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Perimortem C-section at St.Emlyn’s

So, I’m riding my luck. I’m about half way through my EM career and I’ve been lucky so far. No hysterotomies for me, but I’m getting worried...

That day may be tomorrow, it may be never but I want to be prepared and I’d like you to be prepared. It’s therefore time to turn to the #FOAM gods and ask for help. So this post is not about my experience (I have none), it’s a little bit about the practicalities, but mostly it’s about how we can prepare for what I hope will be a never event. There is a lot of stuff already out there on some great blogs, please visit them and use the experience of those writers, but by sharing my thoughts here I hope to give some guidance on the process of…

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Featured

 Maternal and Neonatal Outcomes Following Resuscitative Hysterotomy for OHCA

Resuscitative hysterotomy for OHCA is associated with low maternal survival rates but reasonable neonatal survival rates, even in cases with prolonged maternal resuscitation. This suggests that emergency and prehospital clinicians should not discount resuscitative hysterotomy, even after extended resuscitation attempts, particularly when dealing with viable gestations. Prehospital training, early recognition, and improved decision-making could optimise both maternal and neonatal outcomes in these rare but critical cases.

Articles of Interest

Cardiac arrest and pregnancy

If attempts at maternal resuscitation fail, consider immediate cesarean section. Gestational age greater than 23 weeks is the recommended cut-off for immediate delivery. A fetus younger than 23 weeks has an extremely poor prognosis. Such instances of perimortem delivery are rare, and the chances of fetal survival are generally poor.

Cardiac arrest in pregnancy: the perimortem c-section

Estimate gestational age by palpating the uterus. If the fundus is above the umbilicus, assume 24 weeks gestation, and therefore viability. At the same time, prep the abdomen with chlorhexidine. If fundus above the umbilicus and more than 4 minutes have passed, proceed...

Live Resuscitative Hysterotomy by Dr. Sara Gray: Essentials of EMCrit 2018

So this is for emergency life-saving c-section. Not just emergency c-section, but an emergency delivery to save the mother, and baby, from death.

Perimortem C-section – The Resuscitative Hysterotomy

The indications for perimortem c-section are maternal cardiac arrest with gravid uterus above the umbilicus* or known to be >20 weeks gestational age up to 30 minutes after cardiac arrest started. The most common pitfall in maternal cardiac arrest is delaying the resuscitative hysterotomy. The sooner the procedure is initiated, the more likely maternal and neonatal survival.

Perimortem C-section: Can you cut it in Obstetric resus?

if you are involved in the care of pregnant women, or any acute care then you need to have a think about this – you might need it to save one or two lives one day!

Post-Mortem C-Section: A How-to Guide to Section or Not to Section: The Peri-Mortem C-Section in the ED

Peri-mortem Cesarean section in the ED is one of the most heroic procedures in the EM scope of practice. Peri-mortem C-section is exceedingly rare, and the decision to embark on this procedure must literally be made within seconds to minutes.

Sim Case Series: Perimortem C-Section

Identify pregnant pt with uterine fundus greater than 20 cm above pubic symphysis. Initiate and complete perimortem CS within 5 minutes loss of pulses

Thinking about: Perimortem Caesarean Section

Know the procedure. You won't have time to look it up. So you need to have thought through it in detail (using that high-fidelity simulator in your mind), as well as put your team and leadership abilities through their paces. You could use a DIY trainer like we've seen here previously.

Trauma Tuesday - Pregnant trauma

Best outcome when performed within 4 minutes of Cardiac Arrest. (this patient is already dead at this point, you cannot make them worse, it is time to throw the kitchen sink)

Resources

LFTL

Maternal arrest within 4 minutes (Do not wait for seniors or USS or sterile prep!)

WikEM

Maternal cardiac arrest without ROSC within 4 minutes.

StatPearls

One of the most daunting scenarios to face during an emergency department (ED)/critical care shift is the sudden, adverse change in a pregnant patient's health. These occurrences are rare and are the result of pre-existing conditions with severe, unforeseen medical, obstetric complications. This is also the scenario when patients arrive in extremis from a traumatic insult.