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Journal Article•DOI•

Perimortem caesarean section – why, when and how

Justin Chu, Kim Hinshaw1, Sara Paterson-Brown2, Tracey A. Johnston, Margaret Matthews, Julian Webb3, Paul Sharpe4 •
City Hospitals Sunderland NHS Foundation Trust1, Imperial College Healthcare2, East Surrey Hospital3, University Hospitals of Leicester NHS Trust4
01 Jul 2018-The Obstetrician and Gynaecologist (Wiley)-Vol. 20, Iss: 3, pp 151-158
TL;DR: Effective management of cardiac arrest in pregnancy 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.
Abstract: 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.

Summary (1 min read)

Jump to: [General rights] – [Learning objectives 16] and [Ethical issues 23]

General rights

  • Unless a licence is specified above, all rights (including copyright and moral rights) in this document are retained by the authors and/or the copyright holders.
  • Where a licence is displayed above, please note the terms and conditions of the licence govern your use of this document.
  • Perimortem caesarean section – why, when and how [Running title:].
  • KH researched and edited the article; SPB, TJ, MM, JW and PS edited and approved the final version.
  • 9 In hospital, the procedure should be undertaken at the site of the cardiac arrest without 10 moving to an operating theatre.

Learning objectives 16

  • To understand why perimortem caesarean section is beneficial to maternal survival.
  • 17 To appreciate the need for rapid decision making when perimortem caesarean section is 18 required.
  • 19 To gain practical knowledge of perimortem caesarean section, including the steps to be used 20 when resuscitation is unsuccessful.

Ethical issues 23

  • To be aware that the primary aim of perimortem caesarean section is to aid maternal 24 survival, not necessarily fetal survival.
  • The key to achieving optimum 40 maternal and fetal survival is the rapidity with which the PMCS can be performed following onset of 41 cardiac arrest.
  • Perimortem caesarean section: practical steps 187 [Heading 2].
  • All intravenous access ports, lines and intubation equipment in place at the time of 280 declaration of death should be secured and left in situ.
  • Units may wish to consider a joint debriefing/review, which can include both the staff 366 involved in the patient’s care and the patient and/or their family members.

