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^[1]
Consider various causes of maternal cardiac arrest, but do not delay procedure - best outcome when performed within 5 minutes of maternal arrest^[2]
- Pulmonary embolism (amniotic, thrombosis, other)
- Eclampsia

Maternal cardiac arrest with no return of spontaneous circulation within 5 minutes.^[2]
Estimated Gestational age >24 weeks^[3]
- 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.)

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)

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

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

↑ 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.
↑ ^2.0 ^2.1 Katz V. et al. Perimortem cesarean delivery: Were our assumptions correct? American Journal of Obstetrics and Gynecology (2005) 192, 1916–21 PDF
↑ 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