Cesarean section may be necessary for the cardiac arrested pregnant patient who does not attain ROSC with routine care. After 20 weeks’ gestation, the uterus compresses on the vascular structure, limiting the efficacy of resuscitation efforts. In this case, the best treatment for the mother may be an emergent cesarean section to remove the compressive effect on the IVC and aorta. In turn, as the fetus will ultimately expire without maternal ROSC, this may be the only viable option for the fetus as well. Of course, if the fetus is not viable, i.e., at under 20-23 weeks gestation, then this will result in fetal loss.

Cesarean section is considered if resuscitation does not cause ROSC within an appropriate time frame. Research shows the benefit of the emergency cesarean section at achieving ROSC. 

• Cesarean section is considered if resuscitation efforts with the gravid uterus (at the umbilicus) displaced superiorly and to the left have been ineffective. (Class I, Evidence level C-LD). 
• Consider emergency Cesarean Section at 4 minutes of ineffective resuscitation efforts. (Class IIa, Evidence level C-EO). 
• Provide emergency Cesarean Section if resuscitation of the mother is obviously futile such as in a significant trauma or persistent pulselessness. (Class I, Evidence level C-LD). 
• Patient characteristics and other factors may affect the timing of this procedure. 

Considering Gestational Age (GA)

The emergency cesarean section changes the pregnant patient into two patients that can be managed concurrently. Neonatal resuscitation can begin while the mother’s physiology approaches the non-pregnant state. Since maternal death means fetal death, a cesarean section allows independent chances for survival.

After delivery, the decompressed uterus relieves pressure on the vascular structures. Additionally, intracorporeal cardiac massage (or even intracorporeal cardiac compressions via thoracotomy) can be achieved. However, there is no good evidence to support these treatments.

The following recommendations using gestational age, its effect on maternal vascular structures and viability are reasonable:

• Assess gestation age using patient history and exam. Typically, a 20-week singleton fetus will have a fundal height at the umbilicus. This is not universal as some fetuses may reach this height earlier. Additionally, body habitus or abdomen distension may make this a difficult assessment. The more elevated the fundal height, however, the more likely that it is affecting maternal vasculature. 
• Under 24 weeks gestation: a cesarean section should be accomplished by five minutes of ineffective resuscitation to save maternal life. Note that a fetus under 20 weeks is unlikely to affect maternal vasculature significantly. However, multiple fetuses may lead to more compression of the vasculature. Consult the neonatal team. Reports of survival at 23 weeks gestation are documented.
• Over 24 weeks gestation: consider the patient characteristics and situation. In this case, a cesarean section can be used to save maternal and fetal life. Cesarean section should be accomplished by five minutes of ineffective resuscitation. This usually requires starting the procedure at four minutes following the onset of cardiac arrest.
• Clinicians should also assess the likelihood of fetal survival:
  • The short interval from arrest to delivery. Note that survival has been documented at up to 30 minutes. 
  • Any pre-arrest hypoxemia;
  • Fetal distress on monitoring;
  • The quality of maternal resuscitation;
  • Access to neonatal intensive care.

Timing Emergency Cesarean Section

The decision to proceed with cesarean section should be made early. While the five-minute time frame has been known since the 1980s, this indicates achieving delivery at five minutes, not determining the need for delivery after five minutes. The time frame is not set in stone; in some cases, the decision to proceed to delivery may be made early, especially if there is a non-survivable maternal injury. To achieve the goal of delivery at five minutes, the cesarean section will need to begin by four minutes.

Care systems

The management of the pregnant woman in cardiac arrest requires coordination among many care teams, including emergency services, anesthesiology, obstetrics, neonatology, and ICU. This uncommon situation must be prepared with providers from these different areas working together to provide the best care for the pregnant patient and fetus. Strategies and protocols must be developed so that the teams are notified and mobilized immediately they are needed. 

Emergent Cesarean Section

• If there is an obviously pregnant woman (approximately 20 weeks gestation) in arrest, begin mobilization for a possible emergency cesarean section;
• The goal is for delivery at 5 minutes following arrest, which will require the onset of the procedure at 4 minutes. 

Care Following Arrest

The same care goals, as utilized in the non-pregnant patient, should be considered in pregnancy. Research indicates that temperature management can be used following ROSC in the pregnant patient with successful outcomes in terms of neurologically intact maternal and fetal survival. Temperature management should be considered individually in each case using current guidelines. (Class IIb, Evidence level C). During induced hypothermia, ensure fetal monitoring, and obtain appropriate obstetric and neonatology consultation. (Class I, Evidence level C). There is a theoretical concern for abnormal coagulation, but bleeding risks are not well studied following cesarean section.

Unfortunately, there is a shortage of research regarding the cardiac arrest care of pregnant patients. Hospitals must develop protocols for these uncommon resuscitation events. The use of simulation models may be helpful.