Resuscitative hysterotomy
Background
- Can be life-saving for both mother and neonate
- Fetal age >24 weeks
- Worse outcomes with fetal age between 23 - 28 weeks of gestational age
- Best outcomes are achieved when the infant is delivered within 5 minutes of maternal cardiac arrest
- Documenting fetal heart tones before PMCD is not required
- Continue CPR during C-section
Clinical Indication
- Cardiac arrest with no return of spontaneous circulation within 5 minutes.[1]
- Estimated Gestational age > 24 weeks
- Gestational ages should be estimated based on palpation of the uterine fundus above the level of the umbilicus
- Fundus is at level of umbilicus at approximately 20 weeks and increases ~1 cm each week thereafter
- Fundus is near Xiphoid process at approximately 36-38 weeks
Causation
- Trauma
- Cardiac
- PE (amniotic vs thrombosis)
- Eclampsia
- Drug Use
Contraindications
- Known gestation less than 24 weeks
- Return of spontaneous circulation after brief period of resuscitation
Pre-Procedure
- IV Access
- Cardiac Rhythm/Monitor
- Secure Airway
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, including the peritoneum
- Retractors to pull the abdominal wall 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 Cord (two clamps, cut between)
- Hand Infant to Neonatal Resus Trained Provider
- 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
- Depends on maternal response to resus
- Continue resus of mother if warranted
- 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
- unknown maternal Co-morbids
- Cause for maternal collapse: airway, cardiac, trauma, drugs
- DIC
- Hemorrhagic Shock with End organ damage
Also See
Sources
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 Roe EJ, Hang BS, Lyon D, Sanford JM. Perimortem Cesarean Delivery. eMedicine website. (http://emedicine.medscape.com/article/83059). Accessed January 6, 2012.