OB Nightmares: Peri-Mortem C-Section

Maternal cardiac arrest demands immediate pregnancy-specific ACLS: relieve aortocaval compression, secure oxygenation early, and prepare resuscitative hysterotomy without delay. In a gravid patient with a uterus at or above the umbilicus, the key decision is when to move from standard CPR to peri-mortem cesarean while coordinating OB, anesthesia, and neonatal teams.

Maternal Cardiac Arrest Basics

• Aortocaval compression relief: Pregnant arrest is mechanically different: left uterine displacement while the patient stays supine reduces vena caval compression and preserves CPR quality, with one person assigned to that task.
• Pregnancy airway pitfalls: Hypoxemia develops faster in pregnancy because functional residual capacity is lower and oxygen consumption is higher, so the most experienced airway operator should handle intubation or bag-mask rescue.
• Access above the diaphragm: IV or IO access should be obtained above the diaphragm because the gravid uterus can impede venous return from below, a practical detail that matters early in the code.
• Arrest cause framework: Use an A-H plus trauma differential for maternal arrest: anesthesia, bleeding, cardiac disease, drugs, embolic causes, fever, general metabolic problems, hypertension, and trauma. We lay out the high-yield pregnancy causes in the episode.
• Early team mobilization: Maternal code management is a parallel-process event requiring adult resuscitation, OB, anesthesia, and neonatal or pediatric support at the bedside as quickly as possible.

Peri-Mortem Cesarean Decision and Technique

• Gestational age trigger: If the uterus is at or above the umbilicus, think viable uterine decompression and prepare for resuscitative hysterotomy rather than waiting for prolonged standard ACLS.
• Four-minute decision point: Start peri-mortem cesarean after 4 minutes of maternal resuscitation, aiming for delivery by 5 minutes to improve maternal hemodynamics and neonatal survival.
• Vertical incision preference: A vertical abdominal incision is the fastest ED approach and usually causes less blood loss, a useful procedural default when seconds matter.
• Four-layer abdominal entry: The abdominal wall is opened through fat, fascia, rectus, and peritoneum before entering the uterus, and that anatomy-first framing makes the procedure more manageable under stress. We walk through the tactile landmarks in the chapter.
• Immediate post-delivery priorities: After cord clamping and handoff to pediatrics, remove the placenta, rapidly close the uterus, pack the abdomen, and return focus to maternal resuscitation; post-delivery uterotonics and antibiotics follow.
• Bedside kit readiness: A dedicated cesarean kit with scalpel, clamps, towels, suture, needle driver, and scissors should be preassembled so the procedure can start without a scavenger hunt.

References:

1. Jeejeebhoy FM, Zelop CM, et al. American Heart Association Emergency Cardiovascular Care Committee, Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Cardiovascular Diseases in the Young, and Council on Clinical Cardiology. Cardiac Arrest in Pregnancy: A Scientific Statement From the American Heart Association. Circulation. 2015 Nov 3;132(18):1747-73. PMID: 26443610.
2. Katz V, Balderston K, DeFreest M. Perimortem cesarean delivery: were our assumptions correct? Am J Obstet Gynecol. 2005 Jun;192(6):1916-20 PMID: 15970850.
3. Zelop CM, Brickner B. Sudden cardiac arrest and death in pregnancy. Ed Carolyn Zelop, Vanessa A Barss. UpToDate. Jul 2021.