Professional Documents
Culture Documents
our patient, a 29-year-old G3, P0 high school English teacher at 39-4/7 weeks gestation, without other comorbidities, went into spontaneous labor after rupture of membranes early this morning. She requested and received an epidural approximately 1 hour ago. Her status is 6 cm dilated, 100% effaced, and 1 station. The fetus had a reassuring tracing when you left a few minutes ago to grab lunch. At 12:30 PM, you are in the hospital cafeteria. You are about the pay the cafeteria cashier, when you hear a page overhead Code Blue, Labor and Delivery. Code Blue, Labor and Delivery. You run to Labor and Delivery and see a crowd gathered around your patients room. The family and friends are in the
*Clinical Professor, Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR. Clinical Professor, Department of Human Physiology, University Oregon, Eugene, OR. Peace Health Medical Center, Oregon Health Science University, Springeld, OR. Address reprint requests to Vern L. Katz, MD, Peace Health Medical Center, Oregon Health Science University, 181 W 22nd Ave, Eugene, Oregon 97405. E-mail: vkatz@peacehealth.org
hall. Some are ashen-faced; some are covering their eyes and crying. You push through the crowd of onlookers and staff. A terried labor and delivery aide sees you and says, She just sat up, grabbed her chest, and gasped that she couldnt breath, and then fell over. There is a lot of noise, and people in the room, most of whom you do not recognize, are performing code tasks. The team leader of the code loudly announces, Still no pulses. Prepare to shock her again. There are no fetal heart tones on the monitor because it has been disconnected and moved to the corner to allow space for chest compressions. The Labor and Delivery charge nurse turns to you and says, Its been about 6 minutes since we called the code. What do you do? Do you take a scalpel, squeeze between the code team, and perform a laparotomy right there and then in the bed? The correct action, as terrifying as it is, is to do exactly that. This discussion will present the history, development, and scientic rationale of the perimortem cesarean delivery, emphasizing its role as a vital part of the management of maternal cardiac arrest and maternal mortality.
68
0146-0005/12/$-see front matter 2012 Elsevier Inc. All rights reserved. doi:10.1053/j.semperi.2011.09.013
69 cian. In 1860, the famous obstetrician Scanzoni wrote, The fetus in utero is the same as any other internal organ of the woman. If we recognize the instance of the death of the mother when all organic expression is gone and organic laws yield to chemical laws, that instance we must recognize also the death of the child.3-6 One of the reasons for the high frequency of postmortem sections was the high rate of maternal mortality. Throughout the 19th century, the maternal mortality rate in Europe ranged between 2% and 4% of all births.7 The causes for maternal mortality were often sepsis, dehydration, and maternal shock. As might be expected, fetuses delivered from mothers in sepsis or hemorrhagic shock would usually die before the mother died, thereby contributing to the bad reputation of the postmortem section. However, as the causes of maternal mortality changed in the 20th century, and the incidence of infection and hemorrhagic shock declined, the potential salvage of infants from a postmortem section began to increase. Of recorded cases of postmortem sections between 1879 and 1956, infection represented 40% of the causes of maternal mortality. Between 1970 and 1985, infection accounted for only 3% of the causes of maternal mortality, and the proportion of cases of cardiac, anesthetic, and embolic deaths increased signicantly. Sudden deaths, with the fetus being in better health before the maternal cardiac arrest, led to an increase in anecdotal reports of live infants and a gradual improvement in the attitude toward postmortem section. By the mid 1900s, the attitudes toward postmortem section had evolved remarkably.3-6 The second issue that led to the evolution of physician attitudes was the realization of the difculties of cardiopulmonary resuscitation (CPR) in late pregnancy. As witnessed cardiac arrests in the hospital increased, and modern CPR became widespread, more and more pregnant women had documented attempts at resuscitations. These resuscitations were rarely, if ever, successful. Corke and Spielman pointed out the difculty when cardiac arrest occurred secondary to anesthetic complications.8 DePace et al, in a landmark report published in 1982, described a woman who developed a cardiac arrest during bronchoscopy while being evaluated for hemoptysis. After 20 minutes of unsuccessful CPR, a postmortem section was performed. As soon as the surgery was performed, the patient was able to be successfully resuscitated. Pulsations returned with the chest compressions. Both mother and baby did well, with no long-term sequelae.9 In 1985, we were called to see a morbidly obese mother with severe preeclampsia who developed a cardiac arrest in the Emergency Department parking lot. After 22 minutes of unsuccessful CPR, a postmortem section was performed. Immediately after the viable baby was delivered, we were able to achieve pulsations with chest compressions. However, we could not resuscitate the mother. The observation of the temporal relationship between emptying of the uterus, relieving the aortocaval compression, and successful chest compressions in achieving arterial pulses led us to the concept of the perimortem section.
