COMMENTARY
Preparedness for Emergency “Crash”
Caesarean Section
Thomas F. Baskett, MB, FRCSC
Department of Obstetrics and Gynaecology, Dalhousie University, Halifax NS
T here are a number of obstetric complications in which
a very rapid or “crash” Caesarean section (CS) is
necessary to save the fetus from death or disability. These
situations are relatively rare but can include uterine rupture
(usually after a previous CS), cord prolapse, sustained
bradycardia, and antepartum hemorrhage. In some of these
instances resuscitation manoeuvres may give temporary
respite from the “fetal distress” and allow a more orderly
progression to CS. In others, most often uterine rupture or
sustained bradycardia, the need to deliver the fetus from
inexorable hypoxia is urgent and compelling. For example,
with uterine rupture during labour after previous CS the
fetus needs to be delivered within 20 minutes to avoid
severe neonatal asphyxia,1,2 and even this will not protect
against neonatal acidosis in all cases.3
Through my experience working on the labour wards of
both large and small hospitals, from hospital peer review
surveys, and from litigation case reviews, I have found that
many hospitals do not have an agreed and detailed plan for
the rarely needed crash CS. None of the relevant national
guidelines go into detail on this point, but simply state
“Suspected uterine rupture requires urgent attention and
expedited laparotomy to attempt to decrease maternal and
perinatal morbidity and mortality.”4 The following list of
practical factors need to be agreed upon in advance by all
responsible parties: administration, anaesthesia, midwifery,
nursing, obstetrics, and neonatology.5 The time to debate,
clarify, and formulate these points (below) into an accepted
policy is in committee and not at 3:00 a.m. in the middle
of an emergency.
Key Words: Caesarean section, emergency Caesarean section,
neonatal complications, checklists
Competing Interests: None declared.
Received on May 25, 2015
Accepted on May 28, 2015
1116 l DECEMBER JOGC DÉCEMBRE 2015
•• Limit the preoperative checklist. All of the relevant
points are usually known from the antenatal or
admission records. The dogged and time-consuming
adherence to a preoperative multiple question checklist
is one of the most frustrating and unnecessary delays
for the accoucheur. The Society of Obstetricians and
Gynaecologists of Canada’s obstetrical surgical safety
checklist has 38 items to check off. It does, however,
contain the statement that for cases of urgent CS the
obstetrician should just say, “Doing a crash Caesarean
section. Does anyone have any concerns prior to
proceeding?”6
•• Verbal consent only. Provide a clear, sympathetic,
and decisive explanation of the need for immediate
CS. This is supported by both the American College
of Obstetricians and Gynecologists7 and the Royal
College of Obstetricians and Gynaecologists.8
•• Anticipate the need for general anaesthesia: give oral
antacid, e.g., sodium citrate 30 mL.
•• At the time of the decisive pelvic examination (when
the decision to move to emergency CS is taken) the
obstetrician or midwife/nurse should quickly, and
without full aseptic rituals, insert a Foley catheter into
the bladder.
•• At the time of the decisive pelvic examination the
obstetrician or midwife/nurse should apply a fetal
scalp electrode if one is not in place. This allows an
accurate recording of the fetal heart rate (FHR) in
the operating room (OR), as opposed to the often
ineffective, incomplete, and inconclusive attempts
with a Doptone. Sometimes the FHR will recover
sufficiently to allow a slower and safer approach to
the CS or, alternatively, confirm the need for extreme
urgency.
J Obstet Gynaecol Can 2015;37(12):1116–1117

•• The above equipment (sodium citrate, Foley catheter,
and scalp electrode) should be immediately available in
each labour and delivery room, rather than in a central
location.
•• The bed or trolley should be swiftly transferred to
the OR, including commandeering the elevator if
necessary.
•• The FHR monitor should be quickly transferred to the
OR and re-established there.
•• Accept an “all hands on deck” approach, so that all
personnel (medical, nursing, midwifery, clerical) assist
in the transfer of the patient and equipment to the
OR.
•• OR clothing: in an emergency, personnel need not
change to full OR scrubs. Put on a gown, hair cap, foot
covers, and mask—roll up your sleeves and scrub/
glove.
•• Limit or omit scrub time.
•• Scrub nurse: if full OR nursing personnel are not
available, any nurse or midwife on labour and
delivery should be able to do the initial set-up and
scrub for CS.
•• Skin preparation: accept a “splash and dash” approach
for antiseptic skin preparation.
•• A “starter pack” for emergency CS includes enough
to get the baby delivered. Such a pack can be designed
locally, but might include a scalpel, curved Mayo
scissors, tooth-dissecting forceps, retractor, 2 artery
forceps, 2 Kelly clamps for the cord, 4 laparotomy
sponges, and bulb suction for the neonate. This also
makes the task of the scrub nurse easier and quicker.
•• No preoperative instrument count is necessary:
a postoperative X-ray is acceptable under these
circumstances.
Preparedness for Emergency “Crash” Caesarean Section
•• A clear system of responsibility is needed to alert
the additional personnel required for anaesthesia and
neonatal resuscitation.
Unless streamlined as above, each of these factors can
add one to several minutes of time that cumulatively
may lead to the difference between an intact neonate or a
permanently disabled infant. A clear policy including the
above factors, with which all labour ward personnel must
be familiar, should help inculcate an appropriate, efficient,
and undisputed response on the rare occasions that a crash
Caesarean section is necessary.
REFERENCES
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delivery: maternal and fetal consequences. Am J Obstet Gynecol
1993;169:945–9.
2. Holmgren C, Scott JR, Porter TF, Esplin MS, Bardsley T. Uterine rupture
with attempted vaginal birth after cesarean delivery: decision-to-delivery
time and neonatal outcome. Obstet Gynecol 2012;119:725–9.
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rupture: what are the risk factors? Am J Obstet Gynecol
2002;186:311–6.
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of Canada Cinical Practice Obstetrics Committee. Guidelines for vaginal
birth after previous Caesarean birth. SOGC Clinical Practice Guideline,
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5. Baskett TF. Essential management of obstetric emergencies. 5th ed.
Bristol (GB): Clinical Press Ltd; 2015:229–31.
6. Singh SS, Mehra N, Hopkins L; Society of Obstetricians and
Gynaecolosists of Canada Clinical Practice Gynaecology Committee.
Surgical safety checklist in obstetrics and gynaecology. SOGC Clinical
Practice Guideline, No. 286, January 2013. J Obstet Gynaecol Can
2013;35(Suppl): S1-S5.
7. American College of Obstetricians and Gynecologists. Vaginal birth after
previous cesarean delivery. Practice Bulletin no. 115. Obstet Gynecol
2010;116:1232–40.
8. Royal College of Obstetricians and Gynaecologists. Umbilical cord
prolapse. Green-top Guideline no. 50. London (GB): RCOG; 2014.
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