Perimortem C-section: Can you cut it in Obstetric resus?

Got a tweet from @bearwebster (Broome-bound RMO) about perimortem CS – so I though it seemed like a good idea to look at the evidence, the recommendations and the “how-to-do” of this terrifying, yet potentially lives-saving manoeuvre.

Dr Nolan McDonnell, local west Aussie Obstetric Anaesthetist, wrote this paper for the Brit. Journ Anaesth in 2009. It has 2 case reports and a nice review of the literature and recommendations for resuscitation of Obstetric patients including perimortem C-sections.  Dr McDonnell is a great guy, he was our choice when we had to choose an anaesthetic doc to do my wife’s epidural.  Can I give a higher recommendation than that?!  The original research was done by Katz et al in 1986 and they did another review in 2005 if you are interested – a rare scenario, so hard to extrapolate but it did seem like there were a few saves!

LATE Breaking NEWS:  this just in via Cliff Reid’s blog:  It looks like the outcomes are not too bad on the whole even when time to delivery was 10 – 16 minutes.  See the review here from Einav et al in Resuscitation, 2012.

So here is a quick summary:  if you are involved in the care of pregnant women, or any acute care then you need to have a think about this – you might need it to save one or two lives one day!

For the most part resuscitation of pregnant women is the same as everyone else – the basic principles of continuous CPR, airway support and correcting identifiable causes is identical.

Remember PLACENTAL flow is dependent on maternal flow – so keep doing CPR for mother and baby. Practically though there are a few things that are different:

1) Position: a partial roll, placing a knee, or wedge under the woman’s pelvis and preferably manually displacing the gravid uterus off the midline will help prevent / alleviate aorto-caval compression.

2) Have neonatal resus gear brought to the scene as well as your normal adult trolley – a resuscitation cot is ideal.

3) Late pregnancy = difficult airway / ventilation and rapid desaturation – so it might be better to intubate early, though this will depend on your skills and resources at the scene.  CPR still comes first.

4)  YES, defibrillation is OK.  Just take off  the wires for CTG etc – they are not useful anyway in an arrest!

Perimortem C-section is indicated in maternal arrest for gestation estimated > 24 weeks. (~ a few fingers over the umbi).  This is roughly the age of fetal viability and correlates with the time the gravid uterus exerts significant hemodynamic challenges that C-section might reverse.  C-section should be done in the context of maternal cardio-respiratory arrest, no matter what the presumed aetiology.

Ideally a practitioner who has experience with the anatomy and LUSCS. BUT, this is not the norm – so it can be done by any provider. This is an empirical procedure done in the face of a high likelihood of a poor outcome.  The alternative to delivering the fetus is to continue standard CPR / ALS which we know has a reasonably grim outcome in many cases. 

This is an evidence free zone and recommendations are based on physiology rather than facts.

Katz et al described the “4 minute rule” – the resus team should commence a perimortem CS after 4 minutes of arrest if no ROSC. This seems sensible – but man, that time flies quickly in a Resus – so it needs to be considered at the outset and plans made before 4 minutes clocks over. The 2012 Resuscitation review of 94 case reports showed a 10 minute “delivery time” was pretty good and had a highish rate of good neonatal outcomes.  In reality 4 minutes is really tough, nice to see 10 minutes being not a disastrous outcome.

I think in reality if you are in a non-shockable rhythm and have commenced fluid resus, intubated etc then that is the time to act if there is no response.  Once again it will depend on your crew’s resources – if you have enough people then a dedicated pair of cutters should start prepping ASAP after a maternal arrest.

Perimortem CS should occur at the scene of the arrest – there is not time to “go to theatre”. This is a resuscitative move – like defib or empirical fluids. It needs to be done on the floor, bed or trolley where the woman arrests.

OK this is the crux of the matter.

Equipment required: one scalpel (disposable will do – 11 blade if you like), gloves, wall suction, a splash of betadine, a willing assistant to help retract layers.  If you have dedicated retractors in your “Arrest box” great, but hands will do.

Found this cool presentation with images and a step-by-step.  Dr Charlotte Wills of Oakland California produced this for her ED (TH 229 Post Mortem C-Section perimortem[1])  Pretty nice pictorial review of the procedure.  Cliff Reid at Resus.Me did a review a few months ago on resuscitative hysterotomy – check it out for a bit of a pre-hospital perspective.

So, let me know – have you done a PMCS, seen one, been involved in the care or have any comments?

Does your hospital have a PMCS box – a kit ready to go for this rare, but important occurrence?

Here’s some food for thought – Ines Ramirez of Mexico completed her own C-section in 2000 – both mother and baby survived.  That is awesome!



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