Basics
- The sole indication for ED physician to perform emergency perimortem cesarean section is a gravid female (>24 wk gestation) in cardiopulmonary arrest who has not responded to initial resuscitative measures, regardless of cause
- The most important predictor of fetal survival is length of time between maternal cardiac arrest and cesarean delivery:
- Cesarean section should begin within 4 min of maternal arrest
- Goal is delivering fetus within 1 min
- Obtain immediate consultations from obstetrics, pediatrics (and surgery, if trauma related):
- Do not defer or delay performing procedure until arrival of consultants
- Do not perform emergent cesarean section if patient is <24 wk gestation
Etiology
- Trauma (penetrating or blunt):
- Major cause of maternal mortality
- Pulmonary embolus:
- Thromboembolism is most common cause of nontraumatic maternal mortality
- Cerebral vascular accident
- Amniotic fluid embolism
- DIC
- Placenta previa
- Eclampsia
- Miscellaneous medical disorders:
Diagnosis
Signs and Symptoms
History
Gravid female (>24 wk gestation determined by uterine fundal height) who is in cardiopulmonary arrest �
Physical Exam
Patient is determined to be >24 wk gestation if uterus is at least 4 finger breadths above umbilicus �
Essential Workup
- Physical exam for apnea and pulselessness in obviously gravid female:
- Quickly evaluate for reversible causes of cardiopulmonary arrest:
- Hypoxia
- Hypovolemia
- Hydrogen ion (acidosis)
- Hypokalemia/hyperkalemia
- Hypoglycemia
- Hypothermia
- Trauma
- Thromboembolism
- Toxins/poisons
- Tension pneumothorax
- Tamponade (pericardial)
- Supine hypotension syndrome (compression of inferior vena cava by enlarged uterus)
- Assess gestational age by uterine fundal height
- Distance from pubis to fundus in centimeters is roughly equivalent to gestational age in weeks, i.e., 24 cm = 24 wk
- US is beneficial if immediately available to assess fetus.
Diagnosis Tests & Interpretation
Imaging
- None necessary to establish cardiopulmonary arrest
- Do not use valuable time attempting to determine fetal heart tones
Differential Diagnosis
Cardiopulmonary arrest is final common pathway: �
- Evaluate for underlying cause
Treatment
Pre-Hospital
Cautions: �
- Minimal scene time, "scoop and run"�
- Place the patient in the left lateral decubitus position to avoid compression of inferior vena cava (supine hypotension syndrome)
- Trauma patient requiring spinal immobilization:
- Uterus can be manually displaced to left
- Backboard can be wedged to keep right hip elevated 45 �
Initial Stabilization/Therapy
- Standard resuscitation measures:
- Emergency intubation
- Use a smaller endotracheal tube (0.5-1 mm less in internal diameter compared to that used for nonpregnant women)
- High-flow oxygen
- Cardiac and BP monitoring
- 2 large-bore peripheral IV lines:
- Fluid resuscitation
- O-negative blood if indicated
- Fetal survival correlates with maternal survival and adequacy of initial maternal resuscitation
- If patient is at <24 wk gestation, use advanced cardiac life support (ACLS) and advanced trauma life support protocols directed at maternal resuscitation
- Do not perform emergent cesarean section
- If patient is >24 wk gestation, use 4-min rule:
- Perform ACLS or advanced trauma life support for 4 min
- If no response, proceed to immediate emergency cesarean section
- Goal is to deliver fetus within 1 min
- If it is obvious there is no chance for maternal survival, begin perimortem cesarean section immediately
Ed Treatment/Procedures
- Call for immediate obstetric, surgical, and pediatric consultations:
- Do not delay performing procedure while waiting for consultants
- Ensure a Foley catheter has been inserted to decompress bladder, but do not delay procedure
- Perform cesarean section:
- Use linea nigra as landmark for vertical midline incision
- Incise abdominal wall from pubic hairline to 5 cm above umbilicus.
