title: Challenging the 4- to 5-minute rule: from perimortem cesarean to resuscitative hysterotomy.
abstract: 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.
authors.affiliation: Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN. Electronic address: rose.carl@mayo.edu.
authors.forename: Carl H
authors.initials: CH
authors.lastname: Rose
authors.affiliation: Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN.
authors.forename: Arij
authors.initials: A
authors.lastname: Faksh
authors.affiliation: Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN.
authors.forename: Kyle D
authors.initials: KD
authors.lastname: Traynor
authors.affiliation: Department of Emergency Medicine, Mayo Clinic, Rochester, MN.
authors.forename: Daniel
authors.initials: D
authors.lastname: Cabrera
authors.affiliation: Department of Anesthesiology, Mayo Clinic, Rochester, MN.
authors.forename: Katherine W
authors.initials: KW
authors.lastname: Arendt
authors.affiliation: Department of Obstetrics and Gynecology, Wake Forest University School of Medicine, Winston-Salem, NC.
authors.forename: Brian C
authors.initials: BC
authors.lastname: Brost
mesh_terms: D000063:Accidents, Traffic; D000328:Adult; D022561:Advanced Cardiac Life Support; D000465:Algorithms; D002585:Cesarean Section; D004619:Embolism, Amniotic Fluid / Q000628:therapy; D005260:Female; D005313:Fetal Death / Q000517:prevention & control; D006323:Heart Arrest / Q000401:mortality / Q000628:therapy*; D006801:Humans; D020883:Hysterotomy; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular / Q000628:therapy*; D011256:Pregnancy Outcome; D011379:Prognosis; D012151:Resuscitation / Q000379:methods / Q000592:standards*
keywords: maternal arrest; perimortem cesarean; resuscitative hysterotomy