Chapter 136. Perimortem Cesarean Section

The term “perimortem cesarean section” was introduced in 1986 to describe a cesarean section done at time of cardiopulmonary resuscitation and within the first 4 minutes if resuscitative efforts were not successful.1 The goal of this procedure is to improve survival for the fetus, and sometimes provide a better chance for the mother to be resuscitated.2,3

The incidence of cardiac arrest during pregnancy is estimated to be about 1 in 30,000 pregnancies.4 According to a review of reported perimortem cesarean deliveries from 1985 to 2004, the most frequent causes are trauma, cardiogenic, emboli (e.g., amniotic fluid and air), magnesium overdose, sepsis, anesthesia, eclampsia, spontaneous uterine rupture, and intracranial hemorrhage.2

Trauma is the leading cause of death in women of reproductive age and accounts for 25% to 50% of maternal morbidity. Major maternal injury is associated with a 45% to 50% 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. The perimortem cesarean section is a key procedure that all Emergency Physicians need to be able to perform in the rare instance it is required.

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 strict 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.

Maternal Physiology

Important maternal physiologic changes during pregnancy should be considered in the event of a cardiorespiratory arrest. Pregnancy changes almost all maternal body systems. Cardiac output, blood volume, and heart rate all increase. Pulmonary and systemic vascular resistance decreases. Uteroplacental blood flow increases, with the uterus receiving up to 30% of the cardiac output during pregnancy. Aortocaval compression during the second half of pregnancy can result in decreased venous return to the heart, decreased cardiac output, and systemic hypotension. These changes complicate the resuscitation efforts. The pregnant woman is predisposed to a more rapid decrease in arterial and venous oxygen tension during episodes of hypoxia. Gastrointestinal changes include decreased motility, relaxation of the esophageal sphincter, and thus a predisposition to aspiration of gastric contents.3–6

In general, the same algorithms used for the nonpregnant patient should be used for the pregnant patient during a cardiorespiratory arrest. There are some modifications to keep in mind.5 The stroke volume of a term pregnant patient lying supine is only 30% of normal. Lateral displacement of the uterus will increase the stroke volume and cardiac output by at least 25%.7 Pregnancy increases oxygen requirements and the risk of aspiration. Early intubation to protect airway is indicated. Be cautious in using of sodium bicarbonate to reverse metabolic acidosis. Rapid correction of maternal, but not fetal, acidosis could lead to reduced compensatory hyperventilation and normalization of fetal PaCO2 with worsening of the fetal acidosis.4

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% of normal under ideal circumstances. The enlarged uterus lies anterior to the inferior vena cava and suppresses venous return in the gravid patient. Place a wedge under the patient's right flank and hip to position them in 15° of left lateral tilt to adequately relieve the obstruction of the inferior vena cava by the uterus. Give early consideration to performing a perimortem cesarean delivery.

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 gestational age using ultrasonography, the last known menstrual period, the history of term gestation by family members, or fundal height. A quick rule to remember is if you can place at least four fingers above the umbilicus to the top of the fundus, the gestational age is likely to be equal to or more than 24 weeks.2 Twenty-four weeks is also the beginning of aortocaval compression by the uterus.7 Nevertheless, this estimate can be distorted by overweight patients, abdominal distention, and a history of multiple pregnancies. Unfortunately, no other quick rule has been yet described.

Perform ultrasonography only if the unit is immediately available and if 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 a cardiorespiratory arrest that has not responded to aggressive resuscitation within 4 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.

The major indication for performing a perimortem cesarean section is to optimize maternal cardiopulmonary resuscitation. The rescue of a viable fetus greater than 24 weeks gestation is an important consideration, but such rescue is always secondary to the safety and life of the mother. Consider performing a postmortem cesarean section if CPR does not resuscitate the mother within 4 minutes of the arrest. Waiting for the Obstetrical and Pediatric teams is contraindicated.2,7

There are few contraindications to performing a perimortem cesarean delivery. The best fetal outcomes are reported when cesarean delivery occurs within 5 minutes of maternal arrest. However, perimortem cesarean section should be considered if the time from the maternal arrest to delivery would be no greater than 25 minutes. It is contraindicated if the mother has a serious brain injury but is otherwise hemodynamically stable and the fetus shows no signs of distress. Other contraindications to a perimortem cesarean delivery are the inability to adequately resuscitate the infant after delivery or extreme fetal prematurity/immaturity.

Attempt to obtain consent for the procedure. However, there is no documentation of physician liability in these situations. Do not delay treatment pending consent. The unanimous consensus in the medical literature and of legal authorities is that a civil suit for performing a perimortem cesarean delivery, regardless of the outcome, would not result in a judgment against the Emergency Physician.

