Circulation - Hysterotomy (resuscitative)

Indications

Maternal cardiac arrest for >4 minutes

and

Gestation of >20 weeks (indicated by a fundus palpable above the umbilicus)

Contraindications (absolute in bold)

Maternal cardiac arrest for >15 minutes

Alternatives

Standard non-surgical resuscitation

Informed consent

Medical emergency

Consent is not required

Potential complications

Foetal injury

Haemorrhage

Neurovascular or visceral injury (bladder, bowel)

Procedural hygiene

Standard precautions

Aseptic non-touch technique

PPE: sterile gloves and gown, surgical mask, protective eyewear/shield

Area

Resuscitation bay

Staff

Proceduralist and assistant

Maternal resuscitation team

Neonatal resuscitation team

Equipment (caesarean section)

Scalpel

Scissors (blunt-ended)

Retractors (or assistant’s hand can retract)

Clamps or haemostats (two for cord clamping, extra for bleeding vessels)

Gauze swabs

Large absorbable sutures and needle holder

Equipment (neonatal resuscitation)

Dry linen

Baby warmer (Resuscitaire)

Neonatal bag valve mask, airway adjuncts and suction

Cannula, umbilical venous line and resuscitation drugs

Positioning

Supine with manual uterine displacement to the patient’s left until skin incision

Medication

Oxytocin 10 units IV

Cephazolin 2g IV

Tranexamic acid 1g IV

Sequence

Continue maternal resuscitation algorithm (ALS/traumatic)

Make a vertical incision from umbilicus to the symphysis pubis (approximately 20cm)

Cut through the skin, subcutaneous tissue then fascial layer (white and shiny)

Separate the rectus muscles using hand, exposing peritoneum

Incise the parietal peritoneum with scissors or a scalpel

Direct assistant to pull the abdominal wall laterally on both sides by hand to expose the uterus

Make a midline incision starting at the lower uterus, avoiding the bladder inferiorly

Extend incision upwards towards the uterine fundus (1cm thick) with scissors

Incise anteriorly until gush of amniotic fluid (through placenta if encountered)

Use your dominant hand to locate the presenting part and disengage from pelvis (head, bottom or feet)

Elevate the presenting part through the incision as assistant applies transabdominal pressure

Use traction along with further transabdominal pressure to deliver the rest of the baby

Clamp the cord twice and cut immediately between clamps

Hand the baby to the neonatal resuscitation team

Deliver the placenta by applying traction to the remaining cord or separate manually

Clear the inside of the uterus of remaining debris using a large gauze swab

Massage the uterine fundus to stimulate uterine contraction and lessen further blood loss

Apply clamps to any actively bleeding uterine vessels and temporarily pack uterus with large gauze swabs

Give oxytocin (10 units by slow IV injection)

Consider internal cardiac massage (compress heart against anterior chest wall) and aortic compression

If ROSC, large absorbable sutures may be required to close uterus

Post-procedure care

If maternal return of spontaneous circulation is achieved, provide:

Analgesia, sedation and intubation

Oxytocin infusion at 10 units per hour

Cephazolin 2g IV

Tranexamic acid 1g IV, activate MTP, resuscitate with blood products if required

Transfer mother to theatre for closure of abdomen

Tips

The perceived time of maternal cardiac arrest may not be the time circulation ceases

Consider the possibility of low-flow states with apparent pulseless electrical activity arrest while considering the procedure

The primary purpose of resuscitative hysterotomy is to improve the chances of maternal survival

The target is one minute total duration from initial incision until removal of the foetus

Discussion

From a gestational age of 20 weeks, the gravid uterus causes aortocaval compression, impeding venous return and cardiac output. In non-pregnant women undergoing CPR, chest compressions only achieve around 30% of the normal cardiac output. In pregnant women with aortocaval compression, this drops to around 10% during CPR.

As a primary intervention, the uterus should be manually displaced to the patient’s left side after 20 weeks gestation (where the top of the uterus is palpable at or above the umbilicus), and ‘pulling’ has been shown to be better than ‘pushing’.

Retrospective reviews highlight the difficult of getting knife to skin in less than four minutes from the onset of cardiac arrest. It is important to immediately prepare a team for resuscitative hysterotomy during resuscitation.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Greater Sydney Area Helicopter Emergency Service

CareFlight

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Australian Resuscitation Council and New Zealand Resuscitation Council. ANZCOR guideline 11.10 – resuscitation in special circumstances. Melbourne: Australian Resuscitation Council and New Zealand Resuscitation Council; 2010. 14pp. Available from https://resus.org.au/guidelines/

Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care [published correction appears in Circulation. 2016 Aug 30;134(9):e122]. Circulation. 2015;132(18 Suppl 2):S501-S518. doi:10.1161/CIR.0000000000000264

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges’ clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O’Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Zelop CM, Brickner B. Cardiopulmonary arrest in pregnancy. In: UpToDate. Waltham (MA): UpToDate. 2019 May 9. Available from: https://www.uptodate.com/contents/cardiopulmonary-arrest-in-pregnancy

Groombridge C, Maini A, Noonan M, et al. Resuscitative hysterotomy: Training for this rare life-saving intervention. Emerg Med Australas. 2018;30(6):851-853. doi:10.1111/1742-6723.13112

Battaloglu E, Porter K. Management of pregnancy and obstetric complications in prehospital trauma care: prehospital resuscitative hysterotomy/perimortem caesarean section. Emerg Med J. 2017;34(5):326-330. doi:10.1136/emermed-2016-205979

Parry R, Asmussen T, Smith JE. Perimortem caesarean section. Emerg Med J. 2016;33(3):224-229. doi:10.1136/emermed-2014-204466

Bloomer R, Reid C, Wheatley R. Prehospital resuscitative hysterotomy. Eur J Emerg Med. 2011;18(4):241-242. doi:10.1097/MEJ.0b013e328344f2c5

Drukker L, Hants Y, Sharon E, Sela HY, Grisaru-Granovsky S. Perimortem cesarean section for maternal and fetal salvage: concise review and protocol. Acta Obstet Gynecol Scand. 2014;93(10):965-972. doi:10.1111/aogs.12464

Rose CH, Faksh A, Traynor KD, Cabrera D, Arendt KW, Brost BC. Challenging the 4- to 5-minute rule: from perimortem cesarean to resuscitative hysterotomy. Am J Obstet Gynecol. 2015;213(5):653-653.e1. doi:10.1016/j.ajog.2015.07.019

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