• As the name implies, this is a resuscitative maneuver to perform during maternal cardiac arrest for pregnant women >20 weeks gestation (fundus above umbilicus).
• The physiologic goals are to
  • Relieve aortal-caval pressure to restore preload,
  • Improve pulmonary mechanics through improved diaphragm excursion, and
  • Reduce maternal oxygen demand with blood supply no longer directed towards the fetus and placenta.
• With these goals in mind, this procedure is not indicated when fetal size is unlikely to have any mass effects on maternal vasculature, such as in 1st trimester pregnancies.
• When performed early and rapidly, this procedure significantly improves both maternal and fetal chance of survival after cardiac arrest. Initiating this after 4 minutes of traditional resuscitation measures is preferred; however, starting beyond 4 minutes is not considered futile as there have been documented cases of maternal and fetal survival at 15- and 30-minutes post-arrest respectively.

Mental anticipation for this maneuver as the end-point for the arrested pregnant patient is essential given the extreme rarity of this presentation. The procedure itself is relatively straightforward. However, the decision to perform this maneuver involves the following commonly cited challenges: 

Which patients may benefit from this procedure?

• Pregnant patients in cardiac arrest that have not rapidly responded to initial resuscitative measures. Specifically, pregnant patients in whom the fetus is compressing vasculature and utilizing significant oxygen – determined when fundal height is above the level of the umbilicus (typically >20 weeks gestation). This is a maternal resuscitation procedure, with fetal survival as a secondary effect if possible.

Will I cause harm through performing this procedure?

• In cardiac arrest, both maternal, and subsequent fetal death, are the anticipated and most common outcomes. From that starting point, there is only room to improve with corrective resuscitation measures.

When in the resuscitation should I initiate this procedure?

• Timing to initiate the resuscitative hysterotomy should be performed early but after initial resuscitation measures have been taken to reverse potential causes. Since CPR is much less effective with a gravid patient, time to procedure initiation should be at 4 minutes post-arrest given subsequent cerebral ischemia.

How long post-arrest is considered futile for initiating this procedure?

• Traditional teaching of the “4-minute rule” is not evidence-based as a cut-off point and incorrectly assumes futility in cases where the patient has been in cardiac arrest for longer. While no firm timeline may ever be determined, maternal survival has been documented at 15 minutes post-arrest and neonatal survival as late as 30 minutes post-arrest.

1. Mobilize and prepare the team available in your setting

• Resuscitation team in your setting for any critically ill patients.

Plus

• Pediatric / neonatal support
  • Pediatrician / neonatologist (or second ERP if unavailable)
  • Pediatric RNs x 2
• Obstetrics & Gynecology support
  • Obstetrician (or surgical support if unavailable)

2. Prepare or gather your equipment

(beyond typical resuscitation equipment)

Essential

• Designated “Resuscitative Hysterotomy” tray with the following:
  • #10 Scalpel
  • Heavy scissors
  • 2 x Kelly clamps (umbilical clamps)

If Time Permits

• Neonatal warmer
• Neonatal advanced airway and resuscitation equipment
• Heavy sutures

3. Perform the procedure

• Don appropriate PPE
• Rapidly apply skin antiseptic (optional)

Entry into uterus

• Make a vertical skin incision from xiphoid to pubic symphysis
  • Multiple incisions will be necessary
  • Incise down to peritoneum, aiding separation of layers with gloved hands and create a wide field to expose the uterus
• Noting bladder inferiorly, make a small scalpel entry incision into the midline inferior margin of the uterus
• Extend the incision vertically up the entire uterus, with gloved hand underneath shears to protect the fetus as you progress upwards

Deliver baby and placenta

• Deliver baby, using fundal pressure to assist
• Apply two Kelly clamps for the umbilical cord, and cut between clamps
  • Neonate to pediatric team
• Deliver the placenta

Damage control

• Pack uterus and control any major bleeding with additional clamps
• Heavy suture closure of uterus, soft tissues, and skin in anticipation of surgical management if no surgical help immediately available
• Continue maternal and neonatal resuscitation

• Per AHA recommendations, maternal cardiac arrest should be transported to a hospital setting capable of performing resuscitative hysterotomy – even in the absence of in-house pediatric and obstetric resources.
• If higher levels of care are available regionally (eg. neonatal ICU), delays to that center should be no greater than 10 minutes if both are capable of resuscitative hysterotomy.

All of these critically ill patients will require surgical, intensive care, and neonatal intensive care if there is maternal and neonatal survival.

1. “How to do this on hi-fidelity mannequin”. Live Resuscitative Hysterotomy. By Dr. Sara Gray. Essentials of EMCrit 2018

   
   

2. “Why and how we do this”. Resuscitative Hysterotomy 101. Social Media And Critical Care (SMACC)

   
   

3. “Real Case and Challenges”. BCE 82 Perimortem C-section – The Resuscitative Hysterotomy. Emergency Medicine Cases Podcast.

   
   

1. Parry R, Asmussen T, Smith JE. Perimortem caesarean section. Emerg Med J. 2016 Mar;33(3):224-9. doi: 10.1136/emermed-2014-204466. Epub 2015 Feb 24. PMID: 25714106.

   
   

2. Jeejeebhoy FM, Zelop CM, Lipman S, et al; American Heart Association Emergency Cardiovascular Care Committee, Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Cardiovascular Diseases in the Young, and Council on Clinical Cardiology. Cardiac Arrest in Pregnancy: A Scientific Statement From the American Heart Association. Circulation. 2015 Nov 3;132(18):1747-73. doi: 10.1161/CIR.0000000000000300. Epub 2015 Oct 6. PMID: 26443610.

   
   

3. Benson MD, Padovano A, Bourjeily G, Zhou Y. Maternal collapse: Challenging the four-minute rule. EBioMedicine. 2016 Apr;6:253-257. doi: 10.1016/j.ebiom.2016.02.042. Epub 2016 Mar 2. PMID: 27211568; PMCID: PMC4856753.