How does a perimortem cesarean section (C-section) improve cardiopulmonary resuscitation (CPR) quality in a pregnant woman?

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How Perimortem Cesarean Section Improves CPR Quality in Pregnant Women

Perimortem cesarean section (C-section) improves CPR quality primarily by relieving aortocaval compression, which increases venous return, cardiac output, and coronary perfusion pressure during resuscitation efforts in pregnant women with a fundal height at or above the umbilicus (≥20 weeks gestation). 1

Physiological Mechanisms of Improvement

Relief of Aortocaval Compression

  • The gravid uterus compresses the inferior vena cava in pregnant women, especially when supine
  • This compression:
    • Impedes venous return
    • Reduces stroke volume and cardiac output
    • Decreases coronary perfusion pressure
    • Compromises effectiveness of chest compressions 1

Evidence of Hemodynamic Improvement

  • Animal studies demonstrate significantly higher coronary perfusion pressures during CPR with relief of aortocaval compression (20 mmHg vs. 5 mmHg, P<0.05) 1
  • Removing the weight of the gravid uterus allows:
    • Better diaphragmatic excursion
    • Improved ventilation
    • Enhanced venous return
    • More effective chest compressions 1

Timing Considerations

Optimal Timing for Intervention

  • Ideally performed within 5 minutes of cardiac arrest onset 1
  • Preparation should begin immediately while initial BLS and ACLS interventions are being performed 1
  • Evidence shows median time from collapse to cesarean delivery was:
    • 3 minutes in maternal survivors vs. 12 minutes in non-survivors
    • 10 minutes in surviving neonates vs. 20 minutes in non-surviving neonates 1

Clinical Decision Algorithm

  1. Recognize cardiac arrest in a pregnant woman
  2. Begin high-quality CPR with manual left lateral uterine displacement
  3. If fundal height is at/above umbilicus (≥20 weeks gestation):
    • Immediately prepare for perimortem cesarean delivery while continuing resuscitation
    • If no ROSC within 4-5 minutes, proceed with perimortem cesarean section
    • Continue all maternal resuscitative interventions during and after the procedure 1

Additional Benefits

Improved Airway Management

  • Pregnant patients are more susceptible to hypoxia due to:
    • Increased maternal metabolism
    • Decreased functional residual capacity from uterine pressure on diaphragm
  • Perimortem C-section reduces pressure on the diaphragm, improving:
    • Lung compliance
    • Oxygenation capacity
    • Ventilation effectiveness 1

Enhanced Team Approach

  • Requires coordinated response from:
    • Obstetric team
    • Neonatal team
    • Emergency/critical care team
    • Anesthesiology 1, 2

Common Pitfalls and Caveats

  • Delay in decision-making: Don't hesitate - preparation for perimortem C-section should begin immediately upon recognition of cardiac arrest in a pregnant woman with fundal height at/above umbilicus 1
  • Inadequate left lateral uterine displacement: Manual displacement is preferred over lateral tilt positioning during CPR 1
  • Focus on fetal monitoring: This should NOT be undertaken during maternal cardiac arrest as it may interfere with resuscitation efforts 1
  • Failure to continue maternal resuscitation: All maternal resuscitative interventions must continue during and after cesarean delivery 1
  • Inadequate team preparation: Centers caring for pregnant women should have protocols and training for this rare but critical scenario 2

Special Considerations

  • In situations of non-survivable maternal trauma or prolonged pulselessness, perimortem cesarean delivery should not be delayed 1
  • The best hope for fetal survival is maternal survival - prioritize maternal resuscitation 1
  • Consider potential causes of arrest specific to pregnancy (bleeding/DIC, embolism, anesthetic complications, uterine atony, cardiac disease, hypertension/preeclampsia/eclampsia, placental issues, sepsis) 1

Perimortem cesarean section represents a crucial intervention that can significantly improve maternal outcomes in cardiac arrest by optimizing the physiological conditions for effective CPR.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Research

Management of cardiac arrest in pregnancy.

Best practice & research. Clinical obstetrics & gynaecology, 2014

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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