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Created July 23, 2015, last updated almost 4 years ago.
Collection: 31, Score: 2929, Trend score: 0, Read count: 3218, Articles count: 6, Created: 2015-07-23 10:05:32 UTC. Updated: 2021-02-09 00:03:58 UTC.Notes
Cardiac arrest is rare in pregnancy (1 in 30,000) and resuscitation is founded on the same approach used for the non-pregnant patient, focusing on:
- Recognition
- Calling for help
- A B C (D)
- Good for mother = good for baby
However, unique to maternal resuscitation:
- Airway difficulties are more likely.
- Aortocaval compression dramatically impedes resuscitation – employ left lateral tilt!
- Consider perimortem cesarean section
The rationale for Perimortem Cesarean Section is:
- The presence of baby and gravid uterus severely limits resuscitation of the mother.
- Emergency cesarean section at cardiac arrest is done for the mother’s benefit, not the baby.
- A decision to perform emergency CS must be made within 4 minutes of arrest, and the baby delivered within 5 minutes. (Although there is some evidence of benefit when performed up to 10 minutes after arrest.)
- The only equipment required is a scalpel and an appropriately skilled doctor.
Daniel Jolley
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Collected Articles
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A very practical review of the evidence, indications and rationale for the perimortem cesarean section. Richard Parry describes the specific steps required to perform a PMCS, along with discussion of the pros and cons of different approaches. The importance of multidisciplinary training is emphasised.
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In this review of published perimortem caesarean section cases more than half of the mothers survived to hospital discharge and almost 80% of these with favourable neurological outcome.
PM caesarean section was considered beneficial in 32% of cases.
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Am. J. Obstet. Gynecol. · Jun 2005
ReviewPerimortem cesarean delivery: were our assumptions correct?
A review of all published perimortem cesarean section case reports by Vern Katz, following up his article in 1986 first recommending this procedure.
While this does not offer proof of benefit (huge survival selection bias), of the 38 cases reported, 34 neonates survived (includes multiple gestations), and of the 20 cases with reversible causes, 13 mothers were discharged from hospital.
Katz writes:
summaryIn 12 of 18 reports that documented hemodynamic status, cesarean delivery preceded return of maternal pulse and blood pressure, often in a dramatic fashion. Eight other cases noted improvement in maternal status. Importantly, in no case was there deterioration of the maternal condition with the cesarean delivery.
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McDonnell highlights the differences in managing the collapsed parturient, namely:
- Need to prevent aortocaval compression.
- Early securing of the airway.
- Rapid perimortem Caesarean delivery.
- Likelihood of a non-cardiac/pregnancy cause.
The two cases presented include arrest due to ruptured uterus and arrest possibly due to iatrogenic magnesium overdose. Both resulted in favorable, though not perfect, outcomes for mother and baby.
The need for delivery suite ‘perimortem cesarean section packs’ is also discussed, as well as the use of regular simulation training.
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The first published case of a successful perimortem cesarean section with good neurological outcome for both mother and baby.
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This is the first published recommendation for perimortem cesarean sections in maternal cardiac arrest – from Katz, Dotters and Droegemueller (1986).
It was this recommendation that lead to the ‘4 minute rule’ for deciding to commence a CS in a resuscitation scenario, with the aim of delivering the baby within 5 minutes.
summary