Perimortem Cesarean Delivery
Deborah S. Lyon
Perimortem cesarean delivery (PMCD) is rarely performed; fewer than 300 cases have been reported in the English literature. Two concepts make this an important topic nonetheless.
One is the clear imperative to decide and act promptly when PMCD is indicated. As in all aspects of emergency medicine, the knowledge must precede the crisis rather than await it. Advanced Cardiac Life Support and other algorithmically driven resuscitation measures were, in fact, designed for those who do not often have to use them, in the hope that committing certain “drills” to memory will allow an uncommon medical event to be optimally managed. In addition, the indications for PMCD have broadened considerably since the 1980s, and the procedure may attain a more prominent role in the future.HISTORICAL BACKGROUND
Cesarean delivery is one of the oldest surgical procedures in history, with literature dating back to at least 800 BC (1). Before the 20th century, however, the phrase “postmortem cesarean” would have been redundant, because the procedure was essentially never undertaken in any but a dead or moribund mother (2). Initially, the Roman decree (Lex Cesare; law of Caesar) that unborn infants should be separated from their mothers’ bodies was for purposes of religious ritual rather than with any real hopes of survival of either. It would appear that some infants did survive, because the law specified “with the hope of preserving citizens to the State” and failure to obey the mandate was grounds for “legal suspicion that a living child had been killed” (1). Indeed, several mythologic and ancient historical figures were reported to have been born in this fashion, including Apollos’ son, the Greek physician Asklepios, “from the womb of dead Koronis” (3). Bacchus was supposedly born this way, as was Scipio Africanus (the Roman general who defeated Hannibal).
Pliny the Elder dates this event at 237 BC (2). Pope Gregory XIV had this distinction, as did 15th century Genoese admiral Andrea Doria. Some attribute the birth of Edward VI as occurring after the death of the unfortunate Jane Seymour, although others claim she lived several days after the delivery. Shakespeare referred to this practice in Macbeth (4).Judaic writings from the 1st century through the 3rd century AD identify this practice (and find the mother not liable for a sacrifice of purification, as were women who delivered vaginally) (5), and Christian leaders made it a religious issue in the 1280 Council of Cologne as a means of ensuring the infant’s baptism (3).
The first documented record of maternal survival from a cesarean delivery is that of the Swiss sow gelder Jacob Nufer, who sectioned his own wife for the delivery of their firstborn in 1500 (2). None of the available references describe in detail what must surely have been desperate circumstances leading to this intervention, but this hearty lady survived to have five spontaneous vaginal deliveries, including a delivery of a set of twins. She, thus, became the first recorded successful postcesarean trial of labor patient, as well as the first survivor of the procedure.
By the time of the renaissance, PMCD had become such a standard practice that, in 1749, King Charles of Sicily ruled that failure to perform the procedure was punishable by death, and there is one recorded instance of the law being applied to a physician (2).
During the late 19th and early 20th centuries, case reports began to arise of PMCDs successfully salvaging the fetus, and the procedure began to be seriously entertained as a legitimate medical intervention. Well into the 20th century, the salvage rate was very low, and therefore, wisdom dictated that all possible attempts be made to resuscitate the mother with the infant still in utero unless the demise was clear-cut and inevitable.
During the 1980s, several authors reported unexpected maternal recoveries after “postmortem” cesarean deliveries (5,6).
This led to a consideration of the possibility that PMCD might actually improve, rather than worsen, a mother’s chance of survival during a collapse. Uteroplacental blood flow may require up to 30% of a woman’s cardiac output during pregnancy (7), some of which may be retrieved for other visceral organ perfusion after delivery. Indeed, several animal and laboratory models, as well as a growing body of clinical evidence, suggest that, relieved of the caval compression associated with a term pregnancy and of the tremendous circulatory demands of a placenta and fetus, cardiac compressions are significantly more effective (5). There is a 30% decrease in stroke volume and cardiac output in a pregnant woman who lies supine, largely because there is a complete occlusion of the inferior vena cava (which occurs in 90% of women in late pregnancy). In addition, there is a 20% reduction in functional residual capacity at term, and there is a higher metabolic rate, leading to decreased oxygen reserves and faster onset of anoxia following apnea (4). Delivery of the near-term fetus provides a 30% to 80% improvement in cardiac output and, in conjunction with other resuscitative measures, may provide sufficient circulatory improvement to adequately support the central nervous system’s function during an arrest (5). This has led to the current thinking that PMCD is an appropriate resuscitative intervention for both the mother and the infant. In this light, it is critical to intervene promptly and appropriately to maximize the survival possibilities for two patients simultaneously.In summary, the perspective on PMCD has evolved through 23 centuries as a means of
■ Providing appropriate burial and religious rituals for both the mother and the baby
■ Saving a child’s life when maternal death is inevitable
■ Optimizing resuscitation for both the mother and the baby.
