Perimortem caesarean section in the pre-hospital setting: a case report and suggested changes to guidelines

Introduction

The incidence of cardiac arrest in pregnancy is estimated to be 1 in 36,000 (1), remaining a rare event encountered by healthcare providers. This is especially true within pre-hospital settings, where outcomes for both mother and neonate are poor (2,3).

Clearly defined guidelines for the resuscitation of pregnant patients have been developed, with the intention of mitigating the maternal physiology of pregnancy (4). Recommendations include application of left lateral tilt or manual uterine displacement for patients over 20 weeks gestation to minimise aortocaval compression. In obstetric cardiac arrest, this is carried out alongside standard and well-established advanced life support (ALS) interventions. Early perimortem caesarean section (PMCS) is advised and should be performed within 5 minutes of collapse when return of spontaneous circulation (ROSC) has not been achieved, or immediately in the presence of fatal maternal injury or prolonged pre-hospital cardiac arrest (5). The rationale for PMCS is that delivery of both foetus and placenta enhances the efficacy of resuscitation efforts by allowing greater venous return and cardiac output to be achieved (4).

Despite these guidelines being applicable to any obstetric cardiac arrest scenario, limitations in their translation to pre-hospital care have been identified (1-3,5). Specifically, this revolves around time taken for pre-hospital providers to arrive on scene following receipt of the emergency call, meaning resuscitation efforts can be delayed. This is important considering the recommendation for PMCS to be achieved within 5 minutes of cardiac arrest, as those with the specialist skillset to perform this procedure are not immediately available (3). Within the pre-hospital setting especially, such decisions and human factors can be complicated by incomplete information and uncertainty regarding whether to transfer the patient to hospital or remain in-situ to deliver advanced care (1,2). Furthermore, there is no definitive pre-hospital guidance on post-resuscitation management following PMCS if ROSC is achieved, given that catastrophic haemorrhage will likely ensue (5). We present this case in accordance with the CARE reporting checklist (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-132/rc).

Case presentation

In 2023 an emergency call was placed in the UK to attend a patient in her 40s who had suffered a pre-hospital cardiac arrest at 38 weeks gestation. The information initially provided by the patient’s partner stated the cardiac arrest was witnessed.

A week prior, the patient had been unwell with a LRTI and was prescribed a course of phenoxymethylpenicillin. This infection resulted in a missed antenatal appointment, with several other missed appointments over the course of the pregnancy. The last antenatal review documented a blood pressure of 138/88 mmHg, urine protein-creatinine ratio of 33.3 mmol⁻¹ and 2+ urinary protein on urine dipstick, however no follow-up appointment was made for this. Ultrasound imaging had shown the foetus to be in cephalic presentation, with signs of polyhydramnios and a risk of cord prolapse. Induction of labour had been booked for 39 weeks gestation. The patient’s medical history included borderline personality disorder and substance abuse. She was deemed high-risk for VTE and prescribed enoxaparin. She had no known allergies, and her other regular medications included aspirin, lorazepam, gabapentin, and promethazine.

The first ambulance crew attending found the patient in her living room in a third floor flat. ALS was initiated and the patient was asystolic. Uterine displacement was performed, and proximal tibial intraosseous access obtained. Adequate ventilation was undertaken, and the patient had a tympanic temperature of 34.7 ℃. On arrival to the scene, 29 minutes after the initial emergency call, a pre-hospital doctor performed a PMCS.

A longitudinal incision was made through the patient’s abdomen and uterus. No gross blood or meconium was seen in the uterus. The cord was subsequently cut with no cord pulse. The foetus was delivered with small superficial cuts to the buttock and left shoulder. Neonatal life support was shortly started upon detection of no pulse. This was undertaken as per UK newborn resuscitation guidelines with standard bag-mask ventilation and 2-finger chest compressions. This was performed for 10 minutes and during this time no adrenaline was given. Resuscitation was stopped due to the presence of rigor mortis of the neonate.

Helicopter Emergency Medical Services (HEMS) arrived on scene around 1 minute after the PMCS was performed. An agreement to stop resuscitation was reached following a further 10 minutes given the prolonged period of asystole, along with new information that the cardiac arrest was not witnessed as originally thought and it was unknown exactly when it occurred. Taking into consideration that all appropriate interventions had been undertaken it was felt prolonging resuscitation was futile.

Both patient and neonate were pronounced deceased before their conveyance to hospital. After death, the neonate was examined with the weight (3.6 kg), length (47 cm), and head circumference (34 cm), all found to be within acceptable ranges.

A post-mortem gave a cause of death as a massive pulmonary embolism and there was evidence of recent cocaine use on toxicology.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient’s next of kin for the publication of this case report. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

There are numerous pathologies which can result in obstetric cardiac arrest. In this case, the cause was initially unclear given multiple possible aetiologies. Despite this uncertainty, ALS was undertaken in line with clinical guidelines, and PMCS was performed immediately once a clinician with the required skillset arrived. Importantly, the patient was not transferred to hospital prior to PMCS which is in keeping with best practice (4). Nevertheless, PMCS was delayed, demonstrating the difficulty in adhering to obstetric resuscitation guidelines in the pre-hospital setting.

