Resuscitative hysterotomy
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
- 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 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
- Continue resuscitation 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
- Fetal injury
- DIC
- Hemorrhagic Shock with End organ damage
Also See
- Pulmonary Embolism in Pregnancy
- Trauma in Pregnancy
- Rho(D) Immune Globulin (RhoGAM)
- Preeclampsia
- Emergency 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