REBEL Core Cast 46.0 – Resuscitative Hysterotomy

Take Home Points

• This is a resuscitative hysterotomy – focus is on saving the mother first. Delivering the fetus can improve venous return thus increasing chance to save mom
• Don’t focus on gestational age to make the decision – if you think the belly is big enough to be causing compression of vascular structures, the procedure is indicated
• Once you’ve made the decision – it’s go time. The faster you do it, the more likely you can salvage mom and the fetus
• Large vertical incision to maximize exposure, locate uterus, vertical incision with scalpel and extend with scissors

REBEL Core Cast 46.0 – Resuscitative Hysterotomy

Resuscitative Hysterotomy

Critical Concept: The goal of the procedure is to resuscitate the mother. Performing a resuscitative hysterotomy improves the chances of saving the mother. The procedure can also improve outcomes for the fetus.

Key to procedure: The procedure itself is not difficult but the decision to make the incision is difficult. Delays in procedure lead to worse outcomes in both mother and fetus

Prior to arrival

• Run through the Zero Point Survey 
  • Setup and prepare
  • Rally your consultants – OB/GYN, Trauma, Anaesthesia 
• Team assignments: Need multiple teams
  • Resus team
  • Airway team
  • Hysterectomy team
  • Fetus team
  • If trauma -> blood & thoracotomy team

Indications

• Cardiac arrest 
• Periarrest
• Uterus large enough to cause compression on vasculature
  • Fetus >20 weeks often quoted but, can be challenging to calculate the gestational age in a high-stress situation
  • Uterus palpable above the umbilicus can be used as well

Pre-Procedure

• Time is of the essence 
  • Skip sterility, measuring fetal HR or waiting for OB
• If medical arrest -> continue CPR and arrest algorithm
• If traumatic arrest -> another team should be performing a thoracotomy if indicated

The Procedure 

• Equipment: scalpel, scissors (ideally blunt tipped), and two Kelly clamps
• Located xiphoid process and pubic symphysis 
• Use scalpel to cut from xiphoid process to pubic symphysis. Need to cut down through multiple layers until you reach the uterus
  • Have assistant retract both edges of your incision
• Make a small, 3-4 cm incision with a scalpel into uterine fundus (low incision recommended)
• Will see a rush of amniotic fluid
• Use your scissors to extend the incision caudally
• Can place fingers into the uterus to guide scissors and avoid the fetus
• Deliver baby headfirst – grasp behind neck supporting the head
• Clamp umbilical cord and cut – pass the baby to neonatal resus team
• Deliver placenta
• Pack the uterus

Take-Home Points

1. This is a resuscitative hysterotomy – focus is on saving the mother first. Delivering the fetus can improve venous return thus increasing chance to save mom
2. Don’t focus on gestational age to make the decision – if you think the belly is big enough to be causing compression of vascular structures, the procedure is indicated
3. Once you’ve made the decision – it’s go time. The faster you do it, the more likely you can salvage mom and the fetus
4. Large vertical incision to maximize exposure, locate uterus, vertical incision with scalpel and extend with scissors

Additional Resources:

• Core EM: Perimortem C-Section
• EMCrit: Perimortem C-section
• REBEL EM: Resuscitative Hysterotomy

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

Shownotes Created By: Miguel Reyes, MD (Twitter: @miguel_reyesMD)