With respect to the management of cardiac arrest in the pregnant patient:
a) Discuss the considerations around 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, equipment beyond a scalpel or lengthy antiseptic procedures
Manual lateral uterine displacement +/- left lateral tilt to avoid aorto-caval compression. Early intubation to decrease risk of aspiration – likely to be more difficult in pregnant patient Hand placement for chest compressions may need to be slightly higher.
Standard pad placement may be difficult because of breast size so consider bilateral (bi-axillary) placement.
Early call for obstetric and paediatric help.
This question is very similar to Question 9 from the first paper of 2016, except that time the examiners wanted the candidates to "Outline the factors that govern the decision" instead of "Discuss the considerations around the decision". One can only wonder about the rationale for this change of wording. Whatever it was, it clearly did not change the expectations on the trainees, or the marking rubric, because the college model answers to both questions are identical.
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:
So, what are the "considerations around the decision"? Surely, those considerations would fall into the categories of pros, cons and published data. And so:
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 ALS 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
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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).