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University of Birmingham
Perimortem caesarean section – why, when and
how
Chu, Justin; Hinshaw, Kim; Paterson-Brown, Sara; Johnston, Tracey; Matthews, Margaret;
Webb, Julian; Sharpe, Paul
DOI:
10.1111/tog.12493
License:
None: All rights reserved
Document Version
Peer reviewed version
Citation for published version (Harvard):
Chu, J, Hinshaw, K, Paterson-Brown, S, Johnston, T, Matthews, M, Webb, J & Sharpe, P 2018, 'Perimortem
caesarean section – why, when and how', The Obstetrician and Gynaecologist, vol. 20, no. 3, pp. 151-158.
https://doi.org/10.1111/tog.12493
Link to publication on Research at Birmingham portal
Publisher Rights Statement:
Checked for eligibility: 10/11/2017
"This is the peer reviewed version of the following article: Chu JJ, Hinshaw K, PatersonBrown S, Johnston T, Matthews M, Webb J, Sharpe
P. Perimortem caesarean section – why, when and how. The Obstetrician & Gynaecologist. 2018; 20:151–158, which has been published in
final form at: https://doi.org/10.1111/tog.12493. This article may be used for non-commercial purposes in accordance with Wiley Terms and
Conditions for Self-Archiving."
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Download date: 10. Aug. 2022
The Obstetrician & Gynaecologist.
[Manuscript title:] Perimortem caesarean section – why, when and how
[Running title:] Perimortem caesarean section
Author names and post nominal initials
Justin J Chu MBChB MRCOG PhD,
a,
* Kim Hinshaw MBBS FRCOG,
b
Sara Paterson-Brown MBBch FRCS
FRCOG,
c
Tracey Johnston MBChB MD FRCOG,
d
Margaret Matthews MBBS FRCOG MA,
e
Julian Webb
MBBS FRCS (Ed) FRCEM,
f
Paul Sharpe MBBS FRCA
g
a
Academic Clinical Lecturer, Birmingham Women’s Hospital, Edgbaston, Birmingham B15 2TG, UK
b
Consultant Obstetrician and Gynaecologist, City Hospitals Sunderland NHS Foundation Trust,
Sunderland SR4 7TP, UK
c
Consultant Obstetrician, Queen Charlotte’s Hospital Imperial NHS Trust, London W12 0HS, UK
d
Consultant in Maternal Fetal Medicine, Birmingham Women’s Hospital, Edgbaston, Birmingham
B15 2TG, UK
e
Consultant Obstetrician and Gynaecologist, Tunbridge Wells Hospital, Tunbridge Wells, Kent
TN2 4QJ, UK
f
Consultant in Emergency Medicine, Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital,
Redhill RH1 5RH, UK
g
Consultant Obstetric Anaesthetist, University Hospitals of Leicester NHS Trust, Leicester Royal
Infirmary, Leicester LE1 5WW, UK
*Correspondence: Justin J Chu. Email: j.j.chu@bham.ac.uk
Disclosure of interests
KH, SP-B and PS are members of the MOET UK Working Group. KH is Chair of the UKOSS Steering
Committee. JJC, TJ, MM and JW have no competing interests to disclose.
Contributions to authorship
JJC researched, wrote and edited the article. KH researched and edited the article; SPB, TJ, MM, JW
and PS edited and approved the final version.
Acknowledgements:
We would like to acknowledge Dr Adrian Yoong, Consultant Pathologist, Birmingham Women’s NHS
Foundation Trust, for the personal communication. We would also like to acknowledge Cambridge
University Press and ALSG.org for granting permission for the use of the ‘Manual displacement of the
uterus’ figure.
Comment [JC(GaD1]: The
disclosure of interests are correct but I
have added that the other authors
have no competing interests to
disclose
Perimortem caesarean section
[Abstract] 1
2
Key content 3
• Cardiac arrest in pregnancy is rare. Effective management involves the decision to perform a 4
perimortem caesarean section if the gestation is greater than 20 weeks and return of 5
spontaneous circulation does not occur after 4 minutes of effective cardiopulmonary 6
resuscitation. 7
• Delivery should ideally be achieved within 5 minutes of cardiac arrest as this maximises 8
maternal survival and reduces the risk of long-term neurological impairment. 9
• In hospital, the procedure should be undertaken at the site of the cardiac arrest without 10
moving to an operating theatre. 11
• Minimal equipment is required to undertake the procedure. Clinical areas where pregnant 12
women are seen should have a designated ‘equipment box’. 13
• Debriefing all personnel is of utmost importance after the acute event. 14
15
Learning objectives 16
• To understand why perimortem caesarean section is beneficial to maternal survival. 17
• To appreciate the need for rapid decision making when perimortem caesarean section is 18
required. 19
