Resuscitative hysterotomy

Resuscitative hysterotomy
Other names: Perimortem Caesarean section (PMCS), perimortem Caesarean delivery (PMCD)
A baby being removed from its dying mother's womb. Reproduction of woodcut, 1483.
SpecialtyObstetrics, emergency medicine
IndicationsPregnant women in cardiac arrest after ~20 weeks gestation[1]
Steps1) Started within 4 minutes of a women's heart stopping
2) Make a vertical cut from the top of the uterus to the level of the pubic bone
3) Retractors are used to hold the area open and the bladder is pushed down
4) A small vertical cut is made through the lower part of the uterus and blunt tipped scissors are used to extend it up
5) The baby is removed, has its airway suctioned, and the cord clamped[2]
ComplicationsBladder injury, injury to the baby[3]

A resuscitative hysterotomy, also referred to as a perimortem Caesarean section (PMCS), is a hysterotomy performed to resuscitate a pregnant women in cardiac arrest.[4] To be indicated the size of the uterus should be above the belly button.[2] The procedure removes the baby and thereby removes compression of the aorta and inferior vena cava.[4] This improves the mother's chances of survival, and may potentially also deliver a live baby.[4]

The procedure should be started within 4 minutes of a women's heart stopping.[2] A vertical cut is made from the top of the uterus to the level of the pubic bone.[2] Retractors are used to hold the area open and the bladder is pushed down.[2] A small vertical cut is than made through the lower part of the uterus and blunt tipped scissors are used to extend it up.[2] The baby is than removed, has its airway suctions, and the cord clamped.[2]

The chance of the baby surviving is as high as 70%.[3] The procedure is rarely done as cardiac arrest only occurs in about 1 in 30,000 pregnancies.[5] It may be performed by an obstetrician, emergency physician, or surgeon.[1][6] While the procedure has been described for 1,000s of years, documented cases of babies surviving began to occur in the late 1800s and mother surviving in the late 1900s.[7]

Medical uses

Where cardiac arrest occurs in a pregnant woman, irrespective of the condition of the fetus, the procedure should be performed immediately if basic and advanced life support attempts are proving unsuccessful at achieving return of spontaneous circulation, and the woman's uterus is deemed capable of causing aortocaval compression.[4][6][8] The threshold for this is passed when the uterus is so large that the fundus may be palpated at the level of the woman's umbilicus; for a singleton pregnancy, this occurs at around 20 weeks of gestational age[6][8] (but may be earlier in multiple pregnancy). Although hysterotomy is crucial for resuscitation of the mother in such situations, if the gestational age is less than approximately 24 to 25 weeks the procedure will necessarily lead to sacrifice of the fetus (or fetuses), as this is estimated to be the lower limit for fetal viability.[8] If the fetus is over 24 weeks' gestation, Caesarean delivery also offers the best chance of rescue for the neonate.[8]

If the mother's medical condition is such that there is no reasonable prospect of maternal resuscitation or viability (for example, after a nonsurvivable injury, or an unwitnessed arrest with prolonged pulselessness), then the procedure may be attempted immediately as a means of saving the unborn fetus primarily.[6]

Contraindications

The procedure should not be performed if the uterus is not judged to be large enough to cause maternal haemodynamic changes through aortocaval compression, as there is no potential benefit to the mother and the baby will not be viable in such an early stage of pregnancy.[6]

The procedure is considered to be appropriate when the top of the uterus is at the belly button.[3] This is equivalent to about 20 to 24 weeks of gestation.[3][5]

Technique

Preparation

Once the decision to operate has been made, the procedure should be performed immediately at the site where cardiac arrest has taken place and standard basic and advanced life support resuscitation methods should continue throughout.[6] These should include manual displacement of the uterus towards the person's left side, to reduce aortocaval compression.[1] If the arrest occurs in a healthcare facility that has staff on site who are capable of performing a resuscitative hysterotomy (such as at a hospital), the person should not be moved to an operating theatre as this will delay the procedure.[6] Out-of-hospital cardiac arrests may need to be transported to a healthcare facility first if qualified staff are not immediately available.[8]

Other than a scalpel, no specialised surgical equipment is needed for a resuscitative hysterotomy.[6] The American Heart Association recommends that healthcare facilities that may be required to treat a case of maternal cardiac arrest should keep in stock an emergency equipment tray for the purpose, including a scalpel with a No. 10 blade, a Balfour retractor, surgical sponges, Kelly and Russian forceps, a needle driver, sutures and suture scissors - but the procedure should commence regardless of whether the tray is available.[6]

Basic aseptic measures, such as pouring antiseptic solution over the woman's abdomen, may be considered as long as this adds no delay.[6] An assistant should manually displace the gravid uterus to the woman's left throughout the procedure until the baby has been delivered, to assist the simultaneous efforts of those resuscitating the woman.[6] If there is sufficient time, a foley catheter should be placed.[5]

