Perimortem Cesarean Section

1. See Also
   1. Cardiopulmonary Resuscitation in Pregnancy
   2. Cardiopulmonary Resuscitation
   3. Trauma in Pregnancy
2. Indications
   1. Maternal pulseless Cardiac Arrest duration >4 minutes
      1. Failure of ROSC within 4 minutes despite maximal Resuscitation efforts
         1. High quality Cardiopulmonary Resuscitation performed with uterine displacement
         2. Early Endotracheal Intubation with confirmed placement
         3. Resuscitation medications delivered via IV site above diaphragm level
         4. No other reversible Cardiac Arrest etiologies identified
            1. Consider Reversible Causes of Cardiopulmonary Arrest (see 5H5T)
            2. Consider inciting event (e.g. substances taken immediately prior to arrest)
   2. Gestational age criteria
      1. Gestational age <20 weeks
         1. Consider Emergency Hysterotomy if Twin Gestation
      2. Gestational age 20-23 weeks
         1. Consider Emergency Hysterotomy to improve chance of maternal survival (ROSC)
         2. Not indicated for fetal survival (pre-viable)
      3. Gestational age 23 weeks and greater
         1. Emergency Hysterotomy to improve chance of both fetal and maternal survival
      4. Gestational age unknown
         1. Fundal height >23 cm from the symphysis (or >3-4 cm above the Umbilicus) correlates with 23 weeks
         2. Used estimation only in cases such as Emergency Hysterotomy in which delay cannot be afforded
3. Contraindications
   1. No provider available with the appropriate skills to perform Emergency Hysterotomy
   2. Inadequate equipiment and staff to support two Resuscitations (baby and mother)
   3. Prolonged Resuscitation or Hypoxia with expected poor neurologic outcome even if ROSC achieved
4. Efficacy
   1. Maximal chance of survival with definitive, rapid delivery without delays
   2. Peri-mortem Cesarean Section (hysterotomy) improves chance of survival for both fetus and mother
   3. Case reports of survival of mother, fetus out to 10 minutes pulseless prior to delivery
      1. Einav (2012) Resuscitation 83(10): 1191-200 [PubMed]
5. Preparation
   1. Emergency Hysterotomy should be performed immediately on decision to proceed (4-5 minutes into Resuscitation)
   2. Assemble Emergency Hysterotomy equipment and staff as part of initial code response ("Zero Point Survey")
      1. Overall team leader
      2. Resuscitative Hysterotomy Team
      3. Resucitative Thoracotomy Team
      4. Neonatal Team
      5. Airway Team
      6. Access and Blood Team (Intravenous Access and Blood Product infusion)
   3. Equipment
      1. Scalpel (#10 Blade)
      2. Kelly Clamps (2)
      3. Blunt tip surgical scissors
6. Procedure
   1. Perform rapidly with a single cut through skin and a single cut through Uterus
   2. Skin: Midline vertical incision between xiphoid process and Pubic Symphysis
      1. Assistant retracts the two incision sides
   3. Uterus: Midline vertical incision
      1. Make a 2-3 cm vertical incision in the lower uterine fundus (expect amniotic fluid from incision)
      2. Insert 1-2 fingers into the incision to guide scissors which extend incision caudally (toward feet)
      3. Vertical incision should extend the full length of the Uterus
   4. Deliver infant, head first
      1. Clamp and cut the Umbilical Cord
      2. Hand off infant to neonatal team
   5. Remove placenta
   6. Wipe inside of Uterus (endometrium) with sponge and pack with sterile gauze
7. Resources
   1. EB Medicine
      1. http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=88&seg_id=2198
   2. Emergency Medicine Cases
      1. https://emergencymedicinecases.com/perimortem-c-section-resuscitative-hysterotomy/
8. References
   1. Mattu in Majoewsky (2013) EM:Rap 13(4):11-2
   2. Herbert and Swaminathan in EM:Rap 21(3): 1-2
   3. Farinelli (2012) Cardiol Clin 30(3): 453-61 [PubMed]
   4. Murphy (2014) Am Fam Physician 90(10): 717-22 [PubMed]