eMedicine Specialties > Obstetrics and Gynecology > Obstetrical Complications

Perimortem Cesarean Delivery

Author: Deborah Lyon, MD, Director, Division of Benign Gynecology, Associate Professor, Department of Obstetrics and Gynecology, University of Florida Health Science Center at Jacksonville
Contributor Information and Disclosures

Updated: Aug 14, 2007

Introduction

Fewer than 300 cases of perimortem cesarean delivery (PMCD) have been reported in the English medical literature. Despite the rarity of this procedure, it is worthy of attention because, when appropriately applied, it can save the life of both the mother and infant. Furthermore, recent literature suggests the role for PMCD may be broader than previously envisioned, and the procedure may attain a more prominent role in the future.

Background

Cesarean delivery is one of the oldest surgical procedures in history, with literature dating back to at least 800 BCE.¹ However, before the 20th century, the phrase postmortem cesarean would have been redundant because the procedure was never undertaken unless the mother was dead or moribund.²

Initially, the Roman decree (Lex Cesare, or law of Caesar) that unborn infants should be separated from their mothers' bodies was for purposes of religious ritual rather than attempts for survival of either the newborn or mother. Some infants did survive, and indeed, several mythologic and ancient historical figures were reported to have been born in this fashion, including the Greek physician Asklepios, "from the womb of dead Koronis."³ Some attribute the birth of Edward VI as occurring after the death of the unfortunate Jane Seymour, although others claim she survived for several days after the delivery. Shakespeare referred to the practice of cesarean delivery in Macbeth.⁴

The first documented record of maternal survival after cesarean delivery is that of the Swiss sow gelder Jacob Nufer, who delivered his own firstborn in 1500 by cesarean delivery.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 considered as a legitimate medical intervention. Well into the 20th century, the salvage rate was very low, and, therefore, authors on the subject advocated it only after all other resuscitative measures had failed.

During the 1980s, several authors reported unexpected maternal recoveries after postmortem cesarean deliveries.^5,6 This led to the possibility that PMCD might actually improve, rather than worsen, a mother's chance of survival during a collapse.

Outcomes

Uteroplacental blood flow may require up to 30% of a woman's cardiac output during pregnancy⁷ , and this may be recruited for perfusion of other visceral organs after delivery. Several animal and laboratory models and a growing body of clinical evidence suggest that cardiac compressions are more effective after delivery.⁵ A decrease of 30% occurs in stroke volume and cardiac output in a pregnant woman who lies supine, largely because the inferior vena cava is completely occluded (which occurs in 90% of women in late pregnancy). In addition, a 20% reduction in functional residual capacity occurs at term and the metabolic rate is faster, which lead to decreased oxygen reserves and a more rapid onset of anoxia following apnea.⁴

Delivery of the near-term fetus provides a 30-80% improvement in cardiac output and, in conjunction with other resuscitative measures, may provide sufficient circulatory improvement to adequately support central nervous system function during an arrest.⁵ Accordingly, prompt and appropriate intervention is critical to maximize the survival possibilities for the mother and baby.

Providing reliable estimates of maternal and neonatal outcome from this rare and catastrophic event is virtually impossible. The American literature primarily contains case reports and very small series. The United Kingdom previously included some data in the Confidential Enquiry into Maternal Deaths, but, as the name suggests, the registry applied only to cesarean deliveries in which the mother did not survive. Also, this database was dissolved on March 31, 2003.

When active, the Confidential Enquiry into Maternal Deaths noted that from 1994-1996, 13 deliveries occurred that were classified as either postmortem or perimortem. Of these, only 2 babies were born alive, and one of them died shortly thereafter. The registry strongly supports the concept of rapid choice for delivery because the outcomes in the group labeled "perimortem" (patient moribund or undergoing cardiopulmonary resuscitation) were significantly better than those in the group labeled "postmortem" (patient thought to have already died).⁸ In 10 years, 40 perimortem deliveries were registered, of which 25 resulted in neurologically intact surviving infants (62.5%).

Indications

Currently, maternal diseases are vastly different in the industrialized world than they were a century ago. A 1986 review highlighted the shift over the past century from primarily chronic, mostly infectious causes of death to primarily acute, mostly cardiorespiratory causes of death.⁴ The distinction is vitally important; a chronically ill mother may be inadequately nourishing her unborn child for months, thus making a good outcome of any delivery less likely. However, an acute event, such as pulmonary embolus, leaves the infant with some reserves and allows a less-than-optimal delivery setting to produce a good outcome.

In addition, the ability to monitor high-risk patients and intervene in the event of a crisis has greatly expanded over the past 50 years. The advent of advanced emergency transportation systems, advanced life support protocols, and intensive cardiorespiratory support units allows much better outcomes after prolonged anoxia than might have been the case before these advances.

Several factors must be considered when deciding whether to undertake PMCD.^{2,9,5,4,10,11} The first is the estimated gestational age (EGA) of the fetus. This information is sometimes difficult to obtain in an emergency situation, and allowing time to perform an ultrasonographic estimate is not practical. Thus, a gross visual estimate may be necessary. As a general rule, the uterus reaches the umbilicus at 20 weeks of gestational age and grows at a rate of approximately 1 cm in length for 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.

