Case series of perimortem caesarean delivery during maternal cardiac arrest: Our initial experience and audit

Abstract

Cardiac arrest in pregnancy is a rare, catastrophic condition that can lead to major morbidity and mortality for both mother and baby. Prompt high-quality resuscitative measures need to be employed keeping in mind the altered maternal anatomy and physiology, presence of a compromised fetus, and an urgent need to deliver the baby for optimizing maternal and fetal outcomes. Therefore, it is important that health care facilities make appropriate systems in consonance with the latest recommendations of cardiopulmonary resuscitation (CPR) for this special group of parturients. Despite protocols and training, the clinical scenario often is emotionally overwhelming and brings forth an enormous cognitive load of resuscitating two lives along with the performance of perimortem cesarean delivery (PMCD) or resuscitative hysterotomy. We report five cases of maternal cardiac arrest referred to our tertiary care hospital, wherein PMCD was performed as part of ongoing high-quality CPR with manual left uterine displacement. Two mothers had a return of spontaneous circulation (ROSC), whereas ROSC could not be achieved in three. One neonate had an Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) score of 8. Four neonates needed CPR, and ROSC was achieved in two of these. Underlying causes were mainly severe hemorrhagic shock, eclampsia, severe pre-eclampsia, and anaphylactic reactions. Poor survival rates in our initial experience of setting up a maternal code blue mechanism as per the guidelines reflect the need for reinforcement of early PMCD, use of cognitive aids, and retraining using mock drills and simulation for better outcomes in the future. In addition, awareness of modified obstetric warning signs in peripheral hospitals is essential so that timely referral to tertiary care centers can help salvage precious lives.