Abdominal preparation and insertion of a Foley catheter to decompress the bladder may be performed prior to initial incision if time allows but should not delay the procedure. No anesthesia is required, since the mother is in cardiac arrest. A vertical midline (classical) incision is made from 4 to 5 cm below the xiphoid process to the pubic symphysis through the abdominal wall. The rectus muscles may be separated with blunt dissection, and the peritoneum is entered with a midline incision that is continued superiorly and inferiorly to allow visualization of the uterus. A vertical uterine incision is made from the fundus to the point at which the opaque bladder is adherent to the uterus. An initial small inferior incision may be made until amniotic fluid is obtained and then extended with scissors using the free hand to elevate the uterus, avoiding injury to the fetus. An anterior placenta should be incised in order to reach the fetus. The fetus is then delivered and resuscitated. The placenta is then manually removed from the uterus, and the uterus is wiped clean of membranes with a sponge or towel. The uterus is closed with one or two layers with a locked running stitch using number 0 or number 1 semipermanent suture and a large needle. The fascia and peritoneum may be closed with a permanent or semipermanent number 0 or number 1 suture with a running stitch. Finally the skin is closed. Closure of the abdomen may be delayed until maternal pulse and blood pressure are restored, to allow direct observation of the uterus for ongoing bleeding. Uterine atony after perimortem cesarean section is common and may lead to significant blood loss when the uterus fails to contract after delivery. Because maternal blood circulation may not be sufficient to deliver intravenously administered medication, dilute oxytocin (10 U in 9 mL normal saline solution) may be injected directly into the myometrium in divided doses until contraction occurs. Other possible therapeutic medications include ergometrine (intravenous or intramuscular) or prostaglandin F 2a into the uterus.
Informed consent for perimortem cesarean section is not necessary. The procedure needs to be performed expediently and should be considered part of the resuscitation. The performance of a non-life-threatening operation in the setting of cardiac arrest abides by the ethics of absence of malfeasance and beneficence for both the mother and the fetus. The question of when emergent cesarean section should be performed in critically ill, prearrest patients has not been adequately addressed in the literature. In addition, the recommendations for perimortem cesarean section are based on multiple case reports. No experimental studies have been done to evaluate this procedure.
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