Surgical suture comes in different sizes. Size zero-zero-zero-zero (known more commonly as “4-0”) is very fine silky stuff, good for sewing skin and other delicate tissues. Size zero-zero (or “2-0”) is thicker than that. Size zero is good strong stuff, a jack-of-all-trades of suture, good for sewing up a uterus, or connective tissue, or lots of things. If I could only get one suture to do a cesarean-section with, that’s the one I would choose.
A long, long time ago, when I was first training in obstetrics and gynecology, we had a pregnant patient—well into her third trimester—on our high-risk pregnancy service who was located on the cardiology floor. This was not the usual state of affairs, and it was a situation not welcomed by the cardiology staff (who were very freaked out about the pregnancy) nor by the obstetric staff (who really didn’t like being far from all our gear and medicine and trained people). This patient (let’s call her “G”) was there because she had a cardiac arrhythmia that occasionally became unstable. This meant that her heart stopped conducting electrical impulses properly and stopped pumping blood to her body and brain. She was on cardiac monitoring 24 hours a day in case it happened again, and this monitoring was available only on the cardiology floor.
G’s heart had already stopped once during the pregnancy, and she had required resuscitation. If she had not been pregnant, that resuscitation would have been followed by the implantation of artificial pacemaker to help restart her heart if it stopped again.
However, at the time of the initial event, she was very pregnant, and the general consensus was that the risks of pacemaker placement (including the imaging radiation necessary to correctly insert the device) outweighed the risks. So instead, this woman was hospitalized for weeks. Our plan was to get her to term; have her deliver; and then place the pacemaker.
At least, that was Plan A. But way after Plan A—if Plan B didn’t work, and Plan C, and Plan D—we had Plan Z. And Plan Z was a perimortem cesarean section.
A perimortem cesarean is a cesarean section done peri (around) mortem (death). It refers to the surgery done when a mother is dying or sometimes already clinically dead.
For a long time, it was thought you had a few minutes to resuscitate a mother who had no heartbeat. If after a few minutes of chest compressions, assisted breathing, and lots of heart-shocking electricity and medications, you were not successful, then you probably weren’t going to be. And at that point, the teaching was, you should cut the baby out.
The thinking was that the mom would probably be dead no matter what, and if not, the extra strain of surgery probably would kill her. But you would have a shot at getting a baby out who had received oxygenated blood relatively recently, and who might live, although likely be damaged. The surgery would be essentially bloodless because, of course, there was no active maternal circulation—to the uterus or to anywhere else.
This is the historical cesarean, the cesarean section as it was probably initially invented, before hospitals and supportive care, as a last, desperate measure. It was a surgery that mothers would not survive, but that, rarely, could salvage a live infant from a catastrophe.
This was Plan Z at the time G was in the hospital. In her room was a bottle of iodine surgical prep, a set of surgical drapes, and a scalpel. There was also an infant warmer with neonatal supplies taking up a large corner of her room.
There were none of the drugs we would need to take care of a postpartum woman, such as oxytocin or other agents to help her stop bleeding. There were no postpartum supplies or bandages for an incision. There was not even any suture, or any way to sew G up after the surgery. It seemed clear to me that if we got that far, if G’s heart stopped, and we couldn’t start it again, then after we did many things, after we did all of the other things, then we would have a baby. But at that point, we seemed to be expecting to not have a mom.
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Several years later, sometime after 2003, I went to a conference about high-risk pregnancy. There was an excellent course about critical care obstetrics, which is the science (but mostly the art, since very little of this field can be systematically studied) of taking care of patients who are intensively ill and simultaneously pregnant or postpartum. And during that course, there was a class about perimortem cesarean sections.
The lecturer asked all of the attendees (most of whom were high-risk obstetric specialists) how many had been at a perimortem C-section. About 20 percent of us raised our hands. That seemed like a lot. It seemed, perhaps, like this terrible Plan Z was, over the course of a career in high-risk obstetrics, less of a catastrophic fluke and more of an expected possibility.
Then the lecturer began to talk. Researchers had looked at these cesareans and their outcomes. And they had found something important, and something surprising to me. It turns out that if the perimortem cesarean section is performed after only four minutes of resuscitation—four minutes of assisted breathing, chest compressions, and general pandemonium, but no longer—you would have much, much better fetal outcomes.
That was important, but not particularly surprising. Of course babies would do better if we got them out of a low- or no-oxygen environment sooner. But what was surprising is that these cases had better maternal outcomes. That is, the surgery, by removing the large intra-abdominal mass from the pregnant uterus, allowed for better blood flow to the maternal body and brain. And after it was done, mom often … got a pulse. The women started breathing on their own. Sometimes they woke up. Multiple anecdotes reported women who revived, dramatically and almost immediately, after the baby was out.
And so, according to American Heart Association guidelines, you should start thinking about a perimortem cesarean section at minute three to four of an unsuccessful resuscitation, and should have started on it by minute four to five.
Because you could save the mom and the baby. You could have them both.
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Back when I was the most junior member of a team taking care of patient G, I didn’t know this information. I thought we would have to choose: a possible live baby over a probably dead woman. Every time my pager went off during those weeks when I was part of the team taking care of her, for a second I couldn’t breathe.
One day, though, in the middle of my rotation, I stopped by her room. I listened to G’s heart, her lungs, her fetus, all the usual things we did several times a day. I chatted with her, reviewed her cardiac monitoring, talked with her nurse, and then, before I left, I dropped off some packets of size-zero suture on top of the scalpel and drapes sitting in the infant warmer; four packets that I had gone to the operating room to get for her that morning. Two sutures for the uterus, two for the abdominal wall. She would never know, but that was my way of saying: If we have to, we can take that baby out. But then we will put you back together, and hope for the best. I am hoping to get you both through this.