When is a trauma cesarean section indicated if the fetus is viable?

Trauma Cesarean Section in Viable Fetus

Trauma cesarean section is indicated if the fetus is viable and cardiopulmonary resuscitation has just been initiated or when maternal cardiac arrest occurs, especially when the gravid uterus is large enough to cause aortocaval compression. 1

Timing of Emergency Cesarean Section

• Emergency cesarean section team should be activated as soon as cardiac arrest is identified in a pregnant woman with an obviously gravid uterus 1
• The procedure should be considered at 4 minutes after onset of maternal cardiac arrest if there is no return of spontaneous circulation 1, 2
• The rescue team is not required to wait 5 minutes before initiating emergency hysterotomy, especially in cases of obvious nonsurvivable injury 1
• Best fetal survival occurs when delivery happens within 5 minutes after maternal cardiac arrest, particularly at gestational ages >24-25 weeks 1

Rationale for Emergency Cesarean Section

• Emptying the uterus relieves aortocaval compression, which significantly improves maternal resuscitative efforts 1
• Several case reports show return of spontaneous circulation or improvement in maternal hemodynamic status only after the uterus has been emptied 1
• In a case series of 38 perimortem cesarean sections, 12 of 20 women had return of spontaneous circulation immediately after delivery 1
• No cases of worsened maternal status after cesarean section have been reported 1

When to Consider Emergency Cesarean Section

• When the gravid uterus is large enough to cause maternal hemodynamic changes due to aortocaval compression 1
• Typically when fundal height extends to or above the umbilicus (approximately ≥20 weeks gestation) 1
• Regardless of fetal viability, if the uterus is thought to interfere with maternal hemodynamics 1
• In cases of obvious nonsurvivable maternal injury when the fetus is viable 1

Maternal and Fetal Outcomes

• Perimortem cesarean delivery has shown maternal survival benefit in 31.7% of cases 1
• Survival of the mother has been reported with perimortem cesarean section performed up to 15 minutes after the onset of maternal cardiac arrest 1, 3
• At gestational ages >30 weeks, infant survival has been seen even when delivery occurred after 5 minutes from onset of maternal cardiac arrest 1, 4
• Case reports document successful neonatal outcomes even with cesarean sections performed 15-45 minutes after maternal death, though neurological sequelae may occur 4, 5

Institutional Preparation

• Team planning should be done in collaboration with obstetric, neonatal, emergency, anesthesiology, intensive care, and cardiac arrest services 1, 2
• Providers at medical centers must review whether performance of an emergency hysterotomy is feasible and identify the best means of accomplishing this procedure rapidly 1
• Most neonates delivered by perimortem cesarean section will require active resuscitation 1

Common Pitfalls to Avoid

• Delaying the decision to perform emergency cesarean section beyond 4 minutes after cardiac arrest 1, 3
• Failing to recognize that both mother and infant may die if blood flow to the mother's heart cannot be restored 1
• Underestimating the importance of relieving aortocaval compression in maternal resuscitation 1
• Waiting for a specific time threshold before considering cesarean section in cases of obvious nonsurvivable maternal injury 1