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Perimortem Cesarean Section
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Perimortem Cesarean Section
, Perimortem C-Section, Emergency Hysterotomy, Resuscitative Hysterotomy
See Also
Cardiopulmonary Resuscitation in Pregnancy
Cardiopulmonary Resuscitation
Trauma in Pregnancy
Indications
Maternal pulseless
Cardiac Arrest
duration >4 minutes
Failure of
ROSC
within 4 minutes despite maximal
Resuscitation
efforts
High quality
Cardiopulmonary Resuscitation
performed with uterine displacement
Early
Endotracheal Intubation
with confirmed placement
Resuscitation
medications delivered via IV site above diaphragm level
No other reversible
Cardiac Arrest
etiologies identified
Consider
Reversible Causes of Cardiopulmonary Arrest
(see
5H5T
)
Consider inciting event (e.g. substances taken immediately prior to arrest)
Gestational age
criteria
Gestational age
<20 weeks
Consider Emergency Hysterotomy if
Twin Gestation
Gestational age
20-23 weeks
Consider Emergency Hysterotomy to improve chance of maternal survival (
ROSC
)
Not indicated for fetal survival (pre-viable)
Gestational age
23 weeks and greater
Emergency Hysterotomy to improve chance of both fetal and maternal survival
Gestational age
unknown
Fundal height >23 cm from the symphysis (or >3-4 cm above the
Umbilicus
) correlates with 23 weeks
Used estimation only in cases such as Emergency Hysterotomy in which delay cannot be afforded
Contraindications
No provider available with the appropriate skills to perform Emergency Hysterotomy
Inadequate equipiment and staff to support two
Resuscitation
s (baby and mother)
Prolonged
Resuscitation
or
Hypoxia
with expected poor neurologic outcome even if
ROSC
achieved
Efficacy
Maximal chance of survival with definitive, rapid delivery without delays
Peri-mortem
Cesarean Section
(hysterotomy) improves chance of survival for both fetus and mother
Case reports of survival of mother, fetus out to 10 minutes pulseless prior to delivery
Einav (2012) Resuscitation 83(10): 1191-200 [PubMed]
Preparation
Emergency Hysterotomy should be performed immediately on decision to proceed (4-5 minutes into
Resuscitation
)
Assemble Emergency Hysterotomy equipment and staff as part of initial code response ("Zero Point Survey")
Overall team leader
Resuscitative Hysterotomy Team
Resucitative Thoracotomy Team
Neonatal Team
Airway Team
Access and Blood Team (
Intravenous Access
and
Blood Product
infusion)
Equipment
Scalpel (#10 Blade)
Kelly Clamps (2)
Blunt tip surgical scissors
Procedure
Perform rapidly with a single cut through skin and a single cut through
Uterus
Skin: Midline vertical incision between xiphoid process and
Pubic Symphysis
Assistant retracts the two incision sides
Uterus
: Midline vertical incision
Make a 2-3 cm vertical incision in the lower uterine fundus (expect amniotic fluid from incision)
Insert 1-2 fingers into the incision to guide scissors which extend incision caudally (toward feet)
Vertical incision should extend the full length of the
Uterus
Deliver infant, head first
Clamp and cut the
Umbilical Cord
Hand off infant to neonatal team
Remove placenta
Wipe inside of
Uterus
(endometrium) with sponge and pack with sterile gauze
Resources
EB Medicine
http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=88&seg_id=2198
Emergency Medicine Cases
https://emergencymedicinecases.com/perimortem-c-section-resuscitative-hysterotomy/
References
Mattu in Majoewsky (2013) EM:Rap 13(4):11-2
Herbert and Swaminathan in EM:Rap 21(3): 1-2
Farinelli (2012) Cardiol Clin 30(3): 453-61 [PubMed]
Murphy (2014) Am Fam Physician 90(10): 717-22 [PubMed]
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