Experience Summary

In this 360-degree video, observe the multidisciplinary team perform maternal CPR and perform a perimortem Caesarean section on a pregnant patient who has acutely deteriorated.

Clinical Context

Uterine rupture is a rare but life-threatening obstetric emergency, most commonly occurring in women with a previous Caesarean section or uterine surgery. It involves a full-thickness tear of the uterine wall, potentially leading to catastrophic haemorrhage, fetal hypoxia, and maternal cardiac arrest. Signs may include sudden-onset abdominal pain, vaginal bleeding, loss of fetal station, abnormal fetal heart rate, and haemodynamic collapse.

When uterine rupture results in maternal cardiac arrest, a perimortem Caesarean section (PMCS) becomes an emergency, time-critical intervention. The primary aim of PMCS is to improve maternal resuscitation by relieving aortocaval compression, improving venous return and cardiac output, while potentially also improving fetal outcome if gestation is beyond viability (typically >24 weeks).

Steps in Resuscitation and Performing PMCS

1. Immediate Recognition and Call for Help

Recognise maternal cardiac arrest rapidly. Summon the obstetric, anaesthetic, neonatal, and surgical teams immediately. Activate the major haemorrhage protocol if not already done.

2. Commence CPR and High-Quality Resuscitation

• Begin chest compressions immediately.
• Provide 100% oxygen and secure airway via bag-mask ventilation or intubation.
• Position the patient in left lateral tilt or manually displace the uterus to relieve aortocaval compression until PMCS is performed.
• Monitor rhythm and follow standard ALS protocols.

3. Decision for PMCS Within 4 Minutes

If there is no return of spontaneous circulation (ROSC) by 4 minutes, prepare for perimortem Caesarean section with delivery by 5 minutes.

• The goal is maternal resuscitation, not fetal salvage alone.
• Do not delay for fetal monitoring, anaesthetic, or transfer to theatre.
• PMCS can and should be performed at the bedside, ideally on a resuscitation trolley or ED bed.

4. Surgical Procedure

• Use a midline vertical incision from pubis to xiphisternum for rapid access.
• Incise the uterus vertically and deliver the fetus and placenta.
• Once uterus is empty, CPR becomes more effective.
• Continue standard resuscitation and address causes (e.g., haemorrhage, uterine repair, transfusion).

5. Post-Delivery Management

• Neonatal team to resuscitate the newborn.
• Continue maternal resuscitation with surgical repair and critical care input.

Learning Outcomes

1. Observe the clinical deterioration of this patient
2. Understand CPR nuances key to this situation
3. Observe the steps of perimortem Caesarean section

External Resources

• Maternal Collapse in Pregnancy and the Puerperium (Green-top Guideline No. 56)
• 2021 Resuscitation Guidelines
• Resus Council UK Website