Perimortem Caesarean section

Resuscitative Hysterotomy / Perimortem Caesarean Section

Rationale

• Primarily, may increase chances of maternal ROSC as it improves maternal cardiac output ~25% by two mechanisms
  • Reduces uterine blood flow
  • Relieves diaphragmatic pressure and aortocaval compression
• Secondarily, may save a viable foetus

Indication

• Maternal arrest within 4 minutes (Do not wait for seniors or USS or sterile prep!)
• AND
• >24/40 gestation (Alternatively use fundal height above umbilicus or “visibly pregnant” as a good rough guide)

Contraindications

• None absolute; this is a heroic attempt in an arrested patient

Preparation

• Patient: Continue resuscitation with pregnancy modifications
• Area: The resuscitation room. There is no time for change of location.
• Equipment:
  • Large scalpel e.g. 10-blade
  • Retractors if available
  • Bandage scissors
• Drugs: None essential but oxytocics useful besides standard resuscitation drugs.
• Staff:
  • Most experienced doctor should perform procedure, ideally obstetrician but do not wait for his/her arrival
  • Neonatologist and dedicated neonatal resuscitation team ideal

Procedure

• Duration should not exceed 5 minutes!
• Incise from pubic symphysis to at least umbilicus with a large scalpel along linea nigra into peritoneal cavity. Layers: skin, subcutaneous tissue, fascia between the rectus muscles, peritoneum.
• Retract abdominal wall laterally
• Reflect bladder inferiorly and empty by aspiration
• Make a small incision (~5cm) vertically into the inferior presenting part of the uterus until amniotic fluid comes or through endometrium
• Insert 2 fingers and lift up uterus from foetus
• Extend uterine incision up to fundus with safety scissors curved away from foetus
• Deliver the foetus. May need to disengage the presenting part from the pelvis.
• Clamp the cord twice and cut between clamps
• Give the neonate to the neonatal resuscitation team

Post Procedural care

• Deliver the placenta
• Swab the endometrial cavity to ensure no residual products of conception
• Pack the uterus and abdomen +/- clamp bleeding vessels and suture uterine incision
• Give synthetic oxytocin 5 units IV
• Continue maternal resuscitation
• If ROSC: watch for bleeding, consider further oxytocic drugs, TXA, antibiotic prophylaxis
• Resuscitate neonate

Complications

• Bleeding; marked with ROSC

Helpful tips

• The most difficult step is the decision to perform the procedure. Knowing the indications clearly will help to overcome any hesitation at the critical moment.
• Time is critical. Begin within 4 minutes of maternal arrest and take no longer than 5 minutes to perform the procedure. There is benefit after these time windows, but survival drops precipitously.
• Continue CPR with manual uterine displacement or left lateral tilt during and after the procedure
• Continue ventilating the patient, accounting for diaphragmatic splinting by the gravid uterus

Factors affecting foetal survival

• Time to delivery. Especially poor after 20 minutes.
• Quality of CPR
• Maturity
• NICU availability
• Pre-arrest maternal condition e.g. shocked for hours prior to arrest, chronic illness

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Further reading

FOAM

• Nickson C. CPR and Pregnancy. CCC
• Nickson C. Newborn Resuscitation. CCC
• Nickson C. Physiology of Pregnancy. CCC
• Simulation: Resuscitative Hysterotomy. SMACC
• EMCrit Conference Blast Winner: Peri-Mortem C-Section
• Perimortem C-section at St.Emlyn’s

Journal articles

• Bloomer R, Reid C, Wheatley R. Prehospital resuscitative hysterotomy. Eur J Emerg Med. 2011 Aug;18(4):241-2.
• Healy ME, Kozubal DE, Horn AE, Vilke GM, Chan TC, Ufberg JW. Care of the Critically Ill Pregnant Patient and Perimortem Cesarean Delivery in the Emergency Department. J Emerg Med. 2016 Aug;51(2):172-7.