- This incision should pass through fascial and peritoneal layers
- Retract urinary bladder inferiorly against pubic symphysis
- Make small vertical incision in lower uterine segment, just cephalad to urinary bladder
- Extend incision cephalad with scissors:
- Insert your free hand into uterus
- Lift uterine wall away from fetus to avoid fetal injury
- Deliver fetus
- Clamp umbilical cord in 2 places and cut between the 2 clamps
- Manually deliver placenta
- Perform neonatal resuscitation, as indicated
- Immediately reassess maternal vital signs because occasionally spontaneous circulation may return
- Continue maternal resuscitation as appropriate
- Suture uterus with running lock stitch using no. 0 polyglactin suture
- Suture fascia and peritoneum with running stitch using no. 0 polyglactin suture
- Close the skin with staples or suture
- Administer broad-spectrum antibiotics
- If maternal return of circulation is obtained, consider starting therapeutic hypothermia protocol
Medication
First Line
Resuscitative measures/ACLS medications directed at mother: �
- Treatment of underlying cause
Second Line
Neonatal resuscitation should be anticipated: �
Follow-Up
Disposition
Admission Criteria
- The infant should be admitted to NICU
- If maternal resuscitation is successful, patient should be admitted to appropriate ICU
Discharge Criteria
Neither infant nor mother should be discharged from ED �
Pearls and Pitfalls
- Only females >24 wk pregnant in cardiopulmonary arrest qualify for the procedure.
- Decision to perform perimortem cesarean section must be made quickly (within 4 min of maternal cardiopulmonary arrest)
- Procedure must be done quickly (<1 min).
Additional Reading
- Atta �E, Gardner �M. Cardiopulmonary Resuscitation in Pregnancy. Obstet Gynecol Clin North Am. 2007;34(3):585-597.
- Brown �HL. Trauma in pregnancy. Obstet Gynecol. 2009;114:147-160.
- Capobianco �G, Balata �A, Mannazzu �MC, et al. Perimortem cesarean delivery 30 minutes after a laboring patient jumped from a fourth floor window: Baby survives and is normal at age 4. Am J Obstet Gynecol. 2008;198(1):e15-e16.
- Cusick �SS, Tibbles �CD. Trauma in pregnancy. Emerg Med Clin North Am. 2007;25:861-872.
- Dijkman �A, Huisman �CM, Smit �M, et al. Cardiac arrest in pregnancy: Increasing use of perimortem cesarean section due to emergency skills training? BJOG. 2010;117:282-287.
- Hill �CC, Pickinpaugh �J. Trauma and surgical emergencies in the obstetric patient. Surg Clin North Am. 2008;88:421-440.
- Katz �V, Balderston �K, DeFreest �M. Perimortem cesarean delivery: Were our assumptions correct? Am J Obstet Gynecol. 2005;192:1916-1920.
- Kue �R, Coyle �C, Vaughan �E, et al. Perimortem Cesarean section in the helicopter EMS setting: A case report. Air Med J. 2008;27:46-47.
- Lipman �S, Daniels �K, Cohen �SE, et al. Labor room setting compared with the operating room for simulated perimortem cesarean delivery: A randomized controlled trial. Obstet Gynecol. 2011;118:1090-1094.
- Muench �MV, Canterino �JC. Trauma in pregnancy. Obstet Gynecol Clin North Am. 2007;34:555-583.
- Roberts �JR, Hedges �JR, Chanmugan �AS, eds. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, PA: Saunders; 2004.
- Suresh �MS, LaToya �MC, Munnur �U. Cardiopulmonary resuscitation and the parturient. Best Pract Res Clin Obstet Gynaecol. 2010;24:383-400.
Codes
ICD9
- 427.5 Cardiac arrest
- 659.83 Other specified indications for care or intervention related to labor and delivery, antepartum condition or complication
ICD10
- I46.9 Cardiac arrest, cause unspecified
- O99.419 Diseases of the circ sys comp pregnancy, unsp trimester
SNOMED
- 274130007 Emergency cesarian section (procedure)
- 198609003 complications of pregnancy, childbirth and the puerperium (disorder)
- 410429000 cardiac arrest (disorder)