• To gain practical knowledge of perimortem caesarean section, including the steps to be used 20
when resuscitation is unsuccessful. 21
22
Perimortem caesarean section
Ethical issues 23
• To be aware that the primary aim of perimortem caesarean section is to aid maternal 24
survival, not necessarily fetal survival. 25
26
Keywords: cardiac arrest / maternal cardiac arrest / perimortem caesarean section / 27
resuscitative hysterotomy 28
29
[Heading 1] Introduction 30
Maternal cardiac arrest is a rare event occurring in approximately 1 in 12 500 pregnancies.
1–4
The 31
most common causes of cardiac arrest in pregnancy are haemorrhage (45%), amniotic fluid 32
embolism (13%), heart failure (13%), anaesthetic complications (8%) and trauma (3%) (see 33
Figure 1).
1,5,6,7
Because it is so rare, most obstetricians are unlikely to encounter this challenging 34
situation more than once during their career.
8
When a maternal cardiac arrest does occur, the 35
prospect of performing a perimortem caesarean section (PMCS) is daunting for any healthcare 36
professional, even the most experienced obstetricians. Failure to institute effective life support, 37
which includes performing PMCS in good time, carries devastating consequences for families.
9
Even 38
when abdominal delivery is expedited in a timely manner, maternal survival remains low (17–39
59%),
1,3,4
although fetal survival may be higher (61–80%).
1,10,11
The key to achieving optimum 40
maternal and fetal survival is the rapidity with which the PMCS can be performed following onset of 41
cardiac arrest.
12
42
This article explores the rationale for performing PMCS and reviews maternal and fetal outcomes. 43
The authors describe recently proposed alternative terminology and offer practical, step-by-step 44
Comment [LM1]:
AU/ED: Please note
the comments I have made on the PPT file
re: this figure.
Comment [LW2]: AU: GTG ref moved
from no. 13 to no. 7, as it will appear
earlier in the text when the ref. is added to
the figure 1 legend. References 7-13
renumbered, please check these are OK.
Comment [JC(GaD3]:
The numbering
is fine
Perimortem caesarean section
advice for performing the procedure. Finally, they will consider how care can be improved with 45
better use of simulation and in-house training. 46
47
[Heading 1] Perimortem caesarean section – why and when? 48
In maternal cardiac arrest, the resuscitation algorithm followed is essentially the same as that for 49
nonpregnant women, apart from certain specific anatomical considerations (e.g., manual 50
displacement of the gravid uterus and placement of defibrillator pads).
13
However, the main 51
difference in the continuing management of cardiac arrest in pregnancy is the critical decision to 52
perform PMCS if cardiopulmonary resuscitation (CPR) fails to result in rapid return of spontaneous 53
circulation (ROSC). The current Royal College of Obstetricians and Gynaecologists’ (RCOG) guideline 54
Maternal Collapse in Pregnancy and Puerperium
7
recommends that PMCS should be performed if 55
there is no ROSC after 4 minutes of correctly performed CPR in a woman who is greater than 56
20 weeks of gestation. Delivery of the fetus should ideally be completed 5 minutes after cardiac 57
arrest. The guideline is clear that the procedure is primarily used to assist maternal resuscitation 58
rather than to save the fetus. This has led to the recent recommendation from trauma colleagues to 59
use the alternative term ‘resuscitative hysterotomy’ (RH).
14,15
The term PMCS is more familiar in 60
obstetric circles and the authors feel that both terms are acceptable to use in clinical practice. 61
The time targets of 4 and 5 minutes are sourced from a seminal article published by Katz et al. in 62
1986.
10
The case series focused on infant survival, with 42/61 (69%) surviving when PMCS was 63
undertaken within 5 minutes of cardiac arrest. In reviewing a smaller case series, Katz also noted 64
that maternal hypoxic brain injury only occurred in those women who underwent a caesarean 65
delivery that was started 6 minutes or more after cardiac arrest.
2
Although research evidence for 66
this is not robust, the physiological plausibility is clear: pregnant women are likely to become 67
hypoxic more rapidly than nonpregnant women because of higher oxygen demand.
16
Additionally, 68
Citations
More filters
Journal Article•DOI•
Maternal Collapse in Pregnancy and the Puerperium: Green-top Guideline No. 56.

