Perimortem Cesarean Delivery
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Cesarean delivery is one of the oldest surgical procedures in history, with literature dating back to at least 800 BCE. [1, 2, 3, 4] Before the 20th century, however, the procedure was never undertaken unless the mother was dead or moribund. [2]
During the late 19th and early 20th centuries, case reports began to arise of perimortem cesarean delivery (PMCD) successfully salvaging the fetus, and the procedure began to be seriously considered as a legitimate medical intervention. Well into the 20th century, the salvage rate was very low, and therefore, authors on the subject advocated it only after all other resuscitative measures had failed.
See the figure below.
During the 1980s, several authors reported unexpected maternal recoveries after postmortem cesarean deliveries. [5, 6] This led to the possibility that PMCD might actually improve, rather than worsen, a mother’s chance of survival during a collapse.
Because current pregnancy-related death rates are, fortunately, very low, [7] PMCD is rarely required at present. Although this procedure has traditionally been performed during resuscitative efforts in the emergency department (ED), [8] a case of PMCD in the prehospital setting has been reported. [9]
Before 1986, only 188 PMCDs had been reported; a case review of the data reported between 1986 and 2004 revealed only 38 additional case reports. [10] A review of these 38 case reports revealed that the most common causes of maternal arrest included trauma, pulmonary embolism, cardiac causes, sepsis, and eclampsia. [10] Despite the paucity of data, PMCD infant survival rates as high as 70% have been reported; more recently, successful maternal resuscitations related to expedited delivery of the infant have been reported. [11] Other etiologic factors were noted in a recent case series, as 4 of 5 cases of PMCD involved obese women older than 35 years. [12]
Despite the rarity of PMCD, it is worthy of attention because, when appropriately applied, it can save the life of both the mother and the infant. Furthermore, recent literature suggests that the role for PMCD may be broader than previously envisioned, and the procedure may attain a more prominent role in the future.
Go to Vaginal Birth After Cesarean Delivery and Cesarean Delivery for complete information on these topics.
Currently, maternal diseases are vastly different in the industrialized world from what they were a century ago. A 1986 review highlighted the shift over the past century from primarily chronic, mostly infectious causes of death to primarily acute, mostly cardiorespiratory causes of death. [4]
This shift is vitally important for outcome. A chronically ill mother may be inadequately nourishing her unborn child for months, thus making a good outcome of any delivery less likely. However, an acute event, such as pulmonary embolus, leaves the infant with some reserves and allows a less-than-optimal delivery setting to produce a good outcome.
In addition, the ability to monitor high-risk patients and intervene in the event of a crisis has greatly expanded over the past 50 years. The advent of advanced emergency transportation systems, advanced life support protocols, and intensive cardiorespiratory support units allows much better outcomes after prolonged anoxia than might have been possible before these advances.
Several factors must be considered in deciding whether to undertake PMCD. [13, 14, 15, 2, 4, 5, 16, 17, 18] The first is the estimated gestational age (EGA) of the fetus. This information is sometimes difficult to obtain in an emergency situation, and allowing time to perform an ultrasonographic estimate is not practical. Thus, a gross visual estimate may be necessary.
As a general rule, the uterus reaches the umbilicus at 20 weeks of gestational age and grows at a rate of approximately 1 cm in length for every week thereafter. Thus, in a relatively thin woman, a fundal height of 8 cm above the umbilicus would likely represent a pregnancy of 28 weeks’ gestation.
The resources of the institution should also be considered in the decision regarding PMCD. Under ideal circumstances (ie, with the availability of all skilled personnel and in a controlled setting), fetal salvageability may range from 23 to 28 weeks of EGA. If the EGA is 23 weeks and the institution’s nursery has never had a newborn of this EGA survive, PMCD is probably not indicated for the sake of the fetus.
PMCD also may not benefit the mother, compared with a third-trimester intervention, because the cardiovascular effects of pregnancy are less pronounced before 28 weeks, and delivery therefore will not achieve dramatic maternal cardiovascular improvement. Before 23 weeks of gestational age, aggressive maternal support is the only indicated intervention, and at least 1 case of complete maternal and fetal recovery after a prolonged arrest at 15 weeks of EGA has been reported. [19]
Another concern relates to the length of time between arrest and delivery. Although the rare nature of the condition makes evidence somewhat sketchy at best, early intervention is strongly supported in the course of a cardiopulmonary arrest at advanced gestational age.