• 10 towel clips
• 16 Kelly clamps
• 16 hemostats
• 10 Peon or Pennington clamps
• Eight Allis forceps
• Six Babcock forceps
• Six ring forceps
• Six straight Kocher clamps
• #10 surgical scalpel blade and handle
• #15 surgical scalpel blade and handle
• Straight Mayo scissors
• Curved Mayo scissors
• Metzenbaum scissors
• Bandage scissors
• Two suture scissors
• Two Adson forceps, or other forceps with teeth
• Two Russian forceps, 5 1/2 inches and 8 inches
• Dressing forceps
• Bladder retractor
• Two medium Richardson retractors
• Two small Richardson retractors
• Two malleable retractors
• Two Army–Navy retractors
• Needle drivers, 8 inches and 6 inches long
• Two suction tips
• Suction tubing set(s)
• Wall suction
• Electrocautery unit with disposable tips
• Povidone iodine or chlorhexidine solution
• Sterile drapes
• Sterile gloves
• Two skin staplers
• Three packs 0 chromic suture with CTX taper needle
• One pack 2-0 chromic suture with taper SH needle
• Two packs of 1-0 Vicryl suture with a CT taper needle
• Chromic, Polysorb, or Vicryl suture (2-0 or 1-0)
• Nylon suture, 3-0
• Bulb syringe
• Clean towels or blanket for baby
• Umbilical cord clamp
• Sterile scissors to trim umbilical cord
• Infant warmer
• Neonatal resuscitation equipment

Ideally, all of the equipment should be prepackaged in a sterile cesarean section instrument tray prepared by the hospital. A prepackaged sterile instrument tray is commercially produced but may not be available as this procedure is rarely performed in the Emergency Department. A standard thoracotomy tray or tube thoracostomy tray will contain all the required equipment except for the bulb syringe and umbilical cord clamp.

Time is of the essence. Establishing IV access and endotracheal intubation takes several minutes. Thus, it is very important to activate a protocol for an emergency cesarean section as soon as a cardiorespiratory arrest occurs in a pregnant woman.6,7 Every attempt should be made to contact an Obstetrician and Neonatologist if a perimortem cesarean section is anticipated. Consult a General Surgeon if an Obstetrician is not available. Notify the neonatal resuscitation team and Anesthesia (Physician or Nurse Anesthetist) of the impending procedure. The procedure should not be delayed in an attempt to obtain consent.1,6,8 The medicolegal risks are few since the Emergency Physician is acting under the principle of beneficence.

Administer adequate anesthesia if the patient is awake and aware of their surroundings. General or epidural/spinal anesthesia is preferred as provided by a qualified Anesthesiologist or Nurse Anesthetist. However, local infiltration of anesthetic solution may be performed in conjunction with procedural sedation. The deceased patient requires no anesthesia.

Surgical preparation in an emergency is minimal.1,8,9 Perform a minimal shave of the lower abdomen and pubic region if time permits. Prepare the abdomen with povidone iodine or chlorhexidine solution. Place a Foley catheter to continuously drain the bladder and to decrease the risk of inadvertent entry into the bladder during the procedure. Perform an appropriate surgical scrub if time allows. Apply relevant surgical clothing and covers (i.e., a hat, mask, booties, sterile gloves, and a sterile gown). Apply sterile surgical drapes over the patient to isolate a surgical field.

The patient will be clinically deceased in most cases if this procedure is performed in the Emergency Department. Patient preparation is not necessary and wastes valuable time when trying to salvage the fetus. The Emergency Physician should follow body fluid precautions (hat, mask, sterile gloves, boots, and sterile gown). Administer broad-spectrum intravenous antibiotics if the mother survives the procedure. Continue cardiopulmonary resuscitation throughout the preparation and procedure until the fetus is delivered.

The “classical” technique of cesarean delivery is the most appropriate and is described in this section. It provides better exposure, easy access, and a larger opening for the delivery. Identify the patient's umbilicus and pubic symphysis. Make a vertical midline skin incision with a #10 scalpel blade beginning 1 cm below the umbilicus and extending caudally to 2 to 3 cm above the pubic symphysis (Figure 136-1A). This incision is long enough to deliver a full-term infant.7,8,10 Ignore any subcutaneous bleeding unless it is arterial. Clamp the bleeding artery or use an electrocautery unit, if available, to coagulate the vessel.

Extend the incision through the subcutaneous fat to the rectus sheath (Figure 136-1B). Do not be overzealous and cut through the rectus sheath, peritoneum, uterus, abdominal organs, or bladder. Grasp and elevate the rectus sheath using a toothed forceps (Figure 136-1C). Make an incision in the rectus sheath with a Mayo scissors. Extend the rectus sheath incision superiorly and inferiorly with the Mayo scissors (Figure 136-1C). Be cautious not to cut any abdominal or pelvic organs.

Expose the uterus (Figure 136-2). The underlying peritoneal membrane (peritoneum) should be visible (Figure 136-2A). It may occasionally be attached to the rectus sheath and opened simultaneously. Insert retractors to fully expose the peritoneal membrane (Figure 136-2A). Grasp and elevate the peritoneal membrane with a toothed forceps. Incise the peritoneal membrane with a Mayo or Metzenbaum scissors in a manner similar to that used to open the rectus sheath (Figure 136-2A).10

Make reasonable attempts to protect the bowel and bladder from injury. Elevate the bowel off the field and cover it with a saline-soaked towel. Place a bladder retractor over the pubic symphysis to retract the rectus sheath and bladder (Figure 136-3A).10 This will allow visualization of the uterus and prevent injury to the bladder. Alternatively, grasp and elevate the bladder from the pelvis with a saline-soaked gauze or towel (Figure 136-2B).

