Survival Outcomes following Resuscitative Hysterotomy

Resuscitative Hysterotomy, previously known as perimortem caesarean section, is performed in patients of > 20 weeks gestation, in cardiac arrest, with no immediate response to resuscitation. Our goal is aortocaval compression release by delivering the uterus, thus improving the chances of survival.

The aetiology of in-hospital versus out-of-hospital cardiac arrest differs, with up to a quarter of inhospital cardiac arrests being due to complications of obstetric anaesthesia and are potentially far more reversible.

This study looked at maternal and neonatal survival rates following resuscitative hysterostomy, with some surprising results.

The Verdict

This study found a low maternal rate of survival(contrary to previous studies) from resuscitative hysterotomy and a higher rate of neonatal survival, even following prolonged resuscitation. Specific variables lead to increased neonatal survival. Will this change your practice given the higher rate of neonatal survival? It will change mine, given that we will never have an RCT on this.

The Study

Leech C et al. Maternal and neonatal outcomes following resuscitative hysterotomy for out of hospital cardiac arrest: A systematic review. Resuscitation 207 (2025)110479

What They Did

This was a systematic review looking at maternal and neonatal outcomes following OHCA resuscitative hysterotomy.They included:

• Randomised trials
• Non-randomised controlled trials,
• Observational studies (cohort studies and case-control studies),
• Case series (three or more patient cases),
• Case reports and even some
• Letters to the editor

42 case (38 were case reports), case series and cohort studies were included,, which included a total of 66 maternal and 68 neonatal cases. Cases occurred in Asia, Australia, Europe and North America. Given that cost studies were case reports or series a meta-analysis could not be performed.

Outcomes

Outcome measures included;

1. Maternal outcomes:
   1. Any ROSC,
   2. Survival (to ICU admission),
   3. Survival to hospital discharge or 30 days,
   4. Neurological outcome at hospital discharge or 30 days
2. Neonatal outcomes:
   1. Requirement for ventilation
   2. Requirement for CPR
   3. Survival (to ICU admission),
   4. Survival to hospital discharge or 30 days,
   5. Neurological outcome at hospital discharge or 30 days

What They Found

68.2% (45/66) of cases of medical arrest and 31.8% (21/66) of cases were traumatic cardiac arrest.

27.3% (18/66) of resuscitative hysterotomies were performed in the prehospital setting and 72.7% (48/66) following arrival in hospital.

Time to perform the procedure:

• In the case reports/series the median time from arrest to performing the procedure was 26.5 min (range 4–110, IQR 15-40, n = 54).
• In the cohort study the median time was 41.5 min (range 11–102, IQR 15-40, n = 12).

Outcomes

Maternal:

• 30.3% (20/66) of maternal patients had ROSC at any time during resuscitation,
• 25.7% (17/66) of maternal patients had event survival,
• 4.5% (3/66) maternal patients survived to hospital discharge
  • 2 of the 3 survivors had normal neurological outcome.

Survival was more likely to occur if hysterotomy was performed between 11 and 30 minutes.

Neonatal:

Data was inconsistently recorded including: ventilation and CPR requirements following delivery. Data on outcomes was also missing. Followup was aimed at two years.

42 neonates survived to ICU admission giving a neonatal event survival of 67.7%. Of these 2 patients were lost to followup, and from the remaining 40 patients, there were 27 neonatal survivors to hospital discharge or 30 days. From these :

• 17 were neurologically normal or had a mild developmental delay.
• 6 had a significant disability
• 4 had data missing.

In the 20 neonates reported to have received CPR and who survived:

• 7 survivors were reported as neurologically normal
• 5 survivors were reported to have disability.
• 1 had no followup.

Neonatal survival was less related to time of resuscitative hysterotomy and more to gestation at time of delivery.

The Verdict

This study found a low maternal rate of survival from resuscitative hysterotomy  and a higher rate of neonatal survival, even following prolonged resuscitation. The neonatal survival rate was more related to the gestational age at the time of hysterotomy. The yongest neonate to survive with normal neurological status at two years follow up was 26 + 5 gestation, with 8 survivors from 16 neonates of preterm gestation being 32 to <37 weeks.

Maternal survival was very low. Of the neonates that we have available to followup, there was a 25% (17/27) neurologically intact survival to discharge.

In this study the median time to hysterotomy being performed was 26.5 (15-40) minutes, following maternal arrest.This raises a question of transport time and time to hysterotomy.

Hysterotomy was initially used as a means of increasing maternal survival, or in the potentially unresuscitable arrest, allowing survival of the foetus. This study shows a low maternal survival rate. It is contrary to previous studies, however they have usually been in-hospital studies.

Time again is of the essence, to the mother, and for the neonate, gestational age, appears to be a key characteristic for survival.