Perimortem Cesarean Section

1. See Also
   1. Cardiopulmonary Resuscitation in Pregnancy
   2. Cardiopulmonary Resuscitation
   3. Trauma in Pregnancy
2. Indications
   1. Maternal pulseless Cardiac Arrest duration >4 minutes
      1. Failure of ROSC within 4 minutes despite maximal Resuscitation efforts
         1. High quality Cardiopulmonary Resuscitation performed with uterine displacement
         2. Early Endotracheal Intubation with confirmed placement
         3. Resuscitation medications delivered via IV site above diaphragm level
         4. No other reversible Cardiac Arrest etiologies identified
            1. Consider Reversible Causes of Cardiopulmonary Arrest (see 5H5T)
            2. Consider inciting event (e.g. substances taken immediately prior to arrest)
   2. Gestational age criteria
      1. Gestational age <20 weeks
         1. Consider Emergency Hysterotomy if Twin Gestation
      2. Gestational age 20-23 weeks
         1. Consider Emergency Hysterotomy to improve chance of maternal survival (ROSC)
         2. Not indicated for fetal survival (pre-viable)
      3. Gestational age 23 weeks and greater
         1. Emergency Hysterotomy to improve chance of both fetal and maternal survival
      4. Gestational age unknown
         1. Fundal height >23 cm from the symphysis (or >3-4 cm above the Umbilicus) correlates with 23 weeks
         2. Used estimation only in cases such as Emergency Hysterotomy in which delay cannot be afforded
3. Contraindications
   1. No provider available with the appropriate skills to perform Emergency Hysterotomy
   2. Inadequate equipiment and staff to support two Resuscitations (baby and mother)
   3. Prolonged Resuscitation or Hypoxia with expected poor neurologic outcome even if ROSC achieved
4. Efficacy
   1. Maximal chance of survival with definitive, rapid delivery without delays
   2. Peri-mortem Cesarean Section (hysterotomy) improves chance of survival for both fetus and mother
   3. Case reports of survival of mother, fetus out to 10 minutes pulseless prior to delivery
      1. Einav (2012) Resuscitation 83(10): 1191-200 [PubMed]
5. Preparation
   1. Assemble Emergency Hysterotomy equipment and staff as part of initial code response
   2. Emergency Hysterotomy should be performed immediately on decision to proceed (4-5 minutes into Resuscitation)
6. Procedure
   1. Perform rapidly with a single cut through skin and a single cut through Uterus
   2. Skin: Midline vertical incision between Umbilicus to pubis
   3. Uterus: Midline vertical incision
   4. Deliver infant
   5. Remove placenta and wipe inside Uterus with sponge
7. Resources
   1. EB Medicine
      1. http://www.ebmedicine.net/topics.php?paction=showTopicSeg&#38;topic_id=88&#38;seg_id=2198
8. References
   1. Mattu in Majoewsky (2013) EM:Rap 13(4):11-2
   2. Farinelli (2012) Cardiol Clin 30(3): 453-61 [PubMed]
   3. Murphy (2014) Am Fam Physician 90(10): 717-22 [PubMed]