Resuscitative hysterotomy
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]
- Pulmonary embolism (amniotic, thrombosis, other)
- Eclampsia
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
- 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
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
- ↑ 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.
- ↑ 2.0 2.1 Katz V. et al. Perimortem cesarean delivery: Were our assumptions correct? American Journal of Obstetrics and Gynecology (2005) 192, 1916–21 PDF
- ↑ 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