pre-hospital C-section

Mon Aug 28 14:53:49 BST 2006

Morning all.  Dave, this is truly a touchy subject.  I too being a
paramedic/firefighter have spoken about this with other fellow paramedics.
Yes, the State of N.J did impose sanctions agents the two medics that
preformed the emergent C-section!   From what I understand that the 2 medics
were in constant contact with on-line medical control (OLMC) to guide them
through the procedure.  So even with the(OLMC)they were still in trouble
with the state. However, I'm not aware of the outcome if they were
reinstated there certificates or not.  I have to agree with Pret "do you
have back-up employment?"  This is one of the hypothetic cases where if it
has happened ("it wasn’t us that put them there") and ("we did all we
could")  As a medic for 6 years to me something like that isn't worth
jeopardizing my family, my home, my career and my reputation. There is a
reason why OB/GYN physicians pay 160,000 a year for liability insurance!
Good luck and let me know what happens.  Sincerely,
Anthony M. Caruso NREMT-P
Town Of Natick Fire Department,
Natick, Massachusetts.

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Walter.Mauritz at auva.at
Sent: Monday, August 28, 2006 8:30 AM
To: trauma-list at trauma.org
Subject: RE: pre-hospital C-section

Pret,

what you wrote seems logical, but there is some evidence that perimortem
caesarean delivery might be an option in at least in some cases of maternal
cardiac arrest:

Am J Obstet Gynecol. 2005 Jun; 192(6):1916-20; discussion 1920-1. 
Perimortem cesarean delivery: were our assumptions correct? 
Katz V, Balderston K, DeFreest M. 
Department of Obstetrics/Gynecology, Sacred Heart Medical Center, Oregon
Health Sciences University, Eugene, 97401, USA. vkatz at peacehealth.org

OBJECTIVE: The recommendation to perform a perimortem cesarean delivery
within 4 minutes of maternal cardiac arrest was introduced in 1986. This
recommendation was based on the assumptions that cardiopulmonary
resuscitation is ineffective in the third trimester because of aortocaval
compression, and that fetal and perhaps maternal outcomes would be optimized
by timely delivery. Our objective was to review the outcomes of perimortem
cesarean deliveries to attempt to validate those assumptions. STUDY DESIGN:
Ovid MEDLINE searches using maternal mortality, cardiopulmonary
resuscitation, perimortem cesarean delivery, heart attack, and cardiac
arrest from 1985 until 2004. Citations from bibliographies of identified
publications were perused and cross-referenced for other potential articles.
Case reports were included for analysis when mothers had complete
cardiopulmonary arrest, and cardiopulmonary resuscitation had been initiated
before cesarean delivery. RESULTS: There were 38 cases of perimortem
cesarean delivery identified; 34 infants survived (3 sets of twins, 1 set of
triplets); 4 other infants survived initially, but died several days after
the deliveries from complications of prematurity and anoxia. Of the 34
infants (25-42 weeks' gestation), time of delivery after maternal cardiac
arrest was available for 25. Eleven infants were delivered within 5 minutes,
4 were delivered from 6 to 10 minutes, 2 were delivered from 11 to 15
minutes, and 7 were delivered more than 15 minutes. Of 20 perimortem
cesarean deliveries with potentially resuscitatable causes, 13 mothers were
resuscitated and discharged from the hospital in good condition. One other
mother was successfully resuscitated after the delivery, but died within 24
hours from complications related to her amniotic fluid embolism. In 12 of 18
reports that documented hemodynamic status, cesarean delivery preceded
return of maternal pulse and blood pressure, often in a dramatic fashion.
Eight other cases noted improvement in maternal status. Importantly, in no
case was there deterioration of the maternal condition with the cesarean
delivery. We wish to emphasize the large selection bias in this data.
CONCLUSION: Published reports from 20 years support, but fall far from
proving, that perimortem cesarean delivery within 4 minutes of maternal
cardiac arrest improves maternal and neonatal outcomes.

PMID: 15970850 [PubMed - indexed for MEDLINE]

I do not have access to that journal, and I have not read the full article.
Thus, I don't know whether there were any trauma-related cases of maternal
cardiac arrest (which I doubt). Still, this case series (the only one I
found on medline) shows that perimortem caesarean delivery may be an option
in some cases of maternal cardiac arrest (but very probably not in traumatic
cardiac arrest).

Walter Mauritz MD PhD
Professor of Anesthesia and Critical Care Medicine
Trauma Hospital "Lorenz Boehler"
A - 1200 Vienna, AUSTRIA, EU
phone: ++43 1 33110 789
fax: ++43 1 33110 277
e-mail: walter.mauritz at auva.at

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Bjorn, Pret
Sent: Monday, August 28, 2006 2:15 PM
To: Trauma &amp; Critical Care mailing list
Subject: RE: pre-hospital C-section

The gravid uterus is the first organ sacrificed in the shock response
cascade.  By the time mom is symptomatic, the fetus has been abandoned by
her struggle for homeostasis: God and/or Darwin would rather she live to
rejoin the herd than die for the sake of her unborn child.  All of which
suggests that with regard to perimortem C-section, the mess-to-success ratio
is stultifying.

Where mom is undeniably dead, you can at least claim to be doing no
(physical) harm; but then you're stuck for an indication to justify her
evisceration.  In all other cases, a proper retrospective review may rightly
contend that you were treating the wrong patient without proper training or
direction.  What kind of back-up employment do you have?

The goals are earnest and admirable, but nonetheless delusional.  Focus on
mom's vital signs, make for a trauma center, and prepare for disappointment.

Sorry.  Heroic motives are no substitute for critical thinking.

Pret Bjorn, RN
Bangor, ME USA

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of David Sullivan
Sent: Sunday, August 27, 2006 3:18 PM
To: Trauma &amp, Critical Care mailing list
Subject: pre-hospital C-section

Hello List,

  I was sittting around the fire station at work, and one of my co-workers
brought up an argument that we all had differing opinions on. Is there any
reading out there about the pre-hospital c-section on a pregnant female that
has injuries incompatable with life? ie decapitation, major trauma ect..has
anyone on this list ever run into a situation like that or similar. i do
this is far fetched, but it must have happened somewhere?

  dave sullivan BA NREMT-P

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