Resuscitative hysterotomy

Background

  • Can be life-saving for both mother and neonate
  • Fetal age >24 weeks
    • Worse outcomes with fetal age between 23 - 28 weeks of gestational age
    • Best outcomes are achieved when the infant is delivered within 5 minutes of maternal cardiac arrest
  • Documenting fetal heart tones before PMCD is not required
  • Continue CPR during C-section

Clinical Indication

  • Cardiac arrest with no return of spontaneous circulation within 5 minutes.[1]
  • Estimated Gestational age > 24 weeks
    • Gestational ages should be estimated based on palpation of the uterine fundus above the level of the umbilicus
    • Fundus is at level of umbilicus at approximately 20 weeks and increases ~1 cm each week thereafter
    • Fundus is near Xiphoid process at approximately 36-38 weeks

Causation

  • Trauma
  • Cardiac
  • PE (amniotic vs thrombosis)
  • Eclampsia
  • Drug Use

Contraindications

  • Known gestation less than 24 weeks
  • Return of spontaneous circulation after brief period of resuscitation

Pre-Procedure

  • IV Access
  • Cardiac Rhythm/Monitor
  • Secure Airway

Procedure

  1. Betadine bath
  2. Midline abdominal incision extending from the level uterine fundus to the pubic symphysis
  3. Careful dissection or incision should be made through all layers of the abdominal wall, including the peritoneum
  4. Retractors to pull the abdominal wall laterally on both sides
  5. Bladder retractor may be used to reflect the bladder inferiorly and gain better visualization of the uterus
  6. Vertical incision from the fundus to no farther than the anterior reflection of the bladder (usually a hyper lucent transverse line near the inferior portion of the uterus).
    • Blood vessels are lateral - avoid them
  7. Entered uterus by inserting index and middle fingers to lift the uterine wall away from the fetus and extend the incision as needed, preferably with bandage scissors.
    • Take care when incising the uterus as entry can inflict lacerations on the fetus
    • Take care to avoid fetal limbs with bandage scissors during uterine laparotomy extension
  8. Deliver infant
  9. Clamp Cord (two clamps, cut between)
  10. Hand Infant to Neonatal Resus Trained Provider
  11. 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
  12. Closure
    • Depends on maternal response to resus
    • Should occur in the OR
    • Careful full multi-layered closure should occur
  13. Continue resuscitation of mother if warranted
  14. Broad Spectrum Antibiotics for 'dirty surgery'

Labs

  • Fingerstick
  • CBC
  • Chem 10 (mag, cal, phos)
  • ABO/Rh Status
  • Liver Panel (concern for eclampsia)
  • EKG
  • Type and Screen/Cross
  • Urine Tox
  • Consult OBGYN
  • Consult Neonatology

Complications

  • unknown maternal Co-morbids
  • Cause for maternal collapse: airway, cardiac, trauma, drugs
  • DIC
  • Hemorrhagic Shock with End organ damage

Also See

Sources

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 Roe EJ, Hang BS, Lyon D, Sanford JM. Perimortem Cesarean Delivery. eMedicine website. (http://emedicine.medscape.com/article/83059). Accessed January 6, 2012.

  1. Katz V. et al. Perimortem cesarean delivery: Were our assumptions correct? American Journal of Obstetrics and Gynecology (2005) 192, 1916–21 PDF