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The increasing incidence of caesarean section (CS) increases the risk for placenta accrete spectrum (PAS) conditions in pregnancy. The aortic vascular clamps can be used in low resource settings to minimise major obstetric haemorrhage in a parturient with PAS. We report one case of major obstetric haemorrhage attributable to PAS and other cases that had the potential to bleed post-return of spontaneous circulation (ROSC). The first case had torrential bleed following classical CS done for percreta leading to severe haemodynamic instability and a near arrest situation despite standard protocolised management. As a last resort to control catastrophic bleeding, the aortic vascular clamp was used to avert an imminent cardiac arrest, which successfully lead to effective resuscitation and later uneventful recovery. The second case was a perimortem caesarean delivery in a diagnosed case of placenta percreta where we contemplated to use this clamp during resuscitative hysterotomy [Perimortem caesarean delivery (PMCD)] as its usage is likely to confer haemodynamic stability post-ROSC bleeding. However, the patient could not be revived. We have found that in addition to anaesthetic and major haemorrhage management skills in tackling a massive obstetric haemorrhage, the availability of trained surgical teams for controlling ongoing haemorrhage is crucial for effective resuscitation. Using aortic and common iliac vascular clamps as a damage control measure also plays a very important role in controlling catastrophic maternal haemorrhage. With the growing incidence of PAS and uncontrolled bleeding in these parturients, the skilled anaesthetic and resuscitative skills of anaesthesiologists are futile if haemorrhage is not controlled. We found that the availability and use of the vascular clamps at the time of PMCD are very useful to control bleeding and help in effective resuscitation. Its use has a short learning curve and the personnel can be trained easily.

Summary: Background: Perimortem Caesarean section (PMCS) is a rare surgical procedure that is potentially lifesaving for mother and child. Aim: To describes a live fetus 1 h after maternal cardiac arrest and a rare hospital surgical event, PMCS. Case report: We report on a 22-year-old gravida 1 para 1 woman who had a convulsive loss of consciousness at 31 weeks' gestation. A convulsive loss of consciousness was accompanied by profuse vomiting of gastric contents. Cardiopulmonary resuscitation was initiated. Fetal heartbeats were recorded and the patient was referred to the Clinic for Gynecology and Obstetrics. Perimortem Caesarean section was performed. Neonatal cardiopulmonary resuscitation was initiated, but the infant was pronounced dead after 60 min of attempted resuscitation. Maternal cardiopulmonary resuscitation was without success and it was abandoned following discussion with family members. Conclusion: A cooperative team approach is the key factor to producing a good perinatal outcome. [ABSTRACT FROM AUTHOR]

The increasing incidence of caesarean section (CS) increases the risk for placenta accrete spectrum (PAS) conditions in pregnancy. The aortic vascular clamps can be used in low resource settings to minimise major obstetric haemorrhage in a parturient with PAS. We report one case of major obstetric haemorrhage attributable to PAS and other cases that had the potential to bleed post-return of spontaneous circulation (ROSC). The first case had torrential bleed following classical CS done for percreta leading to severe haemodynamic instability and a near arrest situation despite standard protocolised management. As a last resort to control catastrophic bleeding, the aortic vascular clamp was used to avert an imminent cardiac arrest, which successfully lead to effective resuscitation and later uneventful recovery. The second case was a perimortem caesarean delivery in a diagnosed case of placenta percreta where we contemplated to use this clamp during resuscitative hysterotomy [Perimortem caesarean delivery (PMCD)] as its usage is likely to confer haemodynamic stability post-ROSC bleeding. However, the patient could not be revived. We have found that in addition to anaesthetic and major haemorrhage management skills in tackling a massive obstetric haemorrhage, the availability of trained surgical teams for controlling ongoing haemorrhage is crucial for effective resuscitation. Using aortic and common iliac vascular clamps as a damage control measure also plays a very important role in controlling catastrophic maternal haemorrhage. With the growing incidence of PAS and uncontrolled bleeding in these parturients, the skilled anaesthetic and resuscitative skills of anaesthesiologists are futile if haemorrhage is not controlled. We found that the availability and use of the vascular clamps at the time of PMCD are very useful to control bleeding and help in effective resuscitation. Its use has a short learning curve and the personnel can be trained easily. [ABSTRACT FROM AUTHOR]

