Resuscitation AlgorithmsProcedure Guide
Perimortem C-Section
High-acuity procedural response covering maternal cardiac arrest timing and resuscitative delivery technique.
Query: How to perform perimortem c-section
Summary
Perimortem C-Section (resuscitative hysterotomy) is performed during maternal cardiac arrest (or near-arrest) to relieve aortocaval compression from the gravid uterus, thereby improving maternal venous return and cardiac output. The primary goal is maternal resuscitation, with the potential secondary benefit of fetal salvage.
Indications
- Maternal cardiac arrest/impending arrest with a gravid uterus
- Gestational age >24 weeks, or fundal height above the umbilicus (roughly ≥20 weeks) indicating a sizable uterus
- Failure to achieve return of spontaneous circulation (ROSC) within 4 minutes of arrest
Contraindications
- ROSC within 4 minutes (procedure may not be needed)
- Gestational age clearly too early where maternal hemodynamics will not benefit significantly (though often the decision is made regardless during arrest)
Complications
- Significant hemorrhage / uterine atony
- Injury to adjacent structures (bladder, bowel)
- Fetal injury (secondary consideration given maternal focus)
Equipment
- Essential: Large scalpel (ideally a #10 blade), bandage scissors, gloves, retractor (if available)
- Optional: Sterile drapes, hemostats, uterotonic agents (e.g., oxytocin)
Positioning and Landmarks
- Position: Patient remains supine on a flat back while CPR continues. Manual uterine displacement to the left can be performed during chest compressions
- Landmarks/US: Identify the midline from the xiphoid process to the pubic symphysis. The incision is made vertically along the linea alba
Analgesia/Sedation
| Option | When | Key Note |
|---|---|---|
| None – emergent case | During maternal arrest | Procedural sedation is not applicable; maintain ongoing resuscitation |
Steps
- Call for additional help (obstetrics, neonatology, surgery) and notify your team that a perimortem C-section will be initiated. Continue standard ACLS with modifications for pregnancy.
- Prep the abdominal area rapidly with antiseptic and ensure that resuscitation continues uninterrupted.
- Make a midline vertical incision from the xiphoid to the pubic symphysis with your scalpel, cutting through the skin, subcutaneous tissue, and fascia until reaching the peritoneum.
- Use blunt dissection (with your fingers) to open the peritoneum and expose the uterus.
- Deliver the uterus by making a vertical incision into the lower uterine segment (take care to avoid the placenta), then extend the incision with scissors upward toward the fundus.
- Deliver the fetus and immediately clamp and cut the umbilical cord, then pass the neonate to the neonatal resuscitation team.
- Pack the open uterus and abdomen with sterile towels/gauze to control bleeding, then resume maternal resuscitation measures and definitive surgical management as indicated.
Post-procedure
- Confirm: Check for return of spontaneous circulation via clinical exam and monitor cardiac rhythm.
- Aftercare: Continue maternal resuscitation, manage hemorrhage with uterotonics (e.g., oxytocin), and prepare for transfer to the operating room if the maternal condition stabilizes.
- Re-check: Reassess both the maternal surgical site and the continuation of chest compressions during CPR, ensuring that any bleeding is promptly addressed.