Resuscitative hysterotomy: Difference between revisions
(10 intermediate revisions by 4 users not shown) | |||
Line 8: | Line 8: | ||
==Indications== | ==Indications== | ||
*[[Cardiac arrest in pregnancy|Maternal cardiac arrest]] without ROSC within 4 minutes<ref> 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.</ref> | *[[Cardiac arrest in pregnancy|Maternal cardiac arrest]] without ROSC within 4 minutes<ref> 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.</ref> | ||
*Estimated Gestational age >24 weeks based on fundal height estimate<ref>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</ref> | *Estimated Gestational age >24 weeks based on [[Fundal exam in pregnancy|fundal height estimate]]<ref>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</ref> | ||
**Fundus reaches level of umbilicus at approximately 20 weeks and increases ~1 cm each week thereafter | **Fundus reaches level of umbilicus at approximately 20 weeks and increases ~1 cm each week thereafter | ||
**Fundus approaches xiphoid around 36-38 weeks | **Fundus approaches xiphoid around 36-38 weeks | ||
Line 14: | Line 14: | ||
==Contraindications== | ==Contraindications== | ||
*Known | *Known gestational age <24 weeks | ||
* | *ROSC within 4 minutes of arrest | ||
==Equipment Needed== | ==Equipment Needed== | ||
*C-Section or abdominal | *C-Section or abdominal exploratory laparotomy kit ideal if available | ||
* | *Emergency thoracotomy kit has many of the needed supplies | ||
*If surgical kit unavailable: | *If surgical kit unavailable: | ||
**Scalpel | **Scalpel | ||
Line 25: | Line 25: | ||
**Hemostats | **Hemostats | ||
**Sterile gauze | **Sterile gauze | ||
* | *Betadine or chlorhexadine | ||
* | *Sterile attire | ||
* | *Skin stapler | ||
==Pre-Procedure== | ==Pre-Procedure== | ||
*Call for help | |||
**Anesthesia | |||
**Respiratory therapist | |||
**NICU or pediatrics | |||
**Obstetrics | |||
**General surgery | |||
*Secure airway | *Secure airway | ||
*IV access | *Establish IV access | ||
*Cardiac monitor | *Cardiac monitor | ||
*Place foley | *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== | ==Procedure== | ||
''Continue CPR throughout procedure'' | ''Continue CPR throughout procedure as long as it can be safely accomplished'' | ||
*Widely cleanse | *Widely cleanse abdomen | ||
*Use | *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 | |||
*Make a | |||
* | |||
**If anterior placenta is encountered, sharply incise through it | **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 | ||
[[File:Resuscitative+Hysterotomy+JPEG+2.jpg|thumb|]] | |||
==Complications== | ==Complications== | ||
*Fetal injury | *Fetal injury | ||
*DIC | *[[DIC]] | ||
*Hemorrhagic shock | *[[Hemorrhagic shock]] | ||
==Follow-up== | ==Follow-up== | ||
Line 73: | Line 77: | ||
*[[Trauma in pregnancy]] | *[[Trauma in pregnancy]] | ||
*[[Emergent delivery]] | *[[Emergent delivery]] | ||
*[[Fundal exam in pregnancy]] | |||
==External Links== | |||
*https://first10em.com/cardiac-arrest-in-pregnancy-the-perimortem-cesarean-section/ | |||
==Videos== | |||
{{#widget:YouTube|id=IwDWv2iyAos}} | |||
==References== | ==References== |
Latest revision as of 20:16, 3 August 2022
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
- Fetal injury
- DIC
- Hemorrhagic shock
Follow-up
- Based on maternal outcome
- If maternal survival is anticipated, give broad spectrum antibiotics
See Also
- Pregnancy (main)
- Cardiac arrest in pregnancy
- Trauma in pregnancy
- Emergent delivery
- Fundal exam in pregnancy
External Links
Videos
{{#widget:YouTube|id=IwDWv2iyAos}}
References
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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