Background: The incidence of maternal cardiac arrest is rising in recent years. Medical staff generally lack the experience of performing resuscitation on pregnant patients. Maternal cardiac arrest and perimortem caesarean section simulation training was newly introduced in the Advanced Life Support in Obstetrics provider courses in Hong Kong since April 2021. Objective: To evaluate the course participants' opinions on maternal cardiac arrest simulation training. Methods: A questionnaire survey was conducted for all participants in the Advanced Life Support in Obstetrics provider course in April 2021 to assess their opinions on the usefulness of this training. Results: There were four Advanced Life Support in Obstetrics provider courses in April 2021 with 36 participants in each course, and 137 questionnaires were received at the end of the course. The response rate was 137/144 (95.1%). After excluding the questionnaires with incomplete information, 134 questionnaires were included for final analysis. Almost all of the participants agreed that the maternal cardiac arrest simulation training could help them in their work (97.8%), could improve their knowledge and skill (98.5%) and could improve team training and co-ordination (97.0%). The majority of them (97.0%) felt more confident in managing maternal cardiac arrest after the training, and 97.8% of participants felt that the perimortem caesarean section model was useful for training. Around 80% of the participants would recommend this course to their colleagues. There were no significant differences in opinions on the usefulness of this training among participants with regard to their specialty, whether they were doctors or nurses, their years of experience and the specific hospital settings. Conclusions: Maternal cardiac arrest simulation training was highly valued by all levels of obstetric, emergency medicine and anaesthesia staff in both public and private hospitals. [ABSTRACT FROM AUTHOR]

Maternal cardiac arrest (MCA) requires a multidisciplinary team well versed in the cascade of steps involved during resuscitation. Historically, maternal outcomes were poor, primarily because cardiac arrest management in pregnant women was neither optimum nor standardized. However, current evidence has shown better maternal survival given the young age and reversible causes of death. There are specific interventions such as manual left uterine displacement (MLUD) for relief of aortocaval compression that, if not performed, may undermine the success of resuscitation. The team should simultaneously explore the etiology of MCA, which could be a combination of pregnancy-related causes and comorbid conditions. Resuscitative Hysterotomy or Resuscitative Uterine Interventions (RUI) should be considered if there is no return of spontaneous circulation following 4–5 min of cardiopulmonary resuscitation. Teamwork is critical to success in the high-stakes environment of MCA. This consensus statement was prepared by the experts after reviewing evidence-based literature on maternal resuscitation during MCA.

Maternal cardiac arrest (MCA) requires a multidisciplinary team well versed in the cascade of steps involved during resuscitation. Historically, maternal outcomes were poor, primarily because cardiac arrest management in pregnant women was neither optimum nor standardized. However, current evidence has shown better maternal survival given the young age and reversible causes of death. There are specific interventions such as manual left uterine displacement (MLUD) for relief of aortocaval compression that, if not performed, may undermine the success of resuscitation. The team should simultaneously explore the etiology of MCA, which could be a combination of pregnancy-related causes and comorbid conditions. Resuscitative Hysterotomy or Resuscitative Uterine Interventions (RUI) should be considered if there is no return of spontaneous circulation following 4–5 min of cardiopulmonary resuscitation. Teamwork is critical to success in the high-stakes environment of MCA. This consensus statement was prepared by the experts after reviewing evidence-based literature on maternal resuscitation during MCA. [ABSTRACT FROM AUTHOR]

Maternal cardiopulmonary arrest is a very rare event whose prognosis might depend on the response to the event. We present the case of an unbooked G5P4 who had an arrest following two eclamptic fits. She had an on-site perimortem cesarean section and was delivered of a live female baby with a birth weight of 4.95 kg. She was subsequently transferred to the intensive care unit where she later died 5 days postdelivery. The baby was discharged home 4 days postdelivery with no neurological deficit. In managing such cases, multidisciplinary management must be the approach from the point of making the diagnosis to performing a resuscitative hysterotomy, as such reducing cardiac arrest delivery interval to the barest minimum.

Amniotic fluid embolism is a rare syndrome characterized by sudden cardiorespiratory collapse during labor or soon after delivery. Because of its rarity, many obstetrical providers have no experience in managing amniotic fluid embolism and may therefore benefit from a cognitive aid such as a checklist. We present a sample checklist for the initial management of amniotic fluid embolism based on standard management guidelines. We also suggest steps that each facility can take to implement the checklist effectively. [ABSTRACT FROM AUTHOR]

