
  • >24 weeks: For mother and infant

Time Critical

  • Best outcomes if delivery within 5 minutes
  • Decision should be made early

Procedure

  • Midline incision from fundus to pubic symphysis
  • Vertical uterine incision
  • Deliver infant and placenta
  • Continue maternal resuscitation

Physiological Benefits

  • Relieves IVC compression
  • Improves venous return during CPR
  • Enables aortic clamping/compression
  • Allows internal cardiac massage

Perimortem Caesarean Delivery

Emergency procedure for maternal cardiac arrest in pregnancy

Introduction

Perimortem caesarean delivery is a consideration for women who suffer cardiac arrest in pregnancy. When initial resuscitation attempts fail, delivery of the foetus may improve the chances of successful resuscitation of both the mother and the foetus.

Pathophysiology

Maternal Benefits

Delivery relieves inferior vena cava (IVC) compression and may improve the likelihood of resuscitating the mother by permitting an increase in venous return during the CPR attempt. It also enables access to the abdominal cavity so that aortic clamping or compression is possible; internal cardiac massage may also be possible.

Fetal Benefits

Once the foetus has been delivered, resuscitation of the newborn can also begin. The best survival rate for infants over 24 - 25 weeks gestation occurs when delivery of the foetus is achieved within 5 mins after the mother's cardiac arrest; this a difficult time to achieve in reality but consideration of perimortem caesarean section should be made at an early stage after cardiac arrest.

Indications

Gestational Age Assessment

First, estimated gestational age (EGA) should be determined either based on history or fundal height. In general, the uterus reaches the level of the umbilicus at 20 weeks and grows approximately 1 centimeter for every week thereafter.

Physiological Considerations

In the supine position, the gravid uterus begins to compromise blood flow in the inferior vena cava (IVC) and abdominal aorta at approximately 20 weeks gestation; however foetal viability begins at approximately 24 weeks.

Gestational Age < 20 weeks

Do not consider emergency delivery; a gravid uterus of this size is unlikely to compromise maternal cardiac output.

Gestational Age 20 - 23 weeks

Initiate emergency delivery to permit successful resuscitation of the mother only.

Gestational Age > 24 weeks

Initiate emergency delivery to help save the life of both the mother and infant.

Procedure

Time is Critical

The best outcomes occur when delivery is achieved within 5 minutes of maternal cardiac arrest. Decision-making should be rapid and decisive.

Step-by-Step Procedure

  1. Incision: Perimortem caesarean delivery uses a midline incision from the level of the fundus to the pubic symphysis to gain exposure to the uterus with the use of retractors.
  2. Dissection: Blunt dissection should be performed until the peritoneum is entered.
  3. Uterine Incision: A vertical incision is then made from the fundus inferiorly towards the anterior bladder reflection.
  4. Uterine Entry: When the uterine cavity is first entered, middle and index finger should be inserted to lift the uterine wall away from the infant while the incision is extended preferably with scissors.
  5. Delivery: The infant should then be delivered through the hysterotomy and immediately handed to someone skilled in neonatal resuscitation while the cord is clamped.
  6. Placenta: The placenta should be removed before closure and maternal resuscitative efforts continued.

Team Coordination

This procedure requires a coordinated team approach with personnel dedicated to maternal resuscitation, surgical procedure, and neonatal resuscitation simultaneously.

Special Considerations

Maternal Resuscitation

CPR should continue throughout the procedure. The surgical team must work around the resuscitation efforts. Delivery may improve the effectiveness of chest compressions by relieving aortocaval compression.

Neonatal Preparation

A team skilled in neonatal resuscitation should be present and prepared to receive the infant. Equipment for neonatal resuscitation should be readily available, including warmth source, airway management equipment, and medications.

Emotional Support

When possible, a support person for the family should be available. This is an extremely stressful situation for all involved, including healthcare providers.

Equipment Checklist

Surgical Equipment

  • Scalpel with #10 or #20 blade
  • Abdominal retractors
  • Scissors (Mayo and Metzenbaum)
  • Forceps and clamps
  • Suture material
  • Suction equipment

Maternal Resuscitation

  • CPR board
  • Defibrillator
  • Advanced airway equipment
  • IV access equipment
  • Emergency medications

Neonatal Resuscitation

  • Radiant warmer
  • Neonatal airway equipment
  • Umbilical catheterization kit
  • Neonatal medications
  • Monitoring equipment

Documentation and Follow-up

Documentation Essentials

  • Time of cardiac arrest
  • Time of decision for perimortem C-section
  • Time of incision
  • Time of delivery
  • Neonatal condition at birth
  • Maternal response to procedure
  • Team members involved

Debriefing

All perimortem caesarean deliveries should be followed by a multidisciplinary debriefing session to review the management, discuss outcomes, and provide emotional support to the healthcare team.