Written by Nickolas Srica
Spoon Feed
The decision to perform a perimortem cesarean delivery (aka resuscitative hysterotomy) can cause anxiety in the most seasoned clinicians. This review of the “must knows” will give you the confidence to act swiftly.
Which way should you displace the uterus? To the left, to the left…
While preparing to perform this procedure, remember some basics. Chest compressions, defibrillation, and drug administration guidelines are largely the same as in non-pregnant patients. Displace the uterus to the left, off the great vessels during resuscitation, and estimate gestational age by palpating the uterine fundus at or above the umbilicus to ensure at least 20-24 weeks gestation. Ultrasound is far better if available! The “4-to-5 minute” rule for how quickly we should aim to begin and subsequently deliver the fetus after cardiac arrest tends to be what we are taught here, but in reality, we should try to start and complete the procedure as soon as safely possible.
Procedural Technique
- Make a midline vertical incision from the xiphoid process to the pubic symphysis. Cut around, not through, the umbilicus for style points.
- Lift the uterus into the field and make a small incision at the inferior, anterior portion of the uterus.
- Insert two fingers into the incision, lifting the uterine wall up off the fetus and use Mayo scissors to extend the vertical incision the entire length of the uterus.
- Deliver fetus headfirst; clamp umbilical cord twice, and cut between the clamps.
- Don’t forget the placenta! Deliver after blunt dissection to separate it.
- Pack the uterus and abdomen with towels.
- Consider 1-2g intravenous TXA and 10 units of intramuscular oxytocin.
- Operative closure will happen later once stabilized but can loosely staple if transferring.
- Continue resuscitation of your now two patients.
How will this change my practice?
It’s on us as emergency clinicians to be prepared to perform this rare and anxiety-inducing procedure, especially if you practice in a resource limited setting. Have a plan in place, have a kit made and ready (though a scalpel and scissors are all you really need), and most of all, consider practicing with simulation to increase comfort.
Source
Perimortem cesarean section after severe injury: What you need to know. J Trauma Acute Care Surg. 2024 Nov 1;97(5):670-677. doi: 10.1097/TA.0000000000004444. Epub 2024 Sep 3. PMID: 39225781
