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Challenging the 4- to 5-minute rule: from
perimortem cesarean to resuscitative
hysterotomy
Carl H. Rose, MD; Arij Faksh, DO; Kyle D. Traynor, MD; Daniel Cabrera, MD;
Katherine W. Arendt, MD; Brian C. Brost, MD
F ew obstetrical providers are con-
fronted with an acute MCPA during
clinical practice. The complex medical,
cognitive, operational, and emotional
circumstances surrounding MCPA cre-
ates a substantial challenge, particularly
while trying to expediently balance
competing maternal and fetal priorities.
This monograph will review the histor-
ical evidence for current practices and
suggest modifications based primarily
on maternal status.
Introduction
Antepartum maternal cardiac arrest is a
fortuitously rare event, with an incidence
of approximately 1/12,500 deliveries.1
The most common reported precipi-
tating factors include hemorrhage (45%),
amniotic fluid embolism (13%), heart
failure (13%), sepsis (11%), anesthetic
complications (8%), and trauma (3%).1
Maternal survival range from 17e59%1,2
and fetal survival from 61e80%,3,4 with
approximately 88e100% of surviving
neonates neurologically intact.2,4,5 The
etiology, physiology, and rate of surviv-
ability of maternal cardiac arrest are
categorically distinct from nonpregnant
cardiac arrest. In this document, we
From the Departments of Obstetrics and
Gynecology (Drs Rose, Faksh, Traynor),
Emergency Medicine (Dr Cabrera), and
Anesthesiology (Dr Arendt), Mayo Clinic,
Rochester, MN; and Department of Obstetrics
and Gynecology, Wake Forest University School
of Medicine, Winston-Salem, NC (Dr Brost).
Received May 26, 2015; revised July 8, 2015;
accepted July 17, 2015.
The authors report no conflict of interest.
Corresponding author: Carl H. Rose, MD. rose.
carl@mayo.edu
0002-9378/$36.00
ª 2015 Elsevier Inc. All rights reserved.
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THE PROBLEM: Scenario no. 1: emergency medical services transports a young
woman to the emergency department following high-speed frontal-impact motor
vehicle accident requiring prolonged vehicular extraction. Primary survey reveals
multifocal cranial and extremity trauma, and she appears to be approximately
7 months’ gestation. While lucid at the scene, she becomes unresponsive and
requires airway management with endotracheal intubation. At time of arrival
fetal heart tones are unable to be auscultated (suggestive of intrauterine fetal
demise), and soon thereafter maternal cardiopulmonary arrest (MCPA) occurs.
Scenario no. 2: in the labor and delivery suite, a 25-year-old primigravida at
39 weeks’ gestation in active labor at 9-cm dilation suddenly notes onset of
dyspnea followed by loss of consciousness. No pulse is palpable. Fetal heart
rate tracing previously was category 1 but now demonstrates a prolonged
deceleration for 4 minutes.
A SOLUTION: As the on-call obstetrician, how do you manage these cases? Is
there any difference in your approach?
