Clinical and Ethical Consideration of Perimortem

Clinical and Ethical Consideration of
Perimortem C-Section
Yudianto Budi Saroyo

Fetomaternal Departemen Obstetri Ginekologi
Fakultas Kedokteran Universitas Indonesia/
RSUPN dr. Cipto Mangunkusumo
Jakarta
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.
Krywko DM, Sheraton M, Presley B. Perimortem Cesarean. [Updated 2022 Jun 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-
. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459265/
Purpose and scope
• Maternal collapse is a rare but life-threatening event, with a wide ranging
aetiology
• The outcome primarily for the mother, but also the fetus, depends on prompt
and effective resuscitation.
• Maternal collapse is defined as an acute event involving the cardiorespiratory
systems and/or central nervous systems, resulting in a reduced or absent
conscious level (and potentially cardiac arrest and death), at any stage in
pregnancy and up to 6 weeks after birth.
• Importantly, if maternal collapse which is not as the result of cardiac arrest is
not treated effectively, maternal cardiac arrest can then occur.
Chu J, Johnston TA, Geoghegan J, Royal College of O, Gynaecologists. Maternal Collapse in Pregnancy and the Puerperium: Green-top
Guideline No. 56. BJOG. 2020;127(5):e14-e52.
Purpose and scope
• The incidence of cardiac arrest in pregnancy is much rarer than maternal collapse at
around 1 in 36 000 maternities, with a case fatality rate of 42%. In a UK study, a total
of 25% of cardiac arrests in pregnancy were secondary to anaesthesia and all were
associated with a 100% survival rate
• Whilst maternal collapse is such an uncommon event, the consequences are
potentially devastating, therefore it is essential that the clinical team are skilled in
initial effective resuscitation techniques, and are able to investigate and diagnose the
cause of the collapse to allow appropriate, directed ongoing management
• It should also be remembered that death and disability may result despite excellent
care. It should be noted that vasovagal attacks and epileptic seizures are the most
common causes of maternal collapse and are not covered by this guideline
Philosophy of Thought :
1. During attempted resuscitation of a pregnant woman, providers have
2 potential patients: the mother and the fetus.
2. The best hope of fetal survival is maternal survival.
3. For the critically ill pregnant patient, rescuers must provide
appropriate resuscitation based on consideration of the
physiological changes caused by pregnancy.
A classification relating the degree of urgency to the presence or
absence of maternal or fetal compromise
Summers BA, Flett GG. Obstetric emergencies. Anaesthesia & Intensive Care Medicine. 2019;20(9):500-5
Essa A, Flett GG. Obstetric emergencies. Anaesthesia & Intensive Care Medicine. 2022;23(8):460-6.
Principles of Maternal Cardiac Arrest
(MCA) management.
Fischer C, Bonnet MP, Girault A, Le Ray C. Update: Focus in-hospital maternal cardiac arrest. J Gynecol Obstet Hum Reprod. 2019;48(5):309-14.
Resuscitation
protocol in
pregnancy following
maternal collapse
Drukker L, Hants Y, Sharon E, Sela HY, Grisaru-Granovsky S. Perimortem cesarean section for maternal and fetal salvage: concise review and protocol. Acta Obstet
Gynecol Scand. 2014;93(10):965-72
4Hs & 4Ts aide memoire for causes of
Primary survey for threat to life collapse (*more common causes in
pregnancy)
• Airway (A) • Four Hs • Four Ts
• Breathing and ventilation (B) • Hypoxia* • Thromboembolism*
• Circulation (C) • Hypovolaemia* • Toxicity*
• Disability or neurological status (D) • Hypo/hyperkalaemia • Tension
• Exposure/environmental control (E) • Hypothermia pneumothorax
• Cardiac tamponade
Long L, Penna L. Maternal collapse. Obstetrics, Gynaecology & Reproductive Medicine. 2018;28(2):46-52
Cause of maternal cardiac arrest
by American Heart Association
A - anaesthetic complications C - cardiovascular F - fever
• High neuraxial block • Arrythmia • Sepsis
