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Emergency and Acute Medicine – Emergency Cesarean Section
Alert
The sole indication for an emergency department physician to perform an emergency perimortem cesarean section is a gravid female (>24 weeks gestation) in cardiopulmonary arrest who has not responded to initial resuscitative measures, regardless of cause. The most important predictor of fetal survival is the time interval between maternal cardiac arrest and cesarean delivery. The procedure should begin within 4 minutes of maternal arrest with a goal of fetal delivery within 1 minute. Immediate consultation with obstetrics, pediatrics, and surgery (if trauma related) should be obtained, but the procedure must not be delayed while awaiting consultant arrival. Emergent cesarean section should not be performed if gestational age is <24 weeks.< />pan>
Overview and Definition
Emergency (perimortem) cesarean section is a resuscitative intervention performed during maternal cardiopulmonary arrest to improve maternal hemodynamics by relieving aortocaval compression and to allow potential fetal survival. Uterine decompression improves venous return, cardiac output, and the effectiveness of cardiopulmonary resuscitation.
Etiology
Trauma, both penetrating and blunt, is the most common cause of maternal mortality. Nontraumatic causes include pulmonary embolism, cerebral vascular accident, amniotic fluid embolism, disseminated intravascular coagulation, placenta previa, eclampsia, and medical conditions such as asthma, congestive heart failure, myocardial infarction, and drug overdose.
Diagnosis
Diagnosis is clinical and based on the presence of cardiopulmonary arrest in a gravid female estimated to be beyond 24 weeks gestation.
Signs and Symptoms
The patient is unresponsive, apneic, and pulseless. Gestational age is estimated clinically.
Physical Examination
A uterus palpated at least four fingerbreadths above the umbilicus corresponds to an estimated gestational age of ≥24 weeks.
Essential Assessment
Rapid confirmation of apnea and pulselessness should occur simultaneously with evaluation for reversible causes of arrest including hypoxia, hypovolemia, acidosis, electrolyte abnormalities, hypoglycemia, hypothermia, trauma, thromboembolism, toxins, tension pneumothorax, cardiac tamponade, and supine hypotension syndrome. Fundal height in centimeters approximates gestational age in weeks. Ultrasound may be used only if immediately available and without delay.
Diagnostic Tests and Interpretation
No imaging or laboratory studies are required to establish the diagnosis. Fetal heart tones should not be assessed if this delays intervention.
Prehospital Care
Scene time should be minimized. The patient should be positioned in the left lateral decubitus position to relieve inferior vena cava compression. In trauma patients requiring spinal immobilization, manual uterine displacement or elevation of the right hip should be performed.
Initial Stabilization
Standard ACLS measures should be initiated, including airway management with a smaller endotracheal tube, high-flow oxygen, cardiac monitoring, and large-bore IV access with aggressive fluid resuscitation. If gestational age is ≥24 weeks and no return of spontaneous circulation occurs after 4 minutes of resuscitation, immediate cesarean section is indicated.
Emergency Department Procedure
Do not delay for consultants. Perform a vertical midline abdominal incision from the pubic hairline to approximately 5 cm above the umbilicus. Incise through fascia and peritoneum, retract the bladder inferiorly, make a vertical uterine incision, deliver the fetus, clamp and cut the umbilical cord, deliver the placenta, reassess maternal circulation, and continue resuscitative efforts.
Disposition
The neonate requires admission to the neonatal intensive care unit. If maternal circulation returns, the mother requires intensive care unit admission. Neither patient should be discharged from the emergency department.
Pearls and Pitfalls
Only gravid patients ≥24 weeks gestation qualify for perimortem cesarean section. The decision must be made within 4 minutes of maternal arrest, and delivery should be completed within 1 minute. Speed and decisiveness are critical.
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