Perimortem Cesarean Delivery


Article Author:
Ajit Alexander


Article Editor:
Susan Lobrano


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
2/2/2019 12:03:29 AM

Introduction

Delivery by Cesarean section dates to 800 BCE. Unfortunately, at the time, the procedure was only done on a deceased or dying pregnant patient. It was not until the late 19th and 20th centuries when the first cases of perimortem cesarean section-use for salvage of the fetus were described. During the 1980s, additional case reports described its use to improve the survival of the mother.

One of the most daunting scenarios to face during an emergency department (ED)/critical care shift is the sudden, adverse change in a pregnant patient's health. These occurrences are rare and are the result of pre-existing conditions with severe, unforeseen medical, obstetric complications. This is also the scenario when patients arrive in extremis from a traumatic insult. An astute physician must be prepared and ready to do what is appropriate to save the life of the mother and the fetus. This includes considering a perimortem Cesarean section (C-section) (PMCS). A perimortem C-section is defined as a C-section performed during imminent cardiac arrest or active cardiac arrest, with the ultimate goal to successfully resuscitate the mother and improve fetal survivability. It is also referred to as resuscitative hysterotomy

PMCS is now a rarely performed procedure as the pregnancy-related death rates are overall low. Although the incidence of PMCS has not been well documented, the incidence of cardiac arrests during pregnancy is 1/30,000. Prior to 1986, only 188 cases were reported. From 1986 to 2004, only 38 additional cases were reported in the United States. The majority of them were performed in the ED setting, and occasional reports document pre-hospital scenarios. Despite the scarcity of data, with expedited deliveries, fetal survivability can be as high as 70%, with successful maternal resuscitations. Of the 38 case reports mentioned earlier, additional data revealed that the most common causes of maternal arrest requiring to PMCS were trauma, pulmonary embolism, cardiac causes, sepsis, and eclampsia. In the Netherlands, a retrospective questionnaire and medical survey review over 15 years (1993 through 2008), revealed 55 pregnant patients who suffered cardiac arrest, and only 12 (22%) of them had a PMCS.[1] Other risk factors which have been documented from prior case series include obesity and advanced maternal age older than 35.

Anatomy

Abdominal Wall

Incision of the abdominal wall is one the most frequently performed surgical procedures. Prior to performing a rush PMCS, it is ideal to have a basic understanding of the layers involved. There are 9 layers of the abdominal wall which include the skin, subcutaneous tissue, superficial fascia, external oblique muscle, internal oblique muscle, transversus abdominis muscle, transversalis fascia, preperitoneal adipose and areolar tissue, and peritoneum. The blood supply for the abdominal wall is composed of superficial and deep arteries. The superficial blood supply is located in the subcutaneous tissue and supplies blood to everything above the external oblique aponeurosis and anterior rectus sheath. It consists of the superficial inferior epigastric, superficial external pudendal, and superficial circumflex artery. The deep blood vessels are located in the musculofascial layers and supply blood to the muscles and fascia below the external oblique aponeurosis. A midline incision is an ideal approach in PMCS because it takes advantage that only the terminal branches of the blood vessels and nerves are in the linea alba. This reduces the risk for major bleeds and nerve damage from the procedure and provides the most significant exposure to the abdominal organs.

The Uterus  

Understanding uterine anatomy is imperative for ensuring optimal exposure, maximizing hemostasis, and avoiding injury to critical abdominal structures such as viscera, blood vessels, and nerves. The uterus can be divided into 2 portions, the uterine corpus, and the uterine cervix. The uterine corpus, which is also known as the body, has an inverted triangular shape. The superior portion of the body is called the fundus. An inferior portion which joins the cervix is known as the isthmus. The body is made up of 3 layers which are the serosa (outer layer), myometrium (middle layer), and endometrium (inner layer). The uterus is supported by the uterosacral and cardinal ligament complex, round ligament, broad ligament, and the endo-pelvic fascia. The blood supply for the uterus mainly comes from the uterine artery. The uterine artery originates from the anterior division of the internal iliac arteries in the retroperitoneum. The practioner should be aware of the importance the course of the uterine artery. The uterine artery courses through the cardinal ligament and passes over the ureter (located 1.5-cm lateral to the uterus). It reaches the uterus at the level of the internal cervical os. The uterine arteries give off branches, which tortuously course along the lateral aspect of the uterus, running superiorly to the corpus, and inferiorly to the cervix. The corpus also receives collateral flow from anastomoses of the ovarian arteries.