70
V.L. Katz
other 60%. Ueland et al in a series of radiologic experiments showed that stroke volume in a healthy woman at term and lying in a supine position was approximately 30% of that of a nonpregnant woman.11 Thus, chest compressions, at best, produce 10% of normal cardiac output. Kerr documented that immediately on emptying the uterus, aortocaval compression stops.12
The Paradox: To Achieve Effective Chest Compressions With CPR, the Uterus Must Be Emptied and the Baby Delivered
Most maternal cardiac arrests are from etiologies in which the mother cannot be resuscitated. However, if she can be saved, then there is even greater reason to perform a timely delivery. Delivery within 4-5 minutes would protect the mothers central nervous system as well as the babies. Gerty Marx, the mother of obstetric anesthesia, published an illustrative report of 5 cases of cardiac arrest that occurred at the time of induction of anesthesia for elective cesarean deliveries. These women were at term and on the operating table for cesarean delivery, with their obstetricians scrubbed and the pediatricians in attendance. Three of the mothers had immediate cesarean sections performed at the same time that CPR was initiated. All 3 did well. In 2 other mothers, CPR was continued from 6 to 9 minutes before the cesarean sections were begun. Both mothers had irreversible brain damage from waiting the extra time with no cerebral perfusion.13 In the modern era, more than 200 cases of maternal cardiac arrest with CPR have been published.3-6,14-18 There is obviously a selection bias, with a tendency to publish cases with survival. However, in a review of the literature of the cases of maternal cardiac arrest, we could only nd 3 cases where effective CPR was actually achieved. If pulses can be obtained with CPR, then there is no reason to perform a perimortem section. The exception is when the mother has a nonresuscitable cause. In that case, one would perform the perimortem section to immediately deliver and salvage the baby. If the mother has pulses that can be palpated, then effective CPR negates the need for the perimortem delivery. Again, that in itself has been reported, to our knowledge, rarely. In contrast, multiple case reports and series have noted successful CPR only after the cesarean section was performed. Those reports continue to this day. After the introduction of the 4-minute rule and the perimortem cesarean delivery in 1986, we reexamined the issue in 2005.14 Of the more than 100 cases of perimortem cesarean sections that had subsequently been documented in the medical literature, reports of 38 cases with 34 surviving infants (3 sets of twins and 1 set of triplets) could be extracted to provide insights about the course of the arrests. The question in that review was whether there was a positive impact on CPR from the cesarean delivery; 20 of the 34 women had potentially resuscitable causes, and 13 of the 20 mothers were successfully resuscitated after perimortem cesarean and discharged from the hospital in good condition. One mother who was also able to be resuscitated died later of complications from her
71 dure, if maternal resuscitation is successful, we recommend recovery in the intensive care unit, with the patient remaining intubated until an appropriate time for extubation. Antibiotics may be given afterward as well. The most important point, though, is to keep CPR going until well after the procedure. Sometimes, the question arises about the legality of performing the procedure without obtaining consent. Under basic hospital guidelines, an emergency procedure may be performed if it is in the patients best interest. Given that the perimortem cesarean section is the standard of care, consent would be unnecessary in an emergency. We know of no case, since perimortem section was introduced in 1986, of a physician being charged with either criminal or civil malfeasance for performing a perimortem section. However, we are aware of 2 cases in which a lawsuit was brought against physicians and hospital staff for not performing a perimortem section. Although there is widespread teaching of and acceptance for the perimortem section, in most training programs, the timely performance of the procedure is still problematic. Dijkman et al reviewed recent cases reported in the Netherlands. Since 2003, a program, Managing Obstetric Emergency Trauma, has been introduced to all pregnancy providers.17 The authors noted that the incidence of perimortem cesarean sections has increased over the past several years. However, there still is a lack of timeliness, with many procedures being performed 15 minutes after maternal cardiac arrest. In their series of 12 perimortem cesarean sections, 8 patients who had no cardiac output with CPR had return of pulses immediately after the cesarean section was performed, thereby, in their own words, conrming the hypothesis of the perimortem section.17 They found that there was an association between increased maternal survival and a short interval between arrest and delivery. In their series, many physicians performed Pfannenstiel incisions because of familiarity. The authors also reviewed the maternal morbidity and mortality reports from the United Kingdom from 2003 to 2005, in which 49 instances of perimortem sections were performed. Twenty infants survived. This series was only on mothers who did not survive; therefore, we do not know what the successful ratio of perimortem cesarean section was for surviving cases. An important advancement in maternal cardiac arrest is the development of the Cardiff wedge. This special table allows clinicians to perform CPR by placing the mother in a stabilized lateral tilt. Obviously, the mother has to arrest in the proximity of a Cardiff wedge. These tables are large, and although they may be present in labor and delivery suites, they are not always immediately available. Even with a Cardiff wedge, if pulsations cannot be obtained after 4 minutes, a perimortem section should be performed. In review of the past several decades of perimortem cesarean births, it is clear that the physicians wait too long to perform surgery. Anecdotally, and in case series, physicians who have been trained in simulation of obstetric emergencies seem to move more quickly to the 4-minute rule. We believe that simulation exercises in training programs will help reinforce the optimal initiation of the procedure.
