Resuscitative hysterotomy

Background

  • Previously known as "perimortem c-section"
    • Current terminology emphasizes benefit to mother as well as fetus
    • Removal of infant from gravid uterus is potentially life-saving for both mother and neonate[1]
  • Consider etiologies of maternal cardiac arrest, but do not delay procedure while addressing all possibilities
    • Best outcome within 4 minutes of maternal arrest[2]

Indications

  • Maternal cardiac arrest without ROSC within 4 minutes[3]
  • Estimated Gestational age >24 weeks based on fundal height estimate[4]
    • Fundus reaches level of umbilicus at approximately 20 weeks and increases ~1 cm each week thereafter
    • Fundus approaches xiphoid around 36-38 weeks
  • Not necessary to document fetal heart tones prior to procedure

Contraindications

  • Known gestational age <24 weeks
  • ROSC within 4 minutes of arrest

Equipment Needed

  • C-Section or abdominal exploratory laparotomy kit ideal if available
  • Emergency thoracotomy kit has many of the needed supplies
  • If surgical kit unavailable:
    • Scalpel
    • Large scissors
    • Hemostats
    • Sterile gauze
  • Betadine or chlorhexadine
  • Sterile attire
  • Skin stapler

Pre-Procedure

  • Call for help
    • Anesthesia
    • Respiratory therapist
    • NICU or pediatrics
    • Obstetrics
    • General surgery
  • Secure airway
  • Establish IV access
  • Cardiac monitor
  • Place foley catheter to drain bladder and decrease risk of bladder injury
  • Prepare isolette, blankets, and other appropriate equipment for neonate
  • Divide team into maternal team and neonate team
  • Call for blood products

Do not delay beyond 4 minutes of maternal arrest even if the above preparations have not been achieved

Procedure

Continue CPR throughout procedure as long as it can be safely accomplished

  • Widely cleanse abdomen
  • Use scalpel to make a midline incision from the uterine fundus to pubic symphysis
  • Dissect into peritoneal cavity using scalpel or scissors
  • Make a 2 cm incision into the uterine cavity using scalpel
  • Insert two fingers into the uterine incision between baby's body and myometrium, and use scissors to advance the incised opening
    • If anterior placenta is encountered, sharply incise through it
  • Manually deliver infant from uterus, avoiding grasping the infant around the abdomen
    • Cut and clamp the umbilical cord and pass infant to neonatal team
  • Deliver the placenta by gentle traction
  • Pack uterus with sterile gauze
  • Close abdominal incision using skin stapler
  • Continue maternal resuscitation

Complications

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. Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(18 Suppl 2):S501-518.
  3. Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(18 Suppl 2):S501-518.
  4. 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