December 16, 2020

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:

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

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

Cite this article as: Anand Swaminathan, "REBEL Core Cast 46.0 – Resuscitative Hysterotomy", REBEL EM blog, December 16, 2020. Available at: https://rebelem.com/rebel-core-cast-46-0-resuscitative-hysterotomy/.
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Anand Swaminathan

Clinical Assistant Professor of Emergency Medicine at St. Joe's Regional Medical Center (Paterson, NJ)
REBEL EM Associate Editor and Author
2 Comments
  • Florian Sacherer
    Posted at 05:28h, 18 December Reply

    A thought that has been bothering me for quite a time:
    What would be your approach in maternal cardiac arrest with suspected/confirmed PE?
    For me, there would thrombolysis (and probably more effective with respect to the underlying cause) on one hand and resuscitative hysterotomy on the other one (but not both)….
    Would be interesting to read your point of view.
    Than you for the interesting post.

    Flo

    • Salim Rezaie
      Posted at 05:29h, 19 December Reply

      Hello Florian,
      I agree it is scary but in a cardiac arrest situation. It is tough to make definitive conclusions as this will be a case by case situation with what is available at your institution. In the case of suspected PE you have to do two things…increase blood flow back to heart/brain of mother and decrease afterload in the lungs. If you decrease afterload to the lungs have you increased flow back to the heart/brain of mother. Below is a case report and AHA guidelines to your question. Not sure there is a perfect answer here as this is a tough situation…but for me would be resuscitative hysterotomy followed by 50mg of tPA if PE was suspected.

      Checkout this case report: https://pubmed.ncbi.nlm.nih.gov/32327458/
      Checkout the AHA guidelines: https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.105.166570

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