propose a maternofetal management on low-quality evidence. A landmark
strategy of MCPA that is unlike the cur- 1986 review of all reported maternal and
rent 4-5 rule for perimortem cesarean fetal outcomes from the turn of the
delivery (PMCD) in both its mental century led to widespread adoption of the
model and its priority of actions. 4-5 rule for viable pregnancies into US
residency training curriculum: if resusci-
Examining the evidence tative efforts following maternal circula-
The published literature on MCPA con- tory arrest are unsuccessful, cesarean
sists primarily of retrospective case reports delivery should be commenced at 4 mi-
and epidemiologic reviews; as Dr Vern L. nutes and completed by 5 minutes to
Katz, MD5 has stated: “for obvious rea- optimize fetal outcome.3 A subsequent
sons we will never have a randomized trial interval update in 2005 found 28/38
for this problem..” Initial descriptions of (74%) PMCD resulted in viable neonates
postmortem cesarean delivery date from (thus validating the initial premise), with
before recorded history, with subsequent the conspicuous observation that in 12/22
controversial legal mandates enacted in described cases, maternal hemodyna-
the 13th and 14th centuries to deliver mic status was substantially improved
all fetuses following maternal death for following delivery.5 A 30-year review
independent baptism and burial.6 More found 32% of cases in which PMCD
contemporary practices focused on the was considered beneficial to maternal
possibility of fetal survival following ma- survival and in no instances proved
ternal demise, particularly in instances detrimental.7
of inpatient sudden cardiac death. Even- From a practical perspective, multiple
authors stress the difficulties of accom-
tual accumulation of more favorable re-
ported outcomes led to incorporation of plishing delivery within 5 minutes in
PMCD into clinical practice, albeit based either actual or simulated scenarios.2,5
2015
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Call to Action ajog.org

Hemodynamic effects during

TABLE resuscitation
Approaches to maternal cardiopulmonary arrest during pregnancy Data on the hemodynamic effects of
Variable Value resuscitation in pregnancy are lacking and
Primary survey Airway and breathing: often extrapolated from varied sources;
Treat per BLS algorithm effects of differing maneuvers/positions
Oxygenate and ventilate well with 100% O2 are simulated in mannequins or pregnant
Circulation: women not currently under cardiac arrest
Treat per BLS algorithm conditions.8,9 During cardiopulmonary
Hand placement during chest compressions should be more cephalad resuscitation in nonpregnant patients,
over sternum chest compressions at best can produce
Other considerations: 30% of normal cardiac output, and this
Supine positioning value may be closer to 10% in pregnant
Left uterine displacement
patients.10 Current recommendations for
Estimate of gestational age of fetus
Fetal monitoring not recommended the management of MCPA strongly en-
Remove internal and external fetal monitors if present courage either manual displacement of
Secondary survey Airway and breathing: the gravid uterus or maternal torso tilt of
Insert advanced airway early in resuscitation w30 degrees to decrease compression
of the inferior vena cava (IVC) and pro-
Circulation:
Initiate IV above maternal diaphragm vide maximal cardiac preload.11,12 There
Do not delay defibrillation if indicated per ACLS guidelines is no robust evidence, however, showing
Use ACLS guidelines for drug administration improvement of hemodynamics with
Other considerations: either maneuver, and moreover tilting of
Search for and treat possible contributing factors (BEAU-CHOPS) the torso may decrease the quality of
Bleeding/DIC cardiac compressions.13 An ultrasound
Embolism (coronary, pulmonary, amniotic fluid) study in pregnant noncardiac arrest pa-
Anesthetic complications
Uterine atony
tients showed the largest diameter of the
Cardiac disease IVC in the supine position is approxi-
Hypertension (preeclampsia, eclampsia) mately 25% of that achieved with 30
Other: differential diagnosis of standard ACLS degree of either the right or left lateral
Placental (abruption, previa) tilt.14
Sepsis
Multiple reports highlight the drama-
Perimortem delivery Perimortem delivery performed at site of resuscitation: tic return of spontaneous circulation
Perimortem cesarean delivery or perimortem instrumental vaginal following PMCD, particularly when
delivery is acceptable
Maternal survival (if GA >20 wk): external relief of IVC compression has
If no return of spontaneous circulation by 4 min of resuscitative efforts been ineffective.15 Early evidence for im-
effect emergent hysterotomy with goal of delivery within 5 min provement in maternal circulatory pa-
Neonatal survival (if GA >24 wk): rameters following delivery was suggested
May be optimized when fetus is delivered within 5 min of maternal in a 1986 report describing a 60% incre-
arrest
ase in maternal cardiac output following
ACLS, advanced cardiac life support; BEAU-CHOPS, bleeding, embolism, anesthetic complications, uterine atony, cardiac
disease, hypertension, other, placenta accreta/previa, sepsisa; BLS, basic life support; DIC, disseminated intravascular
delivery due to relief of aortocaval co-
coagulation; GA, gestational age. mpression by the gravid uterus.16 A
Adapted from the American Heart Association.12,20 similar 1998 report suggested cesarean
Rose. Resuscitative hysterotomy in maternal cardiopulmonary arrest. Am J Obstet Gynecol 2015. delivery of twins after maternal arrest
resulted in immediate recovery of cardiac
rhythm, a finding corroborated in a 2010
report from The Netherlands of 12 pa-
This is likely because transitioning from prioritization of fetal status at potential tients undergoing PMCD describing
the mind-set of maternal resuscitation to maternal expense, a fetocentric pers- restoration of cardiac output in 8 pati-
performing a laparotomy seems barbaric pective per se, without considering the ents (67%) postdelivery.2,17 Furthermore,
and teleologically indicative of forfeiture intraresuscitative benefits of PMCD. A among 18 case reports of PMCD that had
of further attempts at maternal salvage. term for the procedure that communi- recorded hemodynamic parameters th-
The term “perimortem cesarean de- cates both maternal and therefore fetal roughout the code, 12 cases (67%)
livery” implies eventual mortality of the benefits could assist providers in opti- described a cesarean delivery immediately
mother (and therefore, a last ditch or mizing maternal resuscitation through preceding return of maternal pulse and
even futile attempt to save her) and uterine evacuation. blood pressure, which often returned,

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ajog.org
as the authors of this review of publis-
hed reports describe it, “in a dramatic
fashion.”5
Current guidelines
The American Heart Association, Society
for Obstetric Anesthesia and Perinatol-
ogy, and European Resuscitation Council
provide similar recommendations for
management of cardiopulmonary arrest
during pregnancy, incorporating the
general principles of11,12,18:
 Rapid assessment of gestational age
based on fundal height (umbilicus or
above).
