Timing of resuscitative hysterotomy and maternal outcomes after cardiac arrest: a systematic review and meta-analysis

Thirumurugan Arikrishnan; Deepak Chakravarthy; Keerti Priya S. B.; Chilakapati Sireesha; Jerry J. Joy; Senthil Kumaran S.; Pratheeba Natarajan

doi:10.18203/2320-1770.ijrcog20264007

Authors

Thirumurugan Arikrishnan Department of Anaesthesiology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India https://orcid.org/0000-0002-1797-021X
Deepak Chakravarthy Department of Anaesthesiology, Indira Gandhi Medical College and Research Institute, Puducherry, India
Keerti Priya S. B. Department of Obstetrics and Gynaecology, JIPMER, Puducherry, India
Chilakapati Sireesha Department of Anaesthesiology, AIIMS Mangalagiri, Andhra Pradesh, India
Jerry J. Joy Department of Anaesthesiology, M.O.S.C. Medical College Hospital, Kerala, India
Senthil Kumaran S. Department of Critical Care, AIIMS Bhopal, Madhya Pradesh, India
Pratheeba Natarajan Department of Anaesthesiology, Indira Gandhi Medical College and Research Institute, Puducherry, India

DOI:

https://doi.org/10.18203/2320-1770.ijrcog20264007

Keywords:

Maternal cardiac arrest, Resuscitative hysterotomy, Perimortem caesarean delivery, Maternal survival, Timing, Meta-analysis, Return of spontaneous circulation

Abstract

Resuscitative hysterotomy (RH) is undertaken during maternal cardiac arrest to relieve aortocaval compression and improve maternal resuscitation. The optimal timing and magnitude of maternal benefit remain uncertain because evidence is observational. PubMed/Medline, Scopus and Embase evidence reported in the registered 2026 base meta-analysis was updated through 31 July 2026 using targeted searches. Eligible primary studies reported maternal or neonatal outcomes according to time from arrest to RH. Random-effects synthesis was used in the base analysis. The primary outcome was maternal survival in relation to arrest-to-hysterotomy time; secondary outcomes included neonatal survival, maternal survival to discharge, neurological outcome and ROSC. An exploratory random-effects logit meta-analysis of survival proportions was undertaken across three major evidence syntheses, but was not used for causal inference because of overlap. The base search identified 762 records; 12 studies (507 patients) were included and 8 studies (176 patients, including 111 undergoing RH) contributed to quantitative synthesis. Maternal survivors underwent hysterotomy at a pooled mean time of 12.55±4.85 minutes, significantly earlier than non-survivors (p=0.023; I²=71%). Neonatal survival was associated with a pooled mean time of 10.25±5.50 minutes (p=0.034; I²=85%). The exploratory review-level analysis yielded a pooled maternal survival proportion of 19.8% (95% CI 3.8-60.4%; I²=94.3%), but this estimate is highly vulnerable to overlap and case-mix differences. A 2026 tertiary-centre cohort reported two hysterotomies completed at four minutes with 100% neonatal survival; maternal RH-specific survival was not separately reported. Earlier RH is associated with better maternal and neonatal survival, but the evidence is very low certainty, heterogeneous and confounded. The five-minute target remains an operational goal rather than an absolute futility threshold. Prospective registries with patient-level timing and neurological outcomes are required.

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