Technical Reports
An Inexpensive and Novel Model for Perimortem Cesarean Section
Christopher S. Sampson, MD;
Nicholas R. Renz, MD;
Jason C. Wagner, MD
Introduction: Perimortem cesarean section is a rare, time-critical, and potentially lifesaving procedure for both the fetus and mother. This makes perimortem cesarean section
an ideal and recommended subject for simulation learning and practice.
Methods: Various attempts have been made to produce models to simulate emergency
caesarian sections. We designed a cost-effective and easy to assemble model that can be
used with any high fidelity simulator.
The model was used as part of a simulation education module that is part of resident educational conferences. After the simulation day, residents were asked to fill out an anonymous online survey using a 5-point Likert scale.
Results: Thirty-four emergency medicine residents took part in a perimortem caesarian
section case. Nine (26%) completed the online survey. Eight respondents agreed or
strongly agreed [4.33 (0.71)] that the model helped to familiarize them with a perimortem
cesarean section. Eight residents also agreed or strongly agreed [4 (0.87)] that they
were better prepared to perform this procedure, and 9 residents felt that knowledge from
this session would help with their emergency department rotations [4.11 (0.33)]. Six
residents agreed or strongly agreed that this model was a good replication of human
anatomy [3.78 (0.97)]. All respondents agreed or strongly agreed [4.56 (0.53)] that this
session enhanced learning more than traditional lectures and reading alone.
Conclusion: We present here an inexpensive, easy to make, and portable model,
which can be used to simulate an emergency caesarian section.
(Sim Healthcare 8:49Y51, 2013)
Key Words: Perimortem cesarean section, Simulation model
P
erimortem cesarean section is a rare, time-critical, and
potentially life-saving procedure for both the fetus and mother.
Postmortem sections have been referenced in distant history,
notably in Shakespeare’s play Macbeth.1 This practice fell out
of favor through the years but was resurrected in the mid
1980s. It still remains a very rare procedure with Katz et al2
finding only 38 case reports identified in the literature during
a review in 2005.
In a 1986 review of causes of maternal death, Katz et al3
identified a shift from chronic infectious disease to more
acute cardiopulmonary collapse. This suggests that an otherwise healthy mother likely nourished a healthy fetus up
until the time of arrest. Because mothers are healthier, the
fetus has some, though limited, reserve buying time for
delivery and resuscitation of the infant. Today, case reports
suggest fetal survival and neurologic outcome are related to
time between maternal death and delivery.2 Further investigation supports the generally accepted goal for initiation
of perimortem cesarean section is 4 minutes with delivery
within 5 minutes for optimal outcome.2 Although fetal
From the Division of Emergency Medicine (C.S.S., N.R.R., J.C.W.), Washington
University in St Louis, St Louis, MO.
Reprints: Christopher Sampson, MD, Division of Emergency Medicine,
Washington University in St Louis, Box 8072, 660 S Euclid, St Louis, MO 63110
(e-mail: [email protected]).
The authors declare no conflict of interest.
Supplemental digital content is available for this article. Direct URL citations appear in
the printed text and are provided in the HTML and PDF versions of this article on the
journal’s Web site (www.simulationinhealthcare.com).
Copyright * 2013 Society for Simulation in Healthcare
DOI: 10.1097/SIH.0b013e318271489c
outcomes tend to be poorer with time, infant survival and
good neurologic outcome has been reported with sectioning
up to 30 minutes after maternal death.4
In the event of maternal cardiac arrest, cardiopulmonary
resuscitation should be initiated. Any fundal height at or
above the level of the umbilicus is potentially a salvageable
fetus. A fetus of this size also has the potential to impede
maternal venous return, so the patient should be placed in
the left lateral position, and case reports suggest perimortem cesarean section can be beneficial for maternal resuscitation by relieving inspiratory vital capacity compression.5,6 If
this is the case, perimortem cesarean section should be
considered with ongoing maternal cardiopulmonary resuscitation using the procedure as described by Stallard et al.7,8
American Heart Association, American College of Obstetricians and Gynecologists, and East group guidelines recommend perimortem cesarean sectioning, ideally within
4 minutes of maternal arrest, as part of both fetal and maternal resuscitation.9Y12
In light of the evidence, experts and organizations have
emphasized the importance of preparation and multidisciplinary collaboration.5 ‘‘Although rare, a strategy for management of circulatory arrest in pregnancy should be
established in all labor and emergency units, including the
availability of an emergency cesarean section kit.’’13
The rare incidence of maternal arrest, the need for timecritical performance of the procedure, the requirement for
ongoing maternal resuscitative efforts during the procedure,
and the need for interdisciplinary collaboration for continued
resuscitative efforts directed at not one but two patients after
the procedure14 makes perimortem cesarean section an ideal
Vol. 8, Number 1, February 2013
Copyright © 2013 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
49
FIGURE 2. Insertion of fetus into uterus.