CHANGES IN MATERNAL CAUSES OF DEATH
One of the reasons PMCD has become more realistic relates to the prevailing etiologies of maternal demise.
In a 1986 review, Katz et al. (4) highlighted the shift over the past century from primarily chronic, mostly infectious causes of death to primarily acute, mostly cardiorespiratory causes of death. The chronically ill mother may be hypoperfusing or inadequately nourishing her unborn child for months, thus making a good outcome of any delivery less likely. An acute event such as pulmonary embolus, on the other hand, leaves the infant with some reserves and allows a less-than-optimal delivery setting to produce a good outcome.In addition to changing diagnoses, the evolution of medicine itself allows more hope for success. The ability to monitor high-risk patients and intervene in advance of a crisis has developed largely over the past 50 years. Cardiac support and respiratory support are available, at least for the short term, in virtually every setting in which medicine is practiced. Emergency transport services allow prompt medical attention to life-threatening conditions, and when time is the single most critical factor determining success, this emergency transport may be the most important development in medicine.
CONSIDERATIONS FOR UNDERTAKING POSTMORTEM
CESAREAN DELIVERY
Several factors must be considered when deciding whether to undertake PMCD (2,4,5,8-10). The first is the estimated gestational age (EGA) of the fetus. This information is sometimes difficult to obtain in an emergency situation, and time for an ultrasonographic estimate is not practical. Thus, an “eyeball estimate” may be necessary. As a general rule, the uterus reaches the umbilicus at 20 weeks of gestational age and grows in length at the rate of approximately 1 cm every week thereafter. Thus, in a relatively thin woman, a fundal height of 8 cm above the umbilicus would likely represent a pregnancy of 28 weeks’ gestation. Depending on the resources of the institution, the fetus may be salvageable, in ideal circumstances (availability of all skilled personnel and a controlled setting), at anywhere from 23 to 28 weeks of EGA and this should be considered in the decision regarding PMCD.
If the fetus is known to be of 23 weeks’ EGA and there has never been a survival of that gestational age in the institution’s nursery, PMCD is probably not indicated for the sake of the fetus. It may be of less help to the mother as well, compared with a third-trimester intervention. Cardiovascular effects of pregnancy are less pronounced before 28 weeks and thus delivery will not achieve a cardiovascular improvement as dramatic as at a later EGA. Indeed, in the first and early second trimesters, aggressive maternal support is the only indicated intervention, and there has been at least one reported case of a complete maternal and fetal recovery after a prolonged arrest at 15 weeks of EGA (11).The second concern relates to the length of time between arrest and delivery. The latest reported survival was of an infant delivered 45 minutes after documented maternal cardiac arrest with multiple knife injuries, and there are scattered case reports of deliveries 20 to 30 minutes after maternal cardiac arrest, with surprisingly good infant outcomes (12). However, most of the authors cited earlier support a 5-minute rule. Best outcomes in terms of infant neurologic status appear to occur if the infant is delivered within 5 minutes of maternal cardiac arrest. This means the decision to operate must be made and surgery begun by 4 minutes into the code. Although the evidence is not based on a huge number of cases, a compelling argument for prompt intervention can be made on both maternal and fetal grounds (13).
The third critical factor for success is adequacy of other resuscitative efforts in the interim. Although chest compressions may provide only 30% of the baseline cardiac output (4), some oxygenation is clearly better than none. Displacement of the uterus leftward until surgery is actually begun allows for better blood return from the inferior vena cava. The fetus lives on the steep portion of the oxygen dissociation curve; therefore, relatively minor changes in maternal oxygenation result in far more dramatic changes for the fetus.
The fourth critical factor is the availability of adequate neonatal resuscitation. It is tragic to successfully extract a 28-week infant only to have no qualified person available to assume resuscitation efforts. All infants in this setting may be presumed to require postdelivery support, and the emergency department team will most likely be fully occupied with the mother. Furthermore, the emergency department team may well be suboptimally experienced with neonatal resuscitation techniques.
Finally, a vital factor beyond the control of the delivery team is the nature of the maternal condition. Acute conditions enable better results than chronic conditions, and conditions that involve primarily cardiopulmonary collapse respond better than more systemic organ failures.
There is no requirement for documentation of fetal heart tones before PMCD, partly because it is time-consuming and may negatively impact the baby’s outcome and partly because maternal indications for the procedure are pressing regardless of fetal status.
