Medical Minute: Perimortem C-Section

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July 8, 2014 by dailybolusoflr

Medical Minute: Perimortem C-Section by ErikVerzemnieks, MD
Perimortem cesarean represents one of the most infrequent procedures performed by the emergency physician.  However, it is important to know the utility in specific circumstances.
Maternal resuscitation:
            – Displace uterus to promote venous return (push it to save time rather than rolling)
            – Allocate resources to take/resuscitate fetus once delivered
Equipment
            – Clamps
            – Scissors
            – Retractors
            – Scalpel
            Use a thoracotomy tray as it is typically stocked and readily accessible.
Method:
Slow is smooth and smooth is fast.
Getting into the abdomen:
Long, straight, vertical midline incision from the subxyphoid to pubis. Do not worry about going through the umbilicus.

Two methods exist:
            1. Pfannensteil transverse lower abdominal incison through skin. Division of rectus sheath and peritoneum vertically.  (Yeah Right!)
            2. Vertical midline incision pubis to umbilicus. Down to peritoneum. Clip open peritoneum, scissors to extend vertically as needed.
Getting into the uterus:
Vertical incision. Once entered, can use scissors to extend. Cut through the placenta if it is there.  Larger the incision the easier next step will be.
Try not to but do not worry about cutting the fetus. This happens not uncommonly in elective cesareans. No big deal.
Get the baby out:
  • Place hand into uterus
  • Find the head
  • Grad the head
  • Deliver head
  • Body should follow
  • Clamp, cut cord and pass child to resus team
  • Cover abdomen with surgical towels
  • Surgery/OB for closure: depending on extent, may be prudent to have general surgery/trauma close abdomen, particularly if you think bowel perforation may have occurred.

Don’t forget about the mother!
Determining Viability
Little history may be available.  Emergent cesarean will be futile if the fetus is non-viable.  Clinical exam may be limited. 
Exam:
Uterus palpated to umbilicus estimates at 20 weeks. Near viability and quick way to estimate.
Limit of viability is approximately 23.5 weeks.  Can use ultrasound to quickly determine viability:
            Biparimetal distance (BPD) = 50 mm
            Femur length (FL) = 35 mm
            These can be easily used without having to be in OB mode
The greatest barrier to doing the procedure is FEAR. It is truly one of the most beneficial interventions you can make for the health of the mother, let alone the child.
2012 review in Resuscitation found that from pooled case series data very few perimortem cesarean deliveries met < 4 minute guideline often proposed, though more than 50% of cases had neonatal survival.  Advocate for consideration PMCD within 10 minutes and even up to 15 minutes after arrest.
Considerations for PMCD Based on Gestational Age
GA < 20 weeks
GA 20 – 24 weeks
GA > 24 weeks
Aortalcaval return
Unlikely to compromise
Likely to compromise
Likely to compromise
Fetus
Non viable fetus
Non viable fetus
Viable fetus
Do PMCD?
Should not be considered
Strongly considered
Strongly considered
For who?
N/A
Life of mother
Life of mother and fetus
References:
Einav S et al. Maternal cardiac arrest and perimortem caesarean delivery: Evidence or
expert-based? Resuscitation. 2012.83:1191-1200.

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