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Learning from resuscitative hysterotomy after out-of-hospital cardiac arrest
The Maternity and Newborn Safety Investigations (MNSI) programme has published a new briefing paper sharing learning from investigations of resuscitative hysterotomy (RH) following out-of-hospital cardiac arrest in pregnancy. The paper is intended to support midwives, obstetricians, anaesthetists, emergency and prehospital teams by highlighting common challenges and practical areas for improvement.
Cardiac arrest in pregnancy is uncommon, but when it occurs beyond 20 weeks’ gestation, national guidance recommends considering RH, also known as a perimortem caesarean birth or perimortem caesarean section. The procedure is undertaken primarily to improve the woman’s chance of survival by relieving pressure on the aorta and vena cava.
MNSI reviewed 24 investigations completed between April 2018 and November 2023, in which women experienced cardiac arrest outside hospital and underwent RH, either at the location of the collapse or in the emergency department. These investigations identified recurring challenges and opportunities for improvement in recognising pregnancy, initiating advanced life support and performing RH in a timely manner.
Key learning points
Early recognition and escalation
Pregnancy was not always identified at the first 999 call, which in some investigations delayed the dispatch of enhanced care teams with the capability to perform RH.
Preparation and equipment
Responding teams were not always informed that the woman was pregnant. This limited their ability to prepare appropriately before arrival. Ambulance crews also reported instances where immediate access to advanced life support equipment was delayed.
Timing of RH
In several investigations there were delays in decision-making, dispatch or transfer which reduced the likelihood of successful maternal or neonatal outcomes. The investigations highlight the importance of early consideration and prompt action when RH is indicated.
Emergency department processes
Some emergency departments did not have systems in place to summon immediate obstetric, anaesthetic and neonatal support, leading to avoidable delays.
Staff wellbeing
Opportunities for structured debrief and psychological support after these highly challenging events were inconsistent. Where support was provided, staff reported this to be of significant value.
Outcomes
In this cohort of 24 maternal deaths, six women survived to admission to intensive care following RH. Eight babies survived to neonatal intensive care admission. Babies who underwent RH within 35 minutes of maternal arrest were reported to have survived to hospital discharge.
Prompts for practice
The briefing paper raises practical questions for prehospital and hospital teams, including:
- How can call-handling systems better identify pregnant women at risk of cardiac arrest?
- Do organisations have clear pathways, training and simulation for obstetric cardiac arrest?
- What processes are in place to provide support to staff and families following RH?
For more detail, including the full set of findings and links to relevant national guidelines, see the briefing paper.
MNSI publishes these resources to share national learning from maternity safety investigations, with the aim of supporting safer care for women, babies and families.