To summarize, conditions that affect the success of PMCD are as follows:
■ Gestational age of the infant (>24 to 28 weeks is optimal)
■ Length of time from arrest to delivery (5 minutes or less is optimal)
■ Adequacy of maternal resuscitative efforts
■ Availability of neonatal resuscitation experts
■ Nature of the underlying maternal condition
There is a special case relating to the “scheduled PMCD.” This involves a woman who would be legally considered “brain dead” but is being maintained on artificial support solely for the purpose of allowing further fetal development. The emergency department is often involved only in the initial stages of this setting, that is, in the decision to initiate extraordinary life-extending measures in the face of a hopeless case. While successful cases of this sort have been reported at an EGA as early as 6 weeks (14), the ethical argument exists that extraordinary support measures for the sole purpose of providing a fetal incubator constitute experimental interventions and require fully informed consent of the next of kin (15). The most likely time frame for both successful support and ethical imperative to support is 24 to 27 weeks of EGA (16), when a few days make a large difference to fetal outcome. Support beyond likely fetal survival ex utero is controversial (17), as is support from a very early EGA. A strong distinction is made by Dillon and colleagues between true brain death and persistent vegetative state, and they argue that termination of support measures is ethically defensible only in the former case. With regard to emergency evaluation, they comment, “The objective of emergent and early management should be to preserve maternal life until fetal viability and prognosis can be assessed” (16).
TECHNIQUE FOR PERFORMANCE OF PMCD
The niceties of preoperative preparation are unlikely to be practical in this setting. If a urinary drainage catheter has not already been placed, time should not be spared to place one. Likewise, a detailed assessment of fetal well-being is impractical. Even assessing for fetal heart tones is unnecessary because this can be difficult and fraught with error (in the large patient or in a noisy room) and because the delivery is done as much for maternal indications as for fetal. A “splash prep” of antiseptic solution across the abdomen is ritually satisfying but of uncertain clinical value. In essence, preparation consists of acquiring some basic equipment and baring the patient’s abdomen.
Full cardiopulmonary resuscitation measures should continue during the delivery. This optimizes oxygen delivery to both patients.
Most young obstetricians perform Pfannenstiel incisions almost exclusively for cesarean deliveries. Although taught that midline incisions allow faster entry into the abdominal cavity, many have found that, with optimal lighting, equipment, and assistance, a Pfannenstiel incision takes little more time, if any, and produces a stronger, prettier scar.
This absolutely does not apply to the incision made under suboptimal conditions. The equipment available is likely to be minimal and not neatly laid out with a scrub technician standing by. While there may be many spectators, there are likely to be no real assistants. Lighting may be poor and not deployable where needed within the incision. Given these restrictions, a midline abdominal incision remains the appropriate choice for performance of PMCD.
Regard for surgical technique should not be abandoned, however, despite the limitations of the setting. Given the possibility of maternal survival, care should be taken to protect bowel and bladder from injury if possible. In any case, the fetus should be protected from the large laceration which is a probable consequence of reckless uterine entry. The infant should be delivered with attention to planes of anatomic function so that permanent nerve damage from overextension does not occur. Someone trained in neonatal resuscitation should be available to assume medical responsibility for the infant as soon as delivery is effected. If desired, a loop of cord may be clamped off at each end and saved for later evaluation of cord gases. The closed loop of cord may sit for up to 60 minutes without significant degradation of the gases (18). Cord blood should also be collected, as it is with all deliveries, so that routine neonatal hematologic studies can be performed without necessitating blood draws from the infant.
The placenta should always be removed before closure. If the mother survives the initial collapse, bleeding or infection with residual placenta as a nidus will worsen her chances of eventual survival. If she does not survive the initial episode, the placenta may deliver spontaneously in the morgue if not extracted at the time of surgery. This is inconvenient at best.
Closure should be undertaken based on maternal circumstances. If the cardiorespiratory resuscitation team thinks that there is any chance of survival, a careful, layered closure should be performed as with any cesarean delivery. In fact, attention to meticulous closure technique is vital, because suboptimal perfusion might not reveal areas of bleeding that could later become problematic when circulatory function is restored. In addition, disseminated intravascular coagulation is a common sequela of massive hemodynamic challenge and might create postoperative problems if closure is not meticulous. If the maternal condition is thought to be hopeless, then a rapid closure for purposes of aesthetics is indicated as a kindness to the family.
If maternal survival seems likely, and in light of the probable absence of sterile technique, consideration should be given to antibiotic prophylaxis. Although there are no series defining an optimal choice for this setting, the rules of “dirty” surgery should apply, and any broad-spectrum penicillin or cephalosporin should be adequate.
