see also: [[Emergency Delivery]], [[Trauma in pregnancy radiology]], [[Pregnant trauma]] #ob-gyn #procedures see also: [Cardiac arrest in pregnancy: scientific statement from AHA](x-devonthink-item://10EB7561-AF2A-46E4-83F8-94F356BF6897?page=0), [abcED RMH resource](x-devonthink-item://AFA1C317-AD15-4BFD-ABD5-263C6CA75FEF?page=0) > [!key points] > **Indictations:** > > - arresting preg patent > > - when fundus above umbulicus > > - patient who has not responded to resus within 4 minutes if arrested in front of the team, with the aim for the fetus to be delivered within 5 minutes of the arrest > > **RWH emergency number:** 08345 2222 > **Neonatal response team:** 08345 2222 > non-emergency RWH: 08345 2000 # Background - Maternal cardiac arrest is rare, ~1/30,000 pregnancies - Trauma may affect 8% of pregnancies and is the [leading cause of non-obstetric death in pregnancy](x-devonthink-item://10EB7561-AF2A-46E4-83F8-94F356BF6897?page=16) - **resuscitative hysterotomy** is a procedure is to rapidly deliver the fetus from an arrested mother - the **aim is to restore circulation to the mother** - A review of all published cases of PMCS up to 2010 showed that PMCS led to a clear maternal survival benefit in 19 of 60 cases (31.7%), and there were no cases in which PMCD may have been deleterious to maternal survival[^1] - A secondary outcome is that RH may improve chances of survival for a fetus of viable gestational age by removing it from a poorly perfused environment # Physiology > overall to improve: > 1. Venous return > 2. ventilation > 3. CPR effectiveness  > 4. Maternal cardiac output - in pregnant women >20 weeks gestation, the gravid uterus impairs venous return, ventilation, and reduces the effectiveness of CPR - The uterus > 20 weeks causes partial aorto-caval compression at the bifurcation of the aorta. - Delivery of the fetus results in a significant increase of the cardiac output returning to the mother and increase the chance of successful resuscitation. - As it is the size and position of the uterus that compromises the maternal circulation greater emphasis should be placed on this than a gestational age. ![[Pasted image 20230404215324.png]] ^ fetus causing aorto-caval compression # Indications 1. cardiac arrest in pregnant patients > 20/40 gestation, or where the fundal height is at the level of the umbilicus or higher # Actions 1. Commence ALS 2. Call obstetric and neonatal teams (neonatal code blue) 3. If not already performed prior to the arrest the uterus should be ==manually displaced to the left to reduce aorto-caval compression==. This is preferable to placing the patient in the left lateral tilt position as it allows CPR and other interventions to be performed concurrently. 4. Correct reversible causes 1. in [[Traumatic arrest]]: airway obstruction/hypoxia, massive haemothorax, tension pneumothorax, massive haemorrhage, tamponade ![[Pasted image 20230404215857.png]] # When to perform resuscitative hysterotomy? - traditional teaching: in a patient who has not responded to resus within 4 minutes if arrested in front of the team, with the aim for the fetus to be delivered within 5 minutes of the arrest. - in reality, it takes more than 1 minute to perform - at first rhythm check, announce plan to perform at next rhythm check if no ROSC - If the patient has arrested prior to arrival the RH should still be performed, as there may still be benefit # Equipment - Scalpel 22 blade (note: procedure may be completed with only a scalpel) - Curved Mayo scissors - Large vascular clamps (Spencer Wells) ×2
 - Needle holder
 - Suture material
 - Gillies toothed forceps # Procedure ![[Pasted image 20230405002913.png]] 1. prep abdomen (no alcohol, risks with defib) 2. at 4 min (or after all reversible causes of traumatic arrest addressed), if no ROSC, start procedure while CPR continues Pre‐operative interventions such as cleaning or draping the abdomen, and insertion of a urinary catheter, should not delay the procedure. 1. With the patient in supine position identify the pubic symphysis and the umbilicus. 2. **Make a midline incision** (approximately 20 cm) **from the umbilicus to the pubic symphysis**. This approach would be preferred for ED/ general surgical staff. Avoid incisions above the umbilicus (especially in pre‐term deliveries) as they are usually not required and may lead to bowel obscuring the surgical field. 3. Incise the subcutaneous tissue and the rectus sheath. 1. Rectus muscles are typically divaricated in a pregnant abdomen and should be spread with gloved hands to achieve a 15–20 cm space. Retractors can be used to assist access to the uterus. 4. Incise the parietal peritoneum with scissors or a scalpel. 3. The gravid uterus should be clearly visible on entry into the abdomen. 5. Make a midline incision in the uterus with the scalpel in a superior–inferior direction, avoiding the lateral aspects of the uterus. 1. The gravid uterus is thinner towards term but in preterm (less than 28 weeks gestation) the uterine wall is around 3–4 cm thick. 2. The density and consistency of the uterus changes with gestation; being similar to ‘dense foam’ around term and ‘tofu’ pre‐term. 3. Ideally finish the incision before the peritoneal reflection to avoid injury to the bladder (this is more problematic in pre‐term delivery and in lower segment incisions such as a Pfannenstiel incision). 4. Care should be taken incising the uterus to avoid injury to the fetus. 6. Once the uterus is entered the amniotic sac or the fetus is visible. 7. Identify the fetal head. 1. Fetal arms may protrude from the incision and should be pushed back to identify the head. 2. Alternatively, a fetal foot can be grasped after being identified by the ankle joint, and used to guide the rest of the fetus through the incision. 8. Scoop a hand behind the fetus and guide the head (or foot) through the uterine incision; the rest of the body follows (avoid ‘pulling’ the fetus out by the presenting part). 9. After delivery double clamp the umbilical cord and cut between the vascular clamps. 10. Hand the fetus to the neonatal resuscitation team (or most appropriate provider as discussed above). 11. The placenta will typically spontaneously deliver into the uterine incision in the few minutes after the baby is delivered. >If the obstetric team is available to perform the RH, a pfannenstiel horizontal incision is appropriate as this is a standard approach for this craft group. # Post procedure care In the event of maternal ROSC, routine post cardiac arrest care should occur. As **the uterus will bleed once circulation is restored**, it should be closed with a continuous locking suture. The placenta needs to be delivered before this is undertaken, and an oxytocin infusion should be started. Prophylactic antibiotics should be given (e.g. Cephazolin 2g). # Contraindications - if ROSC before procedure, do not need to continue resuscitative hysterotomy, but may still be indicated - Otherwise there are unlikely to be any contraindications, as a pregnant woman of childbearing age is unlikely to have advanced care directives declining resuscitation # Complications - infection - damage to structures (bowel, bladder, vascular structures, damage to fetus) [^1]: Einav S, Kaufman N, Sela HY. Maternal cardiac arrest and perimortem caesarean delivery: evidence or expert-based? Resuscitation 2012; 83: 1191–200 #ob-gyn #resus