Depending on the gestational age, successful CPR of a pregnant woman might only be possible after an emergency hysterotomy and evacuation of the uterus has been performed.

This improves venous return, cardiac output and potentially allows more effective chest compressions and improved respiratory mechanics.

The time frame for the decision making is narrow, and four minutes are considered to be the maximum time rescuers will have to determine if the arrest can be reversed by BLS/ACLS interventions. This is usually not enough time to transfer the patient or to set up an operating theatre.

Consequently an emergency hysterotomy/caesarean delivery in the setting of a cardiac arrest should be performed at the site of the resuscitation.

• That all staff follow the Australian Resuscitation Guidelines as adapted by Ballarat Health Services.

• To provide optimal management in a maternal emergency situation.

Maternal cardiac arrest

An emergency hysterotomy/caesarean delivery outside the operating theatre is only justified in the presence of a definite maternal cardiac arrest (asystole, Ventricular fibrillation, pulseless Ventricular tachycardia, Pulseless Electrical Activity) to facilitate CPR. All other Category 1 caesarean sections must be performed in the operating theatre.

Gestational age:

• < 20 weeks gestation an emergency caesarean delivery is NOT indicated. Below this gestational age the size of the gravid uterus is too small to significantly compromise maternal cardiac output.

• Approximately 20 to 23 weeks gestation- An emergency caesarean delivery might enable the successful resuscitation of the mother. However survival of the neonate is unlikely at this gestational age.

• Approximately 24 to 25 weeks gestation- An emergency caesarean delivery might save the life of the mother AND the neonate.

An emergency hysterotomy/caesarean delivery is an aggressive measure, which may be necessary to rescue the mother and potentially the foetus. However, the circumstances and features of the cardiac arrest and the time and availability of staff will determine if this intervention is a viable and reasonable option. Furthermore, this procedure might not be within the rescuers procedural range of experience and skills.

An emergency hysterotomy/caesarean delivery is intended for a witnessed cardiac arrest. It is likely that only under these circumstances appropriate staff can attend within the required time fame. An unclear down-time and prolonged hypoxia make this intervention probably futile in an unwitnessed cardiac arrest.

The Perimortem Bundle consists of:

• Single Use Scalpel Handle & Blade X 2 placed on the top of the bundle (2, one as a spare).

• Small tray of sterile instruments (Long Straight Arteries x 2, Curved Mayo Scissors & Bonnies toothed Dissector) in peel pack to ensure instruments are visible.

• Sterile Packs (5) X 2.

• Located at Level 5 North (5th drawer of Medical Trolley).

1. In case of a cardiac arrest in a pregnant woman, a Code Blue AND Obstetric Response must be initiated and the resuscitation trolley is retrieved. If the woman collapses in a non-maternity department a resuscitation trolley should be sourced from LW (Trolley is located at Level 5 North) or ED depending on the location of the arrest.

2. The CPR team leader should arrange for an emergency hysterotomy/caesarean delivery immediately after the cardiac arrest has been diagnosed, so that the delivery of the foetus can be achieved within five minutes.

3. When aggressive high-quality CPR measures have not led to a return of spontaneous circulation the surgical tray designed for such an event is retrieved from the bottom drawer of the resuscitation trolley.

4. Early intubation is indicated to secure the airway, facilitate surgery and transfer of the patient to theatre.

5. The procedure may only be performed by an appropriately qualified clinician (e.g. Obstetrician).

6. The Operating Theatre must be notified in order to prepare for further surgical management after primary successful or while ongoing CPR.