Physiology 

There are physiologic changes that occur during late pregnancy. During the third trimester of pregnancy, there is an increase in cardiac output and circulating blood volume by 30% to 40%. This is important because maternal signs and symptoms of shock may not manifest until the mother has lost over 40% of her blood volume. Also, an enlarged uterus can elevate the diaphragm about 4 cm which, in turn, can cause a 20% decrease in functional residual capacity. Finally, the gravid uterus can cause compression of inferior vena cave (IVC) leading to hypotension.

Indications

Traditional teaching expresses that resuscitative hysterotomy is performed in mothers carrying a fetus of a gestational age of 24 weeks or older, who are in peri-arrest, or have actively arrested. At 24 weeks, the fetus is considered viable. There is also a 20% to 30% fetal survivability at 24 weeks onward if PMCS is performed in a scenario where appropriate neonatal critical care facilities exist. Newer theories argue the 24-week rule, as the primary goal of resuscitative hysterotomy is the resuscitation of the mother. Also, when a patient arrives in extremis, the gestational age may not be known, and the use of ultrasound is not practical. A quick evaluation of fundal height can aid in estimating gestational age. If the uterus fundus can be seen at the umbilicus, the gestational age can be considered to be about 20 weeks. The uterine fundus grows about 1 cm every week after that.

Another critical factor in determining the need to perform PMCS is the time from arrest. Resuscitative hysterotomy should be performed as soon as the patient arrests, with goal delivery time within the first 4 minutes of arrest. Four minutes is used because this corresponds to the time after which there will be a precipitous decline in neurologic recovery for the infant from anoxic injury. It is important to re-iterate that PMCS can offer resuscitative benefit to the mother despite fetal survivability or neurological outcome. The 2010 American Heart Association (AHA) guidelines for CPR and Emergency Cardiovascular Care recommend considering starting resuscitative hysterotomy after 2 cycles of CPR.[2][3]

Contraindications

Contraindications to PMCS

  • If the patient achieves ROSC within a brief period of resuscitation
  • Gestational age less than 24 weeks (relative contraindication)

Equipment

  1. Definitive airway kit
  2. Oxygen
  3. Two large bore IVs
  4. End-tidal CO2 monitor 
  5. Cesarean delivery kit, trauma laparotomy kit
  6. No. 10 Scalpel
  7. Hemostats
  8. Large scissors
  9. Gauze sponges
  10. Large retractors/bladder retractors
  11. Infant warmer 
  12. Bulb suction 
  13. Pediatric airway kit

It is important to remember that the procedure also includes active simultaneous resuscitation. The first 4 types of equipment ensure adequate and effective resuscitation and the next 6 are required for the surgical aspects of the procedure. The physician and personnel taking part in the resuscitative portion of the procedure must be different than the physician performing the surgical aspect. In the setting of successful resuscitation, an operating room (OR) room must be available for subsequent closure. Finally, the last 3 pieces of equipment will be needed for the infant resuscitation.

Personnel

An interprofessional approach should be employed. As is in the setting for a trauma activation, a team of emergency medicine physicians, trauma surgeons, obstetrics and gynecology physicians, anesthesiologists, pediatric neonatologist, and emergency (ER)/intensive care unit (ICU), obstetrics (OB), and neonatal intensive care unit (NICU) trained nursing staff should be present for these scenarios.

Preparation

If there is a concern for a peri-arrest scenario or if the patient is actively arresting, an interprofessional team must be consulted, including neonatology, and obstetrics and trauma surgery, if needed, and involved early. The physician performing the procedure should try to wear sterile attire if and when possible. The mother should remain the supine position. A left lateral tilt can be employed but is not always necessary. Iodine solutions can be used to sterilize the skin before incision.

