Resuscitative hysterotomy

Background

• Previously known as "perimortem c-section" - new term intended to emphasize benefit to mother as well as the fetus.
• Potentially life-saving for both mother and neonate
• Consider various causes of maternal cardiac arrest, but do not delay procedure - best outcome when performed within 5 minutes of maternal arrest
  • Pulmonary embolism (amniotic, thrombosis, other)
  • Eclampsia

Indications

• Maternal cardiac arrest with no return of spontaneous circulation within 5 minutes.
• Estimated Gestational age >24 weeks
  • Gestational ages should be estimated based fundal height
    • Procedure appropriate if fundus is above level of umbilicus.
      • Fundus is at level of umbilicus at approximately 20 weeks and increases ~1 cm each week thereafter
      • Fundus approaches Xiphoid process at approximately 36-38 weeks
  • (Documenting fetal heart tones before perimortem C-section is not required.)

Contraindications

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

Equipment Needed

• C-Section or abdominal ex-lap kit (often not available in ED, but may be obtained from OR if time allows)
  • Alternatively, emergency thoracotomy kit (available in most EDs) has many of the needed supplies
• If surgical kit unavailable:
  • Scalpel
  • Large scissors
  • Hemostats
  • Sterile gauze
• Suction
• Betadine
• Sterile garb (gown, gloves, mask)

Pre-Procedure

• Secure airway
• IV access (bilateral large-bore)
• Cardiac monitor
• Place foley (↓ risk of incising bladder)

None of these steps should delay procedure beyond 5 minutes after maternal arrest.

Procedure

Continue CPR throughout procedure

• Widely cleanse entire abdomen with betadine ("betadine bath")
• Use salpel to make midline abdominal incision extending from the uterine fundus to the pubic symphysis
• Sharply or bluntly dissect through all layers of the abdominal wall at the midline until abdominal cavity is entered
• Retract the abdominal wall by pulling laterally on both sides
• Bladder retractor may be used to reflect the bladder inferiorly to gain better visualization of the uterus
• 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
• Grasp infant manually and deliver from uterus
• Clamp and cut umbilical cord (two clamps, cut between)
• Hand infant off (ideally to Peds or NICU team)
• 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
• Closure
  • Depends on maternal response to resus
  • Should occur in the OR
• Continue resuscitation of mother

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

References

Authors

Ross Donaldson, Allen Bookatz, Telia DeBoyes, Aaron Snyder, Michael O'Brien, MD