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 12
  • Gestational age >24 weeks, or fundal height above the umbilicus (roughly ≥20 weeks) indicating a sizable uterus 23
  • Failure to achieve return of spontaneous circulation (ROSC) within 4 minutes of arrest 12
Contraindications
  • ROSC within 4 minutes (procedure may not be needed) 5
  • Gestational age clearly too early where maternal hemodynamics will not benefit significantly (though often the decision is made regardless during arrest) 2
Complications
  • Significant hemorrhage / uterine atony 23
  • Injury to adjacent structures (bladder, bowel) 1
  • Fetal injury (secondary consideration given maternal focus) 2

Equipment

  • Essential: Large scalpel (ideally a #10 blade), bandage scissors, gloves, retractor (if available)
  • Optional: Sterile drapes, hemostats, uterotonic agents (e.g., oxytocin) 25

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 13
  • Landmarks/US: Identify the midline from the xiphoid process to the pubic symphysis. The incision is made vertically along the linea alba 25

Analgesia/Sedation

OptionWhenKey Note
None – emergent caseDuring maternal arrestProcedural sedation is not applicable; maintain ongoing resuscitation 3

Steps

  1. 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. 3
  2. Prep the abdominal area rapidly with antiseptic and ensure that resuscitation continues uninterrupted. 5
  3. 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. 12
  4. Use blunt dissection (with your fingers) to open the peritoneum and expose the uterus. 1
  5. 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. 12
  6. Deliver the fetus and immediately clamp and cut the umbilical cord, then pass the neonate to the neonatal resuscitation team. 23
  7. Pack the open uterus and abdomen with sterile towels/gauze to control bleeding, then resume maternal resuscitation measures and definitive surgical management as indicated. 5

Post-procedure

  • Confirm: Check for return of spontaneous circulation via clinical exam and monitor cardiac rhythm. 3
  • Aftercare: Continue maternal resuscitation, manage hemorrhage with uterotonics (e.g., oxytocin), and prepare for transfer to the operating room if the maternal condition stabilizes. 2
  • Re-check: Reassess both the maternal surgical site and the continuation of chest compressions during CPR, ensuring that any bleeding is promptly addressed. 1

23

References

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