[...]

J Chu, T A Johnston, J Geoghegan, Gynaecologists
01 Apr 2020-British Journal of Obstetrics and Gynaecology

29 citations

Cites background from "Perimortem caesarean section – why,..."

  • ...Obstetricians should be aware of this terminology to ensure effective communication.(82) The gravid uterus impairs venous return and thus reduces cardiac output by approximately 60% secondary to aortocaval compression....

    [...]

Journal Article•DOI•
The impact of cardiovascular diseases on maternal deaths in the Nordic countries

[...]

Lill Trine Nyfløt1, Lill Trine Nyfløt2, Marianne Johansen, Ajlana Mulic-Lutvica3, Mika Gissler4, Mika Gissler5, Birgit Bødker, Katarina Bremme6, Liv Ellingsen1, Siri Vangen1, Siri Vangen7 •
Oslo University Hospital1, Drammen Hospital2, Uppsala University3, Karolinska Institutet4, National Institute for Health and Welfare5, Karolinska University Hospital6, University of Oslo7
01 Feb 2021-Acta Obstetricia et Gynecologica Scandinavica
TL;DR: In this article, the authors identified 227 maternal deaths, giving a maternal mortality rate of 5.98 deaths per 100 000 live births in the Nordic countries between 2005 and 2017, the most common cause of death was cardiovascular disease (n = 36 deaths).
Abstract: Introduction Cardiovascular diseases have become increasingly important as a cause of maternal death in the Nordic countries. This is likely to be associated with a rising incidence of pregnant women with congenital and acquired cardiac diseases. Through audits, we aim to prevent future maternal deaths by identifying causes of death and suboptimal factors in the clinical management. Material and methods Maternal deaths in the Nordic countries from 2005 to 2017 were identified through linked registers. The national audit groups performed case assessments based on hospital records, classified the cause of death, and evaluated the standards of clinical care provided. Key messages were prepared to improve treatment. Results We identified 227 maternal deaths, giving a maternal mortality rate of 5.98 deaths per 100 000 live births. The most common cause of death was cardiovascular disease (n = 36 deaths). Aortic dissection/rupture, myocardial disease, and ischemic heart disease were the most common diagnoses. In nearly 60% of the cases, the disease was not recognized before death. In more than half of the deaths, substandard care was identified (59%). In 11 deaths (31%), improvements to care that may have made a difference to the outcome were identified. Conclusions Between 2005 and 2017, cardiovascular diseases were the most common causes of maternal deaths in the Nordic countries. There appears to be a clear potential for a further reduction in these maternal deaths. Increased awareness of cardiac symptoms in pregnant women seems warranted.

9 citations

Journal Article•DOI•
Resuscitative hysterotomy for maternal collapse in a triplet pregnancy.

[...]

Zenab Yusuf Tambawala1, Zenab Yusuf Tambawala2, Masuma Cherawala1, Masuma Cherawala2, Sadia Maqbool1, Sadia Maqbool2, Lama Khalid Hamza1, Lama Khalid Hamza2 •
Dubai Hospital1, Dubai Health Authority2
01 Jul 2020-Case Reports
TL;DR: Timely decision of resuscitative hysterotomy done primarily to restore maternal cardiac output due to a grossly gravid uterus saved the mother and the triplets.
Abstract: We encountered a 47-year-old woman, at 35 weeks of gestation, carrying triplets, who attended the hospital with severe pre-eclampsia and at admission had eclamptic fit followed by cardiac arrest. Cardiopulmonary resuscitation was started when she did not respond to initial measures; resuscitative hysterotomy was started on the site of collapse immediately, within 4 min postarrest, to deliver the triplets within 5 min postmaternal cardiac arrest. Timely decision of resuscitative hysterotomy done primarily to restore maternal cardiac output due to a grossly gravid uterus saved the mother and the triplets. With increasing maternal age and use of in vitro fertilisation resulting in multiple pregnancies, maternal comorbidities are more likely. These could result in maternal collapse in which case timely resorting to resuscitative hysterotomy can make survival of mother and feti more likely.

4 citations

Book Chapter•DOI•
Maternal Chronic Conditions and the Fetus

[...]

Kate Jones1, Abigail Anness1, Farah Siddiqui1•
University Hospitals of Leicester NHS Trust1
01 Jan 2020
TL;DR: This is the first generation where women with complex congenital heart disease are becoming pregnant and requiring obstetric input, providing challenges to the obstetrician, the physician and the neonatologist.
Abstract: Improvements in medical care have meant that more women with complicated chronic illnesses are living into adulthood and are able to bear children. In particular, this is the first generation where women with complex congenital heart disease are becoming pregnant and requiring obstetric input. Caring for these women provides challenges to the obstetrician, the physician and the neonatologist.

1 citations

Journal Article•DOI•
Perimortem caesarean section

[...]