The person best suited to perform the PMCD is the most experienced obstetric surgeon available. It is probably no accident that the first reported cesarean success was in the hands of a sow gelder, presumably comfortable with the feel of live tissue and familiar with concepts of vascular control. Sow gelders are relatively unavailable these days, but most communities have obstetricians. Their expertise in estimating risk-success factors such as gestational age, as well as their operative experience, will serve both patients well. If the emergency department is informed that a pregnant woman who is seriously ill or injured is en route, it is prudent to immediately call for obstetric and pediatric support. Only if these resources are not available when the patient arrives and resuscitation efforts are under way, should the emergency physician consider undertaking the PMCD personally.
To recap PMCD technique, one should
■ Have only what preoperative prep can be performed without delaying the procedure
■ Perform a midline abdominal incision, umbilicus to pubis (longer if necessary), and extend it to and through the uterine wall
■ Protect the bowel, bladder, and other maternal organs to the extent possible in the circumstances
■ Provide due attention to the position of the fetus and deliver by careful, anatomically attentive extraction
■ Extract the placenta before closure
■ Close all layers as meticulously as maternal condition dictates
■ Inspect carefully for unexpected damage and repair if indicated
■ Pay particular regard to hemostasis
■ If maternal survival seems likely, consider 24 hours of antibiotic prophylaxis
EQUIPMENT NECESSARY FOR PMCD
The optimal setting for PMCD is the operating room with an open section pack and a trained operating room crew. Failing this, several equipment packages have been recommended. These can be quite elaborate (10) or as simple as a “precip tray” (normally available in emergency departments for precipitous vaginal deliveries). The essential items are, for the most part, readily available and include
■ Scalpel
■ Pack of laparotomy sponges
■ Bandage scissors or straight Mayos
■ Three or four Kelly clamps
■ Suture material, preferably number 0 or number 1 chromic or Vicryl
■ Needle driver
■ Forceps (preferably Russians, Bonneys, or heavy-toothed)
■ Bulb suction
■ Warmer for the infant
■ Full neonatal resuscitation support (e.g., drugs and endotracheal tubes)
OUTCOMES
Unfortunately, it is virtually impossible to rigorously answer the question of maternal and neonatal outcome after this rare and catastrophic event. The American literature contains primarily case reports and very small series. The United Kingdom includes some data in their Confidential Enquiry into Maternal Deaths, but as the name suggests, the registry applies only to cesarean deliveries in which the mother did not survive. In the Confidential Enquiry registry, infants do not fare particularly well either. For the period 1994 to 1996, there were 13 deliveries classified as either postmortem or perimortem. Of these, only two babies were born alive, and one of these expired shortly thereafter. The registry strongly supports the concept of rapid choice for delivery, as the outcome of the group labeled “peri- mortem” (patient moribund or undergoing cardiopulmonary resuscitation) was significantly better than that of the group labeled “postmortem” (patient felt to have already expired) (19). In 10 years, 40 perimortem deliveries were registered, of which 25 resulted in neurologically intact surviving infants (62.5%).
MEDICOLEGAL CONSIDERATIONS
Unfortunately, the practice of medicine has been irreversibly tainted by physicians’ fear of being held liable for actions undertaken with the best possible knowledge and compassion, but having a bad outcome. This is in large part accountable for the flight of many obstetricians into gynecology-only practices, where litigation risk is much lower. It might also lead to withholding PMCD when it might be effective, in fear of failure leading to legal repercussions.
It is of some comfort that, according to the medical literature on the subject, there has never been a suit filed on the basis of wrongful performance of PMCD. There has, in fact, been only one legal penalty levied, the aforementioned death penalty in the 18th century for failure to perform the procedure.
Generally, PMCD is deemed to fall under the same guidelines as any emergency procedure in which consent is not possible. Although some medical literature opines that consent should be obtained if possible, it may be very difficult to determine who is legally qualified to grant consent. Roseate discussions of “talking to the husband” fail to consider the complexities of relationships in this day. It is true that a patient has the right to refuse a cesarean delivery, even if her baby is in extreme jeopardy. This is based on the ethical principle of maternal autonomy. Nonetheless, when maternal consent is not an issue, no other opinion should be deemed legally binding in the emergency setting. Clearly, when the issue is the ventilator-dependent braindead patient being kept alive solely in an incubator, next-of-kin decisions do become relevant, and legal as well as spiritual counsel should be sought.
SUMMARY
PMCD should be undertaken as part of maternal as well as fetal resuscitation in any gestation advanced beyond 24 to 28 weeks. It should be undertaken within 4 minutes of full cardiac arrest if possible, and the technique should be subject to time and environmental constraints. The most experienced obstetrician available is the optimal person to perform the procedure, and someone trained in neonatal resuscitation should be available if possible. Medicolegal considerations have thus far been only theoretical, and the law is likely to support this procedure under the emergency care rubric if it is ever tried. Brain-dead mothers may have extraordinary support measures undertaken for prolonged periods of time, but this should involve extensive discussion with next of kin.
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