Take Home Points
- This is a resuscitative hysterotomy – focus is on saving the mother first. Delivering the fetus can improve venous return thus increasing chance to save mom
- Don’t focus on gestational age to make the decision – if you think the belly is big enough to be causing compression of vascular structures, the procedure is indicated
- Once you’ve made the decision – it’s go time. The faster you do it, the more likely you can salvage mom and the fetus
- Large vertical incision to maximize exposure, locate uterus, vertical incision with scalpel and extend with scissors
REBEL Core Cast 46.0 – Resuscitative Hysterotomy
Resuscitative Hysterotomy
Critical Concept: The goal of the procedure is to resuscitate the mother. Performing a resuscitative hysterotomy improves the chances of saving the mother. The procedure can also improve outcomes for the fetus.
Key to procedure: The procedure itself is not difficult but the decision to make the incision is difficult. Delays in procedure lead to worse outcomes in both mother and fetus
Prior to arrival
-
Run through the Zero Point Survey
- Setup and prepare
- Rally your consultants – OB/GYN, Trauma, Anaesthesia
-
Team assignments: Need multiple teams
- Resus team
- Airway team
- Hysterectomy team
- Fetus team
- If trauma -> blood & thoracotomy team
Indications
- Cardiac arrest
- Periarrest
-
Uterus large enough to cause compression on vasculature
- Fetus >20 weeks often quoted but, can be challenging to calculate the gestational age in a high-stress situation
- Uterus palpable above the umbilicus can be used as well
Pre-Procedure
-
Time is of the essence
- Skip sterility, measuring fetal HR or waiting for OB
- If medical arrest -> continue CPR and arrest algorithm
- If traumatic arrest -> another team should be performing a thoracotomy if indicated
The Procedure
- Equipment: scalpel, scissors (ideally blunt tipped), and two Kelly clamps
- Located xiphoid process and pubic symphysis
-
Use scalpel to cut from xiphoid process to pubic symphysis. Need to cut down through multiple layers until you reach the uterus
- Have assistant retract both edges of your incision
- Make a small, 3-4 cm incision with a scalpel into uterine fundus (low incision recommended)
- Will see a rush of amniotic fluid
- Use your scissors to extend the incision caudally
- Can place fingers into the uterus to guide scissors and avoid the fetus
- Deliver baby headfirst – grasp behind neck supporting the head
- Clamp umbilical cord and cut – pass the baby to neonatal resus team
- Deliver placenta
- Pack the uterus
Take-Home Points
- This is a resuscitative hysterotomy – focus is on saving the mother first. Delivering the fetus can improve venous return thus increasing chance to save mom
- Don’t focus on gestational age to make the decision – if you think the belly is big enough to be causing compression of vascular structures, the procedure is indicated
- Once you’ve made the decision – it’s go time. The faster you do it, the more likely you can salvage mom and the fetus
- Large vertical incision to maximize exposure, locate uterus, vertical incision with scalpel and extend with scissors
Additional Resources:
- Core EM: Perimortem C-Section
- EMCrit: Perimortem C-section
- REBEL EM: Resuscitative Hysterotomy
Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)
Shownotes Created By: Miguel Reyes, MD (Twitter: @miguel_reyesMD)
The post REBEL Core Cast 46.0 – Resuscitative Hysterotomy appeared first on REBEL EM - Emergency Medicine Blog.