As most of the patients will require PMCS secondary to a traumatic cause, it is essential to discuss basic management principles in the setting of trauma. When faced with a pregnant trauma patient, it is crucial to understand that the focus of care should initially be on resuscitating the mother. Special considerations should also be given to the primary survey, airway, breathing, and circulation (ABCs). First, when managing the airway, it is important to realize that during the third trimester, there is a physiologic narrowing of the airway. Therefore, it is preferential to use an endotracheal tube that is 1 size smaller. Also, rapid sequence intubation is the recommended method of intubation given an increased risk for aspiration.

Regarding breathing, pregnant patients have a higher disposition of rapid decline in their PaO2 during apneic episodes. It is important to place all pregnant patients on supplemental oxygen (O2), regardless of their peripheral capillary oxygen saturation (SpO2). Given the sizeable circulating blood volume, hypovolemia must be considered in pregnant patients before the presentation of clinical signs and symptoms of hypovolemia, and shock. Aggressive fluid resuscitation should be initiated despite normal blood pressure readings.

In addition, while chest compressions are being performed, maneuvers must be employed to displace the gravid uterus from the inferior vena cava. Older teachings have recommended placing a board behind the back, with a 30-degree tilt to the left; however, this may make CPR more difficult and less effective. Newer models propose that the uterus be manually displaced with 2 hands to the left of the patient while CPR is actively being performed.

Technique

The physician performing perimortem cesarean section should ideally be one with the most surgical experience in the room. During normal Cesarean deliveries, the most common types of incisions utilized include the Joel-Cohen incision, Pfannenstiel incision, and midline vertical incision. However, in the setting of a perimortem C-section, a midline vertical incision is the preferred initial approach. The initial incision should begin from the level of the uterine fundus to the pubic symphysis. Other authors have quoted a more optimal approach with an incision from the xiphoid to the pubis. Ideally, a No. 10 blade scalpel should be used for the incision. One should cut through the subcutaneous tissues to get to the peritoneal wall, and blunt dissection can be used to achieve this method as well. Once the peritoneal wall is reached, an incision can be made inferiorly with a scalpel, or scissors (ideally). Subsequently, the peritoneum can be cut vertically with scissors. Once the uterus is delivered, a midline vertical incision should be made on the lower portion of the uterine corpus to avoid the placenta while avoiding the bowel and the bladder. Once the uterine cavity is initially entered, the index and middle fingers should be used to separate the uterine wall away from the fetus, and then the incision can be extended with scissors. The incision should be extended upward until the baby is exposed. Once exposed, the cord should be clamped, and cut. Once delivered the infant should be promptly resuscitated. The open uterus and the abdomen should be packed to prevent further bleeding. Further closure of the incision depends on the maternal response resuscitative efforts. ACLS/ATLS should be continued on mother until ROSC is achieved, and if achieved further closure should be continued in the OR. Also, if maternal survivability is considered likely, then the patient should receive antibiotic prophylaxis with any broad-spectrum penicillin or cephalosporin in a single dose.[4][5]

Complications

Bladder Injury

  • This can be avoided by using retractors to displace the bladder inferiorly.
  • If distended, the bladder can be decompressed with needle aspiration or with the use of a Foley catheter, prior to initiation of the procedure.[6]

Injury to the Fetus

  • This can be avoided by creating a lower midline uterine incision to avoid placental injury.
  • Use scissors to extend the incision superiorly, once the uterine cavity is exposed inferiorly, instead of a scalpel.

Arterial Injury

  • A midline abdominal incision will avoid major arterial bleeding.
  • Avoid transverse of lateral uterine incisions as the uterine blood vessels run laterally along the uterine border.

