Perimortem caesarean section – why, when and how - TOG -2018 Flashcards
After which gestation should peri-mortem caesarean section be considered
20 weeks
Perimortem caesarean section is indicated if spontaneous circulation does not return after how many minutes?
4 minutes
To improve maternal survival and reduce the risk of long term neurological outcome, delivery by perimortem caesarean should be how long after cardiac arrest?
Aim to achieve delivery within 5 minutes.
What is the approximate incidence of cardiac arrest in pregnancy?
1 in 12,500
What are the most common causes of cardiac arrest in pregnancy?
Haemorrhage 45%
amniotic fluid emobolism 13%
heart failure 13%
Anaesthetic complications 8%
Trauma 3%
according to the case series by Katz et al, after how long is maternal hypoxic brain injury more likely to occur after cardiac arrest?
6 minutes
What is the rationale for why mothers become hypoxic more rapidly than non pregnant women?
They have a higher oxygen demand and the gravid uterus impairs venous return with aortocaval compression.
By how much does the gravid uterus reduce cardiac output due to aortocaval compression?
up to 60%
How does perimortem caesarean section make maternal CPR more effective?
Reduced aortocaval compression thereby increases cardiac preload.
reduces oxygen consumption,
allows more effective maternal CPR and potentially more rapid ROSC.
What did a 2017 cohort study by UKOSS identify regarding the importance of the interval between collapse and commencing perimortem caesarean section?
The median interval was significantly shorter in women who survived, 3 vs 12 minutes.
High flow oxygen supplementation might be harmful to the fetus in utero. Should oxygen be given during maternal CPR?
yes 10-15L/min
To maximise the chances of maternal survival.
During CPR, if the maternal breast are large or engorged where should the pads of the defibrillator be placed?
On the anterior and posterior precordium
In CPR, how should the uterus be displaced to the left?
using an up, off and over technique.
If the gestation is uncertain how might you estimate gestation and whether or not to proceed with perimortem caesarean?
Undertake perimortem caesarean if the fundus is at or above the level of the umbilicus.
What equipment is required to perform a perimortem caesarean section?
a knife
and ideally 2 or more clamps or ligatures for the umbilical cord.
What abdominal incision should be used for entry is perimortem caesarean?
Whichever the clinician feels will provide the most rapid access.
Transverse may be more familiar.
Vertical may provide better access and should be used if intra-abdominal trauma is suspected.
Which uterine incision should be used in perimortem caesarean.
Depends on gestation and operator experience
Should faciliatate quickest possible delivery.
20-28 weeks consider classical
28+ consider transverse - may be slower reflecting the bladder down.
At perimortem caesarean, how should the placenta be managed?
Can be delivered or left in situ.
If resus is successful, increasing tone will cause placental separation and the placenta can be delivered.
If ROSC occurs after perimortem caesarean, how should the woman be managed.
Pressure applied for haemostasis.
GA and transfer to theatre for formal exploration and closure.
Broad spectrum abx
Describe how a classical uterine incision should be closed?
upper segment incisions usually require 3 layers
1st layer closed interrupted figure of 8 or z stitches.
Consider a drain.
If maternal death occurs how should they be managed?
Leave all lines in place,
If the placenta was not removed then leave it in place.
Ideally cover an open abdomen with a dressing, however it may be appropriate to cover the skin edges for the feelings of family members.
This must be recorded.
Where should perimorterm caesarean be performed.
If in hospital setting, PMCS should be performed at the site of cardiac arrest.
After how long of a delay from maternal collapse to caesarean can PMCS be performed?
Even when the delay is 30 minutes or more.
