Resuscitative Hysterotomy
Let’s go for it. Get the baby out - Simon Carley
image by: Dean Little
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Perimortem C-section at St.Emlyn’s
So, I’m riding my luck. I’m about half way through my EM career and I’ve been lucky so far. No hysterotomies for me, but I’m getting worried...
That day may be tomorrow, it may be never but I want to be prepared and I’d like you to be prepared. It’s therefore time to turn to the #FOAM gods and ask for help. So this post is not about my experience (I have none), it’s a little bit about the practicalities, but mostly it’s about how we can prepare for what I hope will be a never event. There is a lot of stuff already out there on some great blogs, please visit them and use the experience of those writers, but by sharing my thoughts here I hope to give some guidance on the process of…
Resources
Cardiac arrest and pregnancy
If attempts at maternal resuscitation fail, consider immediate cesarean section. Gestational age greater than 23 weeks is the recommended cut-off for immediate delivery. A fetus younger than 23 weeks has an extremely poor prognosis. Such instances of perimortem delivery are rare, and the chances of fetal survival are generally poor.
Cardiac arrest in pregnancy: the perimortem c-section
Estimate gestational age by palpating the uterus. If the fundus is above the umbilicus, assume 24 weeks gestation, and therefore viability. At the same time, prep the abdomen with chlorhexidine. If fundus above the umbilicus and more than 4 minutes have passed, proceed...
Live Resuscitative Hysterotomy by Dr. Sara Gray: Essentials of EMCrit 2018
So this is for emergency life-saving c-section. Not just emergency c-section, but an emergency delivery to save the mother, and baby, from death.
Perimortem C-section – The Resuscitative Hysterotomy
The indications for perimortem c-section are maternal cardiac arrest with gravid uterus above the umbilicus* or known to be >20 weeks gestational age up to 30 minutes after cardiac arrest started. The most common pitfall in maternal cardiac arrest is delaying the resuscitative hysterotomy. The sooner the procedure is initiated, the more likely maternal and neonatal survival.
Perimortem C-section: Can you cut it in Obstetric resus?
if you are involved in the care of pregnant women, or any acute care then you need to have a think about this – you might need it to save one or two lives one day!
Post-Mortem C-Section: A How-to Guide to Section or Not to Section: The Peri-Mortem C-Section in the ED
Peri-mortem Cesarean section in the ED is one of the most heroic procedures in the EM scope of practice. Peri-mortem C-section is exceedingly rare, and the decision to embark on this procedure must literally be made within seconds to minutes.
Sim Case Series: Perimortem C-Section
Identify pregnant pt with uterine fundus greater than 20 cm above pubic symphysis. Initiate and complete perimortem CS within 5 minutes loss of pulses
Thinking about: Perimortem Caesarean Section
Know the procedure. You won't have time to look it up. So you need to have thought through it in detail (using that high-fidelity simulator in your mind), as well as put your team and leadership abilities through their paces. You could use a DIY trainer like we've seen here previously.
Trauma Tuesday - Pregnant trauma
Best outcome when performed within 4 minutes of Cardiac Arrest. (this patient is already dead at this point, you cannot make them worse, it is time to throw the kitchen sink)
Perimortem C-section at St.Emlyn’s
So, I’m riding my luck. I’m about half way through my EM career and I’ve been lucky so far. No hysterotomies for me, but I’m getting worried. This blog post outlines my anxieties and what I’m doing to help myself. If you find it helpful too then all the better.
LFTL
Maternal arrest within 4 minutes (Do not wait for seniors or USS or sterile prep!)
WikEM
Maternal cardiac arrest without ROSC within 4 minutes.
StatPearls
One of the most daunting scenarios to face during an emergency department (ED)/critical care shift is the sudden, adverse change in a pregnant patient's health. These occurrences are rare and are the result of pre-existing conditions with severe, unforeseen medical, obstetric complications. This is also the scenario when patients arrive in extremis from a traumatic insult.
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