Key result
Earlier resuscitative hysterotomy links to maternal survival at a mean arrest-to-delivery time of ~13 minutes.
Why the study?
Resuscitative hysterotomy is undertaken during maternal cardiac arrest to relieve aortocaval compression, but the optimal timing and magnitude of maternal benefit remain uncertain because existing evidence is observational.
Is earlier resuscitative hysterotomy associated with improved maternal survival, return of spontaneous circulation, or favourable neurological outcome compared with later hysterotomy in pregnant patients experiencing maternal cardiac arrest?
Meta-Analysis (n=507)
Is earlier resuscitative hysterotomy associated with improved maternal survival, return of spontaneous circulation, or favourable neurological outcome compared with later hysterotomy in pregnant patients experiencing maternal cardiac arrest?
Earlier resuscitative hysterotomy during maternal cardiac arrest is associated with improved maternal and neonatal survival, but survival beyond the traditional 5-minute target shows that 5 minutes should be treated as an operational goal rather than a futility threshold.
May support resuscitative hysterotomy beyond the 5-minute target in maternal arrest; extends observational data but leaves open need for prospective confirmation.
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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Arikrishnan et al. (2026) conducted a meta-analysis in Maternal cardiac arrest (n=507). Earlier resuscitative hysterotomy (perimortem caesarean delivery) vs. Later resuscitative hysterotomy / non-survivors was evaluated on Maternal survival in relation to arrest-to-hysterotomy time (minutes) (p=0.023). Earlier resuscitative hysterotomy was associated with maternal survival at a pooled mean arrest-to-hysterotomy time of 12.55±4.85 minutes compared to non-survivors (p=0.023; I²=71%).
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