A new mindset: from perimortem cesarean to resuscitative hysterotomy

Author: Daniel Cabrera, M.D.

I’m lucky to work in an academic center that fosters innovation and multidisciplinary dialogue. Early this year, I was invited by a Maternal-Fetal Medicine team lead by Carl Rose to participate in a task group rethinking the current approach to maternal cardiac arrest; this conversation originated from a very sad case of a maternal traumatic blunt agonal arrest.

This collaborative approach led to the publication in July of “Challenging the 4- to 5-minute rule: from perimortem cesarean to resuscitative hysterotomy”, in the American Journal of Obstetrics and Gynecology. [not OA]

We did a call-for-action; we believe that the concept of perimortem cesarean section should be abandoned and the mindset should transition from a last-ditch futile maneuver to a procedure aim to improve maternal chances of return of spontaneous circulation (ROSC) while giving the best option to the fetus to survive.

Traditionally perimortem c-section was recommended early into a maternal cardiac arrest if resuscitative procedures failed to obtain ROSC. This based on data showing about 75% chances of delivering a viable neonate and at least 50% of probabilities of improving maternal hemodynamics. Although robust high quality evidence is rather sparse, there are multiple reports of ROSC after removal of the fetus from the uterus and the the compression over the inferior vena cava is release, likely increasing preload significantly with some series showing dramatic 67% rate of ROSC. Respiratory physiology may also improve, particularly in late pregnancy, as delivery of the neonate can facilitate diaphragmatic mechanics.

Current guidelines focus on rapid assessment, displacement of gravid uterus, initiation of ACLS, investigation and correction of the primary cause and perimortem c-section if initial maneuvers fail. We recognize the cognitive and operational difficulty of starting this procedure; many times this can be perceived as a failure to save the mother and just as desperate effort to care for the fetus/neonate. Ultimately the human factors around these are quite complicated and require robust stress adaptation and crisis resource management skills.

We propose, from cognitive perspective, the transition from a fetocentric approach to maternal resuscitation approach, where the outcomes of the mother and fetus/neonate are equally important; also, from an operational point of view, is critical to initiate the preparations for the actual procedure at the time of arrest recognition and not after 4-5 minutes of maneuvers. Maternal hemodynamics, chances of return of spontaneous circulation and overall resuscitation management may greatly benefit from resuscitative hysterotomy while preserving a good probability to deliver a viable neonate.

The group proposes the following approach when maternal arrest is recognized

• Immediate assessment of gestational age and uterine size:
  • If the size of uterus or gestational age is known or assess to be  > 20-24 weeks immediate preparation for a resuscitative hysterotomy should be started
  • If the size of uterus or gestational age is known or assess to be  < 20-24 a resuscitative hysterotomy is not advised and resuscitation should follow standard guidelines
• If the arrest rhythm is ventricular fibrillation or pulseless ventricular tachycardia
  • Two rounds (5') of high quality cardiopulmonary massage should be performed with rhythm checks as recommended per ACLS
  • If no ROSC, resuscitative hysterotomy should be performed immediately
  • If ROSC is achieved, resuscitation should follow standard guidelines
• If the arrest rhythm is pulseless electrical activity or asystole
  • Resuscitative hysterotomy should be performed immediately
  • Further resuscitation should follow standard guidelines

A summary of the approach we propose is shown in this figure:

From Rose et al.

References

• Rose CH, Faksh A, Traynor KD, Cabrera D, Arendt KW, Brost BC. Challenging the 4- to 5-minute rule: from perimortem cesarean to resuscitative hysterotomy. Am J Obstet Gynecol. July 2015. doi:10.1016/j.ajog.2015.07.019.