72
V.L. Katz
2. Shakespeare W. Macbeth: Act V, scene viii, in Harbage A (ed): William Shakespeare: The Complete Works. Baltimore, MD, Penguin Books, 1969, p 1134 3. Katz VL, Cefalo RC: History and evolution of cesarean delivery, in Phelan JP, Clark SL (eds): Cesarean Delivery. New York, NY, Elsevier, 1988, p 1 4. Weber CE: Postmortem cesarean section: Review of the literature case reports. Am J Obstet Gynecol 110:158, 1971 5. Duer EL: Postmortem delivery. Am J Obstet Gynecol 12:1, 1879 6. Katz VL, Dotters DJ, Droegemueller W. Perimortem cesarean delivery. Obstet Gynecol 68:571-576, 1986 7. Hayden FJ: Maternal mortality in history and today. Med J Aust 1:100, 1970 8. Corke BC, Spielman FJ: Problems associated with epidural anaesthesia in obstetrics. Obstet Gynecol 65:837, 1985 9. DePace NL, Betesh SS, Kotter MN: Postmortem cesarean section with recovery of both mother and offspring. JAMA 248:971, 1982 10. Montgomery WH, Herrin TJ, Lewis AJ: Basic Life Support for Physicians. Dallas TX, American Heart Association, 1983, p 8 11. Ueland K, Novy MJ, Peterson EN, et al: Maternal cardiovascular dynamics IV: The inuence of gestational age on the maternal cardiovascular response to posture and exercise. Am J Obstet Gynecol 104:856, 1969 12. Kerr MG: The mechanical effects of gravid uterus in late pregnancy. J Obstet Gynaecol Br Commonw 513, 1965 13. Marx GF: Cardiopulmonary resuscitation of late-pregnant woman. Anesthesiology 56:156, 1982 14. Katz V, Balderston K, DeFreest M: Perimortem cesarean delivery: Were our assumptions correct? Am J Obstet Gynecol 192:1916-1921, 2005 15. Warraich Q, Esen U: Perimortem caesarean section. J Obstet Gynaecol 29:690-693, 2009 16. McDonnell NJ: Cardiopulmonary arrest in pregnancy: Two case reports of successful outcomes in association with perimortem caesarean delivery. Br J Anaesth 103:406-409, 2009 17. Dijkman A, Huisman C, Smit M, et al: Cardiac arrest in pregnancy: Increasing use of perimortem caesarean section due to emergency skills training? Br J Obstet Gynaecol 117:282-287, 2010 18. Capobianco G, Balata A, Mannazzu MC, et al: Perimortem cesarean delivery 30 minutes after a laboring patient jumped from a fourth-oor window: Baby survives and is normal at age 4 years. Am J Obstet Gynecol 198:e15-e16, 2008
Conclusion
The perimortem section evolved from the postmortem section as we moved into the modern era of obstetrics. As CPR developed, and as the causes of maternal mortality shifted toward potentially resuscitable causes, the nature of the procedure changed. The operation changed from being a postmortem to a perimortem delivery to aid in resuscitation. The literature suggests that the procedures should be performed within 4 minutes to achieve the least amount of neurologic damage for the fetus. If the mother cannot be resuscitated, then obviously the sooner the procedure can be performed, the better. If the mother has a resuscitable cause, then the procedure in most cases will aid in resuscitation. Importantly, the surgery should be performed at the site of the arrest or as soon as the mother reaches the hospital. CPR should be continued during the delivery. If there are maternal pulsations achievable with chest compressions, then there is no need to do the CPR unless it is to save the baby, as the mother cannot be salvaged. Instances of gunshot wounds, head trauma, or a recent case of suicide by jumping out of an 8-story window would be instances when the mother cannot be resuscitated, and the fetus should be delivered immediately. Perimortem cesarean delivery is an important tool for successful resuscitation when a tragedy does occur. Our instincts are to attempt CPR for as long as we can, to carry the code through. We need to ght our instincts and use our scientic knowledge. This will lead to more successful resuscitation and the delivery of live infants.
References
1. Thompson S: Motif Index of Folk Literature, 2nd ed. Bloomington, IN, University Press, 1955