Olufemi Solaja, AO Fehintola, Adedapo Adetoye
01 Mar 2022-Nigerian journal of medicine : journal of the National Association of Resident Doctors of Nigeria
TL;DR: In managing such cases, multidisciplinary management must be the approach from the point of making the diagnosis to performing a resuscitative hysterotomy, as such reducing cardiac arrest delivery interval to the barest minimum.
Abstract: Maternal cardiopulmonary arrest is a very rare event whose prognosis might depend on the response to the event. We present the case of an unbooked G5P4 who had an arrest following two eclamptic fits. She had an on-site perimortem cesarean section and was delivered of a live female baby with a birth weight of 4.95 kg. She was subsequently transferred to the intensive care unit where she later died 5 days postdelivery. The baby was discharged home 4 days postdelivery with no neurological deficit. In managing such cases, multidisciplinary management must be the approach from the point of making the diagnosis to performing a resuscitative hysterotomy, as such reducing cardiac arrest delivery interval to the barest minimum.
References
More filters
Journal Article•DOI•
Part 14: Pediatric Advanced Life Support 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

[...]

Monica E. Kleinman, Leon Chameides, Stephen M. Schexnayder, Ricardo A. Samson, Mary Fran Hazinski, Dianne L. Atkins, Marc D. Berg, Allan R. de Caen, Ericka L. Fink, Eugene B. Freid, Robert W. Hickey, Bradley S. Marino, Vinay M. Nadkarni, Lester T. Proctor, Faiqa Qureshi, Kennith Sartorelli, Alexis A. Topjian, Elise W. van der Jagt, Arno Zaritsky 
02 Nov 2010-Circulation
TL;DR: In contrast to adults, cardiac arrest in infants and children does not usually result from a primary cardiac cause, more often it is the terminal result of progressive respiratory failure or shock, also called an asphyxial arrest.
Abstract: In contrast to adults, cardiac arrest in infants and children does not usually result from a primary cardiac cause. More often it is the terminal result of progressive respiratory failure or shock, also called an asphyxial arrest. Asphyxia begins with a variable period of systemic hypoxemia, hypercapnea, and acidosis, progresses to bradycardia and hypotension, and culminates with cardiac arrest.1 Another mechanism of cardiac arrest, ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), is the initial cardiac rhythm in approximately 5% to 15% of pediatric in-hospital and out-of-hospital cardiac arrests;2,–,9 it is reported in up to 27% of pediatric in-hospital arrests at some point during the resuscitation.6 The incidence of VF/pulseless VT cardiac arrest rises with age.2,4 Increasing evidence suggests that sudden unexpected death in young people can be associated with genetic abnormalities in myocyte ion channels resulting in abnormalities in ion flow (see “Sudden Unexplained Deaths,” below). Since 2010 marks the 50th anniversary of the introduction of cardiopulmonary resuscitation (CPR),10 it seems appropriate to review the progressive improvement in outcome of pediatric resuscitation from cardiac arrest. Survival from in-hospital cardiac arrest in infants and children in the 1980s was around 9%.11,12 Approximately 20 years later, that figure had increased to 17%,13,14 and by 2006, to 27%.15,–,17 In contrast to those favorable results from in-hospital cardiac arrest, overall survival to discharge from out-of-hospital cardiac arrest in infants and children has not changed substantially in 20 years and remains at about 6% (3% for infants and 9% for children and adolescents).7,9 It is unclear why the improvement in outcome from in-hospital cardiac arrest has occurred, although earlier recognition and management of at-risk patients on general inpatient units …

1,846 citations

British Thoracic Society

[...]

Arl Medford
01 Jan 2004

509 citations

Journal Article•DOI•
Adaptation of the maternal heart in pregnancy

[...]