 Displacement of the gravid uterus
through either manual uterine dis-
placement or table tilt to reduce aor-
tocaval compression.
 Immediate initiation of basic resus-
citative efforts (airway and circulatory
support) with transition to advanced
cardiac life support (ACLS) once
skilled providers and resources are
available.
 Evaluation for primary etiology to
direct therapy.
 Cesarean delivery within 5 minutes if
initial maternal resuscitation attempts
are unsuccessful.
The American Heart Association
guideline is summarized in the Table. It
is important to highlight that despite
a common end result, the shockable
rhythms (ventricular tachycardia and ve-
ntricular fibrillation) carry a better prog-
nosis as these often occur in patients with
previous structural cardiac pathology but
somewhat intact prearrest physiology;
this may occur suddenly in the commu-
nity11,12 or as inpatients with no pre-event
deterioration. Regarding nonshockable
rhythms (pulseless electrical activity and
asystole), these represent terminal rh-
ythms with a grim prognosis, and ty-
pically present as a result of critically
compromised physiology, such as in cases
of trauma in the outpatient setting and
sepsis or bleeding in the inpatient
arena.11-13
Perimortem cesarean to resuscitative
hysterotomy
This call to action reconsiders the 4-5
rule based on 3 important concepts:
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1. The operational and human factor
difficulties inherent in performing
PMCD within 5 minutes of maternal
arrest if cesarean delivery is not
considered at the initiation of the
maternal arrest.
2. Transition from a fetocentric to a
maternofetal resuscitative protocol
where both outcomes are considered
in parallel, and the language used to
describe the procedure reflects the
life-saving benefits to the mother.
3. Maternal hemodynamics, chances of
return of spontaneous circulation,
and overall resuscitative manage-
ment13,15 may greatly benefit from
PMCD or resuscitative hysterotomy.
The main objective of this proposal is
to simultaneously optimize the likeli-
hood of both maternal and fetal survival
following cardiac arrest based on the
cardiopulmonary improvements result-
ing from delivery.
We would like to draw attention to the
importance of this approach and call for a
paradigm shift in the management of
MCPA, with immediate initiation of
a maternal arrest protocol considering
only the apparent uterine size (or gesta-
tional age, if known) and type of arrest
(shockable vs nonshockable). The pro-
posed algorithm is depicted in the Figure.
In brief, immediately after the MCPA is
identified and ACLS is initiated as per
guidelines,11,12,18 a rapid assessment of
uterine size or gestational age is perfor-
med without assessment of fetal viability.
If the uterus is palpable or visible above
the umbilicus or gestational age is known
to be 20-24 weeks then immediate
preparations are made to deliver the baby
without delay (eg, acquisition of surgical
equipment, activation of the obstetrical,
anesthesiology, and neonatology teams).
The next step is to assess for the type of
MCPA, subdividing into either shockable
rhythm (ie, ventricular fibrillation and
ventricular tachycardia) or nonshockable
rhythm (pulseless electrical activity and
asystole), the latter of which is more likely
in maternal arrest. The differential di-
agnosis and etiology of nonshockable
rhythm is broad, ranging from easily
reversible causes such as apnea secondary
to medications to traumatic hemorrhage.
