Challenging the 4- to 5-minute rule: from perimortem cesarean to resuscitative hysterotomy

Cardiac arrest, though rare, is the most feared complication in the pregnant woman as it involves two lives. Most arrests occur because of conditions that result from the pregnancy itself or from preexisting medical conditions exacerbated by the pregnancy. Prompt resuscitative efforts are crucial for favorable outcomes for the mother and fetus. The basic principles of resuscitation during pregnancy such as airway, breathing, and circulation are similar to the resuscitation in a cardiopulmonary arrest in any patient; however, certain modifications are necessary to account for the physiologic changes that occur during the pregnancy. Cardiopulmonary resuscitation (CPR) of the parturient should include uterine tilt or displacement to relieve the compression of the inferior vena cava and aorta by the gravid uterus, intubation using rapid sequence intubation with cricoid pressure, and timely perimortem cesarean section (PMCS). Ideally, the PMCS must be performed within 5 minutes of cardiac arrest if the pregnant woman does not have a return of spontaneous circulation, and resuscitation is deemed unsuccessful. The PMCS is performed if the gestational age is at least 20 weeks or the gravid uterus is evident. A high-quality CPR and multispecialty team approach, consisting of obstetricians, cardiologists, anesthesiologists, neonatologists, and nursing staff, is essential for survival.

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“…There are reports of neonatal survival even when delivery occurred within 30 minutes after onset of maternal cardiac arrest. 38…”

Section: Expected Fetal and Maternal Outcomes Of Perimortem Cesarean mentioning

confidence: 99%

Challenges of Cardiopulmonary Resuscitation during Pregnancy

2019

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“…The final destination depends on the cause of cardiac arrest and the woman's overall clinical state. In all circumstances, senior medical staff should be involved in a multidisciplinary team discussion to ensure an appropriate decision is made …”

Section: Perimortem Caesarean Section: Practical Stepsmentioning

confidence: 99%

“…Maternal cardiac arrest is a rare event occurring in approximately 1 in 12 500 pregnancies . The most common causes of cardiac arrest in pregnancy are haemorrhage (45%), amniotic fluid embolism (13%), heart failure (13%), anaesthetic complications (8%) and trauma (3%) (Figure ) . Because it is so rare, most obstetricians are unlikely to encounter this challenging situation more than once during their career .…”

Section: Introductionmentioning

confidence: 99%

“…Failure to institute effective life support, which includes performing PMCS in good time, carries devastating consequences for families . Even when abdominal delivery is expedited in a timely manner, maternal survival remains low (17–59%), although fetal survival may be higher (61–80%) . The key to achieving optimum maternal and fetal survival is the rapidity with which the PMCS can be performed following onset of cardiac arrest …”

Section: Introductionmentioning

confidence: 99%

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Perimortem caesarean section – why, when and how

Chu

Hinshaw

Paterson‐Brown

et al. 2018

The Obstetric & Gynaecologis

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Cardiac arrest in pregnancy is rare. Effective management involves the decision to perform a perimortem caesarean section if the gestation is greater than 20 weeks and return of spontaneous circulation does not occur after 4 minutes of effective cardiopulmonary resuscitation. Delivery should ideally be achieved within 5 minutes of cardiac arrest as this maximises maternal survival and reduces the risk of long-term neurological impairment.In hospital, the procedure should be undertaken at the site of the cardiac arrest without moving to an operating theatre. Minimal equipment is required to undertake the procedure. Clinical areas where pregnant women are seen should have a designated 'equipment box'. Debriefing all personnel is of utmost importance after the acute event. Learning objectivesTo understand why perimortem caesarean section is beneficial to maternal survival. To appreciate the need for rapid decision making when perimortem caesarean section is required. To gain practical knowledge of perimortem caesarean section, including the steps to be used when resuscitation is unsuccessful. Ethical issuesTo be aware that the primary aim of perimortem caesarean section is to aid maternal survival, not necessarily fetal survival.

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“…If the uterine fundal height is above the level of the umbilicus, manual uterine displacement should be performed, and a resuscitative hysterotomy (also called perimortem cesarean delivery) should be initiated after four to five minutes from the onset of cardiac arrest at the location that the arrest occurred. 86 The recommended ACLS chest compression technique and defibrillation protocol is no different from the non-pregnant guidelines. If a fetal scalp electrode is present, this should be removed prior to defibrillation if possible.…”

mentioning

confidence: 99%