Stewart Hunter1, Stephen C. Robson•
Freeman Hospital1
01 Dec 1992-Heart
TL;DR: Structural changes within the heart reflect the volume loading of pregnancy and include dilatation of the valve ring and increase in myocardial thickness and the resemblance to the cardiovascular changes associated with training and exercise are fascinating and worthy of further study.
Abstract: The first haemodynamic change during pregnancy seems to be a rise in heart rate. Starting between two and five weeks this continues well into the third trimester. Stroke volume increases slightly later than the heart rate and continues throughout the second trimester after an augmentation of venous return and a fall of systemic vascular resistance and afterload. Myocardial contractility is probably slightly increased. During the third trimester there is relatively little change in these cardiac indices. After delivery there is a very early and dramatic reduction in volume loading followed by a return towards normal cardiac output. Structural changes within the heart reflect the volume loading of pregnancy and include dilatation of the valve ring and increase in myocardial thickness. Post partum resolution of the ventricular hypertrophy seems to take longer than the rest of the post partum changes. The resemblance to the cardiovascular changes associated with training and exercise are fascinating and worthy of further study.

501 citations

Saving Lives, Improving Mothers' Care: Surveillance of maternal deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland. Confidential Enquiries into Maternal Deaths and Morbidity 2009-13

[...]

Marian Knight, Derek Tuffnell, Sara Kenyon, Judy Shakespeare, Ron Gray, Jennifer J Kurinczuk 
16 Jan 2017
TL;DR: 1. 妊産褥婦のメンタルヘルス不調が考えられたときは、まず、緊 急の対応を要するか否かを見極める。

349 citations

Journal Article•DOI•
Perimortem cesarean delivery.

[...]

Vern L. Katz, Deborah J. Dotters, William Droegemueller
01 Mar 1987-Obstetrics & Gynecology
TL;DR: In this paper, a review of the past centuries' cases and fetal physiology suggest that to obtain optimum infant survival, cesarean delivery should be initiated within four minutes of maternal cardiac arrest.

333 citations

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Frequently Asked Questions (13)
Q1. What are the contributions in this paper?

`` This is the peer reviewed version of the following article: Chu JJ, Hinshaw K, PatersonBrown S, Johnston T, Matthews M, Webb J, Sharpe P. Perimortem caesarean section – why, when and how. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Self-Archiving. `` 

Fetal survival depends on many factors including 342 gestation, but is a secondary issue and should not be the prime driver for deciding whether or not to 343 perform a PMCS. 

Adequate time should be allowed for uterine closure to ensure that 259 uterine perfusion and blood pressure have normalised to ascertain haemostasis. 

20–23 However, in maternal cardiac arrest, the priority is to 138 maximise the chances of maternal survival, thus high flow supplemental oxygen should be 139 administered. 

The key to achieving optimum 40 maternal and fetal survival is the rapidity with which the PMCS can be performed following onset of 41 cardiac arrest. 

The case series focused on infant survival, with 42/61 (69%) surviving when PMCS was 63 undertaken within 5 minutes of cardiac arrest. 

38 321Simulation courses such as the PRactical Obstetric Multi-Professional Training (PROMPT)39 course 322 and Managing Obstetric Emergencies and Trauma (MOET)13 can help maternity teams to improve 323 technical, communication, decision-making and team-working skills. 

Primary care and supporting community services should be directly 304 informed as soon as possible after the event, whatever the outcome. 

The current Royal College of Obstetricians and Gynaecologists’ (RCOG) guideline 54 Maternal Collapse in Pregnancy and Puerperium7 recommends that PMCS should be performed if 55 there is no ROSC after 4 minutes of correctly performed CPR in a woman who is greater than 56 20 weeks of gestation. 

the only situation in which PMCS is likely to be achieved within the recommended time 345 frame of 4–5 minutes is when maternal cardiac arrest occurs in the delivery suite. 

Although research evidence for 66 this is not robust, the physiological plausibility is clear: pregnant women are likely to become 67 hypoxic more rapidly than nonpregnant women because of higher oxygen demand. 

neonatal survivors 97 had a shorter mean cardiac arrest-to-delivery time of 14 ± 11 minutes compared to non-survivors 98 (22 ± 13 minutes). 

The review 95 also established that if the PMCS was performed within 10 minutes of cardiac arrest, maternal 96 outcomes were more favourable (odds ration [OR] 7.42, P < 0.05).