• Aspiration • Myocardial infarction • Infection
• Local anaesthetic toxicity • Congenital heart disease G - general (UK T’s and H’s)
• Respiratory depression • Aortic dissection • Hypoxia
A - accidents • Heart failure • Hypovolaemia
• Trauma D - drugs • Hypothermia
• Suicide • Oxytocin • Hypokalaemia/Hyperkalaemia
B - bleeding • Magnesium sulphate • Toxins
• Uterine atony • Opioids • Tamponade
• Placenta praevia/Placenta • Anaphylaxis H - hypertension
accrete • Drug administration error • Preeclampsia/Eclampsia
• Placental abruption E - embolism • HELLP syndrome
• Uterine rupture • Pulmonary embolism
• Coagulopathy • Amniotic fluid embolism
• Cerebrovascular event
Fiolna M, Paraschiv D. Maternal collapse. Obstetrics, Gynaecology & Reproductive Medicine. 2021;31(10):282-7.
Mnemonic to aid recall of common causes of
maternal arrest
BEAUCHOPS
B Bleeding/DIC
E Embolism: coronary/pulmonary/amniotic fluid
A Anaesthetic complications
U Uterine atony
C Cardiac: ischaemia/infarction/aortic dissection/cardiomyopathy
H Hypertension/preeclampsia/eclampsia
O Others (differential from standard ACLS guidelines)
P Placental abruption/praevia/accreta
S Sepsis
Eldridge AJ, Ford R. Perimortem caesarean deliveries. Int J Obstet Anesth. 2016;27:46-54.
Causes of maternal cardiac arrest and survival rates
according to cause (nonexclusive categories)
Canada 2002-2015 USA 1998-2011
Causes of
(N = 286) (N = 4843)
Maternal Cardiac Arrest (MCA)
MCA Survival MCA Survival
Postpartum hemorrhage 39% 70% 28% 55%
Antepartum hemorrhage 20% 65% 17% 53%
Heart failure 31% 70% 28% 55%
Anesthesia 13% 100% 8% 82%
Amniotic ﬂuid embolism 13% 67% 13% 52%
Trauma 12% 56% 3% 23%
Sepsis 9% 60% 11% 47%
Eclampsia 7% 85% 6% 76%
Pulmonary embolism 6% 53% 7% 41%
Stroke 5% 46% 4% 40%
Acute pulmonary edema 5% 77% 2% 71%
Myocardial infarction 1% 33% 3% 56%
Aortic dissection 1% 25% 0.3% 0
Aortocaval compression (ACC) and
non-invasive decompression maneuvers
• The 20-week threshold for significant ACC dates back to 1969 [9]; however, ACC was not examined at earlier gestational ages [9]. A
study from as early as 1943 found that ACC occurs even at 12–14 weeks’ gestational age [10]. Therefore, from the above data, it can
be concluded that ACC occurs even from early in pregnancy and that it results in significant maternal haemodynamic changes.
• At 15, 30, and 45 of tilt, ACC can still be found [24–26]. One study found that maximal cardiac index was only achieved with the full
left lateral position [26], a position that is incompatible with resuscitation. Any degree of ACC could affect maternal haemodynamics
enough to negatively affect resuscitation efforts. In a recent study, cardiac output was reported to be on average 5% higher when
tilted 15 or more compared with less than 15 [27]. In a subgroup of women, cardiac output decreased by over 20% without a
change in blood pressure when they were tilted less than 15 [27].
• Furthermore, even experienced clinicians have been shown to be inaccurate when estimating the degree of tilt and, commonly,
overestimate tilt [28]. Finally, even though studies have found that chest compression can practically be carried out in the tilted
position [29], these studies are not physiologic and, therefore, lack critical information about the use of tilt during cardiopulmonary
resuscitation.
• Therefore, many concerns are valid about the use of tilt for the purpose of relieving ACC when resuscitating a pregnant woman with
cardiac arrest [30]. In the pre- and post-arrest phases, when chest compressions are not required, placing the pregnant woman in a
full left lateral decubitus position at 90 is recommended to help prevent haemodynamic deterioration
Jeejeebhoy F, Windrim R. Management of cardiac arrest in pregnancy. Best Pract Res Clin Obstet Gynaecol. 2014;28(4):607-18
Class IIb, LOE C
Manual displacement of the uterus to the left
Manual left uterine displacement during resuscitation
Kikuchi J, Deering S. Cardiac arrest in pregnancy. Semin Perinatol. 2018;42(1):33-8.

