Challenges in Resuscitative Hysterotomy

Educational Objectives

The goal of this program is to improve outcomes of cardiac arrest during pregnancy. After hearing and assimilating this program, the clinician will be better able to:

1. Provide appropriate resuscitative measures for pregnant women with cardiac arrest.
2. Make a timely decision to proceed with emergency hysterotomy.

Summary

Resuscitative hysterotomy (RH): crash caesarean delivery (CD) is performed when the baby is in distress, but the mother is stable; RH or perimortem CD, is performed when the mother is in cardiac arrest and the baby's life is at risk

Management of cardiac arrest in pregnant women: the initial focus should be on aggressive resuscitation efforts, including cardiopulmonary resuscitation (CPR) and intubation; the baby may be compressing the inferior vena cava (IVC) and aorta, causing decreased blood flow back to the mother’s heart; classically, pregnant women in cardiac arrest are positioned at 30 degrees to relieve pressure on the IVC; however, a more effective method is lateral uterine displacement, wherein the uterus is manually pushed to the left side of the patient; it can be performed via a 1- or 2-handed approach; simpler to achieve and allows better quality chest compressions than positioning at 30 degrees; at this point, attention can be turned to the fetus

Indications for RH: considered when the fundus of the uterus is at or above the umbilicus; this suggests a fetal age of 20 to 24 wk, a stage at which the fetus is large enough to potentially compress blood vessels; the American Heart Association supports this approach

Goals of RH: include saving the mother’s life by relieving maternal aortic compression, redirecting blood from the placenta to the mother’s circulation, and improving breathing mechanics

Timing: the ideal timeframe is ≤5 min of the mother’s cardiac arrest; this includes 2 cycles of CPR (≈4 min) and the actual procedure, to be completed ≤1 min; while this may seem unrealistic, the longer the delay, the higher the risk for fetal brain injury because of oxygen deprivation; Katz et al (1986) — demonstrated a 70% chance of fetal survival with good neurologic outcome if the procedure is performed ≤5 min of maternal cardiac arrest; Einav et al (2012) — analyzed 94 cases of RH performed between 1980 and 2010; the actual time taken for RH was ≈16 min; in 93% of the cases, the 4-min mark was not met; among the maternal survivors, the average procedure time was 10 min, and 80% had good neurologic outcomes; among the neonatal survivors, the average procedure time was 14 min, and 70% to 80% had good neurologic outcomes

Procedure: a large vertical incision is made from the xiphisternum to the pubic bone, followed by a low horizontal uterine incision to deliver the fetus; the cord is clamped and placenta is removed; the abdomen is packed with sterile towels, then stapled; uninterrupted compressions are essential to maintain blood flow to the mother’s vital organs and increase her chances of survival; the risk for cardiac arrest is highest immediately after the baby is delivered

Readings

Adan AJ, Nafday A, Beyer AB, et al. Use of Tandem Perimortem Cesarean Section and Open-Chest Cardiac Massage in the Resuscitation of Peripartum Cardiomyopathy Cardiac Arrest. Ann Emerg Med. 2019;74(6):772-774. doi:10.1016/j.annemergmed.2019.03.012; Einav S, Kaufman N, Sela HY. Maternal cardiac arrest and perimortem caesarean delivery: evidence or expert-based?. Resuscitation. 2012;83(10):1191-1200. doi:10.1016/j.resuscitation.2012.05.005; Eldridge AJ, Ford R. Perimortem caesarean deliveries. Int J Obstet Anesth. 2016;27:46-54. doi:10.1016/j.ijoa.2016.02.008; Jeejeebhoy FM, Zelop CM, Lipman S, et al. Cardiac Arrest in Pregnancy: A Scientific Statement From the American Heart Association. Circulation. 2015;132(18):1747-1773. doi:10.1161/CIR.0000000000000300; Katz VL, Dotters DJ, Droegemueller W. Perimortem cesarean delivery. Obstet Gynecol. 1986;68(4):571-576; Soskin PN, Yu J. Resuscitation of the Pregnant Patient. Emerg Med Clin North Am. 2019;37(2):351-363. doi:10.1016/j.emc.2019.01.011.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Bhandari was recorded at Emergency Medicine Update 2024, held January 16-19, 2024, in Stowe, VT, and presented by Larner College of Medicine at The University of Vermont. For information on upcoming CME activities from this presenter, please visit med.uvm.edu/cmie. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

EM420101

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.