The latest reported survival was of an infant delivered 30 minutes after a maternal suicide, [20] but the best outcomes in terms of infant neurologic status appear to occur if the infant is delivered within 5 minutes of maternal cardiac arrest. This means the decision to operate must be made and surgery begun by 4 minutes into the arrest.
The same authors that proposed this timeframe reviewed the literature again in 2005 and reported 7 infant survivals in deliveries occurring more than 15 minutes after maternal cardiac arrest. [10] These findings suggest that considering PMCD is prudent, even if there has been some delay after a diagnosed cardiac arrest. Notably, the authors again confirmed that maternal status did not worsen in any case in which a PMCD was undertaken and seemed to improve in 13 of 20 cases published. In addition, a recent case series notes that of the 4 survivors (out of 5), 3 cases had PMCD initiated 6-14 minutes after maternal arrest, and initial follow-up was encouraging in all 4 infants. [12]
A study by Rose et al reinforced the concept that arrangements for delivery should be made at the same time with initiation of maternal resuscitative efforts if the uterus is palpable at or above the umbilicus. The authors also added that if maternal condition is not rapidly reversible, hysterotomy with delivery should be performed regardless of fetal viability or elapsed time since arrest. [21]
Another factor to be considered is the adequacy of other resuscitative efforts in the interim. Adequate chest compressions and displacement of the gravid uterus off the venous return from the lower extremities are both proven to improve maternal oxygenation. The fetus lives on the steep portion of the oxygen dissociation curve; therefore, relatively minor maternal changes may result in dramatic changes for the fetus. Resuscitative efforts also must include postcesarean infant resuscitation.
Documenting fetal heart tones before PMCD is not required, partly because it is time consuming and may negatively impact the baby’s outcome and partly because maternal indications for the procedure are emergency concerns regardless of fetal status.
A special case of PMCD is the scheduled PMCD. This involves a woman who is deemed brain dead but is maintained on artificial support for the purpose of allowing fetal maturity. Successful cases of scheduled PMCD have been reported from EGAs as early as 6 weeks, [22] but an ethics issue arises regarding extraordinary support measures for the sole purpose of providing a fetal incubator. Full informed consent from the next of kin is mandatory. [23]
The most likely timeframe for both successful support and acceptance of the value of support is at 24-27 weeks of EGA, [24] when a few days make a large difference to fetal outcome. Support beyond likely fetal survival is controversial. [25] Dillon and colleagues make a strong distinction between true brain death and persistent vegetative state, arguing that termination of support measures is ethically defensible only in the former case. [24]
Yet another factor that may affect decision making is potential medicolegal considerations. Fear of litigation may prevent intervention in what would be, by all medical judgment, appropriate circumstances for a PMCD. It should be kept in mind, however, that no lawsuits filed on the basis of wrongful performance of PMCD have been reported in the literature. [26] Only 1 legal penalty has been levied in regard to PMCD—the death penalty, which was given in the 18th century for failure to perform the procedure.
Generally, PMCD is deemed an emergency procedure for which consent is not possible. When maternal consent is not an issue, no other opinion should be deemed as legally binding in the emergency setting. Clearly, when the situation involves a ventilator-dependent, brain-dead patient being kept alive solely as a nursery, next-of-kin decisions become relevant, and legal and, possibly, spiritual, counsel should be sought.
Contraindications to PMCD include the following:
Known gestation less than 24 weeks
Return of spontaneous circulation after brief period of resuscitation
A perimortem cesarean delivery (PMCD) should be performed by the present physician with the most surgical experience, preferably an obstetrician or surgeon, if available. A neonatologist should also be in attendance, if possible.
It is understandable that the first reported successful cesarean delivery was performed by a sow gelder, who presumably was comfortable with the feel of live tissue and familiar with concepts of vascular control. [2] However, PMCD is not the time to teach a junior resident the technique. If the emergency department (ED) is informed that a pregnant woman who is seriously ill or injured is en route, the prudent plan is to immediately summon obstetric and pediatric support personnel.
