Resuscitative hysterotomy: Difference between revisions
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==Background==
==Background==
*Can be life-saving for both mother and neonate
*Potentially life-saving for both mother and neonate
*Fetal 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>
*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" />
**Worse outcomes with fetal age between 23 - 28 weeks of gestational age
**[[Pulmonary Embolism]] (amniotic, thrombosis, other)
**Best outcomes are achieved when the infant is delivered within 5 minutes of maternal cardiac arrest<ref name="Katz"></ref>
**[[Eclampsia]]
*Documenting fetal heart tones before PMCD is not required
*Continue CPR during C-section


==Clinical Indication==
==Clinical Indication==
*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>
*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>
*Estimated Gestational age > 24 weeks
*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>
**Gestational ages should be estimated based on palpation of the uterine fundus above the level of the umbilicus
**Gestational ages should be estimated based fundal height
**Fundus is at level of umbilicus at approximately 20 weeks and increases ~1 cm each week thereafter
***Procedure appropriate if fundus is above level of umbilicus.
**Fundus is near Xiphoid process at approximately 36-38 weeks
****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
==Causation==
**(Documenting fetal heart tones before perimortem C-section is not required.)
*Trauma
*[[Cardiac Arrest]]
*[[Pulmonary embolism]] (amniotic vs thrombosis)
*[[Eclampsia]]
*Toxic Ingestion


==Contraindications==
==Contraindications==
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==Pre-Procedure==
==Pre-Procedure==
*Secure Airway
*IV Access
*IV Access
*Cardiac Rhythm/Monitor
*Cardiac Monitor
*Secure Airway
*Continue CPR throughout procedure
 
''None of these steps should delay procedure beyond 5 minutes after maternal arrest.''


==Procedure==
==Procedure==
#Betadine bath
#Betadine bath
#Midline abdominal incision extending from the level uterine fundus to the pubic symphysis
#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, including the peritoneum
#Careful dissection or incision should be made through all layers of the abdominal wall at the midline, including the peritoneum
#Retractors to pull the abdominal wall laterally on both sides
#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
#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).
#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).
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==Complications==
==Complications==
*unknown maternal Co-morbids
*Fetal injury
*Cause for maternal collapse: airway, cardiac, trauma, drugs
*DIC
*DIC
*Hemorrhagic Shock with End organ damage
*Hemorrhagic Shock with End organ damage
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*[[Emergency delivery]]
*[[Emergency delivery]]


==Sources==
==References==
 
<references/>
<references/>


Revision as of 08:05, 18 June 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]

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
    • (Documenting fetal heart tones before perimortem C-section is not required.)

Contraindications

  • Known gestation less than 24 weeks
  • Return of spontaneous circulation after brief period of resuscitation

Pre-Procedure

  • Secure Airway
  • IV Access
  • Cardiac Monitor
  • Continue CPR throughout procedure

None of these steps should delay procedure beyond 5 minutes after maternal arrest.

Procedure

  1. Betadine bath
  2. Midline abdominal incision extending from the level uterine fundus to the pubic symphysis
  3. Careful dissection or incision should be made through all layers of the abdominal wall at the midline, including the peritoneum
  4. Retract the abdominal wall by pulling laterally on both sides
  5. Bladder retractor may be used to reflect the bladder inferiorly and gain better visualization of the uterus
  6. 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
  7. 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
  8. Deliver infant
  9. Clamp Cord (two clamps, cut between)
  10. Hand Infant to Neonatal Resus Trained Provider
  11. 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
  12. Closure
    • Depends on maternal response to resus
    • Should occur in the OR
    • Careful full multi-layered closure should occur
  13. Continue resuscitation of mother if warranted
  14. Broad Spectrum Antibiotics for 'dirty surgery'

Labs

  • Fingerstick
  • CBC
  • Chem 10 (mag, cal, phos)
  • ABO/Rh Status
  • Liver Panel (concern for eclampsia)
  • EKG
  • Type and Screen/Cross
  • Urine Tox
  • Consult OBGYN
  • Consult Neonatology

Complications

  • Fetal injury
  • DIC
  • Hemorrhagic Shock with End organ damage

Also See

References

  1. ↑ 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
  2. ↑ 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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