Resuscitative hysterotomy
| Resuscitative hysterotomy | |
|---|---|
 A baby being removed from its dying mother's womb. Reproduction of woodcut, 1483. | |
| Other names | Perimortem Caesarean section |
| eMedicine | 83059 |
A resuscitative hysterotomy, also referred to as a perimortem Caesarean section (PMCS) or perimortem Caesarean delivery (PMCD), is a
Medical uses
Where cardiac arrest occurs in a pregnant woman, irrespective of the condition of the
If the mother's medical condition is such that there is no reasonable prospect of maternal resuscitation or viability (for example, after a nonsurvivable injury, or an unwitnessed arrest with prolonged pulselessness), then the procedure may be attempted immediately as a means of saving the unborn fetus primarily.[3]
Contra-indications
The procedure should not be performed if the uterus is not judged to be large enough to cause maternal haemodynamic changes through aortocaval compression, as there is no potential benefit to the mother and the fetus or fetuses will not be viable in such an early stage of pregnancy.[3]
Risks and complications
Potential structures that may be damaged during the procedure are as for Caesarean section, including the fetus itself and the maternal bowel, bladder, uterus and uterine blood vessels.[5]
Technique
Once the decision to operate has been made, the procedure should be performed immediately at the site where cardiac arrest has taken place and standard basic and advanced life support resuscitation methods should continue throughout.
Other than a
Basic aseptic measures, such as pouring antiseptic solution over the woman's abdomen prior to incision, may be considered as long as this adds no delay.[3] An assistant should manually displace the gravid uterus to the woman's left throughout the procedure until the fetus has been delivered, to assist the simultaneous efforts of those resuscitating the woman.[3] Either a classical midine incision or a Pfannenstiel incision may be used depending on operator preference; the former may theoretically give better exposure, but practising obstetricians or surgeons may be more comfortable with a Pfannenstiel approach as this is more commonly used for Caesarean sections.[3] Once the uterus is opened, the fetus is delivered and should be resuscitated by a separate team.[3] It may be possible to then use the abdominal incision to deliver direct cardiac massage through the (intact) diaphragm.[2][4]
After the placenta is delivered, the uterus is massaged to stimulate contraction and is closed with a running locking absorbable suture and the abdomen is then closed; alternatively, the wound may be temporarily packed with sterile gauze, with definitive closure delayed until specialist obstetric help arrives or until the patient is fit for transport to a formal operating theatre.
History
The American Heart Association first added resuscitative hysterotomy to its recommended guidelines for cardiopulmonary resuscitation and emergency cardiac care in 1992, based on limited case report evidence.[4] Many case reports have since been published reporting that, in maternal cardiac arrest, evacuation of the uterus is often associated with abrupt return of spontaneous circulation or other improvement in the mother's condition.[4]
References
- ^ PMID 26212180.
- ^ S2CID 23101650.
- ^ PMID 26443610.
- ^ ISBN 978-1-61669-355-8.
- ^ Roe, Edward Jedd; Lyon, Deborah; Sanford, Janyce Marie; Hang, Bophal Sarha; Lovato, Luis M. Windle, Mary L; Smith, Carl V; Isaacs, Christine (eds.). "Perimortem Cesarean Delivery". Medscape. WebMD. Retrieved 25 October 2015.