Continuing Education Activity

The perimortem cesarean section, as described in its name, is the surgical delivery of the fetus, performed during or near the time of death of the mother. The perimortem cesarean section is one of the most anxiety-provoking surgical procedures. At this time, there are no clear, standardized guidelines regarding when this procedure should be performed. The lack of consensus data makes this procedure even more stressful. It is imperative for providers to know the indications, as well as be able to perform the procedure efficiently, thus giving both the mother and neonate an increased chance of survival. This activity describes the evaluation and management of perimortem cesarean sections and stresses the role of team-based interprofessional care for affected patients.

Objectives:

• Identify the epidemiology of perimortem cesarean sections.
• Describe exam findings suggesting the need for a perimortem cesarean section.
• Explain when a perimortem cesarean section is done.
• Explain the importance of optimizing coordination amongst the interprofessional team to enhance the delivery of care to patients undergoing perimortem cesarean section.

Introduction

The perimortem cesarean section, as described in its name, is the surgical delivery of the fetus, performed at or near death of the maternal patient. Given the high stakes and emergency situation that leads to the consideration of this surgery, the perimortem cesarean section is one of the most anxiety-provoking surgical procedures in the medical field.  It is also one of the oldest described surgical procedures.

At this time, there are no clear, standardized guidelines as to when to perform the procedure. The lack of data consensus makes performing this procedure even more stressful. It is imperative for emergency care providers to know the indications, as well as be able to perform the procedure efficiently, thus giving both patients an increased chance of survival.[1][2][3]

Etiology

There is no clear consensus on the origin of the procedure's name, nor when it was first performed. However, the belief that Julius Caesar was born in this fashion appears to be inaccurate. At the time of his birth, the procedure was performed only on a dead mother, in hopes to increase the population of the empire. Caesar's mother, Aurelia, was documented to have witnessed his invasion of Britain in 55 BC.

There are multiple speculations as to the origin of the name. One such speculation is that Lex Regia, Royal Law, prohibited a pregnant woman dying in pregnancy to be buried until the fetus was first removed for separate burial. Roman King Numa Pompilius made this declaration sometime between 715 BC and 673 BC[4]. This ultimately became Lex Caesarea (Caesarian Law) under the Caesars. [5].  Another theory is the derivation from the Latin verb "caedare," meaning to cut.

The origin of the procedure's names is as mysterious as the date the procedure first was first. Greek mythology attributes Apollo as the one delivering Asclepius from his mother in this manner. According to modern medicine, one report dated the first procedure in Switzerland in 1500, and others place it in the British Isles in 1738 by a midwife. Both report survival of the mother.

Epidemiology

The true incidence of cardiac arrest during pregnancy has been estimated to be about one over 30,000 pregnancies[6]. Given the rarity of cardiac arrest during pregnancy, perimortem cesarean section is an uncommon procedure. Most commonly, cardiac arrest during pregnancy is attributed to obstetrical anesthesia, and more rarely, to trauma.

History and Physical

A patient's history rarely is obtained on the scene of a pregnant trauma patient in arrest. If any information can be gathered, the prehospital provider should focus primarily on three questions, and later on a secondary history including allergies, medication, past medical history, last meal intake, events of the accident, and prenatal care history. The first three pertinent questions are:

1. How many fetuses are present in the uterus? This will allow adequate equipment and personnel preparation for multiple fetal resuscitations, if necessary.
2. What is the estimated date of confinement (due date), last menstrual cycle, or estimated gestational age? This will help to determine the age of the fetus and subsequently the viability. Only a fetus of viable age should be considered to be delivered via perimortem cesarean section.
3. Are any drugs present in the maternal system? This information can be utilized to direct antidote treatment of the fetus.

Evaluation

Evaluation of the maternal patient must be done efficiently to determine the timing of loss of circulation. A vital part of the evaluation includes monitoring vital signs.  If time and resuscitative efforts permit, then fetal tocometry should be initiated rapidly. Early on, obstetrics should be advised and prepared. The procedure must be initiated no more than 4 minutes from loss of pulse for a maximum beneficial outcome.

Often, the expected gestational age is not able to be obtained.  In this case, a uterine fundal height at the level of the umbilicus is correlated with a gestational age of 24 weeks.[7][8][9]

Treatment / Management

In 2005, the American College of Obstetrics and Gynecology (ACOG) concluded that there was insufficient data to make recommendations as to when to perform this procedure. Most agree that it be considered in a maternal arrest with pregnancy greater than 23 weeks gestation. Although data regarding the optimal time to delivery post-arrest is limited, in a hospital setting, survival drastically decreases when the time from maternal death to delivery reaches 5 minutes. Hence a 4-minute rule has become standard: Maternal CPR for 4 minutes, infant delivery by the fifth minute[4]. Recently, Benson et al[10]. challenged this protocol.

The procedure itself, though uncomplicated, creates intense anxiety and fear among providers for obvious reasons. It is done rapidly, and, while preferably performed by an obstetrician, may be done by advanced prehospital providers, trauma surgeons, and emergency medicine physicians. One should not delay assessing fetal heart tones. Simultaneously with maternal resuscitation and perimortem section, the neonatal intensive care unit (NICU) and other medical personnel should be preparing for the infant(s) resuscitation.

The following are the steps for the procedure:

1. The maternal patient is placed in the left lateral decubitus position and if time permits, a Foley is placed for bladder decompression.
2. The surgeon makes an incision from the xiphoid to the symphysis pubis, through all layers of the abdominal wall.
3. The bladder should be decompressed via the previously placed Foley catheter. It is retracted manually.
4. A second vertical uterine incision is made from the fundus toward the bladder, taking care not to incise too deeply and cause penetrating trauma to the fetus.
5. The fetus is bluntly delivered from the uterus.
6. As in usual deliveries, suction is performed orally, then nasally.  The cord is clamped and cut.
7. Resuscitation continues on the maternal patient and resuscitation begins on the neonate. Note that there is likely to be a large amount of pooled blood in the abdominal-pelvic cavities. Along with the large uterus, resuscitation efforts will be difficult.

Differential Diagnosis

• Endometritis abscess

• Face and brow presentation

• Gastrointestinal dysfunction and obstruction

• Pelvic hematoma

• Pelvic vein thrombophlebitis

• Wound complications

Enhancing Healthcare Team Outcomes

Performing perimortem cesarean requires a great deal of clinical judgment and is best done with an interprofessional team that includes NICU and labor and delivery nurses. 

During the 17th and 18th centuries, physicians were required by law to perform cesarean sections. In 1747, a Sicilian physician was condemned to death for not performing a post-mortem cesarean section. Combined with the dismal patient outcome and such harsh ramifications, it is no surprise that physicians were reluctant and opposed to this procedure.

Outcomes and attitudes alike have changed as survival rates have increased and legal matters have shifted in favor of good samaritan involvement. To this author's knowledge, no healthcare provider has been found liable for the outcome when performing this procedure in the United States.