Resuscitative cesarean delivery: when every second counts

The incidence of maternal cardiac arrest is rising, paralleling the escalating maternal morbidity and mortality rates in the United States. Effective management of cardiac arrest in pregnancy requires timely initiation of a resuscitative cesarean delivery when indicated. Understanding the history, indications, maternal physiology, and surgical principles of resuscitative cesarean delivery is essential for all clinicians caring for pregnant patients. Resuscitative measures during maternal cardiac arrest have evolved through the centuries-beginning as a burial practice for both mother and baby, evolving further to attempt fetal salvage, and now, to maternal rescue. During this evolution, performing resuscitative cesarean delivery was most effective if initiated within 4 minutes of maternal cardiac arrest. This concept led to the term "4-minute rule" or the principle of initiating a resuscitative cesarean delivery within 4 minutes of arrest to optimize maternal and fetal outcomes. Furthermore, the terminology has also progressed. "Resuscitative cesarean delivery" is now preferred over "perimortem cesarean delivery," emphasizing the goal of maternal resuscitation rather than fetal salvage. Successful maternal resuscitation may occur from resuscitative cesarean delivery due to relieving aortocaval compression by the gravid uterus, thus restoring venous return and cardiac output. Additional benefits include an autotransfusion effect from the uteroplacental circulation and improved oxygenation. Due to this aspect of maternal physiology, resuscitative cesarean delivery is indicated when maternal cardiac arrest occurs at 20 weeks' gestation or greater, or when the fundus is at the level of the umbilicus and should be considered immediately upon cardiac arrest in term patients or in those arriving pulseless from the prehospital setting. Rapid bedside initiation of resuscitative cesarean delivery is critical; transporting the patient to the operating room causes harmful delays. Training multidisciplinary teams to perform resuscitative cesarean delivery at the site of arrest can improve adherence to the "4-minute rule" and survival rates. Surgical technique prioritizes speed and simplicity, favoring a vertical midline skin incision and a vertical uterine incision to minimize vascular injury and facilitate rapid uterine evacuation. Postprocedure, recovery is optimized by proper wound management via broad-spectrum antibiotics and consideration of delayed wound closure, stabilization of uterine hemostasis, and careful application of critical care in the postpartum setting. In summary, resuscitative cesarean delivery is a critical, life-saving intervention during maternal cardiac arrest, providing physiological decompression, enhancing maternal resuscitation efforts, and improving neonatal outcomes. Resuscitative cesarean delivery substantially improves the chances of maternal return of spontaneous circulation and fetal survival in cases of maternal cardiac arrest. Given the persistent rise in maternal morbidity and mortality, increased awareness and readiness to perform resuscitative cesarean delivery using protocolized training and interdisciplinary coordination are imperative to improving maternal and perinatal outcomes in the modern healthcare landscape.