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

Perimortem Caesarean section
(1) Vertical incision through the abdominal wall from level of uterine fundus to symphysis pubis
(2) Use retractors (if available) to expose the anterior surface of the uterus; Retract the bladder inferiorly.
(3) Use scalpel to make incision through the lower uterine segment.
(4) Extension of the incision superiorly using bandage scissors.
(5) Delivery of the fetus; suction the nose and mouth; clamp and cut the cord
Healy et al 2016

EMCrit Conference Blast Winner: Peri-Mortem C-Section

Further reading

FOAM

Journal articles

Critical Care

Compendium

WA emergency doctor

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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