Perimortem Cesarean Delivery

The need to perform perimortem cesarean delivery in cases of maternal cardiac arrest arises extremely infrequently. Nevertheless, it involves complex ethical, medical, and emotional considerations. The largest review of reported attempts to date in the literature revealed fewer than 200 successful fetal outcomes from the procedure.16 The time to delivery from the onset of maternal arrest was found to be critical to fetal survival with good neurologic outcome. Excellent outcomes were reported when delivery took place within 5 min of maternal death. Survival was unlikely if delivery occurred after 20 min of maternal arrest. It has since been recommended that the procedure be performed after 4 min of maternal resuscitation. Recently, the first successful out-of-hospital perimortem cesarean delivery was reported and with a time interval of 34 min between maternal collapse and delivery, although with severe neurologic deficits in the infant. 17

Consideration of perimortem cesarean delivery must be made only after immediate and optimal advanced maternal cardiopulmonary resuscitative measures have been instituted. The procedure may be attempted in gestations estimated at beyond 23 weeks17 (Tab]§..246-2). Full maternal resuscitation must continue unabated while preparing for and during the actual delivery. It is universally recommended that the procedure be performed rapidly with the most readily available materials and that a single vertical incision be made to enter the peritoneum, followed by a vertical uterine incision to deliver the fetus. Successful maternal revival following fetal delivery has been reported. Improved venous return to the central circulation, increased maternal oxygen delivery following removal of the high uterine demand, and decreased pooling of blood in the uteroplacental circulation have all been suggested explanations.

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