Perimortem Cesarean Delivery (PMCD)

Perimortem Cesarean Delivery (PMCD)

David Ray Velez, MD

Table of Contents

Background
Procedure

Also Known as “Resuscitative Hysterotomy” or “Perimortem C-Section”

Background

Definition: A Cesarean Section Performed During Cardiac Arrest in a Pregnant Patient

The Primary Goal is to Increase the Chance of Maternal ROSC with a Secondary Goal of Saving the Fetus

Effects

  • Improves Maternal Cardiac Output
  • Decreased Blood Flow to the Uterus
  • Reduced Aortocaval Compression – Improved Venous Return
  • Reduced Pressure on the Diaphragm – Improved Respiratory Mechanics

Outcomes

  • Maternal Survival: 34-54%
    • An Estimated 24% Have a Maternal Benefit with No Evidence of Maternal Harm
  • Fetal Survival: 40-70% Under Optimal Conditions
    • Earlier Delivery Increases the Chances of Survival
    • Significantly Worse if Performed After 20 Minutes of Arrest
  • Higher Rates of Fetal Neurologic Disability After Delayed Fetal Delivery

Indication

  • Consider in a Pregnant Patient as Soon as Possible After Cardiac Arrest – Preferably within 4 Minutes
    • May Even Consider in a Peri-Arrest State
  • Relative Contraindication if in Arrest > 20 Minutes
  • Baby Must Be ≥ 24 Weeks – Approximated by Fundal Height Above the Umbilicus
    • May Consider Delivery Prior to 24 Weeks to Assist in Maternal Resuscitation Although Fetus Will Likely Be Nonviable

Residents Training to Perform a PMCD 1

Procedure

Ideally Performed by an Obstetrician but Should Not Delay if They are Not Present

Continue Resuscitation by ATLS/ACLS Measures While Performing the Procedure

Minimum Equipment

  • Scalpel
  • Scissors

Procedure

  • Make a Lower Midline Incision from the Umbilicus to the Pubic Symphysis
    • Can Extend the Incision to the Xiphoid Process if Needed
  • Cut Through the Abdominal Wall to Enter the Peritoneal Cavity
  • Deliver/Eviscerate the Uterus into View
  • Make a Midline Hysterotomy (Uterine Incision)
    • Start with a Small (2-5 cm) Vertical Incision in the Lower Uterus
    • Insert Two Fingers into the Uterus and Pull it Away from the Fetus
    • Extend the Incision to the Fundus with Scissors Curved Away from the Fetus
  • Deliver the Fetus
  • Doubly Clamp the Umbilical Cord and Cut Between
  • Pass Off the Fetus
  • Deliver the Placenta
  • Pack the Opened Uterus

After Care

  • Continue with Maternal Resuscitation During and After the Procedure
  • Consider Giving 5 U IV Oxytocin After the Procedure
  • Monitor for Bleeding, Particularly When/If ROSC is Achieved
  • Will Eventually Need to Close Hysterotomy and Abdominal Wall if ROSC is Achieved

References

  1. Adams J, Cepeda Brito JR, Baker L, Hughes PG, Gothard MD, McCarroll ML, Davis J, Silber A, Ahmed RA. Management of Maternal Cardiac Arrest in the Third Trimester of Pregnancy: A Simulation-Based Pilot Study. Crit Care Res Pract. 2016;2016:5283765. (License: CC BY-4.0)