Thinking about: Perimortem Caesarean Section

With the news of a fatal car crash in Hobart earlier this year, social media was abuzz with rumours of a perimortem caesarian section as part of resuscitative efforts. Amazingly, the newborn was delivered safely amongst this, but his mother tragically died.

This week, the local newspaper published the doctor's side of the story. Emergency specialist Kate Field describes her thought processes and preparation in the 2-3 minutes before the patient arrived in their ED. The decision to deliver the baby, one of the most difficult decisions (similar to deciding to do a surgical airway, resuscitative thoracotomy or other life & limb saving procedures), was made prior to patient arrival, and the resources and personnel allocated appropriately.

Although exceedingly rare, all EDs should have the ability to perform a perimortem c-section.

From Roberts & Hedges Clinical Procedures in Emergency Medicine 6ed
From Roberts & Hedges Clinical Procedures in Emergency Medicine 6ed

Learning from tragedy

For me, there are a few important messages from this story that are also applicable to other such procedures.

  1. Know the indications and make the decision early. Traditionally, this  procedure should aim to deliver the baby within 6 minutes, so an early decision is required.
  2. Have a clear plan in mind. This procedure requires 3 teams and appropriate resources:
    1. Maternal resuscitation
    2. Performing the procedure and managing the aftermath
    3. Neonatal resuscitation
    4. And overall, there needs to be a single leader of all of the individual teams
  3. 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.
    preg3

  4. Know what to do once the procedure is complete. Getting through the procedure is only the first bit. You then need to have a plan for treating the mother and the baby, as well as dealing with the aftermath of the procedure: debriefing, auditing, grandstanding and criticism (if the outcomes are poor).

 

A Timely Review

This review just published in the EMJ (although available online for the past year! That's a time lag!) describes the indications, contraindications, technique and logistic considerations of perimortem caesarean section.

The indications is for maternal cardiac arrest with a foetus at >20-24 weeks gestation, or fundus above the level of the umbilicus. Prior to this, the pressure effect of the uterus will not have significant effect on the venous return, so the procedure would be unhelpful (and the foetus would not be viable).

It is important to remember that this procedure is predominantly a resuscitative procedure for the mother, but also affords some increased chance of survival for the foetus. The greater the gestational age and earlier the procedure is performed, the greater the chance of a good outcome for the foetus.

parry2016-perimortemcsectionalgorithm

The procedure is described in 24 simple steps, that could be performed with simply a scalpel, but ideally a more complete kit is available.

parry2016-perimortemcsectionkit

 

These is the overly simplified basic steps (not all 24):

  1. Continue CPR with manual uterus displacement
  2. Prep skin and self
  3. Vertical midline incision from pubis symphysis to umbilicus
  4. Extend incision down to uterus
  5. Vertical incision through uterus. Don't cut baby. Cut through placenta if in the way
  6. Deliver baby, cut cord and hand off to waiting resus team
  7. Deliver placenta and clean out uterus
  8. Rub down and pack uterus, clamp bleeding vessels, give oxytocin
  9. Be prepared for atonic uterus and PPH with ROSC
  10. Close in layers if ROSC (hopefully someone more skilled will be available to perform this by now!)

 

Time for a bit more thinking, training and perhaps in-situ simulation, methinks...

 

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