Resuscitative hysterotomy: Difference between revisions

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==Background==
==Background==
*Potentially life-saving for both mother and neonate
*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>
*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 embolism]] (amniotic, thrombosis, other)
**[[Pulmonary embolism]] (amniotic, thrombosis, other)
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==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 at the midline, including the peritoneum
*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
*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).
#*Blood vessels are lateral - avoid them
**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.
*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 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
**Take care to avoid fetal limbs with bandage scissors during uterine laparotomy extension
#Deliver infant
*Deliver infant
#Clamp and cut umbilical cord (two clamps, cut between)
*Clamp and cut umbilical cord (two clamps, cut between)
#Hand infant off (ideally to Peds or NICU team)
*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
#*Depends on maternal response to resus
**Depends on maternal response to resus
#*Should occur in the OR
**Should occur in the OR
#*Careful full multi-layered closure should occur
**Careful full multi-layered closure should occur
#Continue resuscitation of mother if warranted
*Continue resuscitation of mother if warranted
#Broad Spectrum Antibiotics for 'dirty surgery'
*Broad Spectrum Antibiotics for 'dirty surgery'


==Complications==
==Complications==

Revision as of 21:19, 9 August 2015

Background

  • Potentially life-saving for both mother and neonate[1]
  • Consider various causes of maternal cardiac arrest, but do not delay procedure - best outcome when performed within 5 minutes of maternal arrest[2]

Indications

  • Maternal cardiac arrest with no return of spontaneous circulation within 5 minutes.[2]
  • Estimated Gestational age > 24 weeks[3]
    • 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

Equipment Needed

  • C-Section or abdominal ex-lap kit (often not available in ED, but may be obtained from OR if time allows)
    • Alternatively, emergency thoracotomy kit (available in most EDs) has many of the needed supplies
  • If surgical kit unavailable:
    • Scalpel
    • Large scissors
    • Hemostats
    • Sterile gauze
  • Suction
  • Betadine
  • Sterile garb (gown, gloves, mask)

Pre-Procedure

  • Secure airway
  • IV access (bilateral large-bore)
  • Cardiac monitor
  • Continue CPR throughout procedure
  • Place foley (↓ risk of incising bladder)

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'

Complications

  • Fetal injury
  • DIC
  • Hemorrhagic shock

Follow-up

  • Based on maternal outcome

See Also

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. ↑ 2.0 2.1 Katz V. et al. Perimortem cesarean delivery: Were our assumptions correct? American Journal of Obstetrics and Gynecology (2005) 192, 1916–21 PDF
  3. ↑ 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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