A patient's history rarely is obtained on the scene of a pregnant trauma patient in arrest. If any information can be gathered, the prehospital provider should focus primarily on three questions, and later on a secondary history including allergies, medication, past medical history, last meal intake, events of the accident, and prenatal care history. The first three pertinent questions are:

1. How many fetuses are present in the uterus? This will allow adequate equipment and personnel preparation for multiple fetal resuscitations, if necessary.
2. What is the estimated date of confinement (due date), last menstrual cycle, or estimated gestational age? This will help to determine the age of the fetus and subsequently the viability. Only a fetus of viable age should be considered to be delivered via perimortem cesarean section.
3. Are any drugs present in the maternal system? This information can be utilized to direct antidote treatment of the fetus.

Evaluation of the maternal patient must be done efficiently to determine the timing of loss of circulation. A vital part of the evaluation includes monitoring vital signs.  If time and resuscitative efforts permit, then fetal tocometry should be initiated rapidly. Early on, obstetrics should be advised and prepared. The procedure must be initiated no more than 4 minutes from loss of pulse for a maximum beneficial outcome.

Often, the expected gestational age is not able to be obtained.  In this case, a uterine fundal height at the level of the umbilicus is correlated with a gestational age of 24 weeks.[7][8][9]

In 2005, the American College of Obstetrics and Gynecology (ACOG) concluded that there was insufficient data to make recommendations as to when to perform this procedure. Most agree that it be considered in a maternal arrest with pregnancy greater than 23 weeks gestation. Although data regarding optimal time to delivery post-arrest is limited, in a hospital setting, survival drastically decreases when the time from maternal death to delivery reaches 5 minutes. Hence a 4-minute rule has become standard: Maternal CPR for 4 minutes, infant delivery by the fifth minute[4]. Recently, Benson et al[10]. challenged this protocol.

The procedure itself, though uncomplicated, creates intense anxiety and fear among providers for obvious reasons. It is done rapidly, and, while preferably performed by an obstetrician, may be done by advanced prehospital providers, trauma surgeons, and emergency medicine physicians. One should not delay assessing fetal heart tones. Simultaneously with maternal resuscitation and perimortem section, the neonatal intensive care unit (NICU) and other medical personnel should be preparing for the infant(s) resuscitation.

The following are the steps for the procedure:

1. The maternal patient is placed in the left lateral decubitus position and if time permits, a foley placed for bladder decompression.
2. The surgeon makes an incision from the xiphoid to the symphysis pubis, through all layers of the abdominal wall.
3. The bladder should be decompressed via the previously placed foley catheter. It is retracted manually.
4. A second vertical uterine incision made from the fundus toward the bladder, taking care not to incise too deeply and cause penetrating trauma to the fetus.
5. The fetus is bluntly delivered from the uterus.
6. As in usual deliveries, suction is performed nasally, then orally.  The cord is clamped and cut.
7. Resuscitation continues on the maternal patient and resuscitation begins on the neonate. Note that there is likely to be a large amount of pooled blood in the abdominal-pelvic cavities. Along with the large uterus, resuscitation efforts will be difficult.

• Endometritis abscess

• Face and Brow Presentation

• Gastrointestinal dysfunction and obstruction

• Pelvic hematoma

• Pelvic vein thrombophlebitis

• Wound complications

Performing perimortem cesarean requires a great deal of clinical judgment and is best done with an interprofessional team that includes NICU and labor and delivery nurses. 

During the 17th and 18th centuries, physicians were required by law to perform cesarean sections. In 1747, a Sicilian physician was condemned to death for not performing a post-mortem cesarean section. Combined with the dismal patient outcome and such harsh ramifications, it is no surprise that physicians were reluctant and opposed to this procedure.

Outcomes and attitudes alike have changed as survival rates have increased and legal matters have shifted in favor of good samaritan involvement. To this author's knowledge, no healthcare provider has been found liable for the outcome when performing this procedure in the United States.