Despite the limitations of the setting, regard for surgical technique is a key consideration. Care should be taken to protect the bowel and bladder from injury if possible. The emergency nature of the procedure also generally precludes assessment of fetal heart tones, placement of a urinary drainage catheter, and surgical preparation of the patient’s abdomen (scrub and shave).
Providers should take care to avoid needle sticks, scalpel cuts, and other safety issues. Provider safety is at higher risk in emergency situations, where appropriate lighting, proper equipment, and provider experience may be lacking.
Maternal resuscitation efforts—including definitive management of the airway, cardiopulmonary resuscitation (CPR), fluids, and advanced cardiac life support (ACLS) protocol–driven pharmaceutical therapy—should not be interrupted to allow more room for the surgical intervention team. Full CPR measures should continue during the delivery.
Most young obstetricians perform Pfannenstiel incisions almost exclusively for cesarean deliveries; however, this is problematic in the setting of PMCD. The available equipment is likely to be minimal, the equipment is generally not neatly arranged, and a scrub technician probably will not be standing at the ready. Although many spectators may be present, none is likely to be of value as an assistant. Lighting may be poor and not deployable where needed within the incision.
Given these restrictions, a midline abdominal incision remains the appropriate choice for PMCD. The incision should extend from the level of the uterine fundus to the pubic symphysis. Rapid but careful dissection or incision should be made through all layers of the abdominal wall, including the peritoneum.
Gain exposure to the uterus. Use retractors to pull the abdominal wall laterally on both sides, and bluntly dissect down until the peritoneum is entered. A bladder retractor may be used to reflect the bladder inferiorly and gain better visualization of the uterus.
While avoiding the bowel and bladder, make a vertical incision from the fundus to no farther than the anterior reflection of the bladder. Take care to avoid the blood vessels laterally.
When the uterine cavity is first entered, insert the index and middle fingers to lift the uterine wall away from the fetus and extend the incision as needed, preferably with bandage scissors. Take care when incising the uterus; reckless uterine entry can inflict lacerations on the fetus.
Deliver the infant, suction the infant’s mouth and nose, and clamp the umbilical cord. Pay close attention to planes of anatomic function, so that permanent nerve damage from overextension does not occur. Upon delivery, the infant should be immediately handed to someone trained in infant resuscitation.
A loop of cord should be clamped at each end and saved for later cord gas evaluation. The closed loop of cord may sit for up to 60 minutes without significant deterioration of the gas values. [27] Cord blood should also be collected, as with all deliveries, so that routine neonatal hematologic studies can be performed without drawing blood from the infant. The placenta should always be removed before closure.
Continue maternal resuscitation, as indicated.
Closure should be based on maternal circumstances and the mother’s response to resuscitative efforts. If possible, closure should be performed in the operating room.
If the resuscitation team believes the mother has a chance of survival, a careful, layered closure should be performed. Attention to meticulous closure technique is vital because poor perfusion at the time of surgery may cause areas of bleeding to be inactive, which would then become active when circulation is restored. In addition, disseminated intravascular coagulation is a common sequela of massive hemodynamic challenge. Avoiding needless blood loss may help prevent or mitigate this condition.
If the mother’s condition is thought to be hopeless, then a rapid closure for purposes of aesthetics is indicated.
If maternal survival seems likely, antibiotic prophylaxis should be given. The rules of “dirty” surgery should apply, and any broad-spectrum penicillin or cephalosporin in a single dose should be adequate.
Anesthesiologists are frequently available when a patient has arrested. If available, they can administer anesthetic as appropriate.
Equipment includes the following:
Cesarean delivery or abdominal major kit, if available in the emergency setting
Scalpel, No. 10
Hemostats
Suction
Large scissors
Gauze sponges
Large retractors or bladder retractor (sometimes difficult to find but very useful)
Because PMCD is infrequently performed, EDs may not have a preselected pack of instruments for this procedure. However, most of the necessary items are readily accessible in the ED.
The mother should be in the supine position with left lateral tilt. [28] Preparing and draping the patient is unnecessary.
Expeditious decision-making is crucial. Delayed decision-making may lead to unnecessary prolongation of the time from arrest to PMCD.
