|Year : 2013 | Volume
| Issue : 1 | Page : 35-36
Perimortem caesarean section: Rethinking the resuscitation codes?
Deepak Mathur, Sng Ban Leong
Department of Women's Anesthesia, KK Women's and Children's Hospital, Singapore
|Date of Web Publication||1-Jul-2013|
Department of Women's Anesthesia, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899
Source of Support: None, Conflict of Interest: None
Perimortem cesarean section is being recommended in pregnant women beyond 20-week gestation who are in extremis or cardiac arrest and in whom resuscitation appears to be failing. Aortocaval compression is removed by the delivery that promotes cardiac output in response to chest compressions. Feto-maternal outcome is thought to improve if the delivery is accomplished within 5 min of arrest. We describe the use of a public call announcement to minimize the time to delivery by bringing together a multidisciplinary team with the required equipment to the patients location and are able to perform a timely perimortem cesarean delivery if required, potentially improving the survival.
Keywords: Cardiorespiratory arrest, maternal resuscitation, perimortem cesarean section
|How to cite this article:|
Mathur D, Leong SB. Perimortem caesarean section: Rethinking the resuscitation codes?. J Obstet Anaesth Crit Care 2013;3:35-6
|How to cite this URL:|
Mathur D, Leong SB. Perimortem caesarean section: Rethinking the resuscitation codes?. J Obstet Anaesth Crit Care [serial online] 2013 [cited 2020 Feb 17];3:35-6. Available from: http://www.joacc.com/text.asp?2013/3/1/35/114289
| Introduction|| |
We report two perimortem cesarean sections (PMCS) with the multidisciplinary involvement and prompt response using the hospital public announcement code system (PACS). This enables the resuscitation team to attend to a collapsed parturient, reducing response time to resuscitation, cesarean delivery, and neonatal care. The urgent prompt arrival of medical specialists and nurses is especially important in remote locations such as the emergency room and delivery suite where PMCS may be required. We obtained Ethics Committee approval for the reports.
| Case Reports|| |
A 32 year old primigravida at 37 week gestation was brought to our emergency room in a collapsed state. She had complained of acute breathlessness that morning. She was found collapsed at home and bystander cardiopulmonary resuscitation (CPR) was administered for an indeterminate time. She was transferred to our hospital by ambulance with continued CPR and bag-mask ventilation, after failed laryngeal mask airway insertion. She was taking oral methyldopa for treatment of pregnancy-induced hypertension, but had no other medical history of note.
The hospital "code-blue" and "code-green" protocol was activated upon her arrival with no recordable pulse. The resuscitation team secured her airway by endotracheal intubation and CPR continued with left uterine displacement (LUD) to minimize aorto-caval compression. She remained unresponsive and a PMCS was performed during CPR. A stillborn was delivered within 8 min of hospital code. She demised, despite inotropic support and fluid resuscitation. The post-mortem examination revealed death consequent to amniotic fluid embolism.
A 39-year-old primigravida at 29 weeks gestation was admitted with sudden onset dyspnea, cold sweats, and chills. Other than a previous myomectomy she had no significant medical history. On arrival at the delivery suite, she was found to be hemodynamically unstable with a tachycardia (133 bpm) and hypotension (43/12 mm Hg) recorded upon arrival to the delivery suite.
The hospital "code-blue," followed by 'code-green' were activated as she was in shock with reduced consciousness. Intrauterine death was confirmed during initial resuscitation. Rapid fluid infusion and ephedrine were administered, but she progressed to pulseless electrical activity. CPR was commenced and airway secured by endotracheal intubation. A pre-formed wedge provided LUD. Suspecting concealed bleeding, the massive transfusion protocol was activated. A PMCS was performed and the stillborn fetus delivered within 5 min of arrest. The uterus was found ruptured at the myomectomy scar. Post-partum hemorrhage developed due to uterine-atony requiring massive blood transfusion, bimanual compression, uterotonic drugs, and a B-lynch suture. She regained spontaneous return of circulation (SROC) after inotropic support and blood products. Despite early problems, she recovered well and was discharged from our intensive therapy unit after five days.
| Discussion|| |
An early recourse to PMCS within 4 min to circumvent aorto-caval compression unrelieved by LUD is important in parturients of ≥20 week's gestation in cardiorespiratory arrest. Stroke volume in supine, healthy, term-parturients falls to about 30% of a non-pregnant woman due to aortocaval compression.  Furthermore, chest compression in CPR produces only about 30% of normal cardiac output.  Hence, for the 1 st case, one could not be certain of the adequacy of maternal CPR until PMCS was performed. Radiographic studies have shown that once the uterus is emptied at cesarean delivery, the vena cava pre-load quickly returns to normal and CPR should provide adequate cardiac output.  Several case-reports confirm this, with SROC or improved maternal hemodynamics during resuscitation occurring only after cesarean delivery.  Cases with gestation ≥24 weeks and delivery by PMCS completed within 5 min of a cardiac-arrest following the "4-min rule" have best neonatal outcomes. 
Following PMCS, once SROC and cardiovascular stability are achieved, transfer to an operating theater to control bleeding or complete the operation in a more sterile environment can be performed. Although some believe that PMCS should be performed in operating theatres even in cardiac arrest, this may impede on-going CPR and worsen maternal survival. In addition, our hospital follows a massive-transfusion protocol for emergencies such as impending cardiac arrest due to bleeding, allowing us rapid access to blood products. Protocols such as these can be lifesaving as seen in the 2 nd case.
center in Singapore provides tertiary-care in obstetrics-gynecology and pediatrics, with about 12000 deliveries annually. In our protocol, the hospital operator is advised to activate the codes using the PACS. A 'code-blue' activates a team-response for obstetric-gynecological resuscitation, assembling a rostered team of anesthesia and obstetrics-gynecology specialists and intensive care unit nurse bringing resuscitation equipment and drugs. A simultaneous "code green" indicating a "crash" cesarean section brings additional specialist neonatologist and operating theatre staff with surgical equipment for PMCS. These predefined codes, using systems like our PACS, concentrate specialist manpower and resources to the collapsed parturients location more quickly than compared to contacting them individually, thereby reducing time to PMCS. PACS use, after incorporation into our hospital protocol, demonstrated a reduced decision-delivery interval from 14.9 min to 7.7 min for "crash" cesarean deliveries in the operating theatre. 
Due to the rarity of cardiac arrest in pregnancy, many practitioners are unfamiliar with specific resuscitative interventions for a parturient. This leads to slow or incorrect decisions during a crisis, leading to poorer outcomes. Cohen et al. demonstrated that knowledge of physiological changes in parturients and role of LUD, ACLS protocols and timely PMCS pertinent to resuscitation of a parturient was inadequate among clinicians.  Using PACS would ensure timely arrival of senior specialists to make decisions such as PMCS and perform advanced cardiac life support.
In conclusion, to improve the maternal and fetal outcomes following cardiac arrest, there is a need to increase awareness and training among all health-care workers. This is achievable if key interventions like correctly performed CPR following up to date protocols for parturients, LUD, timely PMCS in a failing resuscitation and specific protocols for massive-hemorrhage are uniformly incorporated in the clinical guidelines. Hospitals have a duty of care to educate and train their staff to adapt guidelines and evolve appropriate systems such as our PACS and massive transfusion protocol for their local practice. Further, audits of hospital protocols regarding response times and clinical outcomes are required.
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