Trauma is the leading cause of death in women of reproductive
age and accounts for 25 to 50 percent of maternal morbidity. Major
maternal injury is associated with a 45 to 50 percent fetal loss rate. The primary goal in the management of the
severely injured pregnant patient is maternal assessment and stabilization.
Prompt attention to the needs of the gravid patient can save the
life of both the fetus and the mother. Nonetheless,
there are occasions when emergent cesarean delivery of the fetus
is necessary to save the fetus, and sometimes, the mother. This
procedure is best performed by a qualified Surgeon in the Operating
Room. However, there are circumstances that may necessitate the
performance of this procedure in the Emergency Department. These
include the possibility of uterine rupture, placental abruption,
fetal distress, and imminent maternal demise.
There are several simple principles to keep in mind. Quickly
establish that the mother is deceased or that no further intervention
is possible. Quickly open the abdominal wall and uterus with vertical
incisions. The use of aseptic technique is not required and only
wastes valuable time. Deliver the fetus and begin resuscitation.
Manually remove the placenta. Close the uterus and abdominal wall
with running sutures.
The performance of adequate CPR in the gravid patient at or near
term is extremely difficult. Adequate CPR produces a cardiac output
equivalent to 30 percent of normal under ideal circumstances. The
enlarged uterus lies anterior to the inferior vena cava and suppresses
venous return in the gravid patient. Place the patient in 15 degrees
of left lateral tilt to adequately relieve the obstruction of the
inferior vena cava by the uterus. Evacuation of the uterus by cesarean
section may save the fetus and, by enabling adequate maternal resuscitation,
save the mother as well. The pregnant patient has a decreased tolerance
for anoxic brain injury. The fetus can tolerate anoxic injury slightly
longer than the mother.
Evaluation for Perimortem Cesarean Section
Quickly determine the fetal age using ultrasonography, the last
known menstrual period, the history of term gestation by family
members, or fundal height. Perform ultrasonography only if the unit
is immediately available and if the operator is experienced in obstetric
ultrasound. Note the time of the maternal arrest. Immediately consider
performing a perimortem cesarean section in the resuscitation of
a pregnant patient with an estimated gestational age of 24 weeks
or greater and with cardiac arrest that has not responded to aggressive
resuscitation within four minutes from onset. The single most important
prognostic factor for neonatal outcome is the time from maternal
arrest to delivery. Delivery of the fetus can also maximize maternal
resuscitation efforts and minimize the risk of maternal brain injury.
Delay the initiation of vasopressor agents until after adequate
volume replacement. However, they should not be withheld
if needed to resuscitate the patient. Place a wedge under the patient’s