Resuscitative hysterotomy

Background

  • Previously known as "perimortem c-section" - new term intended to emphasize benefit to mother as well as the fetus.
  • 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
  • Place foley (↓ risk of incising bladder)

None of these steps should delay procedure beyond 5 minutes after maternal arrest.

Procedure

Continue CPR throughout procedure

  • Widely cleanse entire abdomen with betadine ("betadine bath")
  • Use salpel to make midline abdominal incision extending from the uterine fundus to the pubic symphysis
  • Sharply or bluntly dissect through all layers of the abdominal wall at the midline until abdominal cavity is entered
  • Retract the abdominal wall by pulling laterally on both sides
  • Bladder retractor may be used to reflect the bladder inferiorly to gain better visualization of the uterus
  • Make a careful vertical incision from the uterine fundus to the anterior reflection of the bladder (usually a hyper-lucent transverse line near the inferior portion of the uterus).
    • Alternatively, make smaller incision, insert two fingers and lift uterine wall away from fetus, then use scissors to extend incision
    • Take care when incising the uterus as it can be very thin and entry can inflict lacerations on the fetus
    • Be sure to avoid major blood vessels (lateral)
    • If anterior placenta is encountered, sharply incise through it
  • Grasp infant manually and deliver from uterus
  • 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
  • Continue resuscitation of mother

Complications

  • Fetal injury
  • DIC
  • Hemorrhagic shock

Follow-up

  • Based on maternal outcome
  • If maternal survival is anticipated, give broad spectrum antibiotics

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

Authors:

Michael Holtz