We welcome the perspective of Dr Littman and colleagues on the principle of resuscitative hysterotomy as proposed in our manuscript and appreciate the opportunity to respond to specific concerns raised. We are honored by the commentary from such a distinguished group of authors.

On a fundamental level, our proposed algorithm and the 2015 American Heart Association/Society for Obstetric Anesthesiology and Perinatology statement are concordant on a majority of points. Form should mirror function much as a name should be reflective of its procedural intent.

Preference of procedural nomenclature (resuscitative hysterotomy vs perimortem cesarean section) constitutes an inherently subjective debate; we believe the term hysterotomy in a pregnant patient does imply fetal delivery, but we could see how this could be confusing to providers who do not practice in an obstetric setting often. However, we believe that the term perimortem cesarean delivery implies the idea that the provider is giving up on the mother’s resuscitation vs performing a potentially resuscitative intervention. Therefore, we appreciate the continued thoughtful discourse and education of providers regarding appropriate terms for the procedure but would encourage the American Heart Association and Society for Obstetric Anesthesiology and Perinatology to consider including the word resuscitative in the descriptor to emphasize the potential to improve both the maternal and fetal status.

We recognize that maternal cardiopulmonary arrest is inherently a chaotic situation, but we believe that asking a team trained in resuscitation to determine subsequent actions contingent on the recognition/interpretation of a current or evolving cardiac rhythm does fall within the scope of performance expectation (similar to management of a difficult airway or administration of advanced cardiac life support medications); in fact, this represents the basis for most existing resuscitation protocols.

In regard to predicating intervention on a rhythm-based approach (shockable vs nonshockable), we concur that at present there is no robust evidence that nonshockable rhythms will directly benefit from resuscitative hysterotomy; however, the rationale for use of resuscitative hysterotomy in nonshockable rhythms is based on the improvement in maternal hemodynamics often realized in conditions that frequently deteriorate into pulseless electrical activity such as hemorrhagic shock, as noted in references 93–103 in the American Heart Association/Society for Obstetric Anesthesiology and Perinatology statement. Deferring consideration of resuscitative hysterotomy until 4 minutes have elapsed without successful maternal resuscitation will inevitably lead to further delay in actually accomplishing delivery, ergo the rationale for suggesting greater expediency in action.

We agree that providers should follow the current American Heart Association/Society for Obstetric Anesthesiology and Perinatology guidelines; however, our group believes that medicine in general can do even better for pregnant women in cardiac arrest. Therefore, we thank the Journal for allowing papers such as our call for action to continue what the American Heart Association/Society for Obstetric Anesthesiology and Perinatology statement has started: to research maternal cardiac arrest more thoroughly, to develop better systems, to improve gestational resuscitation protocols, and to create collective multidisciplinary competence among all who could care for a pregnant woman in cardiac arrest. We suggest that in this process we change the paradigm and the language from a fetocentric intervention with an aura of futility (ie, perimortem cesarean delivery) to a resuscitative approach for both mother and fetus.