Resuscitative hysterotomy: Difference between revisions
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==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 | ||
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*Close abdominal incision using skin stapler | *Close abdominal incision using skin stapler | ||
*Continue maternal resuscitation | *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== | ||
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*[[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