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Perimortem Caesarean section ( PMCS) ;Validating the techniqueEllepola Hasthika1, Seneviratna S2, Haran Mano12

1 Department of Obstetrics and Gynaecology Logan Hospital, QLD, Australia 2 Schools of Medicine, Griffith University, QLD, Australia

Introduction

•Cardiopulmonary arrest during pregnancy presents a unique clinical scenario involving two patients; the mother and the fetus

•Management of these patients demands a rapid multidisciplinary approach

• Basic and advanced cardiac life support algorithms should be implemented

•The physiological and anatomical changes of pregnancy may require a perimotem caesarean (PMCS) delivery

•PMCC is a rare event; only few Obstetricians would have experience in performing this life saving operation.

OBJECTIVES

•Validate the technique of this rare Obstetrics procedure based on case series

• We describe two cases of cardiac arrest in pregnancy in which a PMCS was performed as part of the resuscitation process

• The authors of this study has personally been involved in one or both of the case series

Clinical cases•Case 1

A 36 year old uncomplicated mulipara was in active labour

Subsequently; experienced a cardiopulmonary arrest secondary to amniotic fluid embolism (AFE).

Code blue was called and cardiopulmonary resuscitation (CPR) commenced

To facilitate on going CPR perimotem caesarean section was performed in the birthing suit an aid of a scalpel blade

•Case 2

A 24 years old uncomplicated primi in labour was fully dilated and had a cardiac arrest in the birthing suite

CPR was commenced and with in four minutes of unsuccessful resuscitation a PMCS was performed

Due to the clinical urgency fetus was delivered with an aid of a scalpel blade

Findings

•In both occasions to facilitate the ongoing resuscitation Obstetrics team performed a PMCS approximately between 4-5 minutes since commencement of CPR

• Scalpel blade with out the handle was the only surgical instrument that was used.

• Skin to delivery time was between 15 to 30 seconds

ResultsFindings

•In both occasions to facilitate the ongoing resuscitation Obstetrics team performed a PMCS approximately between 4-5 minutes since commencement of CPR

• Scalpel blade with out the handle was the only surgical instrument that was used.

• Skin to delivery time was between 15 to 30 seconds

Technique

Transverse skin incision performed with the scalpel blade with out the handle and blunt dissection of the subcutaneous tissue

The fascial incision extended bluntly by inserting the fingers of each hand under the fascia and then pulling in a cephalad-caudad direction

Rectus muscle layer and the peritoneum separated bluntly by the operator’s fingers

Lower transverse incision made on the uterus with out reflecting the bladder

Once the fetus delivered in both occasions atonic uterus noted

uterine closure performed in two-layer, continuous closure with absorbable suture

Skin approximated with interrupted stitches using delayed absorbable synthetic sutures

Conclusions

References

•Time lines of the intervention is of extreme importance for both maternal and fetal outcome

• Time-consuming activities such as fetal monitoring and transportation to the operating theatre reduce the chances of maternal and neonatal survival and should be avoided

Conclusion

•PMCC which is potentially a lifesaving procedure for both mother and baby

• Could be promptly performed effectively even in a suboptimum location with minimum surgical instruments

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1 Zelop, CM, Grimes EP. Cardiopulmonary Resuscitation in Pregnancy. In: The textbook of Emergency Cardiovascular Care and CPR Philadelphia 2009. p.538

2Lewis, G. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: Reviewing Maternal Deaths to make Motherhood Safer 2003-2005. The Seventh Confidential Enquiry into Maternal Deaths in the United Kingdom. RCOG Press. 2007