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
  • Pulmonary embolism (amniotic, thrombosis, other)
  • Eclampsia

Clinical Indication

• Maternal cardiac arrest with no return of spontaneous circulation within 5 minutes.
• Estimated Gestational age > 24 weeks
  • 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 (bilateral large-bore)
• 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 and cut umbilical cord (two clamps, cut between)
10. Hand infant off (ideally to Peds or NICU team)
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 glucose
• CBC
• CMP
• ABO/Rh Status
• Liver panel (concern for eclampsia)
• EKG
• Type and screen/cross
• Urine tox
• Consult OB/Gyn
• 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
• Emergent delivery