Resuscitative hysterotomy: Difference between revisions
(Attempted to clean up - will need further work) |
No edit summary |
||
| Line 2: | Line 2: | ||
*Potentially life-saving for both mother and neonate | *Potentially life-saving for both mother and neonate | ||
*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" /> | *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" /> | ||
**[[Pulmonary | **[[Pulmonary embolism]] (amniotic, thrombosis, other) | ||
**[[Eclampsia]] | **[[Eclampsia]] | ||
| Line 19: | Line 19: | ||
==Pre-Procedure== | ==Pre-Procedure== | ||
*Secure | *Secure airway | ||
*IV | *IV access (bilateral large-bore) | ||
*Cardiac | *Cardiac monitor | ||
*Continue CPR throughout procedure | *Continue CPR throughout procedure | ||
| Line 38: | Line 38: | ||
#*Take care to avoid fetal limbs with bandage scissors during uterine laparotomy extension | #*Take care to avoid fetal limbs with bandage scissors during uterine laparotomy extension | ||
#Deliver infant | #Deliver infant | ||
#Clamp | #Clamp and cut umbilical cord (two clamps, cut between) | ||
#Hand | #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 | #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 | #Closure | ||
| Line 49: | Line 49: | ||
==Labs== | ==Labs== | ||
*Fingerstick | *Fingerstick glucose | ||
*CBC | *CBC | ||
* | *CMP | ||
*ABO/Rh Status | *ABO/Rh Status | ||
*Liver | *Liver panel (concern for eclampsia) | ||
*EKG | *EKG | ||
*Type and | *Type and screen/cross | ||
*Urine | *Urine tox | ||
*Consult | *Consult OB/Gyn | ||
*Consult | *Consult neonatology | ||
==Complications== | ==Complications== | ||
*Fetal injury | *Fetal injury | ||
*DIC | *DIC | ||
*Hemorrhagic | *Hemorrhagic shock with end organ damage | ||
==Also See== | ==Also See== | ||
| Line 70: | Line 70: | ||
*[[Rho(D) Immune Globulin (RhoGAM)]] | *[[Rho(D) Immune Globulin (RhoGAM)]] | ||
*[[Preeclampsia]] | *[[Preeclampsia]] | ||
*[[ | *[[Emergent delivery]] | ||
==References== | ==References== | ||
Revision as of 02:38, 9 August 2015
Background
- Potentially life-saving for both mother and neonate
- Consider various causes of maternal cardiac arrest, but do not delay procedure - best outcome when performed within 5 minutes of maternal arrest[1]
- Pulmonary embolism (amniotic, thrombosis, other)
- Eclampsia
Clinical Indication
- Maternal cardiac arrest with no return of spontaneous circulation within 5 minutes.[1]
- Estimated Gestational age > 24 weeks[2]
- Gestational ages should be estimated based fundal height
- Procedure appropriate if fundus is above level of umbilicus.
- Fundus is at level of umbilicus at approximately 20 weeks and increases ~1 cm each week thereafter
- Fundus approaches Xiphoid process at approximately 36-38 weeks
- Procedure appropriate if fundus is above level of umbilicus.
- (Documenting fetal heart tones before perimortem C-section is not required.)
- Gestational ages should be estimated based fundal height
Contraindications
- Known gestation less than 24 weeks
- Return of spontaneous circulation after brief period of resuscitation
Pre-Procedure
- Secure airway
- IV access (bilateral large-bore)
- Cardiac monitor
- Continue CPR throughout procedure
None of these steps should delay procedure beyond 5 minutes after maternal arrest.
Procedure
- 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'
Labs
- Fingerstick glucose
- CBC
- CMP
- ABO/Rh Status
- Liver panel (concern for eclampsia)
- EKG
- Type and screen/cross
- Urine tox
- Consult OB/Gyn
- Consult neonatology
Complications
- Fetal injury
- DIC
- Hemorrhagic shock with end organ damage
Also See
- Pulmonary Embolism in Pregnancy
- Trauma in Pregnancy
- Rho(D) Immune Globulin (RhoGAM)
- Preeclampsia
- Emergent delivery
References
- ↑ 1.0 1.1 Katz V. et al. Perimortem cesarean delivery: Were our assumptions correct? American Journal of Obstetrics and Gynecology (2005) 192, 1916–21 PDF
- ↑ 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