Clinical Significance

The goal of resuscitative hysterotomy should be primarily aimed at saving the life of the mother. PMCS improves maternal survivability by decreasing compression of the IVC by the gravid uterus which improves venous return. PMCS will also improve diaphragmatic displacement, which in turn improves respiratory dynamics.[7][8][9]

Enhancing Healthcare Team Outcomes

In the setting of a peri-arresting or arrested pregnant patient, the highest likelihood for survival for the mother and the infant is when an interprofessional approach is employed early in the course of the arrest. As is in the setting for a trauma activation, a team of emergency medicine physicians, trauma surgeons, obstetrics and gynecology physicians, anesthesiologists, pediatric neonatologist, and ER- or ICU-trained nursing staff should be present for these scenarios. Hospital policies should be set in place for a peri-arrest or arresting pregnant patient. This allows for easy and early activation of the groups mentioned above. As mentioned earlier, the procedure should be performed by the physician with the most surgical experience in the room, to reduce complications. Areas, where this situation can occur (i.e., ED, ICU, labor and delivery), should also have easy access to all equipment required to perform the procedure. Per AHA 2010 guidelines, "Team planning should be done in collaboration with the obstetric, neonatal, emergency, anesthesiology, intensive care, and cardiac arrest services (Class I, LOE C)."[2]


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Perimortem Cesarean Delivery - Questions

Take a quiz of the questions on this article.

Take Quiz
A 23-year-old G2P1001 female who is 34 weeks by first-trimester ultrasound presents to the emergency department via emergency medical services after a front end motor vehicle collision. The patient was a restrained front seat passenger. Airbags were deployed. The patient did not have any loss of conscience, but extrication was required. The patient was altered on arrival and lost pulses during the emergency medical services report. It is decided to perform a crash perimortem Cesarean section. When making an incision in the lower portion of uterine fundus what structure must be identified and avoided to prevent significant complications?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following statements about perimortem Cesarean sections (PMCS) is true?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 30-year-old G3P1102 female with EGA of 36 weeks 3 days by first-trimester ultrasound who presents to the emergency department after a multi-vehicle collision. The patient was reported to be hypotensive at the scene with Glasgow coma scale of 10. Emergency medical services report that the patient is 10 minutes from your facility. As you activate your trauma team, you began to go over the changes to be expected in the primary survey, which occur late pregnancy. Which of the following are changes noted in the primary survey that must considered when evaluating the patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 36-year-old female who appears pregnant is in route to your facility in extremis via emergency medical services after she was involved in a high impact motor vehicle collision. In preparation for the resuscitation, you remember the importance of the need to start oxygen early for prevention of early hypoxemia. Which of the following physiologic changes seen in pregnancy predisposes the patient to early desaturation?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following patients is the ideal candidate for resuscitative hysterotomy and perimortem c-section?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Perimortem Cesarean Delivery - References

References

Vanden Hoek TL,Morrison LJ,Shuster M,Donnino M,Sinz E,Lavonas EJ,Jeejeebhoy FM,Gabrielli A, Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 2     [PubMed]
Kikuchi J,Deering S, Cardiac arrest in pregnancy. Seminars in perinatology. 2018 Feb     [PubMed]
Drukker L,Hants Y,Sharon E,Sela HY,Grisaru-Granovsky S, Perimortem cesarean section for maternal and fetal salvage: concise review and protocol. Acta obstetricia et gynecologica Scandinavica. 2014 Oct     [PubMed]
Stokes N,Kikucki J, Management of Cardiac Arrest in the Pregnant Patient. Current treatment options in cardiovascular medicine. 2018 Jun 19     [PubMed]
Zelop CM,Einav S,Mhyre JM,Martin S, Cardiac arrest during pregnancy: ongoing clinical conundrum. American journal of obstetrics and gynecology. 2018 Jul     [PubMed]
Krywko DM,Presley B, Cesarean, Perimortem null. 2018 Jan     [PubMed]
Baraka A, PERIMORTEM CESAREAN DELIVERY. Middle East journal of anaesthesiology. 2016 Feb;     [PubMed]
Benson MD,Padovano A,Bourjeily G,Zhou Y, Maternal collapse: Challenging the four-minute rule. EBioMedicine. 2016 Apr;     [PubMed]
Eldridge AJ,Ford R, Perimortem caesarean deliveries. International journal of obstetric anesthesia. 2016 Aug;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of PA-Hospital Medicine. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for PA-Hospital Medicine, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in PA-Hospital Medicine, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of PA-Hospital Medicine. When it is time for the PA-Hospital Medicine board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study PA-Hospital Medicine.