Resuscitative hysterotomy: Difference between revisions

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==Background==
==Background==
*Potentially life-saving for both mother and neonate
*Previously known as "perimortem c-section"
*Consider various causes of maternal cardiac arrest, but do not delay procedure - best outcome when performed within 5 minutes of maternal arrest<ref name="Katz" />
**Current terminology emphasizes benefit to mother as well as fetus
**[[Pulmonary embolism]] (amniotic, thrombosis, other)
**Removal of infant from gravid uterus is potentially life-saving for both mother and neonate<ref>McDonnell, NJ. Cardiopulmonary arrest in pregnancy: two case reports of successful outcomes in association with perimortem Caesarean delivery.  Br J Anaesth. (2009)103(3):406-409.</ref>
**[[Eclampsia]]
*Consider etiologies of maternal cardiac arrest, but do not delay procedure while addressing all possibilities
**Best outcome within 4 minutes of maternal arrest<ref>Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(18 Suppl 2):S501-518.</ref>


==Indications==
==Indications==
*Maternal cardiac arrest with no return of spontaneous circulation within 5 minutes.<ref name="Katz"> Katz V. et al. Perimortem cesarean delivery: Were our assumptions correct? American Journal of Obstetrics and Gynecology (2005) 192, 1916–21 [http://ape.med.miami.edu/Doc/Resident%20Web%20Site%20Articles/Maternal%20Morbidity%20and%20Mortality/cardiac%20arrest%20in%20pregnancy/perimortem%20cesarean%20delivery%202005.pdf PDF]</ref>
*[[Cardiac arrest in pregnancy|Maternal cardiac arrest]] without ROSC within 4 minutes<ref> Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(18 Suppl 2):S501-518.</ref>
*Estimated Gestational age > 24 weeks<ref>Datner EM, Promes SB: Resuscitation Issues in Pregnancy, in Tintinalli JE, Stapczynski JS, Ma OJ, et al (eds): Tintinalli’s Emergency Medicine, ed 7. New York, The McGraw-Hill Companies Inc., 2011, (Ch) 16:p 91-97</ref>
*Estimated Gestational age >24 weeks based on [[Fundal exam in pregnancy|fundal height estimate]]<ref>Datner EM, Promes SB: Resuscitation Issues in Pregnancy, in Tintinalli JE, Stapczynski JS, Ma OJ, et al (eds): Tintinalli’s Emergency Medicine, ed 7. New York, The McGraw-Hill Companies Inc., 2011, (Ch) 16:p 91-97</ref>
**Gestational ages should be estimated based fundal height
**Fundus reaches level of umbilicus at approximately 20 weeks and increases ~1 cm each week thereafter
***Procedure appropriate if fundus is above level of umbilicus.
**Fundus approaches xiphoid around 36-38 weeks
****Fundus is at level of umbilicus at approximately 20 weeks and increases ~1 cm each week thereafter
*Not necessary to document fetal heart tones prior to procedure
****Fundus approaches Xiphoid process at approximately 36-38 weeks
**(Documenting fetal heart tones before perimortem C-section is not required.)


==Contraindications==
==Contraindications==
*Known gestation less than 24 weeks
*Known gestational age <24 weeks
*Return of spontaneous circulation after brief period of resuscitation
*ROSC within 4 minutes of arrest


==Equipment Needed==
==Equipment Needed==
*C-Section or abdominal exploratory laparotomy kit ideal if available
*Emergency thoracotomy kit has many of the needed supplies
*If surgical kit unavailable:
**Scalpel
**Large scissors
**Hemostats
**Sterile gauze
*Betadine or chlorhexadine
*Sterile attire
*Skin stapler


==Pre-Procedure==
==Pre-Procedure==
*Call for help
**Anesthesia
**Respiratory therapist
**NICU or pediatrics
**Obstetrics
**General surgery
*Secure airway
*Secure airway
*IV access (bilateral large-bore)
*Establish IV access
*Cardiac monitor
*Cardiac monitor
*Continue CPR throughout procedure
*Place foley catheter to drain bladder and decrease risk of bladder injury
*Prepare isolette, blankets, and other appropriate equipment for neonate
*Divide team into maternal team and neonate team
*Call for blood products
''Do not delay beyond 4 minutes of maternal arrest even if the above preparations have not been achieved''


''None of these steps should delay procedure beyond 5 minutes after maternal arrest.''
==Procedure==
''Continue CPR throughout procedure as long as it can be safely accomplished''
 
*Widely cleanse abdomen
*Use scalpel to make a midline incision from the uterine fundus to pubic symphysis
*Dissect into peritoneal cavity using scalpel or scissors
*Make a 2 cm incision into the uterine cavity using scalpel
*Insert two fingers into the uterine incision between baby's body and myometrium, and use scissors to advance the incised opening
**If anterior placenta is encountered, sharply incise through it
*Manually deliver infant from uterus, avoiding grasping the infant around the abdomen
**Cut and clamp the umbilical cord and pass infant to neonatal team
*Deliver the placenta by gentle traction
*Pack uterus with sterile gauze
*Close abdominal incision using skin stapler
*Continue maternal resuscitation