Abstract Resuscitative hysterotomy is a daunting and rarely performed procedure in the emergency department (ED). Given the paucity of clinical exposure to this intervention, resuscitative hysterotomy is an ideal opportunity for simulation-mediated deliberate practice. The authors propose a novel training program using a homegrown, realistic, simulation device as a means to practice resuscitative hysterotomy. Two high-fidelity, tissue-based task-trainer models were constructed and tested on a convenience sample of 14 emergency medicine (EM) residents. The simulated human placenta, bladder, amniotic sac, and uterus were constructed through the use of porcine skin, porcine stomach, transparent plastic bag, Foley tubing, and squid mantle, all secured with nylon sutures. A Gaumard S500 Articulating Newborn was inserted in the simulated uterus, and the entire model was placed into a Gaumard S500 Childbirth Simulator. Each model required less than 1 h for assembly. Emergent hysterotomy was first demonstrated by an EM faculty facilitator, followed by hands-on deliberate practice. Formal feedback on the learners’ self-reported confidence and satisfaction levels was solicited at the end of the workshop through a survey previously cited for use with a low-fidelity resuscitative hysterotomy. Quantitative evaluation of the simulated training session was extracted through a 5-item questionnaire using a 5-point Likert-type scale (i.e., from 1, strongly disagree, to 5, strongly agree). Item scores were added for a cumulative total score, with a possible maximum score of 25 and minimum score of 5. Responses were overwhelmingly positive [24.13 (± 1.36)]. Qualitative feedback was extracted from the survey through open-ended questions; these responses highlighted learners’ appreciation for hands-on practice and the development of a novel, tissue-based simulation task trainer. All participants recommended the training session be available to future learners. Resuscitative hysterotomy is a high-stakes, low-frequency procedure that demands provider practice and confidence. Our hybrid, tissue-based hysterotomy model represents a feasible opportunity for training. The model is cost conscious, easily reproducible, and portable and allows for ample deliberate practice.

Background: Prehospital perimortem caesarean delivery (PCD) is a rarely performed procedure. In this study, we aimed to examine all PCDs performed by the four Helicopter Emergency Medical Services in the Netherlands; to describe the procedures, outcomes, complications, and compliance with the recommended guidelines; and to formulate recommendations.Methods: We performed a population-based retrospective cohort study of all consecutive maternal out-of-hospital cardiac arrests that underwent PCD in the prehospital setting between May 1995 and December 2019. Registered data included patient demographics, operator background, advanced life support interventions, and timelines. Resuscitation performance was evaluated according to the 2015 European Resuscitation Guidelines.Results: Seven patients underwent a prehospital PCD. Three mothers died on the scene, while four were transported to a hospital but died in the hospital. Seven neonates were born by PCD. One neonate died on the scene and six were transported to a hospital. Three neonates were eventually discharged from the hospital. Among the three surviving neonates, the periods from dispatch to start of PCD were 13, 14, and 21 min.Conclusions: There was a low incidence of maternal perimortem caesarean deliveries in The Netherlands. Only some neonates survived after PCD. It is recommended that PCD be performed as quickly as possible. Due to the delay, the mother has a far lower chance of survival than the neonate. In fatal cases, autopsy is strongly recommended. [ABSTRACT FROM AUTHOR]

Cardiac arrest in pregnancy is rare. It has a reported incidence of approximately 1 in 30000 pregnancies worldwide and occurs prehospitally with rates of around 3 in every 100000 live births within the developed world. The management of maternal cardiac arrest is complicated by the anatomical and physiological changes of pregnancy, its rarity and clinician unfamiliarity. The presentation and the prehospital environment can make for an incredibly challenging, stressful and highly emotive scene. One aspect of maternal cardiac arrest management is the perimortem cesarean section, a surgical procedure that is potentially lifesaving for both mother and child. Although rarely reported in the field it is possible to successfully perform the procedure. This report details the emergent prehospital treatment of a 41-year-old woman pregnant with her first child of 30 weeks gestation. It describes a case of maternal cardiac arrest, her resuscitation and the undertaking of a prehospital perimortem cesarean section resulting in a neurologically intact infant survivor. [ABSTRACT FROM AUTHOR]

Abstract Background During maternal cardiac arrest, emergency hysterotomy (EH) is recommended after four minutes of resuscitation, if no signs of spontaneous circulation are detected. This extreme procedure is believed to be potentially beneficial for both the mother and the infant. Both maternal and neonatal survivals seem to be associated to the time delay between the cardiac arrest and the delivery and in-hospital resuscitation location. In addition to this, gestational age is an important determinant to neonatal outcome. Case presentation We report two emergency hysterotomies executed in an out-of-hospital location. The infants delivered by EH were low birth weight infants and born 20–23 min after maternal cardiac arrest. Both infants survived and had normal physical and neurological growth at the age of two years. Unfortunately, mothers in these both cases died in the field. Conclusion Contrary to earlier beliefs, it is possible to perform a successful EH also in out-of-hospital setting, even with incomplete surgical skills. However, training and preparation are extremely important for achieving the highest possible readiness to treat maternal cardiac arrest situations also prehospitally.

