Perimortem/Emergency Cesarean Section: 

When to Perform?
- Maternal cardiac arrest
- Fetus presumed/estimated to be viable (beyond 24 weeks gestation)
- Best if within the first 5 minutes of arrest

Fetal survival rate can be as high as 75% when:
- Gestation age is greater than 26 weeks
- Fetal heart tones are present on arrival
- The procedure is performed at the earliest indication of fetal distress
*Additionally, relief of aortic/vena caval compression can aid with maternal resuscitation. For this reason, offers possible benefits even if fetus is pre-viable

The Set Up:
- Call for help! Pre-notification is ideal but not always possible. OB and NICU teams should be notified ASAP
- Multiple teams required: Maternal Resuscitation, Cesarean (you) and Neonate Resuscitation
- Equipment: scalpel, retractors, sponges/towel, suction, clamps (x2), large (1 or 0) absorbable sutures, staples, oxytocin

Procedure Outline:
-Incision
     - Iodine prep over abdomen
     - Vertical skin incision from below umbilicus to pubic symphysis
           o Multiple quick strokes, avoid cutting too deep in a single cut
           o Layers: skin, subcutaneous tissue, fascia
     - Blunt dissection of rectus muscles
     - Enter peritoneum and exposure uterus
     - Vertical midline uterine incision
           o Uterine vessels enter laterally
           o Gush of amniotic fluid will occur, have suction ready
           o If an anterior placenta encountered, continue directly through placenta

-Delivery
     - Place hand in the uterine cavity between pubic bone and fetal vertex
     - Elevate the vertex out of the pelvis
     - Apply steady fundal pressure (assistant can help)
     - Clamp the cord in two places and cut between the clamps
     - Pass the baby to the next time of providers (hopefully NICU team has arrived)

-Placental Separation
     - Manually remove the placenta
     - Administer 20 units of oxytocin in 1L NS to aid uterus contraction and decrease bleeding
     - Uterine massage
     - Clean out cavity (clots, retained placenta) with sponges
           o Temporarily pack with moistened laps until OB or surgery arrives
           o If no back-up available, close the uterus with locked, running stitch then close skin with staples

The following videos (simulations) help with more visual context to the steps above. The first demonstrates how quickly this can be performed.
     -The first minute of the video is key: https://youtu.be/lW0-2t_CGbk
     -This second video (simulation as well) begins with the uterus exposed and highlights the steps to take while demonstrating how to perform the procedure. https://youtu.be/j1QfnaS2reY

References:
1 Salvatore, Michelle. “Maternal Emergencies.” Emergency Medicine Resident Lectures. Cooper University Hospital. November 2017
2 Stapczynski, J. Stephan,, and Judith E. Tintinalli. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, N.Y.: McGraw-Hill Education LLC., 2011