The arrest buzzer is going in Majors.
Everyone piles in.
It can’t be her.
She’s 25 years old and 32 weeks pregnant.
You’ve just had handover – breathless for a few days.
But it is.
She’s blue, no sign of life. No pulse.
Your’s is about 180bpm.
You quickly start CPR and move her to resus. 2222 call goes out. Where do you work? In a hospital with paeds, obstetrics, they all get called ‘Maternal cardiac arrest’. Imagine you work in a hospital where the children’s and neonates service are 5 miles away. Obstetrics is 5 miles away in a separate hospital. between you and them lies a network of roads lined with potholes and traffic jams so bad its quicker to run than drive at rush hour. Only you can’t run. She needs you. Now. In this room. FOCUS.
Luckily you’re reading this now, and then you’re going to read the excellent review article in March’s EMJ by Parry et al (2016) on Perimortem caesarean section (PMCS) (1). This review article is superbly written and covers the current evidence and approach to this, one of the most nightmarish scenarios in resuscitation.
The aim of PMCS is to improve the mother’s chances are survival, keep this fact at the forefront of your mind. Fetal survival becomes possible at around 24 weeks.
The aim initially is to do the basics well. She needs early CPR, She needs intubating asap to facilitate oxygenation as best as possible. Whilst assigning staff to deliver CPR, assign a staff member to be uterus puller. Displace this to the left. Pulling is better than pushing. Tilting the table isn’t possible in resus. Don’t try.
Gather kit and hands. In an ideal world you’ll have a PMCS kit. In reality do you know where it is. Ask around in your dept.. . if there isn’t one – make one. A thoracotomy tray will likely have everything you need. A scalpel, some scissors, gauze, clamps. That’ll do for now.
You need to think about the baby’s chances too. A warmer, the PICU team, appropriate size resuscitation equipment, if you work somewhere without PICU/Paeds call them early to mobilize them.
To be clear – you need a team for the Mum’s resuscitation, someone skilled to do the PMCS (this will vary depending on where you work) and a resuscitation team for the neonate.
The salient points for me reading the review in terms of the approach to the procedure are
1: Do it early – the paper suggest 4 mins from start of arrest to 5 mins for delivery of baby. I think this is achievable if you have mentally rehearsed this event, or practiced in simulation. If she arrests in front of you.
2: A vertical midline skin incision is recommended. Pubis to umbilicus. Or higher. Blunt dissect to the uterus.
3: Make a vertical or horizontal incision through the uterine wall. the thinnest part of the uterus is at the bottom. Be careful to avoid the bladder. It’s yellow and covered in fatty tissue.
4: Deliver the baby. Clamp the cord twice and cut. Pass the baby to the designated neonatal team. they need to start their resucitation efforts. A link to the NLS algorithim can be found here. (2)
5: Clear the uterus and clamp bleeding vessels.
6: Continue resuscitating Mum whilst all of this is happening.
This is the suggested algorithm from the review.
Despite your best efforts, resuscitation attempts fail, both mother and baby die. You break the bad news to her partner, you look him in the eye and say you did everything you could. You all did.
From here I recommend you read the review article in the EMJ. Then read this superb piece by Greg Press (3). He’s an ED doc who has had the misfortune of doing two of these. EMcrit has a superb resource with a link to a videos of the procedure on a life like model and in sim here (4).
Then go back to your dept. Look at what contingency you have in place for this. Mentally rehearse this scenario. If you can organise some MDT simulation team training I think it would be invaluable. Simon Carley among many others have spoken with great passion and vigor on deliberate practice and how its the path to awesomeness, don’t rely on your perceived ‘talent’. Practice and rehearse, then do it again. And again.
You might just save someone’s life.
Link to the one minute wonder can be found here.
- Parry R, Asmussen T, Smith J. Emerg Med J 2016 33: 224-229
- Resus Council UK. https://www.resus.org.uk/resuscitation-guidelines/resuscitation-and-support-of-transition-of-babies-at-birth/#suggested.