• Jika kedua teknik diatas tidak berhasil
maka pasien ditempatkan untuk miring
ke kiri 27° to 30°dengan ikatan yang
kuat (Figure 4)
(Class IIb, LOE C).
AHA Guidelines 2010

• Untuk menurunkan kompresi aorta
selama RJP ➔ manual left uterine
displacement pada saat posisi pasien
berbaring (Class IIa, LOE C).
• Bisa dengan kedua telapak tangan atau

dengan satu tangan kanan.
AHA Guidelines 2010

Left lateral uterine displacement
One-handed left lateral uterine

displacement that enables access to
abdomen if perimortem delivery is
required. Not shown is alternative
2-handed technique that displaces
uterus by pulling it toward rescuer
positioned on left side of patient.
Zelop CM, Einav S, Mhyre JM, Martin S. Cardiac arrest during pregnancy: ongoing clinical conundrum. Am J Obstet Gynecol. 2018;219(1):52-61
Aortocaval compression (ACC) and
non-invasive decompression maneuvers
Left uterine displacement (LUD) from Left uterine displacement (LUD) from
left side of patient. right side of patient
Four Minute Rule
• Maternal apnea associated with rapid declines in PaO2 and arterial
pH
• Fetus of an apnoeic and a systolic mother has ≤ 2 minutes of
oxygen reserve
• After 4 minutes without restoration of circulation, dramatic action
must occur
PERIARREST / PERIMORTEM CAESAREAN SECTION TO IMPROVE
CHANCES OF MATERNAL SURVIVAL
• The Resuscitation Council for special situations has recommended

that prompt caesarean delivery
• should be considered as a resuscitative procedure for cardiac arrest
in near-term pregnancy. Delivery
• of the fetus will obviate the effects of aortocaval compression and
significantly improve the chance for
• maternal resuscitation. This will reduce maternal oxygen
consumption, increase venous return, make
• ventilation easier and allow CPR in the supine position.
When to do it
• Evidence from literature and review of maternal and fetal
physiology suggests that a caesarean delivery should begin
within four minutes of cardiac arrest and delivery be
accomplished by five minutes.
• Pregnant women develop anoxia faster than non-pregnant
women and can suffer irreversible brain damage within four to
six minutes after cardiac arrest.
• When a mother in the second half of her pregnancy suffers a
cardiac arrest, immediate resuscitation should commence.
• Should immediate resuscitation fail, every attempt should be
made to start the caesarean section by four minutes and
deliver the infant by five minutes.
• CPR must be continued throughout the caesarean section and
afterwards, as this increases the chances of a successful
neonatal and maternal outcome
Where to do it
• Moving the mother to an operating theatre (e.g. from a labour
room or accident and emergency department) is not necessary.
• Diathermy will not be needed initially, as there is little blood loss if
no cardiac output.
• If the mother is successfully resuscitated, she can be moved to
theatre to complete the operation.
How to do it
• A limited amount of equipment is required in this situation. Sterile preparation and
drapes are unlikely to improve survival.
• A surgical knife and forceps should be sufficient to effect delivery of the baby.
• There are no recommendations regarding the surgical approach for caesarean
section but there is no doubt that the classical approach is aided by the natural
diastasis of recti abdomini that occurs in late pregnancy and a bloodless field in this
clinical situation.
• It is accepted, however, that operators should use the technique with which they
are most comfortable, and in the current context most obstetricians can deliver a
baby via a routine approach in less than a minute.
• Consider open cardiac massage in the context of Caesarean section when the
abdomen is already open and the heart can be reached relatively easily through the
diaphragm.
What is the optimal initial management of maternal collapse?
Maternal Collapse in Pregnancy and the Puerperium RCOG Green Top Guideline No 56 December 2019
Can women at risk of impending collapse be identified early?
Recomendation
An obstetric modified early warning score chart should be D
used for all women undergoing observation, to allow early
recognition of the woman who is becoming critically ill.
What are the causes of maternal collapse?
Recomendation
Maternal collapse can result from a number of causes. B
A systematic approach should be taken to identify the
cause. [New 2019]
What are the physiological and anatomical changes in pregnancy that
affect resuscitation?
Recomendation
Aortocaval compression significantly reduces cardiac output from C
20 weeks of gestation onwards and the efficacy of chest
compressions during resuscitation. [New 2019]
Changes in lung function, diaphragmatic splinting and increased C
oxygen consumption make pregnant women become hypoxic
more readily and make ventilation more difficult. [New 2019]
Difficult intubation is more likely in pregnancy. [New 2019] C
Pregnant women are at an increased risk of aspiration. [New C
2019]
Recomendation
Maternal collapse resuscitation should follow the Resuscitation Council (UK) D
guidelines using the standard ABCDE approach, with some modifications for
maternal physiology, in particular relief of aortocaval compression
Manual displacement of the uterus to the left is effective in relieving aortocaval D
compression in women above 20 weeks’ gestation or where the uterus is palpable
at or above the level of the umbilicus. This permits effective chest compressions in
the supine position in the event of cardiac arrest
A left lateral tilt of the woman from head to toe at an angle of 15–30o on a firm C
surface will relieve aortocaval compression in the majority of pregnant women and
still allow effective chest compressions to be performed in the event of cardiac
arrest
In cases of major trauma, the spine should be protected with a spinal board
before any tilt is applied. In the absence of a spinal board, manual displacement of
the uterus should be used. [New 2019]
Recomendation
Intubation in an unconscious woman with a cuffed endotracheal
tube should be performed immediately by an experienced
anaesthetist.
Supplemental high flow oxygen should be administered as soon as
possible to counteract rapid deoxygenation.
Bag and mask ventilation or insertion of a simple supraglottic airway
should be undertaken until intubation can be achieved.
Two wide-bore cannulae (minimum 16 gauge) should be inserted as

