Perimortem Cesarean Delivery - Indications, Contraindications, and Procedure

Introduction -

A sudden and adverse change in a pregnant woman's health is a very crucial and challenging task. These occurrences of such situations are rare and are the result of pre-existing conditions with severe, obstetric, and medical complications. This can also occur due to extreme traumatic insults. In such an instance, a perimortem cesarean section (PMCS) is performed. A perimortem C-section, also known as resuscitative hysterotomy is done during an active cardiac arrest or an impending cardiac arrest. The primary aim of this surgery is to bring back the mother's health and improve fetal survival.

When Is This Procedure Performed?

Indication -

• In mothers carrying a baby of the gestational age of more than 20 weeks experiencing peri-arrest or active cardiac arrest.

• Perimortem cesarean delivery should be performed four minutes after the patient arrests. Four minutes is used because of the time after which there will be a decline in the neurologic recovery of the fetus from anoxic injury.

Contraindications-

• If the patient achieves a return of spontaneous circulation within two cycles of resuscitation.

• If the gestational age is less than 20 weeks.

What Are the Procedures Followed in Case of Maternal Cardiac Arrest?

Initial resuscitation and perimortem cesarean section - In cases with maternal cardiac arrest, the resuscitation process is a similar process to that of a nonpregnant woman. The medical team looks for the signs of life on arrivals like carotid pulse and breathing. If the patient is in a hospital situation, the cardiac arrest team should be informed at the earliest followed by obstetric, obstetric anesthetic, and neonatal resuscitation teams. Standard basic life support (BLS) is initiated, with CPR with 30 cardiac compressions and the following factors are checked.

1) Airway - Standard airway procedures should be performed (like head tilt chin lift) while looking for signs of life. But, advanced airway management is often required. Difficulties can be encountered, especially during the third trimester like high gastric aspiration due to the pressure of the uterus on the stomach and the laxity of the cardiac gastric sphincter. The airway is established with an endotracheal tube, without damaging the respiratory tissue.

2) Breathing - Due to the physiological changes in pregnancy, higher oxygen consumption is required for pregnant women. Deoxygenation usually happens in maternal cardiac arrest so additional oxygen must be provided. A high flow of oxygen supplementation might be dangerous to the baby. However, in cases of maternal cardiac arrest, the priority is to increase the chances of maternal survival.

3) Circulation - Cardiac compressions are very helpful for a positive outcome so they should be performed immediately and competently. Thirty cardiac compressions should be for every two ventilation breaths until the defibrillator and the defibrillator pads are available. Manual uterine displacement is done to reduce the compression of the major blood vessels like the inferior vena cava. The uterus is manually displaced using an ‘up, off, and over’ technique. Cardiac compression will be more effective if the pregnant woman is maintained in a fully supine position with the manually displaced uterus. Blood should be requested early and administered according to the needs.

4) The Decision to Proceed With Perimortem Cesarean Section - If there is no improvement after four minutes of effectively performed CPR, then primordium c-section delivery should be initiated. The gestational age should be greater than 20 weeks. To optimize the maternal outcome, cardiopulmonary resuscitation should be continued uninterruptedly during the procedure until the return of spontaneous circulation is confirmed.

Where Is Perimortem Cesarean Delivery Done?

The perimortem delivery can become delayed if the patient is moved to the operating theater, so as soon as possible the surgery should be performed in the emergency department or in the delivery room. In rare cases, perimortem delivery may be done in the pre-hospital care setting. It is only done when appropriately trained medical staff are available. In such situations, it is difficult to give more guidance since the decision whether to undergo perimortem delivery out of the hospital or to transport the patient rapidly to the hospital is always different on a case-by-case basis. Perimortem delivery following cardiorespiratory arrest does not require general anesthesia and initially, there will be minimal bleeding. However, after the return of spontaneous circulation general anesthesia is required for the surgery to be completed.

How Is Perimortem Cesarean Delivery Performed?

This is an extremely rare, but life-saving procedure. The resuscitative hysterotomy (RH), when performed promptly, improves survival during the terrible stage of maternal cardiac arrest. It is performed on a pregnant woman who has passed 20 weeks of gestation and has suffered a cardiac arrest. The decision is made to perform a resuscitative hysterotomy right away and start prepping for the surgery. These are the following steps carried out during the procedure.

• Preparation -.Minimal surgical instruments are required to perform perimortem cesarean surgery. The bladder is not required to be routinely emptied and general anesthesia is also not needed to start the procedure.

• Abdomen Incision - Before the incision, the abdomen is wiped with an antiseptic solution like betadine. Then a long vertical incision is made from the fundus of the uterine to the pubic symphysis. The cut is made on the skin to enter the peritoneum (lining the cavity of the abdomen).

• Uterine Incision - The cut is carefully extended into the uterus. The uterus is first located. Then, very cautiously a vertical cut is made into the uterus, with blunt scissors, and using fingers the incision is extended upward. If the anterior placenta is reached, cut right through it.

• Delivery of the Fetus - The fetus is delivered either by cupping the head of the fetus and raising it through the vertical incision made or by grabbing a leg, waggling the shoulders, and flexing the head. The baby is then handed over to the neonatal resuscitation, the baby is warmed, stimulated, and aggressively resuscitated. The umbilical cord is clamped and cut, a long enough umbilical stump is left behind for an easy umbilical line. Gentle traction is used for the delivery of the placenta. If the placenta is not coming easily, it is left to prevent excess bleeding.

If the surgery is successful without any complications then resuscitation can be continued, focusing on stopping the uterine bleeding. It can be very helpful to close the uterine incision to prevent more blood loss. It can be done with a whip stitch and packed with sterile gauze. Medications like oxytocin are given to stimulate uterine contraction and slow bleeding, and antibiotics as well.

What Are the Complications of Perimortem Cesarean Delivery?

• Injury to the bladder during the procedure.

• Injury to the fetus by improper incision and by the instrument can occur.

• Heavy bleeding due to injury to the arteries can occur.

Conclusion -

Perimortem cesarean delivery is a very rare case. The aim of the procedure is to increase the chances of maternal survival. Therefore prompt action should be taken by the medical team within four minutes. The procedure is relatively simple but utmost care should be taken by the medical team to maintain the airway, breathing, and circulation.