From the Guidelines
Perimortem cesarean section (C-section) should be performed when a pregnant woman in the second half of pregnancy suffers cardiac arrest and does not respond to initial resuscitation efforts, with the decision made quickly to maximize both maternal and fetal survival chances. The American Heart Association guidelines [ 1 ] and the 2024 international consensus on cardiopulmonary resuscitation [ 1 ] suggest that delivery of the fetus by perimortem cesarean delivery may improve outcomes for women in cardiac arrest in the second half of pregnancy.
Key Considerations
- The gestational age threshold for considering perimortem C-section is not strictly defined, but a uterine size ≥20 weeks’ gestation is often cited [ 1 ].
- The timing of the procedure is critical, with shorter times from arrest to delivery associated with improved maternal and neonatal outcomes [ 1 ].
- High-quality usual resuscitation care and therapeutic interventions that target the most likely cause(s) of cardiac arrest remain important in this population [ 1 ].
Procedure Details
- The procedure involves a vertical midline incision from umbilicus to pubis, followed by a vertical uterine incision.
- Equipment needed includes basic surgical instruments (scalpel, retractors), with sterility being secondary to speed.
- The physiological basis for this intervention is that removing the fetus and placenta eliminates aortocaval compression, decreases oxygen demand, and improves venous return, potentially facilitating successful maternal resuscitation even if the fetus cannot be saved.
Decision-Making
- The decision to perform perimortem C-section should be made quickly, ideally within 4-5 minutes of cardiac arrest, if there is no return of spontaneous circulation after properly performed CPR.
- No additional consent is required beyond that for resuscitation efforts.
- The procedure should be initiated by a trained healthcare provider, with consideration of the patient's overall clinical condition and the availability of resources.
From the Research
Parameters for Deciding to do Perimortem C Section
The decision to perform a perimortem C section is based on several parameters, including:
- Gestational age: The procedure is typically considered for mothers with a gestational age of more than 20 weeks 2, 3
- Cardiac arrest: Perimortem C section is often performed in cases of maternal cardiac arrest, particularly when other resuscitation efforts have been unsuccessful 2, 4, 5, 6
- Time since cardiac arrest: Current recommendations suggest performing the procedure after 4-5 minutes of unsuccessful cardiopulmonary resuscitation 5, 6
- Maternal and fetal salvage: The goal of perimortem C section is to save both the mother and the fetus, and the procedure is considered critical for maternal resuscitation and fetal salvage 2, 4, 5
Indications and Contraindications
The indications for perimortem C section include:
- Maternal cardiac arrest with no return of spontaneous circulation after 4-5 minutes of cardiopulmonary resuscitation 5, 6
- Gestational age of more than 20 weeks 2, 3 The contraindications for perimortem C section are not well-established, but the procedure is generally not recommended if the mother has a clear "do not resuscitate" order or if the fetus is not viable 2
Equipment and Technical Aspects
The equipment needed for perimortem C section includes:
- Surgical instruments, such as scalpels and forceps 2
- Anesthesia equipment, if available 2 The technical aspects of the procedure involve:
- A rapid and simple approach to the uterus, often using a midline incision 2
- Delivery of the fetus as quickly as possible, often within 10 minutes of the decision to perform the procedure 6
Maternal and Fetal Outcomes
The outcomes of perimortem C section can be favorable for both the mother and the fetus, with: