II. Indications
- Maternal pulseless Cardiac Arrest duration >4 minutes
- Failure of ROSC within 4 minutes despite maximal Resuscitation efforts
- High quality Cardiopulmonary Resuscitation performed with uterine displacement
- Early Endotracheal Intubation with confirmed placement
- Resuscitation medications delivered via IV site above diaphragm level
- No other reversible Cardiac Arrest etiologies identified
- Consider Reversible Causes of Cardiopulmonary Arrest (see 5H5T)
- Consider inciting event (e.g. substances taken immediately prior to arrest)
- Failure of ROSC within 4 minutes despite maximal Resuscitation efforts
-
Gestational age criteria
- Gestational age <20 weeks
- Consider Emergency Hysterotomy if Twin Gestation
- Gestational age 20-23 weeks
- Consider Emergency Hysterotomy to improve chance of maternal survival (ROSC)
- Not indicated for fetal survival (pre-viable)
- Gestational age 23 weeks and greater
- Emergency Hysterotomy to improve chance of both fetal and maternal survival
- Gestational age unknown
- Fundal height >23 cm from the symphysis (or >3-4 cm above the Umbilicus) correlates with 23 weeks
- Used estimation only in cases such as Emergency Hysterotomy in which delay cannot be afforded
- Gestational age <20 weeks
III. Contraindications
- No provider available with the appropriate skills to perform Emergency Hysterotomy
- Inadequate equipiment and staff to support two Resuscitations (baby and mother)
- Prolonged Resuscitation or Hypoxia with expected poor neurologic outcome even if ROSC achieved
IV. Efficacy
- Maximal chance of survival with definitive, rapid delivery without delays
- Peri-mortem Cesarean Section (hysterotomy) improves chance of survival for both fetus and mother
- Case reports of survival of mother, fetus out to 10 minutes pulseless prior to delivery
V. Preparation
- Emergency Hysterotomy should be performed immediately on decision to proceed (4-5 minutes into Resuscitation)
- Assemble Emergency Hysterotomy equipment and staff as part of initial code response ("Zero Point Survey")
- Overall team leader
- Resuscitative Hysterotomy Team
- Resucitative Thoracotomy Team
- Neonatal Team
- Airway Team
- Access and Blood Team (Intravenous Access and Blood Product infusion)
- Equipment
- Scalpel (#10 Blade)
- Kelly Clamps (2)
- Blunt tip surgical scissors
VI. Procedure
- Perform rapidly with a single cut through skin and a single cut through Uterus
- Skin: Midline vertical incision between xiphoid process and Pubic Symphysis
- Assistant retracts the two incision sides
-
Uterus: Midline vertical incision
- Make a 3 to 5 cm vertical incision in the lower uterine fundus (expect amniotic fluid from incision)
- Insert 1-2 fingers into the incision to guide scissors which extend incision caudally (toward feet)
- Vertical incision should extend the full length of the Uterus
- Deliver infant, head first
- Clamp and cut the Umbilical Cord
- Hand off infant to neonatal team
- Remove placenta
- Wipe inside of Uterus (endometrium) with sponge and pack with sterile gauze
VII. Resources
VIII. References
- Mattu in Herbert (2013) EM:Rap 13(4):11-2
- Herbert and Swaminathan in EM:Rap 21(3): 1-2
- Warrington (2024) Crit Dec Emerg Med 38(6): 20-1
- Farinelli (2012) Cardiol Clin 30(3): 453-61 [PubMed]
- Murphy (2014) Am Fam Physician 90(10): 717-22 [PubMed]