Resuscitative hysterotomy: Difference between revisions
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==Procedure==
==Procedure==
''Continue CPR throughout procedure''
''Continue CPR throughout procedure as long as it can be safely accomplished''


*Widely cleanse entire abdomen with betadine ("betadine bath")
*Widely cleanse abdomen
*Use salpel to make midline abdominal incision extending from the uterine fundus to the pubic symphysis
*Use scalpel to make a midline incision from the uterine fundus to pubic symphysis
*Sharply or bluntly dissect through all layers of the abdominal wall at the midline until abdominal cavity is entered
*Dissect into peritoneal cavity using scalpel or scissors
*Retract the abdominal wall by pulling laterally on both sides
*Make a 2 cm incision into the uterine cavity using scalpel
*Bladder retractor may be used to reflect the bladder inferiorly to gain better visualization of the uterus
*Insert two fingers into the uterine incision between baby's body and myometrium, and use scissors to advance the incised opening
*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
**If anterior placenta is encountered, sharply incise through it
*Grasp infant manually and deliver from uterus
*Manually deliver infant from uterus, avoiding grasping the infant around the abdomen
*Clamp and cut umbilical cord (two clamps, cut between)
**Cut and clamp the umbilical cord and pass infant to neonatal team
*Hand infant off (ideally to Peds or NICU team)
*Deliver the placenta by gentle traction
*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
*Pack uterus with sterile gauze
*Closure
*Close abdominal incision using skin stapler
**Depends on maternal response to resus
*Continue maternal resuscitation
**Should occur in the OR
*Continue resuscitation of mother


==Complications==
==Complications==

Revision as of 00:15, 12 May 2019

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
  • Suction
  • Betadine or chlorhexadine
  • Sterile attire

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

  • 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. ↑ 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
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