FIGURE 1. Completed abdominal wall.
and recommended subject for simulation learning and
practice.6,15,16 Given that simulation had been found in previous studies to improve team training and enhance didactic
teaching, this model is an ideal teaching tool for this topic.17
METHODS
Cesarean Section Model
Various attempts have been made to produce models to
simulate emergency caesarian sections. We designed a costeffective and easy to assemble model that can be used with
any high fidelity simulator.
To construct the model, we assembled the following
items: foam mattress pad ($10 each), 1 bushel-sized laundry
basket ($2.75), 2 shower curtains (1 flesh-colored and 1 clear)
($5.00), 1 child’s 15-in play ball ($3.00), punching balloons,
and zip ties. All of the previous items were purchased for a
total of $70. These materials yielded 7 models.
Mattress pad foam was cut into 20 22-in pieces. Two
pieces of the laundry basket sides 12-in high 6-in wide were
cut and then stapled to the rough side of the mattress pad
foam. These pieces were spaced equally apart on the foam.
The laundry basket pieces provide support to the model. The
flesh-colored shower curtain was then placed on the smooth
side of the mattress pad foam and curled around the edges
where it was stapled along the border. Keeping the shower
curtain material as tight as possible is important to model
integrity. The shower curtain material served as the skin.
Clear shower curtain material was now applied to the rough
side of the model by stapling it to the laundry basket pieces.
This served as the peritoneal layer.
The external portion of the model was now completed
(Fig. 1). This model can be combined with a Noelle simulator. If using a different simulator model, a rope can be
attached to the border of the external abdomen, which can
be tied around the mannequin.
50
Model for Perimortem Cesarean Section
To assemble the internal portion of the model, we started
by filling the punching balloon with water. We tied off the
top and put it aside. The 15-in play ball was cut with an
opening large enough to accommodate the fetus. This served
as the uterus. We used a Gaumard birthing fetus in our
model. For ease of insertion, we folded the fetus and wrapped
the umbilical cord around the model. Be careful when
inserting the fetus because the ball can easily tear. Applying
baby powder inside the ball helps with facilitating insertion of
fetus (Fig. 2). Next, we inserted the punching balloon inside
the ball on the anterior aspect of the uterine model. This
added realism to the delivery by providing simulated amniotic fluid. The ball was closed with a zip tie.
Now the uterus was loaded into the empty Noelle abdomen or can be placed on the abdomen of any mannequin.
Tape can be applied to any open edges of abdomen (Fig. 3).
The model was then used as part of a simulation education module that is part of resident educational conferences.
The residents were presented with a young female patient who
was 38 weeks pregnant and was involved in a motor vehicle
collision. Just before arrival, emergency medical services
reported a loss of vital signs. During this 30-minute scenario,
the residents were expected to perform a perimortem cesarean section and resuscitate the neonate. The mother expires
in this scenario. Debriefing followed the scenario, which included indications for a perimortem cesarean section and
how to perform the procedure.
FIGURE 3. Final model.
Simulation in Healthcare
Copyright © 2013 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
perimortem caesarian section. Limitation included the small
response rate for the survey leading to the possibility of response bias. Duplication of the study with mandatory
survey response could be considered for more reliable data.
Further research would need to be conducted to establish if
this model would lead to improved patient outcomes, but
given the rare occurrence of perimortem cesarean section,
data will be scarce (see Video, Supplemental Digital Content 1,
http://links.lww.com/SIH/A72; construction of cesarean section model and use in practice).
REFERENCES
1. Shakespeare W., edited by Braunmueller A. Macbeth. Act V, scene 4.
New York: Cambridge UP, 2008.
2. Katz V, Balderston K, Defreest M. Perimortem cesarean delivery: were
our assumptions correct? Am J Obstet Gynecol 2005;192:1916Y1920.
3. Katz VL, Dotters DJ, Droegenmueller W. Perimortem cesarean
delivery. Obstet Gynecol 1986;68:571Y576.