It is known that the longer time elapsed between collapse to PMCS increases the futility of resuscitation efforts, with survival being more likely if PMCS is achieved within the recommended 5 minutes from collapse (1). Given that PMCS was performed 29 minutes after what was initially believed to be a witnessed event, it raises the question of whether this was futile and ethically the right decision. Outcomes from pre-hospital and delayed PMCS have been analysed with varied results (2,3,6-8). One literature review examining maternal and foetal harm-free survival rates after PMCS, found most of the mothers survived without any detriment, even with resuscitation attempts lasting greater than 5 minutes before foetal delivery (6). There was however an established relationship between maternal and foetal outcome, with the likelihood of harm-free survival worsening with increasing time from cardiac arrest to PMCS, being approximately 50% at 25 minutes for the mother, and 26 minutes for the foetus. It should be noted that these cases are nearly all in-hospital and witnessed cardiac arrests, which limits their translatability to this case and makes it challenging to determine whether PMCS at 29 minutes was advisable.

Where maternal resuscitation is futile, particularly due to non-survivable injury, there is an argument for proceeding with delayed PMCS in favour of foetal outcome (7,8), which may apply to pre-hospital care, and supports the decision for PMCS at 29 minutes. One such case, documenting a traumatic obstetric cardiac arrest with substantially delayed pre-hospital resuscitation, had a PMCS undertaken 40 minutes after the time of maternal death due to ultrasound confirming a foetal heartbeat (7). Although the neonate died 11 days later, this case highlights whether pre-hospital PMCS could have benefitted foetal survival. It is worth mentioning the utility of ultrasound in guiding decision-making for delayed PMCS is alluded to within these case reports, with one advocating for continued maternal resuscitation until foetal viability can be assessed (8). Whilst this may be useful in allowing healthcare teams to decide on the suitability of PMCS with greater confidence, it would not have changed the decision to undertake PMCS in the presented case. Furthermore, added delays to foetal delivery are generally not advised (1,4), and within the UK pre-hospital setting, ultrasound use is not routine for these situations (9).

Overall, the literature predominantly supports undertaking immediate PMCS in the event of obstetric cardiac arrest. Notably, there is no recommendation of an upper time limit to which attempting PMCS is advised. Considering the delay to PMCS in this case, an evidence-guided time limit would have been useful.

The undertaking of a highly invasive procedure in such emotionally charged scenes is fraught with ethical considerations, especially considering the diminishing chances of survivability with time. The main considerations are balancing the futility of the procedure, doing no harm, maintaining patient dignity and protecting the healthcare providers on scene from witnessing such an intervention, against ensuring everything has been done. This is a complex subject, complicated by the lack of evidence, the rarity of these events and the high emotional burden that goes with such cases. The mainstay of this consideration is what chance of success justifies proceeding, and this, understandably differs from person to person. It is our view that whilst there is a chance of survival, however low, proceeding is ethically justifiable considering the dire patient condition and the possible moral injury associated with not undertaking a PMCS. We also feel that this offers the relatives the assurance and knowledge that everything was done. We believe that extending this beyond 60 minutes however, where there are no documented survivors, tips this balance to not performing it given the emotional impact such an invasive procedure would have on those witnessing it for no benefit and clear futility, which we appreciate may not be a shared view amongst all those reading.

There are also various other non-clinical factors which influence this decision. Whilst this has not been explored for obstetric cardiac arrest due to its rarity, a systematic review focusing on out-of-hospital cardiac arrests identified that patient demographics, the presence of family and bystanders, individual clinician factors, and team dynamics, all had the potential to affect resuscitation decisions (10). This will almost certainly feed into one’s perceived ethics of the procedure too.

Whilst there was not a good maternal or foetal outcome in this case, it is important to consider the patient’s ongoing management if ROSC had been achieved. A highly vascular post-partum uterus, alongside major invasive surgery, predisposes to significant blood loss requiring immediate action to prevent exsanguination. This is particularly relevant given the inevitably grossly hypoxic uterus which will limit uterine contraction (11).

Within the limited literature and pre-hospital guidance available (5,12,13), the consensus is to pack the abdomen with haemostatic gauze, apply pressure, and immediately transport the patient to a suitable hospital. The concurrent administration of tranexamic acid and uterotonic medications has also been advised. Aortic compression, or cross-clamping, via the laparotomy incision used for PMCS, is briefly mentioned as a further haemorrhage control option post-ROSC in this scenario but is not overtly recommended (5). Resuscitative thoracotomy (RT), is instead, a more commonly practiced intervention for managing major pre-hospital abdominal haemorrhage (14,15). With this, thoracic access is rapidly obtained surgically to manually compress, or cross-clamp, the descending thoracic aorta. Although this could potentially be a means to controlling haemorrhage post-PMCS, the survival benefit from undertaking RT in haemorrhagic abdominal trauma is uncertain (15), being altogether unknown following PMCS.