Resuscitative hysterotomy (RH) is a resuscitation technique, allowing the restoration of a pregnant patient's heartbeat. Here, we reported a case of RH performed in a patient with cardiac arrest as a complication of a peripartum cardiomyopathy. A 29‐year‐old woman with suspected hemolysis, elevated liver enzymes, low platelet syndrome was admitted to the hospital. Cardiopulmonary resuscitation and RH were initiated at 30 weeks of gestation. The infant was successfully delivered 2 min after the mother's cardiac arrest, weighting 1388 g. At the first minute, the Apgar score was 3 and the 5th minute was 6. After delivery, defibrillation was performed on the mother and restoration of spontaneous circulation was observed. However, she was hemodynamically unstable and approximately 2 months later she died. After cardiac arrest, it is possible that RH could improve the hemodynamic status. The opportunity of performing a RH is rare; however, it is necessary to be familiarized with the technique as a resuscitation method. [ABSTRACT FROM AUTHOR]

Key content: Cardiac arrest in pregnancy is rare. Effective management involves the decision to perform a perimortem caesarean section if the gestation is greater than 20 weeks and return of spontaneous circulation does not occur after 4 minutes of effective cardiopulmonary resuscitation. Delivery should ideally be achieved within 5 minutes of cardiac arrest as this maximises maternal survival and reduces the risk of long‐term neurological impairment. In hospital, the procedure should be undertaken at the site of the cardiac arrest without moving to an operating theatre. Minimal equipment is required to undertake the procedure. Clinical areas where pregnant women are seen should have a designated ‘equipment box’. Debriefing all personnel is of utmost importance after the acute event. Learning objectives: To understand why perimortem caesarean section is beneficial to maternal survival. To appreciate the need for rapid decision making when perimortem caesarean section is required. To gain practical knowledge of perimortem caesarean section, including the steps to be used when resuscitation is unsuccessful. Ethical issues: To be aware that the primary aim of perimortem caesarean section is to aid maternal survival, not necessarily fetal survival. [ABSTRACT FROM AUTHOR]

Background: During maternal cardiac arrest, emergency hysterotomy (EH) is recommended after four minutes of resuscitation, if no signs of spontaneous circulation a re detected. This extreme procedure is believed to be potentially beneficial for both the mother and the infant. Both maternal and neonatal survivals seem to be associated to the time delay between the cardiac arrest and the delivery and in-hospital resuscitation location. In addition to this, gestational age is an important determinant to neonatal outcome. Case presentation: We report two emergency hysterotomies executed in an out-of-hospital location. The infants delivered by EH were low birth weight infants and born 20 – 23 min after maternal cardiac arrest. Both infants survived and had normal physical and neurological growth at the age of two years. Unfortunately, mothers in these both cases died in the field. Conclusion: Contrary to earlier beliefs, it is possible to perform a successful EH also in out-of-hospital setting, even with incomplete surgical skills. However, training and preparation are extremely important for achieving the highest possible readiness to treat maternal cardiac arrest situations also prehospitally. [ABSTRACT FROM AUTHOR]

