What are the steps for performing a perimortem cesarean section (C-section) in the emergency department (ED)?

From the Guidelines

Perimortem cesarean section (C-section) in the emergency department should be performed within 4 minutes of maternal cardiac arrest and completed within 5 minutes, as this timing optimizes fetal survival and may improve maternal resuscitation by relieving aortocaval compression, as suggested by the most recent guidelines 1.

Step-by-Step Instructions

To perform a perimortem C-section, follow these steps:

• Continue maternal CPR throughout preparation and procedure.
• Position the patient supine with left lateral displacement of the uterus or manual displacement if needed.
• Quickly prepare the abdomen with available antiseptic solution, but don't delay for formal sterile preparation.
• Use a scalpel to make a vertical midline incision from just below the umbilicus to the pubic symphysis, cutting through skin and subcutaneous tissue.
• Incise the fascia and separate the rectus muscles vertically.
• Enter the peritoneum and make a vertical incision in the lower uterine segment.
• Rupture the amniotic membranes and deliver the fetus, clamping and cutting the umbilical cord.
• Extract the placenta manually.
• If maternal circulation returns, close the uterus with absorbable sutures in two layers, followed by fascial closure and skin closure as appropriate.

Key Considerations

• Have neonatal resuscitation equipment ready, including warmer, suction, and appropriate-sized equipment.
• The procedure works by relieving aortocaval compression, improving venous return and cardiac output during resuscitation, while simultaneously delivering the fetus before irreversible hypoxic damage occurs.
• Team planning for cardiac arrest in pregnancy should be done in collaboration with the obstetric, neonatal, emergency, anesthesiology, intensive care, and cardiac arrest services, as recommended by the American Heart Association guidelines 1.
• The goal of perimortem cesarean delivery is to improve maternal and fetal outcomes, and it should be performed by skilled healthcare professionals in a timely and efficient manner.

From the Research

Peri-Mortem C-Section Procedure

To perform a peri-mortem C-section in the emergency department, the following steps can be taken:

• The decision to perform a peri-mortem C-section should be made quickly, ideally within 4 minutes of maternal cardiopulmonary arrest 2.
• The procedure should be performed by a trained healthcare professional, such as an emergency physician or a trauma clinician, as a board-certified obstetrician may not be present 3.
• The patient should be placed in a supine position, but care should be taken to avoid aortocaval compression 2.
• A midline laparotomy should be performed to access the uterus 4.
• The procedure should be performed as quickly and safely as possible, with the goal of delivering the baby and improving the chances of survival for both the mother and the baby 5.

Key Considerations

• The gestational age of the fetus should be greater than 24-26 weeks for a peri-mortem C-section to be considered 2.
• The procedure should be performed in a timely manner, as delays can reduce the chances of survival for both the mother and the baby 4, 5.
• The use of ultrasound evaluation and continuous fetal monitoring can help assess the fetal status and guide decision-making 2.
• A safety net should be set up by notifying appropriate specialists when a complicated delivery is suspected 2.

Additional Techniques

• In some cases, tandem peri-mortem cesarean section and open-chest cardiac massage may be used to resuscitate the mother and the baby 6.
• Goal-directed resuscitation, including diagnostic ultrasonography and capnography, can be used to assist in decision-making and improve outcomes 6.