FIGURE 4. Trainee feedback.
After the simulation day, residents were asked to fill
out an anonymous, online survey (www.surveymonkey.com)
using a 5-point Likert scale (5=strongly agree). Likert scale
results are reported as mean (SD). The Washington University institutional review board approved the study.
RESULTS
Thirty-four emergency medicine residents of a 4-year
training program took part in perimortem caesarian section
case. Nine (26%) completed the online survey (Fig. 4). Eight
respondents agreed or strongly agreed [4.33 (0.71)] that the
model helped to familiarize them with perimortem cesarean
section. Eight residents also agreed or strongly agreed [4 (0.87)]
that they were better prepared to perform this procedure, and
9 residents felt that knowledge from this session would help
with their emergency department rotations [4.11 (0.33)].
Only 6 residents agreed or strongly agreed that this model
was a good replication of human anatomy [3.78 (0.97)]. All
respondents agreed or strongly agreed [4.56 (0.53)] that this
session enhanced learning more than traditional lectures and
reading alone.
DISCUSSION
We have described how to build an inexpensive, portable,
and well-accepted model from those who responded to the
survey that can be used by emergency medicine residents and
other practitioners to gain experience in the skills required to
perform a perimortem caesarian section. All respondents
agreed that this style of teaching enhanced the learning when
compared with lectures alone. The majority of residents
responding also found that this model helped to better prepare them for this rarely needed but high-risk skill.
CONCLUSION
We present here an inexpensive, easy to make, and portable model, which can be used to simulate an emergency
Vol. 8, Number 1, February 2013
4. Campobianco G, Balata A, Mannazzu MC, et al. Perimortem cesarean
delivery 30 minutes after a laboring patient jumped from a fourth floor
window: baby survives and is normal at age 4 years. Obstet Anesth
Digest 2008;28:185.
5. McDonnell NJ. Cardiopulmonary arrest in pregnancy: two case reports
of successful outcomes in association with perimortem caesarean
delivery. Obstet Anesth Digest 2010;30:133.
6. Morris S, Stacey M. Resuscitation in pregnancy. BMJ
2003;327:1277Y1279.
7. Mathews M, Prabha J, Mathurathinam S. Screening for
light-for-gestational age infants: a comparison of three simple
measures. Br J Obstet Gynaecol 1987;94:217Y221.
8. Stallard TC, Burns B. Emergency delivery and perimortem
C-section. Emerg Med Clin North Am 2003;21:679Y693.
9. Vanden Hoek TL, Morrison LJ, Shuster M, et al. 2010 American
heart association guidelines for cardiopulmonary resuscitation and
emergency cardiovascular care part 12.3: cardiac arrest associated
with pregnancy. Circulation 2010;122:S833YS838.
10. Barraco RD, Chiu WC, Clancy TV, et al. Practice management
guidelines for the diagnosis and management of injury in the pregnant
patient: the EAST practice management guidelines work group.
J Trauma 2010;69:211Y214.
11. American College of Obstetricians and Gynecologists. Obstetric
aspects of trauma management. Washington DC: ACOG Educational
Bulletin 249; ACOG, 1998.
12. American College of Obstetricians and Gynecologists. Critical care
in pregnancy. Washington DC: ACOG Practice Bulletin 100;
ACOG, 2009.
13. Zdolsek HJ, Holmgren S, Wedenberg K, Lnnmarken C. Circulatory
arrest late in pregnancy: cesarean section is a vital decision for both
mother and child. Obstet Anesth Digest 2010;30:195.
14. Lyon DS. Perimortem cesarean delivery. In: The Handbook of
Obstetric and Gynecologic Emergencies. 4th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2010.
15. Lanoix R, Akkapeddi V, Goldfeder B. Perimortem cesarean section case
reports and recommendations. Academic Emergency Medicine
1995;2:1063Y1067.
16. Dijkman A, Huisman CM, Smit M, et al. Cardiac arrest in
pregnancy: increasing use of perimortem cesarean section due to
emergency skills training? Obstet Gynecol Surv 2010;65:294Y295.
17. Shapiro MJ, Morey JC, Small SD, et al Simulation based teamwork
training for emergency department staff: does it improve clinical
team performance when added to an existing didactic teamwork
curriculum? Qual Saf Health Care 2004;13:417Y421.
* 2013 Society for Simulation in Healthcare
Copyright © 2013 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
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