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Resuscitation and Critical Care

A2.1 Peri-mortem Caesarean Delivery

Dr Meliza CW Kong
Department of Obstetrics and Gynaecology,
United Christian Hospital

Dr Meliza CW Kong is the Consultant in Department of Obstetrics and Gynaecology of United Christian Hospital. She is a Maternal and Fetal Medicine Subspecialist. She has a Master degree in Medical Genetics. She is the Board member of Advanced Life Support in Obstetrics (ALSO) (Hong Kong) Board since 2015. Her research interests focus on postpartum hemorrhage and prenatal diagnosis. She had published more than 30 original papers in peer reviewed journals.

She is interested in simulation training and scenario-based training.

Perimortem Caesarean section (PMCS) was originally performed as a religious ritual in Roman times to save the soul of the child from the womb of a dying mother through baptism and burial. The unexpected benefits of neonatal or maternal survival were only recognised centuries afterwards. PMCS is now considered as a legitimate medical intervention during resuscitation of maternal cardiac arrest to improve maternal and neonatal survival.

Importance of perimortem Caesarean section
PMCS should be initiated within 4 minutes after maternal cardiac arrest for women ≥20 weeks of gestation in order to relieve the aortocaval compression from the gravid uterus to increase maternal venous return and cardiac output. PMCS can also help to decrease oxygen demand and improve pulmonary mechanics. A review of 38 cases of PMCS in 2005 reported that 34 fetuses survived and 13 of 20 mothers with reversible causes survived to time of discharge, and that there was no evidence of maternal deterioration after PMCS. Neonatal survival and neurologic outcome were related to the time between maternal death and delivery.

Importance of training for perimortem Caesarean section
The incidence of maternal cardiac arrest is increasing in the recent decade. Medical staff generally lack the experience of PMCS. However, prompt PMCS with ongoing effective maternal cardiopulmonary resuscitation can potentially improve maternal and neonatal outcomes. Therefore, practical training in maternal resuscitation and PMCS is crucial to both obstetrics and accident and emergency staff, and thus it has been included in the curriculum of obstetric emergency training courses.

PMCS should be performed at the site of maternal cardiac arrest (for in-hospital cases). Consent for PMCS and urinary bladder drainage as well as strict sterility are not necessary. Midline incision may provide the quickest way to deliver the fetus. Individual units can work out their own workflow logistics and protocols. A prepacked set of instruments for PMCS is recommended to be stored in the obstetrics and accident and emergency departments.

Simulation training can improve team training and enhance didactic teaching. A simple and inexpensive manikin model is recommended for simulation training in PMCS. Maternal cardiac arrest drills can be held regularly in order to increase staff awareness, update staff knowledge, enhance team cooperation, and identify deficient areas.

Prompt delivery of the baby by PMCS in the event of maternal cardiac arrest is crucial for improving maternal and neonatal outcomes. Regular training is essential to improve staff competence.

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