Cardiopulmonary arrest in pregnancy is broken down into two categories: before and after fetal viability. Typically, the onset of fetal viability varies between 22 and 26 weeks, with some institutional variation considering backup and available resources. By 20 weeks, the uterine fundus is palpable at the umbilicus; then from 20 to 32 weeks, the fundal height (in centimeters) approximates the gestational age (for singleton pregnancies). If the fundal height is at or below the umbilicus, resuscitative effort should focus on the mother with no modifications of CPR. If the uterus is palpable above the umbilicus, one person should provide manual left lateral displacement of the uterus while another is performing CPR.5,36
Perimortem Cesarean Section
Michael A. Bohrn
If maternal cardiac arrest occurs and the fetus is presumed to be of viable gestational age (estimated beyond 24 weeks), then perform a perimortem cesarean section. The prognosis of intact neonatal survival is best if delivery occurs <5 minutes after the maternal arrest.1,2,3 If maternal arrest has exceeded5 minutes, still proceed with the perimortem cesarean section, because there is at least one case report of neonatal survival with good neurologic function after perimortem cesarean section at 30 minutes after maternal death.4 Current Advanced Cardiovascular Life Support guidelines also recommend proceeding with cesarean delivery in this situation.5
Plan the procedure prior to the patient's arrival if advanced warning is available. Consider activation of a multidisciplinary code-type team, if this resource is available.6 The chance of a neurologically intact neonate is increased with a more rapid delivery. Maternal pulses can return after delivery, once aortocaval compression is relieved.7,8
In an ideal setting, an emergency physician, nurses or technicians to assist with CPR, an obstetrician, a surgical assistant, and a neonatologist or pediatrician would be the team assembled to meet the patient immediately on arrival, but the reality is that the emergency physician and a nurse may be the only individuals present. Shift focus from a typical cardiac arrest scenario to one that focuses both on maternal CPR and rapid delivery of the baby. Once the baby is delivered, the resuscitation of the mother and baby can continue. The perimortem cesarean section should occur in the ED. Time to transport to the operating room only delays a potentially lifesaving procedure. EQUIPMENT REQUIRED FOR EMERGENCY PERIMORTEM CESAREAN SECTION
PROCEDURE FOR PERIMORTEM CESAREAN SECTION MATERNAL CPR
Bandage scissors (if available)
0 or 1 vicryl or chromic sutures
0 or 1 permanent suture
Bladder blade (may substitute another retractor if not available)
IM oxytocin (Pitocin) administration: 10 units/mL oxytocin vials and a 10-mL syringe with IM needle
Or IV oxytocin administration: 1 L of IV fluids with 20 units of oxytocin per liter
Sponges and/or towel
Wall or other suction (wall suction preferred as large amounts of amniotic fluid may need to be cleared)
Clamps × 2
Equipment for neonatal resuscitation
Continue maternal CPR during the procedure. Remember personnel need to step away from the table if defibrillating the patient during the resuscitation. Keep the patient in left lateral tilt position if good compressions can be performed with the patient in that position; otherwise, keep the patient supine. MATERNAL PREPARATION
Splash the abdomen with povidone-iodine or other antiseptic if it is readily available, but to avoid unnecessary delay, do not prep, drape, or give preoperative IV antibiotics. Place a Foley catheter only if it will not delay the delivery procedure. Draining the bladder will allow better visualization for the procedure and can decrease the risk of bladder injury. STEPS FOR CESAREAN SECTION
Make a vertical incision with the scalpel from just below the umbilicus to the symphysis pubis (Figure 25–1). Some authors advocate a xiphoid to symphysis pubis incision (Figure 25–2), but umbilicus to symphysis pubis is typically adequate. The pigmented linea nigra is your guide for the midline. The incision should penetrate the skin, subcutaneous layer, and fascia (white layer).
Use your fingers to bluntly separate the rectus muscles laterally.
Sharply (using the scalpel) or bluntly (using your fingers) enter the peritoneum.
Once the uterus is exposed, have an assistant retract from above and place a bladder blade or other retractor inside the inferior aspect of the incision to aid with visualization.
Make a vertical incision in the midline of the uterus (Figure 25–3). Continue incising with the scalpel to the level of the intrauterine cavity; the uterine muscle wall is thick. Enter the uterine cavity bluntly (using your fingers) or sharply and extend the incision with bandage scissors. Keep the incision in the midline of the uterus because the uterine vessels enter laterally. If an anterior placenta is encountered upon entry, go through the placenta and rapidly proceed with delivery of the baby. Expect some increased bleeding, but this is only temporary.
Rupture the amniotic sac with a sharp instrument if it has not occurred spontaneously. Have wall suction ready to evacuate the fluid.
1. Place your hand into the uterine cavity between the symphysis pubis and the fetal vertex (or buttocks if breech) (Figure 25–4). Elevate the vertex (or buttocks) out of the pelvis, and then the physician or assistant should remove the bladder blade.
Once the head (or buttocks) is to the level of the uterine incision, have the assistant apply steady pressure to the fundus to assist in delivery of the baby's vertex (or buttocks) through the incision followed by shoulders and body.
In a breech presentation, deliver the buttocks first, followed by both legs, and then the body of the baby to the level of the shoulders. When one arm is delivered, rotate and deliver the contralateral arm, flex the head, and deliver the baby.
If a footling breech is encountered, gently grasp both feet and deliver to the level of the baby's shoulder and continue as a breech extraction as noted earlier.
2. Once the baby is delivered, doubly clamp the cord, cut the cord between the clamps, and take the baby to the providers who will be performing additional evaluation and resuscitation (if additional providers are available). There is some debate about delayed clamping of the umbilical cord. Delaying clamping for longer than 60 seconds (or beyond when cord pulsations cease) may provide the benefit of increased hemoglobin and iron stores in the newborn.9 However, this is primarily based on studies of healthy babies, so do not delay cord clamping if the baby requires immediate resuscitation. If no additional providers are present, quickly determine the emergency physician's greatest benefit for resuscitation and proceed accordingly (i.e., lead/aid ongoing resuscitation of the mother or proceed to lead/aid resuscitation of the newborn baby). PLACENTAL DELIVERY AND UTERINE CARE
1. Manually remove the placenta and begin an infusion of 20 units of oxytocin (Pitocin) in 1 L NS wide open or 10 units of oxytocin (Pitocin) IM to help the uterus contract and decrease bleeding. Uterine massage will also aid in uterine contraction and decrease blood loss. The average estimated blood loss for a cesarean section is 1000 mL.
2A. If an obstetrician or surgeon is available to complete the closure, once the placenta is delivered, clean out the uterine cavity with sponges until it is completely cleared. Temporarily pack the uterus and abdomen with moistened laparotomy sponges until the obstetrician or surgeon arrives.
2B. If a surgeon or obstetrician is not available, then exteriorize the uterus and clean out the uterine cavity with sponges until it is completely cleared.
3. Close the uterus with one or two layers with a locked running stitch of number 0 or 1 vicryl or chromic suture on a large needle. Close the fascia with number 0 or 1 permanent suture in a running fashion.
4. Finally, close the skin with staples or suture.
Informed consent for perimortem cesarean section is not necessary because it is part of resuscitation. Perimortem cesarean section during cardiac arrest fulfills the criteria for absence of malfeasance and beneficence for the mother and the fetus, and as yet, there has not been a physician charged with criminal or civil malfeasance for the procedure. REFERENCES 1.
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