soon as possible. If peripheral venous access is not possible, early
consideration of central venous access, intraosseous access or
venous cutdown should be considered
Recomendation
There should be an aggressive approach to volume replacement,
although caution should be exercised in the context of pre-eclampsia
or eclampsia.
There should be no alteration in algorithm drugs or doses used in the
Resuscitation Council (UK) protocols.
Resuscitation efforts should be continued until a decision is taken by
the consultant obstetrician and consultant anaesthetist to discontinue
resuscitation efforts. This decision should be made in consensus with
the cardiac arrest team.
When, where and how should perimortem caesarean section (PMCS)
be performed?
Recomendation
In women over 20 weeks of gestation, if there is no response to correctly D
performed CPR within 4 minutes of maternal collapse or if resuscitation is
continued beyond this, then PMCS should be undertaken to assist maternal
resuscitation. Ideally, this should be achieved within 5 minutes of the collapse.
PMCS should not be delayed by moving the woman. It should be performed where
maternal collapse has occurred and resuscitation is taking place.
The operator should use the incision, which will facilitate the most rapid access.
This may be a midline vertical incision or a suprapubic transverse incision.
A scalpel and umbilical cord clamps (or alternative ligatures) should be available on
the resuscitation trolley in all areas where maternal collapse may occur, including
the accident and emergency department.
What does the ongoing management consist of?
Recomendation
Senior staff with appropriate experience should be involved at an
early stage
Transfer should be supervised by an adequately skilled team with
appropriate equipment.
In the case of maternal collapse secondary to antepartum
haemorrhage, the fetus and placenta should be delivered promptly
to allow control of the haemorrhage.
In the case of massive placental abruption, caesarean section may
occasionally be indicated even if the fetus is dead to allow rapid
control of the haemorrhage.
Intravenous tranexamic acid significantly reduces mortality due to A
postpartum haemorrhage. [New 2019]
Recommendation
Massive pulmonary embolism should be treated according to D
RCOG Green-top Guideline No. 37b Acute Management of
Thrombosis and Embolism during Pregnancy and the Puerperium.
[New 2019]
The management of amniotic fluid embolism (AFE) is supportive
rather than specific, as there is no proven effective therapy.
Early involvement of senior experienced staff, including midwives,
obstetricians, anaesthetists, haematologists and intensivists, is
essential to optimise outcome.
Recommendation
Coagulopathy needs early, aggressive treatment, including the use of fresh frozen
plasma
Recombinant factor VII should only be used if coagulopathy cannot be corrected by C
massive blood component replacement as it causes poorer outcome in women
with AFE. [New 2019]
After successful resuscitation, cardiac cases should be managed by an expert
cardiology team.
The antidote to magnesium toxicity is 10 ml 10% calcium gluconate or 10 ml 10%
calcium chloride given by slow intravenous injection.
If local anaesthetic toxicity is suspected, stop injecting immediately.
Intralipid 20% should be available in all hospitals offering maternity services.
D Recommendation
Manage arrhythmias as usual, recognising that they may be very refractory to treatment
All cases of lipid rescue should be reported to NHS Improvement and the Lipid Rescue site.
Eclampsia should be managed in accordance with the NICE Clinical Guideline 107 D
Hypertension
in Pregnancy: Diagnosis and Management. [New 2019]
Neuroradiologists and neurosurgeons should be involved in the care of pregnant women
with
intracranial haemorrhage at the earliest opportunity. [New 2019]
In cases of anaphylaxis, all potential causative agents should be removed, and the ABCDE
approach to assessment and resuscitation followed.
Recommendatio
n
If the anaphylactic reaction occurs in the community, the woman
should have basic life support and be transferred to a hospital setting
as quickly as possible, unless a suitably trained healthcare
professional is present with appropriate equipment and drugs in
which case definitive resuscitation and treatment should be
commenced.
The treatment for anaphylaxis is 1:1000 adrenaline 500 micrograms
(0.5 ml) intramuscularly. This dose is for intramuscular use only.
Perubahan pada kehamilan Dampak pada resusitasi
Anemia dilusional
Sistem Kardiovaskular ↑ hingga 50 %
Penurunan kapasitas oksigen
Nadi ↑ hingga 15-20 dpm ↑ sirkulasi RJP
Cardiac output ↑ hingga 40% ↑ sirkulasi RJP
SVR Menurun
Tekanan darah arteri ↓ 10-15 mmHg ↓ reserve

Venous return ↓ tekanan pada pasien hamil ↑ sirkulasi RJP
RCOG Green Top Guideline No 56 January 2011

• Kompresi dada tidak boleh
ditunda dengan meraba denyut
nadi tetapi harus dimulai segera
saat tidak ada pernapasan dan
berlanjut hingga irama jantung
dapat diperiksa.
• Kompresi dada tidak efektif

setelah kehamilan 20 minggu
kehamilan oleh karena itu perlu
tindakan melahirkan bayi dan
plasenta dengan segera.
RCOG Green Top Guideline No 56

January 2011
• Jika tidak ada respon setelah
dilakukan CPR dalam waktu 4 menit
pada kehamilan di atas usia 20
minggu kehamilan ➔SC harus
dilakukan untuk membantu resusitasi
maternal.
• Tindakan ini tercapai pada 5 menit

setelah henti nafas dan jantung.
RCOG Green Top Guideline No 56

January 2011
• SC perimortem mengurangi kompresi aorta dan meningkatkan
efektifitas resusitasi jantung paru. ➔ ↑ cardiac output 60-80%.1,2
• American Heart Association (AHA) guidelines (2010) ➔

rekomendasi SC dilakukan setelah 4 menit usaha resusitasi gagal.
Hill CC, Pickinpaugh J. Trauma and surgical emergencies in the obstetric patient.
Operator sebaiknya menggunakan
metode insisi yang nyaman digunakan.
Uterus dan abdomen ditutup dengan cara yang

biasa karena mengurangi perdarahan dan
menurunkan resiko infeksi.
RCOG Green Top Guideline No 56 January

2011
What are the outcomes for mother and baby after maternal collapse?
Recommendation
Outcomes for mothers and babies depend on the cause of collapse, C
gestational age and access to emergency care, with survival rates
being poorer if the collapse occurs out of hospital. In maternal
cardiac arrest maternal survival rates of over 50% have been
reported. [New 2019]
- Kausa henti jantung
- Lokasi terjadinya henti jantung
- Kemampuan resusitasi
Morris S, Stacey M. Resuscitation in pregnancy. BMJ 2003;327:

Tindakan Jumlah kasus Keberhasilan
SC 12 2 (17%)
Tidak dilakukan SC 43 6 ( 14%)
Dijkman A, Huisman C, Smit M, Schutte J, Zwart J, van Roosmalen J, Oepkes D. Cardiac arrest in pregnancy: increasing use of perimortem
caesarean section due to emergency skills training? BJOG 2010;117:282–287.
Perimortem cesarean deliveries with surviving infants with reports of time
from maternal cardiac arrest to delivery of the infant, 1985-2004
Time (min) Gestational age (wk) Number of patients
8 (normal infant)
0-5 25-42 1 (retinopathy of prematurity and hearing loss)
3 (condition not reported)
Subtotal 12
1 (normal infant)
6-10 28-37 2 (neurologic sequelae)
1 (condition not reported)
Subtotal 4
1 (normal infant)
11-15 38-39
1 (neurologic sequelae)
Subtotal 2
4 (normal infants)
>15 30-38 2 (neurologic sequelae)
1 (respiratory sequelae)
Subtotal 7
Total 25
Katz V, Balderston K, DeFreest M. Perimortem cesarean delivery: were our assumptions correct? Am J Obstet Gynecol. 2005;192(6):1916-20
Reported cases of perimortem Effect of perimortem cesarean section
cesarean deliveries with cause of on maternal circulation, reported cases
maternal cardiac arrest, 1985-2004 1985-2004
Cause of maternal cardiac arrest Cases Time from Return of
Trauma 8 maternal spontaneous
No
cardiac arrest circulation and or
Cardiac 8 change
until delivery improvement in
Embolism (AFE, air) 7 (min) hemodynamic status
Magnesium overdose 5 0-5 5 2
Sepsis 3 6-10 3 -
Anesthesia 2 11-15 1 -
Eclampsia 1 >15 4 5
Spontaneous uterine rupture 1 Not reported 1 1
Intracranial hemorrhage 3 Total 12 8
TOTAL 38
Katz V, Balderston K, DeFreest M. Perimortem cesarean delivery: were our assumptions correct? Am J Obstet Gynecol. 2005;192(6):1916-20
Who should be on the team?
Recommendatio
n
In addition to the general arrest team, there should also be a senior
midwife, an obstetrician and an obstetric anaesthetist included in the
team in cases of maternal collapse]
The neonatal team should be called early if delivery is likely
(antepartum collapse over 22+0 weeks of gestation).
Where the woman survives, a consultant intensivist should be
involved as soon as possible
Training
Recommendation
All generic life support training should consider the adaptation of
CPR in pregnant women.
All maternity staff should have annual formal multidisciplinary
training in generic life support
and the management of maternal collapse.
Amniotic fluid
embolism checklist for
initial management
Combs CA, Montgomery DM, Toner LE,
Dildy GA. Society for Maternal-Fetal
Medicine Special Statement (Patient
Safety Quality Committee, Society for
Maternal-Fetal Medicine): Checklist for
initial management of amniotic fluid
embolism. Am J Obstet Gynecol.
2021;224(4):B29-B32.
Equipment for likely sites of perimortem
caesarean delivery
• Surgical masks with eye protection, gloves and gown
• Scalpel and blades
• Surgical forceps and a pair of large surgical scissors x 4
• Retractor
• Obstetric lift-out forceps
• Umbilical cord clamps x 2
• Large sterile gauze swabs
• Urinary catheter
Eldridge AJ, Ford R. Perimortem caesarean deliveries. Int J Obstet Anesth. 2016;27:46-54.
Maternal resuscitation
Fiolna M, Paraschiv D. Maternal collapse. Obstetrics, Gynaecology & Reproductive Medicine. 2021;31(10):282-7.
The American Heart
Association cardiac
arrest in pregnancy
algorithm
Kikuchi J, Deering S. Cardiac arrest in pregnancy. Semin Perinatol.

2018;42(1):33-8.
American Heart Association (AHA) algorithm
for the management of cardiac arrest in pregnancy
Algorithm for
maternal
resuscitation
Zelop CM, Einav S, Mhyre JM, Martin S. Cardiac arrest during pregnancy: ongoing
clinical conundrum. Am J Obstet Gynecol. 2018;219(1):52-61.
Check list for the management of the
first minutes of maternal cardiac arrest
Similarities and differences between standard adult
resuscitation and resuscitation in a pregnant patien
Identical to Advanced Life Support

Relevant differences
(ALS) guidelines
• Rate/rhythm/depth of compressions • Airway difficulties
• Drugs used and doses • Shorter apnoea to desaturation time
• Energies for defibrillation • Aortocaval compression
• ALS, • Diffrent causes (Mg2+ overdose, local
anaesthetic toxicity)
• Time cycles 30:2 ratios
• Peri-mortem caesarean section
Essa A, Flett GG. Obstetric emergencies. Anaesthesia & Intensive Care Medicine. 2022;23(8):460-6.
Maternal and neonatal outcomes
Maternal Fetal
outcome— outcome—
N (%) N (%)
Deceased 33(44·59) 17(23·29)
Injury free survival curve Injury 8(10·81) 14(19·18) Injury free survival curve
Maternal (N= 33). Normal 33(44·59) 42(57·53) Newborn (N = 33).
Benson MD, Padovano A, Bourjeily G, Zhou Y. Maternal collapse: Challenging the four-minute rule. EBioMedicine. 2016;6:253-7.
Incision to birth interval (N= 19).
Benson MD, Padovano A, Bourjeily G, Zhou Y. Maternal collapse: Challenging the four-minute rule. EBioMedicine. 2016;6:253-7.
Outcome
When the group of women who were

discharged without major sequelae (n = 6) was
compared with the group of non-discharged
women who were dead or in persistent
vegetative state (n = 12), median interval time
from arrest to PCS was significantly shorter in
the former group (9 vs 34 min, P = 0.002). CPA,
cardiopulmonary arrest; PCS, perimortem
cesarean section.
Kobori S, Toshimitsu M, Nagaoka S, Yaegashi N, Murotsuki J. Utility and limitations of perimortem cesarean section: A nationwide survey in Japan. J Obstet
Gynaecol Res. 2019;45(2):325-30
Outcome
Relationship between time from CPA to return Relationship between introducing PCPS and
of spontaneous circulation and the blood loss and red the blood loss and blood transfusion
blood transfusion
Time from CPA to ROSC p-value