Although resuscitation in trauma requires a multidisciplinary and multifaceted approach, one of the Big Five procedures may need to be performed as lifesaving and improving intervention. Your patient's lives depend on understanding, timing, and techniques of these elusive and difficult-to-master procedures. This article focuses on and reviews these five critical procedures: cricothyroidotomy, burr hole craniotomy, resuscitative thoracotomy, emergent hysterotomy, and lateral canthotomy. Prepare the team, system, and yourself when performing any of these procedures. It is important to be facile with your equipment and familiar with the steps to maximize success., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Resuscitative hysterotomy (RH) is a rare, time-sensitive, invasive procedure that can be frightening for emergency physicians and yet potentially life-saving for fetus and mother. Several low-cost RH task trainers have been described in the literature. We set out to construct a model using improved synthetic materials for the uterine and abdominal wall and to devise hemorrhage capability. The primary aim of this study was to evaluate the model's perceived usefulness of its features. Secondarily, we wished to assess the confidence of emergency medicine (EM) residents before and after performing a RH using our task trainer in a simulated environment. We constructed an inexpensive task trainer that can function both as a table-top model (TTM) and be adapted to a high-fidelity simulator. We created the abdominal wall and uterus from polyurethane carpet padding, subcutaneous fat from upholstery foam, fascia from synthetic chamois, and blood vessels from IV tubing and angio-catheters. We utilized the task trainer during our monthly EM residency simulation conference. After completing a simulation of a gravid female in cardiac arrest requiring a RH on a high-fidelity simulator adaptated model (HFSAM), residents repeated the procedure during debriefing on a TTM. Residents then completed anonymous paper surveys in which they rated aspects of the RH model and their procedural confidence on a 10-point Likert scale. 20 EM residents took part in the RH simulation scenario followed by a TTM demonstration. All (100%) residents completed the survey. 11 (55%) of the residents performed a RH on either the HFSAM or the TTM while the others assisted. The residents rated the overall educational value of the training event as very high (mean 9.8 (SD 0.68)). Both the TTM (mean 8.9 (SD 1.15)) and HFSAM (mean 8.7 (SD 1.29)) were similarly rated as highly realistic. Before the simulation session, residents rated their confidence in performing a RH as low (mean 4.0 (SD 2.62)). After the session, they were much more confident in their ability to perform a RH (mean 7.9 (SD 1.48); P<0.001). Most residents rated bleeding as very important to the utility of a RH model (mean 8.6 (SD 1.74)). We demonstrate an inexpensive but realistic RH task trainer that can be used as a stand-alone model or adapted to a high-fidelity simulator. A single simulation using the TTM and the HFSAM lead to increased resident confidence in their ability to perform a RH., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Palm et al.)

Simulation-based medical education (SBME) is an educational technique that enables participants to experience an immersive representation of a clinical event for the purpose of practice, learning, and evaluation. This experience is intended to improve trainees' competency and confidence in both procedural tasks, as well as team-based and interpersonal skills when responding to real-world clinical encounters. Moreover, SBME improves procedural exposure and competency in low-frequency, high-stakes clinical procedures without the risk of adverse consequences, error, or patient harm - a priority for physician training at all levels. This technical report describes a novel bi-phasic maternal cardiac arrest simulation that can be used to teach and train post-graduate year one (PGY1) emergency medicine and obstetrics and gynecology trainees in the use of perimortem cesarean sections (PMCS) prior to in-situ exposure. Using a high-fidelity simulation protocol employing training manikins and 3-D printed models of gravid uteri, this bi-phasic simulation, completed over two sessions, six months apart, will equip trainees with the knowledge, skills, and professionalism behaviors necessary for difficult clinical decisions and time-critical procedures., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, O'Dea et al.)

Many health care providers lack familiarity with maternal physiologic changes and the distinctive underlying etiology of cardiac arrest in pregnancy. Knowledge of what changes are expected in pregnancy and an understanding of how to adapt clinical practice is essential for the care of the pregnant woman in the emergency department. Amniotic fluid embolism should be recognized as a rare cause of cardiac arrest in pregnancy, characterized by the triad of cardiovascular collapse, hypoxic respiratory failure, and coagulopathy. Cardiopulmonary resuscitation should follow standard AHA ACLS guidelines. Resuscitative hysterotomy may be attempted to restore perfusion to both mother and fetus., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Although perimortem delivery has been recorded in the medical literature for millennia, the procedural intent has evolved to the current fetocentric approach, predicating timing of delivery following maternal cardiopulmonary arrest to optimize neonatal outcome. We suggest a call to action to reinforce the concept that if the uterus is palpable at or above the umbilicus, preparations for delivery should be made simultaneous with initiation of maternal resuscitative efforts; if maternal condition is not rapidly reversible, hysterotomy with delivery should be performed regardless of fetal viability or elapsed time since arrest. Cognizant of the difficulty in determining precise timing of arrest in clinical practice, if fetal status is already compromised further delay while attempting to assess fetal heart rate, locating optimal surgical equipment, or transporting to an operating room will result in unnecessary worsening of both maternal and fetal condition. Even if intrauterine demise has already occurred, maternal resuscitative efforts will typically be markedly improved following delivery with uterine decompression. Consequently we suggest that perimortem cesarean delivery be renamed "resuscitative hysterotomy" to reflect the mutual optimization of resuscitation efforts that would potentially provide earlier and more substantial benefit to both mother and baby. [ABSTRACT FROM AUTHOR]