==Procedure==
[[File:Resuscitative+Hysterotomy+JPEG+2.jpg|thumb|]]
#Betadine bath
#Midline abdominal incision extending from the level uterine fundus to the pubic symphysis
#Careful dissection or incision should be made through all layers of the abdominal wall at the midline, including the peritoneum
#Retract the abdominal wall by pulling laterally on both sides
#Bladder retractor may be used to reflect the bladder inferiorly and gain better visualization of the uterus
#Vertical incision from the fundus to no farther than the anterior reflection of the bladder (usually a hyper lucent transverse line near the inferior portion of the uterus).
#*Blood vessels are lateral - avoid them
#Entered uterus by inserting index and middle fingers to lift the uterine wall away from the fetus and extend the incision as needed, preferably with bandage scissors.
#*Take care when incising the uterus as entry can inflict lacerations on the fetus
#*Take care to avoid fetal limbs with bandage scissors during uterine laparotomy extension
#Deliver infant
#Clamp and cut umbilical cord (two clamps, cut between)
#Hand infant off (ideally to Peds or NICU team)
#Placental removal -- Do not yank hard on cord as this can invert the uterus. Gentle traction on the cord or around the edge of the placental border should remove the organ
#Closure
#*Depends on maternal response to resus
#*Should occur in the OR
#*Careful full multi-layered closure should occur
#Continue resuscitation of mother if warranted
#Broad Spectrum Antibiotics for 'dirty surgery'


==Complications==
==Complications==
*Fetal injury
*Fetal injury
*DIC
*[[DIC]]
*Hemorrhagic shock
*[[Hemorrhagic shock]]


==Follow-up==
==Follow-up==
*Based on maternal outcome
*Based on maternal outcome
*If maternal survival is anticipated, give broad spectrum antibiotics


==See Also==
==See Also==
*[[Emergent delivery]]
*[[Pregnancy (main)]]
*[[Pregnancy (main)]]
*[[Pulmonary embolism in pregnancy]]
*[[Cardiac arrest in pregnancy]]
*[[Trauma in pregnancy]]
*[[Trauma in pregnancy]]
*[[Emergent delivery]]
*[[Fundal exam in pregnancy]]
==External Links==
*https://first10em.com/cardiac-arrest-in-pregnancy-the-perimortem-cesarean-section/
==Videos==
{{#widget:YouTube|id=IwDWv2iyAos}}


==References==
==References==
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[[Category:Critical Care]]
[[Category:Critical Care]]
[[Category:OB/GYN]]
[[Category:OBGYN]]
[[Category:Procedures]]
[[Category:Procedures]]

Latest revision as of 20:16, 3 August 2022

Background

  • Previously known as "perimortem c-section"
    • Current terminology emphasizes benefit to mother as well as fetus
    • Removal of infant from gravid uterus is potentially life-saving for both mother and neonate[1]
  • Consider etiologies of maternal cardiac arrest, but do not delay procedure while addressing all possibilities
    • Best outcome within 4 minutes of maternal arrest[2]

Indications

  • Maternal cardiac arrest without ROSC within 4 minutes[3]
  • Estimated Gestational age >24 weeks based on fundal height estimate[4]
    • Fundus reaches level of umbilicus at approximately 20 weeks and increases ~1 cm each week thereafter
    • Fundus approaches xiphoid around 36-38 weeks
  • Not necessary to document fetal heart tones prior to procedure

Contraindications

  • Known gestational age <24 weeks
  • ROSC within 4 minutes of arrest

Equipment Needed

  • C-Section or abdominal exploratory laparotomy kit ideal if available
  • Emergency thoracotomy kit has many of the needed supplies
  • If surgical kit unavailable:
    • Scalpel
    • Large scissors
    • Hemostats
    • Sterile gauze
  • Betadine or chlorhexadine
  • Sterile attire
  • Skin stapler

Pre-Procedure

  • Call for help
    • Anesthesia
    • Respiratory therapist
    • NICU or pediatrics
    • Obstetrics
    • General surgery
  • Secure airway
  • Establish IV access
  • Cardiac monitor
  • Place foley catheter to drain bladder and decrease risk of bladder injury
  • Prepare isolette, blankets, and other appropriate equipment for neonate
  • Divide team into maternal team and neonate team
  • Call for blood products

Do not delay beyond 4 minutes of maternal arrest even if the above preparations have not been achieved

Procedure

Continue CPR throughout procedure as long as it can be safely accomplished

  • Widely cleanse abdomen
  • Use scalpel to make a midline incision from the uterine fundus to pubic symphysis
  • Dissect into peritoneal cavity using scalpel or scissors
  • Make a 2 cm incision into the uterine cavity using scalpel
  • Insert two fingers into the uterine incision between baby's body and myometrium, and use scissors to advance the incised opening
    • If anterior placenta is encountered, sharply incise through it
  • Manually deliver infant from uterus, avoiding grasping the infant around the abdomen
    • Cut and clamp the umbilical cord and pass infant to neonatal team
  • Deliver the placenta by gentle traction
  • Pack uterus with sterile gauze
  • Close abdominal incision using skin stapler
  • Continue maternal resuscitation
Resuscitative+Hysterotomy+JPEG+2.jpg

Complications

Follow-up

  • Based on maternal outcome
  • If maternal survival is anticipated, give broad spectrum antibiotics

See Also

External Links

Videos

{{#widget:YouTube|id=IwDWv2iyAos}}

References

  1. ↑ McDonnell, NJ. Cardiopulmonary arrest in pregnancy: two case reports of successful outcomes in association with perimortem Caesarean delivery. Br J Anaesth. (2009)103(3):406-409.
  2. ↑ Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(18 Suppl 2):S501-518.
  3. ↑ Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(18 Suppl 2):S501-518.
  4. ↑ Datner EM, Promes SB: Resuscitation Issues in Pregnancy, in Tintinalli JE, Stapczynski JS, Ma OJ, et al (eds): Tintinalli’s Emergency Medicine, ed 7. New York, The McGraw-Hill Companies Inc., 2011, (Ch) 16:p 91-97
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