PCPS (n = 4) Non-PCPS (n = 5) P-value
<20 min (n = 3) >20 min (n = 9)

Blood loss
13 000 ± 9100 2870 ± 1939 0.05
(ml)
Blood loss
1260 ± 458 7970 ± 8810 0.03
(ml)
RCC
RCC transfusion transfusion 67 ± 43 16 ± 12 0.04
0 48 ± 42 0.01 (unit)
(unit)
Kobori S, Toshimitsu M, Nagaoka S, Yaegashi N, Murotsuki J. Utility and limitations of perimortem cesarean section: A nationwide survey in Japan. J Obstet
Gynaecol Res. 2019;45(2):325-30
Fetal outcome
• Timing of delivery is also important for the survival of the infant and its
normal neurological development.
• In a comprehensive review of postmortem caesarean deliveries between
1900 and 1985 by Katz et al., 70% (42/61) of infants delivered within five
minutes survived and all developed normally. However, only 13% (8/61)
of those delivered at 10 minutes and 12% (7/61) of infants delivered at
15 minutes survived. One infant in both of these groups of later survivors
had neurological sequelae.
• Evidence suggests that if the fetus survives the neonatal period then the
chances of normal development are good.
Katz V, Balderston K, DeFreest M. Perimortem cesarean delivery: were our assumptions correct? Am J Obstet Gynecol. 2005;192(6):1916-20; discussion 20-1.
Resuscitative Hysterotomy: Steps
• Make a vertical midline incision through all layers of the abdominal wall from
the uterine fundus to the pubic symphysis.
• Expose the anterior surface of the uterus and retract the bladder inferiorly.
• Make a small vertical incision through the lower uterine segment of the uterus.
• Lift the uterine wall away from the fetus and use scissors to extend the incision
to the fundus.
• Deliver the infant, clamp and cut the cord, and hand off for neonatal
resuscitation.
• Deliver the placenta.
• Pack the abdomen with sterile blue towels.
• Consider antibiotics and oxytocin.
Soskin PN, Yu J. Resuscitation of the Pregnant Patient. Emerg Med Clin North Am. 2019;37(2):351-63.
Perimortem Cesarean
Delivery
(A) Vertical incision through the abdominal