2015
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ClinicalKey.com
Call to Action
FIGURE
Suggested resuscitation
algorithm
ACLS, advanced cardiac life support; CPR, cardiopulmonary
resuscitation; ROSC, return of spontaneous circulation.
Rose. Resuscitative hysterotomy in maternal cardiopulmo-
nary arrest. Am J Obstet Gynecol 2015.
 If a shockable rhythm MCPA is iden-
tified, standard ACLS should be initi-
ated,12 including an initial shock
followed by 2 cycles of cardiopulmo-
nary resuscitation. If 4 minutes elapse
without successful resuscitation, im-
mediate delivery should be performed.
 For an MCPA with a nonshockable
rhythm, we recommend immediate
delivery or resuscitative hysterotomy
as this will enhance success of other
interventions and procedures while
optimizing fetal outcome.13,15
Following delivery, improvements in
cardiac preload, autotransfusion of uter-
ine blood,19 facilitation of external car-
diac massage, and improved respiratory
mechanics are anticipated.13 Standard
resuscitation efforts should continue, and
(if successful) postarrest protocols should
include postoperative care.
Conclusions
Revisiting the fundamental question of
“what is the priority during MCPA?”
leads to the obvious conclusion of
maternal health, yet if one concludes the
American Journal
on May & Gynecology
of Obstetrics
by Elsevier 655
Call to Action
experiential evidence supports delivery to
improve effectiveness of resuscitative ef-
forts, resuscitative hysterotomy offers the
best chance for both maternal and fetal
survival. In application to the hypothetic
cases above, this would promote a ma-
ternofetal management strategy, in that
from an obstetrical perspective both sce-
narios would be managed similarly. In the
first case, the patient developed a blunt
trauma agonal arrest, in which the sur-
vival of mother and fetus are based
on rapid correction of injuries such as
cardiac tamponade and massive hem-
orrhage, with resuscitative hysterotomy
facilitating management via improved
circulation and ventilatory parameters. In
the second scenario, a case of amniotic
fluid embolism, delivery of the fetus
would facilitate hemodynamic and res-
piratory support enormously. We believe
the concept and nomenclature of the 4-5
rule should be superseded in favor of a
paradigm shift from PMCD to resusci-
tative hysterotomy, the process of which
is initiated at the moment of recognition
of acute MCPA. - 10. Gatti F, Spagnoli M, Zerbi SM, Colombo D,
REFERENCES
1. Mhyre JM, Tsen LC, Einav S, Kuklina EV,
Leffert LR, Bateman BT. Cardiac arrest
during hospitalization for delivery in the United
States, 1998-2011. Anesthesiology 2014;120:
810-8.
656 American JournalDownloaded
of Obstetrics & Gynecology
for Anonymous User NOVEMBER
(n/a) at Royal2015
18, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
2. Dijkman A, Huisman CM, Smit M, et al.
Cardiac arrest in pregnancy: increasing use of
perimortem cesarean section due to emergency
skills training? BJOG 2010;117:282-7.
3. Katz VL, Dotters DJ, Droegemueller W. Peri-
mortem cesarean delivery. Obstet Gynecol
1986;68:571-6.
4. Baghirzada L, Balki M. Maternal cardiac
arrest in a tertiary care center during 1989-2011:
a case series. Can J Anaesth 2013;60:1077-84.
5. Katz V, Balderston K, DeFreest M. Peri-
mortem cesarean delivery: were our assump-
tions correct? Am J Obstet Gynecol 2005;192:
1916-21.
6. Katz VL. Perimortem cesarean delivery: its
role in maternal mortality. Semin Perinatol
2012;36:68-72.
7. Einav S, Kaufman N, Sela HY. Maternal car-
diac arrest and perimortem cesarean delivery:
evidence or expert-based? Resuscitation
2012;83:1191-200.
8. Ip JK, Campbell JP, Bushby D, Yentis SM.
Cardiopulmonary resuscitation in the pregnant
patient: a manikin-based evaluation of methods
for producing lateral tilt. Anaesthesia 2013;68:
694-9.