Injury to the bladder may be prevented by reflecting the organ inferiorly and decompressing it by means of needle aspiration. Injury to the fetus can be prevented by using bandage scissors or blunt dissection to extend the initial incision into the uterus. (See Technique.)
Providing reliable estimates of maternal and neonatal outcomes from perimortem cesarean delivery (PMCD) is virtually impossible. The American literature primarily contains case reports and very small series. The United Kingdom previously included some data in the Confidential Enquiry into Maternal Deaths, but, as the name suggests, the registry applied only to cesarean deliveries in which the mother did not survive. In addition, this database was dissolved on March 31, 2003.
When active, the Confidential Enquiry into Maternal Deaths noted that from 1994-1996, 13 deliveries occurred that were classified as either postmortem or perimortem. Of these, only 2 babies were born alive, and one of them died shortly thereafter.
The registry strongly supports the concept of rapid choice for delivery because the outcomes in the perimortem group (patients who were moribund or undergoing cardiopulmonary resuscitation) were significantly better than those in the postmortem group (patients who were thought to have already died). [29] In 10 years, 40 perimortem deliveries were registered, of which 25 resulted in neurologically intact surviving infants (62.5%).
Uteroplacental blood flow may require up to 30% of a woman’s cardiac output during pregnancy, [30] and this may be recruited for perfusion of other visceral organs after delivery. Several animal and laboratory models and a growing body of clinical evidence suggest that cardiac compressions are more effective after delivery. [5]
A decrease of 30% occurs in stroke volume and cardiac output in a pregnant woman who lies supine, largely because the inferior vena cava is completely occluded (which occurs in 90% of women in late pregnancy). In addition, a 20% reduction in functional residual capacity occurs at term, and the metabolic rate is faster; these changes lead to decreased oxygen reserves and a more rapid onset of anoxia following apnea. [4]
When previous maternal resuscitative efforts have failed, cesarean delivery of the infant is beneficial to both the infant and the mother. Emptying the uterus improves maternal physiology and the effectiveness of CPR. The data from Katz et al support this notion (see the table below). [10]
Table 1. Cases of Maternal Improvement Upon Cesarean Delivery of Infant (Open Table in a new window)
Time From Maternal Arrest to Delivery, min
Return of Spontaneous Circulation, Improvement of Hemodynamic Status, or Both
No Change in Maternal Status
0-5
5
2
6-10
3
…
11-15
1
…
>15
4
5
Not reported
1
1
Delivery of the near-term fetus provides a 30-80% improvement in cardiac output and, in conjunction with other resuscitative measures, may provide sufficient circulatory improvement to adequately support central nervous system function during an arrest. [5] Accordingly, prompt and appropriate intervention is critical to maximize the survival possibilities for the mother and baby.
Several factors directly influence infant survival, including gestational age, time from maternal arrest to infant delivery, [31] adequacy of resuscitative efforts, and access to neonatal intensive care resources.
Most centers estimate fetal viability as beginning around 24 weeks of gestation. In an emergency situation where PMCD is indicated, spending the time required to obtain an accurate estimate of gestational age (if gestational age is not already definitively known) by means of ultrasonography is not practical, and fundal height is used as a crude estimate of fetal viability.
However, whereas the use of ultrasonography to evaluate fetal cardiac activity has been more recently supported in the literature, [32] it is not a requirement for proceeding with PMCD. In addition, useful historical information, such as the date of the last menstrual period, is likely to be unavailable.
One fast and easy way to estimate the gestational age is to measure the distance (in cm) from the pubic symphysis to the top of the fundus (ie, fundal height). Between 18 and 30 weeks, each 1 cm of fundal height roughly correlates to 1 week of gestational age. Thus, for a rough determination of fetal viability, the fundal height should be greater than 24 cm, or 4 cm above the umbilicus.
To increase the likelihood of infant survival, the procedure should be performed as soon after maternal arrest as possible. [33] Initial recommendations were based primarily on theory and a few case reports. They suggested that PMCD should be initiated within 4 minutes of maternal arrest when resuscitative efforts have failed.
Subsequently, Katz et al reported on the 38 cases of PMCD reported from 1986-2004. [10] Of the 34 infants who survived, the time from maternal rest to delivery was recorded for 24 (see the table below).
