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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
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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
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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.
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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.
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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.
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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
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