wall. (B) Retraction of the bladder inferiorly.
(C) Incision through the lower uterine
segment. (D) Extension of the incision
superiorly. (E) Delivery of the fetus.
Zelop CM, Einav S, Mhyre JM, Martin S. Cardiac arrest during pregnancy: ongoing clinical conundrum. Am J Obstet Gynecol. 2018;219(1):52-61
Madden AM, Meng ML. Cardiopulmonary resuscitation in the pregnant patient. BJA Educ. 2020;20(8):252-8
Practice points
• Left lateral tilt is no longer recommended during active resuscitation of
maternal cardiac arrest during pregnancy.
• Left uterine displacement is currently the preferred method of
minimizing ACC during active resuscitation in pregnancy.
• Defibrillation and all usual resuscitation medications should be used as
they would be in nonpregnant resuscitation.
• Perimortem caesarean section should be used at the resuscitation site
if there has been no response after 4 min.
• Multidisciplinary team training should be undertaken to optimise team
preparation for resuscitation of cardiac arrest during pregnancy.
Practice points
1. Clinicians and nurse practitioners should be aware of the anatomical and physiological changes that occur in
pregnant woman.
2. Awareness of the slight deviations from BLS and ACLS protocols needs to be borne in mind when performing
resuscitation on pregnant woman <20 weeks, >20 weeks and in the third trimester.
3. The focus of training needs to be based on minimal didactic content and more on using simulation-based
training with greater emphasis on teamwork and collaboration.
4. Reflection and feedback of behavioural, cognitive and technical skills should be integral to the simulation
training (fire drills).
5. Master trainers are essential to develop capacity at an institutional level.
6. Performing fire drills in the workplace is key to ensuring that skills are maintained for rare obstetric
emergencies.
7. Knowledge of the common causes of maternal collapse is essential for midwives and clinicians working in
obstetrics. The application of this knowledge in fire drills is important to develop and maintain professional
competencies.
8. A regular programme of clinical audit and quality improvement needs to be built into the facility-based
training.
Naidoo M. Maternal collapse: Training in resuscitation. Best Pract Res Clin Obstet Gynaecol. 2015;29(8):1058-66.
Out of hospital maternal cardiac arrests (OHCAP).
• In summary, we believe the only way to resuscitate effectively pregnant women is by early
recognition of cardiac arrest in a woman with a uterus at the umbilicus or above, and
resuscitation with manual displacement of the uterus followed by prompt Perimortem C-
section (PMCS) by a trained paramedic, if immediate transfer to hospital is not possible.
• Additional guidelines for analgesia, post-ROSC sequelae, as well as the newborn, need to be in
place before further consideration of prehospital PMCS becomes a routine recommendation.
• Current evidence supports its role in improving maternal outcomes in OHCAP settings where
survival rates are extremely poor. It is time to rethink our approach to out-of-hospital maternal
cardiac arrest.
Hillman SL, Cooper NC, Siassakos D. Born to survive: A critical review of out-of-hospital maternal cardiac arrests and pre-hospital perimortem caesarean
section. Resuscitation. 2019;135:224-5.
Mnemonic to aid
recall of the key
guidelines for
pregnant women
suffering from an
out-of-hospital
cardiac arrest.
Maurin O, Lemoine S, Jost D, Lanoe V, Renard A, Travers S, et al. Maternal out-of-hospital cardiac arrest: A retrospective
observational study. Resuscitation. 2019;135:205-11
Medico-legal issues
• No doctor has been found liable for performing a postmortem caesarean
section. Theoretically, liability may concern either criminal or civil
wrongdoing.
• Operating without consent may be argued as battery
• if the mother is successfully resuscitated. However, the doctrine of
emergency exception would be applied because a delay in treatment
could cause harm.
• The second criminal offence could be ‘mutilation of corpse’.
• An operation performed to save the infant would not be wrongful,
because there would be no criminal intent.
• The unanimous consensus of the literature is that a civil suit for
performing perimortem caesarean is very unlikely to succeed.
• Vencken dkk : kasus SC perimortem diikuti dengan
perdarahan yang banyak dan DIC ➔ relaparotomi.
• Apapun etiologi henti jantung ➔ dapat

menyebabkan DIC.
• DIC dan TD yang naik setelah tindakan sc

perimortem ➔ atonia uterus.
Shigeki Matsubara et al.erimortem cesarean section or perimortem cesarean supracervical hysterectomy.

Arch Gynecol Obstet (2013) 287:389–390
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Clinical and Ethical Consideration of

Yudianto Budi Saroyo

• As described in its name, is the surgical delivery of the fetus,

Kikuchi J, Deering S. Cardiac arrest in pregnancy. Semin Perinatol. 2018;42(1):33-8.

AHA Guidelines 2010

• Bisa dengan kedua telapak tangan atau

AHA Guidelines 2010

One-handed left lateral uterine

• The Resuscitation Council for special situations has recommended

Two wide-bore cannulae (minimum 16 gauge) should be inserted as

Intralipid 20% should be available in all hospitals offering maternity services.

Tekanan darah arteri ↓ 10-15 mmHg ↓ reserve

RCOG Green Top Guideline No 56 January 2011

• Kompresi dada tidak efektif

RCOG Green Top Guideline No 56

• Tindakan ini tercapai pada 5 menit

RCOG Green Top Guideline No 56

• American Heart Association (AHA) guidelines (2010) ➔

Uterus dan abdomen ditutup dengan cara yang

RCOG Green Top Guideline No 56 January

Morris S, Stacey M. Resuscitation in pregnancy. BMJ 2003;327:

Tidak dilakukan SC 43 6 ( 14%)

Kikuchi J, Deering S. Cardiac arrest in pregnancy. Semin Perinatol.

Identical to Advanced Life Support

When the group of women who were

Time from CPA to ROSC p-value

<20 min (n = 3) >20 min (n = 9)

(A) Vertical incision through the abdominal

• Apapun etiologi henti jantung ➔ dapat

• DIC dan TD yang naik setelah tindakan sc

Shigeki Matsubara et al.erimortem cesarean section or perimortem cesarean supracervical hysterectomy.

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