Steps

The procedure should be started within 4 minutes of a women's heart stopping.[2]

  1. A vertical cut is made from the top of the uterus to the level of the pubic bone.[2]
  2. Retractors are used to hold the area open and the bladder is pushed down.[2]
  3. A small vertical cut is than made through the lower part of the uterus and blunt tipped scissors are used to extend it up.[2]
  4. The baby is removed, has its airway suctions, and the cord clamped.[2]

Post-procedure

It may be possible to then use the abdominal incision to deliver direct cardiac massage through the (intact) diaphragm.[1][8] After the placenta is delivered, the uterus is massaged to stimulate contraction and is closed with a running locking absorbable suture and the abdomen is then closed; alternatively, the wound may be temporarily packed with sterile gauze, with definitive closure delayed until specialist obstetric help arrives or until the patient is fit for transport to a formal operating theatre.[1][6] Uterotonic agents like oxytocin may be considered, balancing potential reduction of haemorrhage with the tendency of oxytocin to cause hypotension.[6] Antibiotics should be administered to reduce infection risk if maternal survival is thought feasible at this stage of the resuscitation.[6] If there is return of spontaneous circulation, additional uterotonic agents will likely be needed due to bleeding from uterine atony.[1]

Complications

Potential structures that may be damaged during the procedure are as for Caesarean section, including the fetus itself and the maternal bowel, bladder, uterus and uterine blood vessels.[9]

History

The American Heart Association first added resuscitative hysterotomy to its recommended guidelines for cardiopulmonary resuscitation and emergency cardiac care in 1992, based on limited case report evidence.[8] Many case reports have since been published reporting that, in maternal cardiac arrest, evacuation of the uterus is often associated with abrupt return of spontaneous circulation or other improvement in the mother's condition.[8]

References

  1. 1 2 3 4 5 6 Parry R, Asmussen T, Smith JE (Mar 2015). "Perimortem caesarean section". Emergency Medicine Journal. BMJ Group (published 2015-02-24). 33 (3): 224–229. doi:10.1136/emermed-2014-204466. PMID 25714106. Archived from the original on 2021-07-11. Retrieved 2019-11-24.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 Roberts and Hedges' clinical procedures in emergency medicine and acute care (Seventh ed.). Philadelphia, PA: Elsevier Health Sciences. 2019. pp. 1207–1210. ISBN 9780323547949.
  3. 1 2 3 4 Alexander, AM; Sheraton, M; Lobrano, S (January 2021). "Perimortem Cesarean Delivery". PMID 30480973. {{cite journal}}: Cite journal requires |journal= (help)
  4. 1 2 3 4 Rose CH, Faksh A, Traynor KD, Cabrera D, Arendt KW, Brost BC (Nov 2015). "Challenging the 4- to 5-minute rule: from perimortem cesarean to resuscitative hysterotomy". American Journal of Obstetrics and Gynecology. Elsevier (published 2015-07-26). 213 (5): 653–6, 653.e1. doi:10.1016/j.ajog.2015.07.019. PMID 26212180.
  5. 1 2 3 Krywko, DM; Sheraton, M; Presley, B (January 2021). "Perimortem Cesarean". PMID 29083739. {{cite journal}}: Cite journal requires |journal= (help)
  6. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Jeejeebhoy FM, Zelop CM, Lipman S, Carvalho B, Joglar J, Mhyre JM, Katz VL, Lapinsky SE, Einav S, Warnes CA, Page RL, Griffin RE, Jain A, Dainty KN, Arafeh J, Windrim R, Koren G, Callaway CW (Nov 2015). "Cardiac Arrest in Pregnancy: A Scientific Statement From the American Heart Association". Circulation. Dallas, Texas: American Heart Association. 132 (18): 1747–73. doi:10.1161/CIR.0000000000000300. PMID 26443610.
  7. ↑ "Perimortem Cesarean Delivery: Overview, Technique, Preparation". Medscape. 27 August 2020. Archived from the original on 9 June 2021. Retrieved 20 March 2021.
  8. 1 2 3 4 5 6 7 8 Sinz, Elizabeth; Navarro, Kenneth; Soderberg, Erik, eds. (2013). ACLS for Experienced Providers Manual and Resource Text. Dallas, Texas: American Heart Association. pp. 368–370. ISBN 978-1-61669-355-8.
  9. ↑ Roe, Edward Jedd; Lyon, Deborah; Sanford, Janyce Marie; Hang, Bophal Sarha; Lovato, Luis M. Windle, Mary L; Smith, Carl V; Isaacs, Christine (eds.). "Perimortem Cesarean Delivery". Medscape. WebMD. Archived from the original on 26 October 2015. Retrieved 25 October 2015.
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