The most common causes of cardiac arrest in pregnant patients include trauma/hemorrhage, pulmonary embolism, amniotic fluid embolism, stroke, maternal cardiac disease, anesthetic complications, and flash pulmonary edema.
Standard Advanced Cardiac Life Support protocols should be followed without modification for pregnancy.
Left lateral tilt to displace the uterus from the IVC should be used during compressions if it will not compromise the quality of chest compressions.
Administer medications and defibrillation per protocol. Pressors should not be withheld because fetal outcome depends on successful maternal resuscitation.
Consider early intubation to reduce aspiration risk, which is increased at baseline in pregnancy.
Perimortem or emergency cesarean delivery is rarely required except in patients with a viable fetus who do not respond to resuscitation. In the latter half of gestation, it may improve maternal resuscitation by increasing venous return and cardiac output.
The decision to proceed with perimortem cesarean delivery should be made within 4 minutes of cardiac arrest with delivery as soon as possible for the best outcome.
Perimortem cesarean should be performed immediately at the bedside. A sterile field is unnecessary. Generally, a midline vertical skin incision is made with a scalpel and carried down to the uterus. The hysterotomy is also performed by midline vertical incision. After delivery of the fetus and placenta, the uterus is closed using running locked sutures. It is important to continue cardiopulmonary resuscitation throughout the procedure. If maternal survival is possible, start broad-spectrum antibiotics.
Infant survival has been reported at 67% if delivered within 15 minutes and 40% if delivered between 16 and 25 minutes. Attempt delivery if any signs of fetal life are detected.
Delivery does not need to be emergent for maternal brain death unless fetal compromise is present.
Careful documentation of the circumstances and indications for the performance of perimortem cesarean is essential.