Identify the position of the fetal head by palpating the uterus. Make a 2 to 4 cm midline vertical incision in the uterus (Figure 136-3A). The amniotic sac will bulge through the incision if the membranes are intact. Place a finger into the uterine incision and aimed vertically (Figure 136-3B). Insert one blade of a bandage or Mayo scissors between the finger and the uterine wall (Figure 136-3B). The finger will protect the fetus from the scissors. The other blade of the scissors should be outside the uterus. Extend the vertical uterine incision fundally, superior and away from the bladder (Figure 136-3B). The finger inside the uterus will protect the fetus from injury when opening the uterine wall. Repeat this procedure to open the uterine wall inferiorly (Figure 136-3C).

Rupture the amniotic membranes with a clamp or other blunt instrument. The placenta will often be embedded in the anterior wall of the uterus. It is imperative to expedite the delivery of the fetus by cutting through the placenta. Carefully transect the placenta if it is anterior to the fetus. There is an urgency to deliver the fetus and clamp the umbilical cord to prevent significant fetal hemorrhage. Insert a hand between the pubic symphysis and the fetal occiput if the fetus is in a cephalic presentation (Figure 136-4A). Advance the hand to the base of the occiput. Gently flex the fetal head with your fingers and palm (Figure 136-4A). Apply gentle anteriorly and superiorly directed traction to elevate and deliver the head (Figure 136-4B). Deliver the entire fetal head (Figure 136-4C). Suction the mouth and nose with a bulb syringe (Figure 136-4D).10 Deliver the shoulders in a manner similar to that of a vaginal delivery (Figure 136-4E). Apply gentle upward traction on the head while an assistant applies pressure on the uterine fundus. First deliver the anterior shoulder. Deliver the other shoulder followed by the torso and lower extremities. Once the shoulders are delivered, the remainder of the fetus readily follows.

If the fetus is in a breech presentation or transverse lie, the feet first delivery is easiest. During the delivery, grasp the fetus by the pelvic bones and not by the abdomen to protect the delicate viscera.8,10

Clamp the umbilical cord with a hemostat or umbilical cord clamp approximately 10 to 15 cm from the fetus. Attach a second hemostat or clamp 2 to 3 cm distal to the first. Cut the umbilical cord between the clamps with a Mayo scissors. Hand the neonate to waiting personnel for resuscitation.8,10 Resuscitate the neonate yourself if additional help is not available.

Palpate inside the uterus for another fetus to rule out an unknown twin pregnancy. Deliver the placenta if the patient is still alive or if they regain vital signs (Figure 136-5). Begin an oxytocin infusion of 20 units in 1 L of normal saline at a rate of 10 mL/min to help the uterus contract.10 Apply gentle upward traction on the umbilical cord while holding the uterine wall open (Figure 136-5A). Insert the other hand between the placenta and uterine wall (Figure 136-5B). Apply gentle pressure to separate the placenta from the uterus.

Close the patient if they are still alive or if they regain vital signs (Figure 136-6). Apply ring forceps to the uterine incision. Close the uterus in two layers with 0 or 1-0 absorbable chromic gut, Polysorb, or Vicryl suture. Close the first layer in a running locked fashion (Figure 136-6A). This will provide hemostasis. A second running layer is necessary to ensure hemostasis and reapproximate the uterine wall. Closure of the serosa of the uterus (Figure 136-6B) and the peritoneal membrane (Figure 136-6C) is recommended but not required. Close the serosa and peritoneum with running 2-0 absorbable chromic gut, Polysorb, or Vicryl suture. Identify and grasp the cut ends of the rectus sheath with hemostats. Close the rectus sheath in a running pattern with 2-0 Vicryl suture (Figure 136-6D). Close the skin with running 3-0 nylon (Figure 136-6E) or staples for speed.7,8,10

The only closure required if the mother will not survive is a minimal closure of the skin. Use either a running baseball stitch or skin staples.

The major associated complications of the procedure include maternal sepsis, maternal visceral injury, maternal hemorrhage, and fetal injury secondary to delivery. The possible benefits of maternal and/or fetal survival far outweigh these considerations.1

The perimortem cesarean section is a valuable procedure that should be considered in any maternal arrest with an estimated fetal gestational age of greater than 24 weeks. The procedure will bring a great deal of stress and fast decision making is required. It provides the fetus with a chance for survival in the face of maternal death. In addition to potentially saving the life of the infant, emergent delivery might also aid in the resuscitation of the mother. The medicolegal risks are few. It should ideally be performed within 5 minutes of maternal arrest, as this gives the greatest potential for successful fetal, and possibly maternal, resuscitation.