Proposed recommendations

There is no current evidence which is demonstrative of undertaking PMCS beyond 60 minutes to be in either maternal or foetal best interests (5,6) but there is a reasonable argument for this to be 45 minutes. We feel that 45 minutes should be the initial upper limit of performing a PMCS unless there are significant confounding clinical factors (e.g., foetal heartbeat on ultrasound). We feel that doing a PMCS beyond 60 minutes from time of cardiac arrest is hard to ethically justify and should form part of a hard upper time limit.

In the event of ROSC pre-hospitally we feel that guidelines should advocate for manual uterine compression with the operator’s hands, packing the uterus with standard or haemostatic gauze, and the administration of 2 g tranexamic acid is a reasonable first line. If there continues to be haemodynamic instability or insufficient haemostatic control, then there should be a very low threshold for proceeding to abdominal aortic compression/clamping via either the laparotomy wound or by performing a RT depending on operator familiarity and confidence. This should be continued until arrival in hospital. Pre-hospital blood products should be administered if available. In addition, we would recommend taking the patient directly to an operating theatre, bypassing the emergency department, and activating the hospital’s major haemorrhage protocol.

Conclusions

This case presentation details the difficulties in promptly initiating pre-hospital resuscitation for obstetric cardiac arrest, resulting in delayed PMCS and poorer overall outcomes. Whilst the available literature largely supports directly proceeding to PMCS, there is no defined guidance on when this should not be attempted in the pre-hospital setting, but we believe this should fall at 45 minutes. In addition, a lack of guidance on post-PMCS management should ROSC occur, creates a high level of clinical uncertainty, highlighting a need to develop new guidance which is tailored to pre-hospital care and can support practitioners to make informed decisions.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-132/rc

Peer Review File: Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-132/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-132/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient’s next of kin for the publication of this case report. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Beckett VA, Knight M, Sharpe P. The CAPS Study: incidence, management and outcomes of cardiac arrest in pregnancy in the UK: a prospective, descriptive study. BJOG 2017;124:1374-81. [Crossref] [PubMed]
2. Maurin O, Lemoine S, Jost D, et al. Maternal out-of-hospital cardiac arrest: A retrospective observational study. Resuscitation 2019;135:205-11. [Crossref] [PubMed]
3. Moors X, Biesheuvel TH, Cornette J, et al. Analysis of prehospital perimortem caesarean deliveries performed by Helicopter Emergency Medical Services in the Netherlands and recommendations for the future. Resuscitation 2020;155:112-8. [Crossref] [PubMed]
4. Chu J, Johnston TA, Geoghegan J, et al. Maternal Collapse in Pregnancy and the Puerperium: Green-top Guideline No. 56. BJOG 2020;127:e14-e52. [Crossref] [PubMed]
5. Battaloglu E, Porter K. Management of pregnancy and obstetric complications in prehospital trauma care: prehospital resuscitative hysterotomy/perimortem caesarean section. Emerg Med J 2017;34:326-30. [Crossref] [PubMed]
6. Benson MD, Padovano A, Bourjeily G, et al. Maternal collapse: Challenging the four-minute rule. EBioMedicine 2016;6:253-7. [Crossref] [PubMed]
7. Oncel Yel G, Kemanci A, Yılmaz A, et al. Delayed postmortem cesarean section due to trauma. Travmaya bağlı gecikmiş postmortem sezaryen. Ulus Travma Acil Cerrahi Derg 2023;29:440-2. [PubMed]
8. Gunevsel O, Yesil O, Ozturk TC, et al. Perimortem caesarean section following maternal gunshot wounds. J Res Med Sci 2011;16:1089-91. [PubMed]
9. Akanuwe J, Niroshan Siriwardena A, Bidaut L, et al. PP33 Use of point of care ultrasound in prehospital care: an interview study. Emerg Med J 2022;39:e5. [Crossref]
10. Milling L, Kjær J, Binderup LG, et al. Non-medical factors in prehospital resuscitation decision-making: a mixed-methods systematic review. Scand J Trauma Resusc Emerg Med 2022;30:24. [Crossref] [PubMed]
11. Escobar MF, Nassar AH, Theron G, et al. FIGO recommendations on the management of postpartum hemorrhage 2022. Int J Gynaecol Obstet 2022;157:3-50. [Crossref] [PubMed]
12. Parry R, Asmussen T, Smith JE. Perimortem caesarean section. Emerg Med J 2016;33:224-9. [Crossref] [PubMed]
13. Rayner S, Leech C. CSOP 027 – Resuscitative Hysterotomy. The Air Ambulance Service. Available online: https://theairambulanceservice.org.uk/wp-content/uploads/2022/02/CSOP-027-Resuscitative-Hysterotomy-V2.pdf (accessed 24 March 2024).
14. Ter Avest E, Carenzo L, Lendrum RA, et al. Advanced interventions in the pre-hospital resuscitation of patients with non-compressible haemorrhage after penetrating injuries. Crit Care 2022;26:184. [Crossref] [PubMed]
15. Hughes M, Perkins Z. Outcomes following resuscitative thoracotomy for abdominal exsanguination, a systematic review. Scand J Trauma Resusc Emerg Med 2020;28:9. [Crossref] [PubMed]