9. Butcher M, Ip J, Bushby D, Yentis SM. Effi-
cacy of cardiopulmonary resuscitation in the
supine position with manual displacement of the
uterus vs lateral tilt using a firm wedge: a manikin
study. Anaesthesia 2014;69:868-71.
Landriscina M, Kette F. Out-of-hospital peri-
mortem cesarean section as resuscitative hys-
terotomy in maternal posttraumatic cardiac arrest.
Case Rep Emerg Med 2014;2014:121562.
11. Lipman S, Cohen S, Einav S, et al. The So-
ciety for Obstetric Anesthesia and Perinatology
consensus statement on the management of
cardiac arrest in pregnancy. Anesth Analg
2014;118:1003-16.
College of Surgeons of England from ClinicalKey.com by Elsevier on May
ajog.org
12. Vanden Hoek TL, Morrison LJ, Shuster M,
et al. Part 12: cardiac arrest in special situations:
2010 American Heart Association guidelines for
cardiopulmonary resuscitation and emergency
cardiovascular care. Circulation 2010;122:
S829-61.
13. Jeejeebhoy FM, Zelop CM, Windrim R,
Carvalho JC, Dorian P, Morrison LJ. Man-
agement of cardiac arrest in pregnancy: a
systematic review. Resuscitation 2011;82:
801-9.
14. Fields JM, Catallo K, Au AK, et al.
Resuscitation of the pregnant patient: What is
the effect of patient positioning on inferior
vena cava diameter? Resuscitation 2013;84:
304-8.
15. Jeejeebhoy F, Windrim R. Management of
cardiac arrest in pregnancy. Best Pract Res Clin
Obstet Gynaecol 2014;28:607-18.
16. Lee RV, Rodgers BD, White LM, Harvey RC.
Cardiopulmonary resuscitation of pregnant
women. Am J Med 1986;81:311-8.
17. Cardosi RJ, Porter KB. Cesarean delivery of
twins during maternal cardiopulmonary arrest.
Obstet Gynecol 1998;92:695-7.
18. Soar J, Perkins GD, Abbas G, et al. Euro-
pean Resuscitation Council guidelines for
resuscitation 2010, section 8. Cardiac arrest in
special circumstances: electrolyte abnormal-
ities, poisoning, drowning, accidental hypother-
mia, hyperthermia, asthma, anaphylaxis, cardiac
surgery, trauma, pregnancy, electrocution.
Resuscitation 2010;81:1400-33.
19. Robbins KS, Martin SR, Wilson WC. In:
Creasy RK, Resnik R, Iam JD, et al, eds. Creasy
and Resnik’s maternal-fetal medicine: principles
and practice, 7th ed. Philadelphia, PA: Elsevier-
Saunders; 2013:1209-10.
20. American Heart Association. Part 10.8:
cardiac arrest associated with pregnancy.
Circulation 2005;112: IV-150-IV-153.
ajog.org
ABSTRACT
Challenging the 4- to 5-minute rule: from
perimortem cesarean to resuscitative
hysterotomy
Although perimortem delivery has been recorded in the medical liter-
ature for millennia, the procedural intent has evolved to the current
fetocentric approach, predicating timing of delivery following maternal
cardiopulmonary arrest to optimize neonatal outcome. We suggest a
call to action to reinforce the concept that if the uterus is palpable at or
above the umbilicus, preparations for delivery should be made simul-
taneous with initiation of maternal resuscitative efforts; if maternal
condition is not rapidly reversible, hysterotomy with delivery should be
performed regardless of fetal viability or elapsed time since arrest.
Cognizant of the difficulty in determining precise timing of arrest in
clinical practice, if fetal status is already compromised further delay
while attempting to assess fetal heart rate, locating optimal surgical
Supplemental Materials Call to Action
equipment, or transporting to an operating room will result in unnec-
essary worsening of both maternal and fetal condition. Even if intra-
uterine demise has already occurred, maternal resuscitative efforts will
typically be markedly improved following delivery with uterine
decompression. Consequently we suggest that perimortem cesarean
delivery be renamed “resuscitative hysterotomy” to reflect the mutual
optimization of resuscitation efforts that would potentially provide
earlier and more substantial benefit to both mother and baby.
Key words: maternal arrest, perimortem cesarean, resuscitative
hysterotomy

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