With respect to the management of cardiac arrest in the pregnant patient:
a) Outline the factors that govern the decision to perform peri-mortem Caesarian section (PMCD). (70% marks)
b) List the other modifications to the standard advanced life support (ALS) protocol that need consideration in this situation. (30% marks)
Guidelines recommend PMCD for pregnant women in cardiac arrest > 24/40 weeks (with fundus height at or above the umbilicus) when ROSC has not been achieved with usual resuscitation measures with manual lateral uterine displacement (LUD). In extreme circumstances may be considered in 20 – 24/40 week pregnancy but evidence for benefit is limited.
Decisions on the optimal timing of a PMCD for both the infant and mother are complex and require consideration of factors such as the cause of the arrest, maternal pathology and cardiac function, foetal gestational age, and resources. Shorter arrest-to-delivery time is associated with better outcome.
PMCD should be strongly considered for every mother in whom ROSC has not been achieved after ≈4 minutes of resuscitative efforts.
If maternal viability is not possible (through either fatal injury or prolonged pulselessness), the procedure should be started immediately; the team does not have to wait to begin PMCD.
There is no requirement for transfer to an operating theatre, obstetric/surgical expertise, and equipment beyond a scalpel or lengthy antiseptic procedures
"Factors that govern the decision " is a strange thing to ask for, and could have been worded better. Unfortunately, the college could not have directly ased for "indications and contraindications" because no guidelines exist to strictly define them. In the absence of hard evidence, the following expert suggestions act as criteria for perimortem caesarian section:
If the delivery is being performed with foetal survival as the rationale, further criteria apply:
Other "factors that govern" could be listed. In fact, the whole things could really be interpreted as a "critically evaluate perimortem caesarian" sort of question. In which case, one should offer arguments for and against PMCD, as well as the current evidence. Thus:
Arguments for peri-mortem Caesarian
Arguments against peri-mortem Caesarian
Theoretical risks of perimortem Caesarian
Evidence regarding the efficacy and safety of peri-mortem Caesarian
Modifications to standard protocols consist of the following points:
Modifications to diagnostic thinking
Issues which complicate the pregnant arrest and peri-arrest scenario
Modifications to basic life support
Einav, Sharon, Nechama Kaufman, and Hen Y. Sela. "Maternal cardiac arrest and perimortem caesarean delivery: evidence or expert-based?." Resuscitation 83.10 (2012): 1191-1200.
Morris Jr, John A., et al. "Infant survival after cesarean section for trauma." Annals of surgery 223.5 (1996): 481.
Beckett, V. A., P. Sharpe, and M. Knight. "CAPS—A UKOSS STUDY OF CARDIAC ARREST IN PREGNANCY AND THE USE OF PERI-MORTEM CAESAREAN SECTION. IMPLICATIONS FOR THE EMERGENCY DEPARTMENT." Emergency Medicine Journal 32.12 (2015): 995-995.
Elkady, A. A. "Peri-mortem Caesarean Section Delivery: A Literature Review and Comprehensive Overview." Enliven: Gynecol Obstet 2.3 (2015): 005.
Campbell, Tabitha A., and Tracy G. Sanson. "Cardiac arrest and pregnancy." Journal of emergencies, trauma, and shock 2.1 (2009): 34.
Katz, Vern L., Deborah J. Dotters, and William Droegemueller. "Perimortem cesarean delivery." Obstetrics & Gynecology 68.4 (1986): 571-576.
Manner, Richard L. "Court-Ordered Surgery for the Protection of a Viable Fetus:, 247 6a. 8b, 274 SE 2d 457 (1981)." (1982).