Perimortem Cesarean Delivery

Perimortem cesarean delivery (PMCD), also referred to as resuscitative hysterotomy by some clinicians, is an emergency procedure performed when a pregnant patient experiences cardiac arrest, usually conducted during resuscitation efforts, to relieve maternal aortocaval compression and facilitate both maternal and fetal survival. Maternal cardiac arrest is a rare catastrophic condition that can result secondary to trauma, acute hemorrhage, heart failure, amniotic fluid embolism, drug use, sepsis, thromboembolism, severe hypertensive disorders, or anesthesia complications. The incidence of maternal cardiac arrest is estimated to be 1 in 30,000 pregnancies and 1 in 12,000 delivery admissions. Due to the rarity of this event, the evidence guiding PMCD recommendations, including optimal techniques and indications, is also limited.

While outcomes for both mother and baby vary, timely PMCD at 20 weeks or more of gestation can improve survival when resuscitation efforts fail. However, the decision to perform PMCD is challenging and influenced by several factors, including the cause of arrest, gestational age, and available resources. The most widely accepted guidelines regarding PMCD are those established by the American Heart Association (AHA), which recently updated recommendations on cardiopulmonary resuscitation in pregnant patients and PMCD. The primary purposes of PMCD are to improve the effectiveness of maternal resuscitation by enhancing venous return and to deliver the fetus promptly, minimizing the risk of brain damage from oxygen deprivation.

Research indicates timely PMCD improves outcomes, with a recommended delivery time within 5 minutes of cardiac arrest. Experts recommend the procedure be initiated as soon as possible after the decision to proceed with PMCD is made at the site of resuscitation rather than moving the patient or awaiting surgical equipment to improve maternal and fetal survival. Ideally, however, institutions that provide obstetrical care should have healthcare teams assigned and protocols already instituted and prepared to treat maternal cardiac arrest and perform PMCD if needed.