Gestational age must have progressed to at least 24 to 26 weeks to consider perimortem C-section. Dating of the fetus can be done by dates of last menstrual cycle or by measurement of the fundal height. After 20 weeks’ gestation the fundal height (in centimeters) from the pubic symphysis to the uterine fundus, roughly corresponds to weeks of gestation. The neurological outcome of the fetus is based on the gestational age and time to perimortem delivery. It is recommended that the procedure be started within 4 minutes of maternal cardiopulmonary arrest and the baby be delivered within 5 minutes. Extending the delivery time to 10 minutes is acceptable and a good neurological outcome of the infant is likely. If there are signs of fetal life, then it would be appropriate to operate regardless of the time interval. Delivery of the infant will decompress the IVC, increase the maternal cardiac output, and improve the effectiveness of chest compressions which may help in recovery of maternal circulation.
Summary of the procedure
- Cardiopulmonary resuscitation should not be stopped and a left lateral position is best
- Vertical midline incision through all abdominal layers from epigastric to symphysis pubis is made with a scalpel. The bladder can be decompressed to aid in visualization and decrease chance of injury
- Retraction can be performed with gloved hands of an assistant or retractors
- Once the uterus is exposed, a vertical incision in the lower uterine segment is made and the uterus is lifted away from the child. Blunt dissection or scissors are used to extend the incision to the fundus. Keep the incision in the midline of the uterus as the paired uterine vessels are lateral. If an anterior placenta is encountered while extending the incision, it should be incised
- Deliver the baby and began resuscitation
- CPR should never have stopped and continuing resuscitation of the mother should be performed if indicated
- Repair internal incisions for hemostasis
- Analgesia/anesthesia will be needed if ROSC is achieved
Roberts and Hedges 5th ed., 1058-1062
Stallard TC, Burns B. Emergency delivery and perimortem C-section. Emerg Med Clin North Am. 2003 Aug;21(3):679-93.
Warraich Q, Esen U. Perimortem caesarean section. J Obstet Gynaecol. 2009 Nov;29(8):690-3.