Table 2. Reported Surviving Infants With Time of Maternal Arrest to Perimortem Cesarean Delivery [10] (Open Table in a new window)
Time From Maternal Arrest to Delivery (min)
Gestational Age (wk)
Normal Infants
Total Infants
0-5
25-42
8
11
6-10
28-37
1
4
11-15
38-39
1
2
>15
30-38
4
7
These data support the previous recommendations; additionally, they indicate that infant survival was seen when PMCD was performed well beyond 4 minutes after maternal arrest. Therefore, although earlier is better, PMCD should be attempted even in the face of prolonged maternal downtime if circumstances suggest that the fetus is potentially viable. [20]
Normal infants have been delivered as late as 22-29 minutes after maternal arrest, although in these cases, follow-up was limited to 18 months. A recent case report by Capobianco et al documented normal neurologic development at age 4 years in a child who had been delivered by PMCD 30 minutes after maternal death. [20]
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Healy ME, Kozubal DE, Horn AE, Vilke GM, Chan TC, Ufberg JW. Care of the Critically Ill Pregnant Patient and Perimortem Cesarean Delivery in the Emergency Department. J Emerg Med. 2016 Aug. 51 (2):172-7. [Medline].
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Capobianco G, Balata A, Mannazzu MC, Oggiano R, Pinna Nossai L, Cherchi PL, et al. Perimortem cesarean delivery 30 minutes after a laboring patient jumped from a fourth-floor window: baby survives and is normal at age 4 years. Am J Obstet Gynecol. 2008 Jan. 198(1):e15-6. [Medline].
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. 2015 Nov. 213 (5):653-6, 653.e1. [Medline].
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Stehr SN, Liebich I, Kamin G, Koch T, Litz RJ. Closing the gap between decision and delivery–amniotic fluid embolism with severe cardiopulmonary and haemostatic complications with a good outcome. Resuscitation. 2007 Aug. 74(2):377-81. [Medline].
Time From Maternal Arrest to Delivery, min
Return of Spontaneous Circulation, Improvement of Hemodynamic Status, or Both
No Change in Maternal Status
0-5
5
2
6-10
3
…
11-15
1
…
>15
4
5
Not reported
1
1
Time From Maternal Arrest to Delivery (min)
Gestational Age (wk)
Normal Infants
Total Infants
0-5
25-42
8
11
6-10
28-37
1
4
11-15
38-39
1
2
>15
30-38
4
7
E Jedd Roe, lll, MD, MBA, FACEP, FAAEM, MSF, CPE Professor, Department of Emergency Medicine, University of Florida at Jacksonville College of Medicine
E Jedd Roe, lll, MD, MBA, FACEP, FAAEM, MSF, CPE is a member of the following medical societies: American Academy of Emergency Medicine, American Association for Physician Leadership, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Bophal Sarha Hang, MD Resident Physician, Department of Emergency Medicine, William Beaumont Hospital
Bophal Sarha Hang, MD is a member of the following medical societies: Phi Beta Kappa
Disclosure: Received none from None for none.
Deborah Lyon, MD Director, Division of Gynecology, Associate Professor, Department of Obstetrics and Gynecology, University of Florida Health Science Center at Jacksonville
Deborah Lyon, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of American Medical Colleges, Association of Professors of Gynecology and Obstetrics, Florida Medical Association
Disclosure: Nothing to disclose.
Janyce Marie Sanford, MD Associate Professor, Chair, Department of Emergency Medicine, University of Alabama at Birmingham School of Medicine
Janyce Marie Sanford, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Carl V Smith, MD The Distinguished Chris J and Marie A Olson Chair of Obstetrics and Gynecology, Professor, Department of Obstetrics and Gynecology, Senior Associate Dean for Clinical Affairs, University of Nebraska Medical Center
Carl V Smith, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, Council of University Chairs of Obstetrics and Gynecology, Nebraska Medical Association
Disclosure: Nothing to disclose.
Nicole W Karjane, MD Associate Professor, Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center
Nicole W Karjane, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, North American Society for Pediatric and Adolescent Gynecology
Disclosure: Received income in an amount equal to or greater than $250 from: Merck<br/>Served as Nexplanon trainer for: Merck.
Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
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