Author:
John A.Guisto
Gregory L.Gaskin
- Emergent delivery in the setting of maternal cardiac arrest
- Requires immediate recognition and initiation of resuscitation
- Must quickly assess etiology to direct therapy
- Rapid delivery offers the best chance for both maternal and fetal survival
- Synonym: Resuscitative hysterotomy
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- The sole indication for ED physician to perform emergency perimortem cesarean section is a gravid female (≥20-wk gestation) in cardiopulmonary arrest who has not responded to initial resuscitative measures, regardless of cause
- The most important predictor of fetal survival is length of time between maternal cardiac arrest and cesarean delivery:
- Cesarean section should begin within 4 min of maternal arrest
- Goal is delivering fetus within 1 min
- Obtain immediate consultations from obstetrics, pediatrics, and surgery, if trauma related:
- Do not defer or delay performing procedure until arrival of consultants
- Notify nearest NICU team if available
- Do not perform emergent cesarean section if patient is <20-wk gestation
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Etiology
- Antepartum maternal cardiac arrest is rare:
- Maternal survival is 17-59%
- Fetal survival is 61-80%:
- 88-100% of surviving infants are neurologically intact
- Most common causes of maternal cardiac arrest:
- Hemorrhage - 45%:
- Amniotic fluid embolism - 13%
- Sepsis - 11%
- Anesthetic complications - 8%
- Trauma - 3%
Signs and Symptoms
History
Gravid female (≥20-wk gestation determined by uterine fundal height) who is in cardiopulmonary arrest
Physical Exam
Patient is determined to be ≥20-wk gestation if uterus is at or above the umbilicus
Essential Workup
- Physical exam for apnea and pulselessness in obviously gravid female:
- Quickly evaluate for reversible causes of cardiopulmonary arrest:
- Hypoxia
- Hypovolemia
- Hydrogen ion (acidosis)
- Hypokalemia/hyperkalemia
- Hypoglycemia
- Hypothermia
- Trauma
- Thromboembolism
- Toxins/poisons
- Tension pneumothorax
- Tamponade (pericardial)
- Supine hypotension syndrome (compression of inferior vena cava by enlarged uterus)
- Assess gestational age by uterine fundal height:
- Distance from pubis to fundus in centimeters is roughly equivalent to gestational age in weeks, i.e., 20 cm = 20 wk
- US is beneficial if immediately available to assess fetus, but do not delay procedure for US confirmation of gestational age
Diagnostic Tests & Interpretation
Imaging
- None necessary to establish cardiopulmonary arrest
- Do not use valuable time attempting to determine fetal heart tones
Differential Diagnosis
- Cardiopulmonary arrest is final common pathway
- Evaluate for underlying cause
Prehospital
Cautions:
- Minimal scene time, “scoop and run”
- Manually displace the uterus to the left (recommended) or place the patient in the left lateral decubitus position avoid compression of inferior vena cava (supine hypotension syndrome)
- Trauma patient requiring spinal immobilization:
- Uterus can be manually displaced to left
- Backboard can be wedged to keep right hip elevated 45°
Initial Stabilization/Therapy
- Stand ard resuscitation measures:
- Emergency intubation:
- Use a smaller endotracheal tube (0.5-1 mm less in internal diameter compared to that used for nonpregnant women)
- High-flow oxygen
- Cardiac and BP monitoring
- 2 large-bore peripheral IV lines (above diaphragm, if possible):
- Fluid resuscitation
- O-negative blood if indicated
- Fetal survival correlates with maternal survival and adequacy of initial maternal resuscitation
- If patient is at <20-wk gestation, use advanced cardiac life support (ACLS) and advanced trauma life support protocols directed at maternal resuscitation:
- Do not perform emergent cesarean section
- Transporting patient from scene of arrest to operating theater is NOT recommended as this can delay C-section and is associated with lower quality compressions en route
- If patient is ≥20-wk gestation, use 4-min rule:
- Perform ACLS or advanced trauma life support for 4 min
- If no response, proceed to immediate emergency cesarean section
- Goal is to deliver fetus within 1 min
- If it is obvious there is no chance for maternal survival, begin perimortem cesarean section immediately:
- Some would suggest if there is no shockable rhythm to proceed immediately with C-section
ED Treatment/Procedures
- Call for immediate obstetric, surgical, and pediatric consultations:
- Do not delay performing procedure while waiting for consultants
- Ensure a Foley catheter has been inserted to decompress bladder, but do not delay procedure
- Perform cesarean section:
- Use linea nigra as land mark for vertical midline incision
- Incise abdominal wall from pubic hairline to 5 cm above umbilicus
- This incision should pass through fascial and peritoneal layers
- Retract urinary bladder inferiorly against pubic symphysis
- Make small vertical incision in lower uterine segment, just cephalad to urinary bladder
- Extend incision cephalad with scissors:
- Insert your free hand into uterus
- Lift uterine wall away from fetus to avoid fetal injury
- Deliver fetus
- Clamp umbilical cord in 2 places and cut between the 2 clamps
- Manually deliver placenta
- Perform neonatal resuscitation, as indicated
- Immediately reassess maternal vital signs because most often spontaneous circulation may return after delivery
- Continue maternal resuscitation as appropriate
- Suture uterus with running lock stitch using large diameter absorbable suture
- Suture fascia and peritoneum with running stitch using large diameter absorbable suture
- Close the skin with staples or suture
- Administer broad-spectrum antibiotics
- If maternal return of circulation is obtained, consider starting therapeutic hypothermia protocol
Medication
First Line
Resuscitative measures/ACLS medications directed at mother:
- Treatment of underlying cause
- Consider uterotonics after delivery to control hemorrhage
Second Line
Neonatal resuscitation should be anticipated:
Disposition
Admission Criteria
- The infant should be admitted to NICU
- If maternal resuscitation is successful, patient should be admitted to appropriate ICU
Discharge Criteria
Neither infant nor mother should be discharged from ED
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The authors gratefully acknowledge Jonathan B. Walker for his contribution to the previous edition of this chapter.