The resources of the institution should be considered in the decision regarding PMCD. Fetal salvageability under ideal circumstances (availability of all skilled personnel and a controlled setting) may range from 23-28 weeks EGA. If the fetus is known to be 23 weeks EGA and the institution's nursery has never had a newborn of this EGA survive, PMCD is probably not indicated for the sake of the fetus. PMCD also may not benefit the mother, compared with a third-trimester intervention, because the cardiovascular effects of pregnancy are less pronounced before 28 weeks and thus delivery will not achieve dramatic maternal cardiovascular improvement. Before 23 weeks gestational age, aggressive maternal support is the only indicated intervention, and at least one case of complete maternal and fetal recovery after a prolonged arrest at 15 weeks EGA has been reported.¹²

A second concern relates to the length of time between arrest and delivery. Although the rare nature of the condition makes evidence somewhat sketchy at best, intervention early is strongly supported in the course of a cardiopulmonary arrest at advanced gestational age. The latest reported survival was of an infant delivered 22 minutes after documented maternal cardiac arrest¹³ , but the 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 arrest.

Another issue is adequacy of other resuscitative efforts in the interim. Adequate chest compressions and displacement of the gravid uterus off the venous return from the lower extremities are both proven to improve maternal oxygenation. The fetus lives on the steep portion of the oxygen dissociation curve; therefore, relatively minor maternal changes may result in dramatic changes for the fetus. Resuscitative efforts also must include postcesarean infant resuscitation.

Documenting fetal heart tones before PMCD is not required, partly because it is time consuming and may negatively impact the baby's outcome and partly because maternal indications for the procedure are emergent concerns regardless of fetal status.

A special case of PMCD is the scheduled PMCD. This involves a woman who is deemed brain dead but is maintained on artificial support for the purpose of allowing fetal maturity. Successful cases of scheduled PMCD have been reported from as early as 6 weeks EGA¹⁴ , but an ethics issue arises regarding extraordinary support measures for the sole purpose of providing a fetal incubator. Full informed consent from the next of kin is mandatory.¹⁵ The most likely timeframe for both successful support and acceptance of the value of support is at 24-27 weeks EGA¹⁶ , when a few days makes a large difference to fetal outcome. Support beyond likely fetal survival is controversial.¹⁷ 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.¹⁶

Technique

Full cardiopulmonary resuscitation measures should continue during the delivery. Most young obstetricians perform Pfannenstiel incisions almost exclusively for cesarean deliveries; however, this is problematic in the setting of PMCD. The available equipment is likely to be minimal, the equipment is generally not neatly arranged, and a scrub technician probably will not be standing at the ready. While many spectators may be present, none is likely to be of value as an assistant. Lighting may be poor and not deployable where needed within the incision. Given these restrictions, a midline abdominal incision remains the appropriate choice for PMCD.

Regard for surgical technique is a consideration, despite the limitations of the setting. Care should be taken to protect the bowel and bladder from injury if possible. The emergent nature of the procedure also generally precludes assessment of fetal heart tones, placement of a urinary drainage catheter, and surgical preparation of the patient's abdomen (scrub and shave). Maternal resuscitation efforts should not be interrupted to allow more room for the surgical intervention team.

The fetus should be protected from lacerations, which can occur as a consequence of reckless uterine entry. The infant should be delivered with attention to planes of anatomic function so that permanent nerve damage from over extension does not occur. The infant should be immediately handed to someone trained in infant resuscitation. A loop of cord should be clamped at each end and saved for later cord gas evaluation. The closed loop of cord may sit for up to 60 minutes without significant deterioration of the gas values.¹⁸ Cord blood should also be collected, as with all deliveries, so that routine neonatal hematologic studies can be performed without drawing blood from the infant. The placenta should always be removed before closure.

Closure should be undertaken based on maternal circumstances. If the resuscitation team believes the mother has a chance of survival, a careful, layered closure should be performed. Attention to meticulous closure technique is vital because poor perfusion at the time of surgery may cause areas of bleeding to be inactive, which would then become active when circulation is restored. In addition, disseminated intravascular coagulation is a common sequela of massive hemodynamic challenge. Avoiding needless blood loss may help prevent or mitigate this condition. If the mother's condition is thought to be hopeless, then a rapid closure for purposes of aesthetics is indicated.

If maternal survival seems likely, antibiotic prophylaxis should be given. The rules of "dirty" surgery should apply, and any broad-spectrum penicillin or cephalosporin in a single dose should be adequate.

The person best suited to perform the PMCD is the most experienced obstetric surgeon available. It is understandable that the first reported successful cesarean delivery was performed by a sow gelder, presumably comfortable with the feel of live tissue and familiar with concepts of vascular control. PMCD is not the time to teach a junior resident the technique. If the emergency department is informed that a pregnant woman who is seriously ill or injured is en route, the prudent plan is to immediately summon obstetric and pediatric support personnel.

Medicolegal Considerations

Fear of litigation may prevent intervention in what would be, by all medical judgment, appropriate circumstances for a PMCD. However, no lawsuits filed on the basis of wrongful performance of PMCD have been reported in the literature. Only one legal penalty has been levied in regard to PMCD, the death penalty, which was given in the 18th century for failure to perform the procedure.

Generally, PMCD is deemed an emergency procedure for which consent is not possible. When maternal consent is not an issue, no other opinion should be deemed as legally binding in the emergency setting. Clearly, when the situation involves a ventilator-dependent, brain-dead patient being kept alive solely as a nursery, next-of-kin decisions become relevant, and legal and, possibly, spiritual, counsel should be sought.

Keywords

PMCD, postmortem cesarean section, C-section, cesarean birth, cesarean section, postmortem C-section, postmortem cesarean delivery, caesarean birth, caesarean delivery, caesarean section, perimortem caesarean delivery, emergency delivery, maternal compromise, maternal-fetal compromise

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