Resuscitative Hysterotomy: Sara Gray
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Resuscitative hysterotomy is an emergency cesarean section performed to relieve aorto-caval compression and improve the chances of resuscitating a baby in distress, by reducing maternal oxygen demand, improving pulmonary mechanics, and potentially reviving up to 50% of otherwise non-viable babies. The procedure involves making a small incision in the uterus and delivering the baby and placenta while ongoing resuscitation efforts are performed, and should be done as soon as possible upon determining the need, within 16 minutes of deciding to perform the procedure. Preparation and mental readiness are important to successfully perform this emergency procedure.
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Resuscitative Hysterotomy: Sara Gray
- 8. Code OB Neonatal MD Neonatal RN x 2 Baby gear OB MD x 2 RT x 2 Airway gear
- 9. Code OB Neonatal MD Neonatal RN x 2 Baby gear OB MD x 2 RT x 2 Airway gear
- 14. “Won’t this hurt Mom?”
- 15. Resuscitative hysterotomy gives Mom a chance
- 17. 32% 50%
- 18. “But isn’t it too late?”
- 20. TOTAL MYTH
- 21. ? minutes
- 22. 16 minutes
- 28. Cut skin, fundus to symphysis Small opening of uterus Extend uterine incision Deliver baby then placenta With ongoing ACLS
- 33. Cut skin, fundus to symphysis Small opening of uterus Extend uterine incision Deliver baby then placenta With ongoing ACLS Resuscitative Hysterotomy
- 34. You can do this.
- 38. 42 seconds
- 42. Call a Code OB Choose a room with 2 beds RH helps Mom Prep for RH before Mom arrives Do it ASAP Scalpel, scissors, clamps Mentally prepare right now You can do this Resuscitative Hysterotomy
Editor's Notes
- I’m at work one summer evening in my hospital, which is a big downtown trauma centre. And I’m working in the Emerg, in the resuscitation area. It’s a normal busy shift at around 6pm. I have no premonition that things are about to rapidly deteriorate.
- And out there in my city, it is HOT. Like 35d Celsius. In Canada! As in, too hot for most Canadians to really tolerate. And somewhere out there a woman calls 911, because she feels like she can’t breathe. And of course, she tells them WALK
- that she is 8 months pregnant. This, people, is time 0. I don’t know it yet, but out there somewhere the clock has just started ticking…
- EMS arrives 5 minutes later, and she has deteriorated since she made the call. LOUDER. They find her collapsed in her doorway, alone and naked. I don’t know why she’s naked. She just is. Work with me. SMILE. And she is in PEA. A non-shockable rhythm. They start driving and resuscitating at the same time. CPR is ongoing, but they are unable to get a line. They are also unable to get an airway, and she vomits several times en route. WALK
- So it’s right about now that I get the phone call. We are about 8 minutes into this lady’s care. And I get a call from EMS, about a pregnant lady, who is VSA, and two minutes from my doorstep. WALK. So this is the moment where you should start picturing what YOU would do. Use this 20 minutes for your personal mental preparation. For who you would call. For how you would prepare. What would you do first?
- Ok to pause here. Step one, I believe, is to take a deep breath. Step two is use all that oxygen you just sucked in to call for help. SMILE Preferably lots of help. Who has a Code OB at their place? Or a maternal cardiac arrest code?
- Having this type of code is a game-changer. WALK At my place, when I call a code OB, I get…
- A neonataologist, 2 neonatal nurses, 2 obstetricians, 2 Resp Ther’s and most of the gear I need. One phone call, most of my gear and all my people. If you do not have this, email your chief right now to get this organized. This is pearl # 1 for this talk. Having a Code OB is life-saving – this is saving the patients life, the babies life and your butt.
- Next step: choose a resuscitation room Do you have a mental image of one? Can you picture it? Yes? Excellent. OK, how many of you chose a space with two beds? WALK
- Two beds. Cause chances are, you’re going to need a bed for the baby. So the second pearl is choose a BIG space. Seriously big. With 2 beds. Because by the end of this case, I will tell you, there were 35 people in this room. And in case you weren’t stressed enough, most of them will be watching you. Be prepared for this fact, AND be ready to kick them all out if they are shaking your focus. Because this is a case where a little concentration might just come in handy. SMILE
- 11 minutes after her 911 call, she arrives at my ED. She is in PEA. My team starts ACLS. And what is my brain doing? My brain is screaming at me: PMC, PMC, holy crap, PMC (big arms) I will tell you that the single hardest part of this, happens right there, when you’re MAKING THE DECISION TO DO IT And that’s why we need to talk about these cases, so you can prepare make that decision RIGHT here and now, so you can skip this whole hesitation.
- Given the timing here, you can certainly argue that we should have done C section as soon as she hit the doors. I will tell you, that I was not mentally ready for this. Furthermore, the timing weren’t entirely clear at first, and I needed a couple minutes to process. You should put in your processsing time right now, so that ideally, if 11 minutes have elapsed, you start this procedure in the first minute of your resus. WALK I am lucky to work in a big centre, so I have my OB colleague standing there, looking as terrified as I feel, and I say, let’s do this, perimortem c-section, and she says:
- won’t this just hurt the Mom? This is real life people, it is always stranger than fiction. The answer to this question is: this is mom’s best shot.
- This is why we don’t call it PMC any more, we call is resus hysterotomy, because this procedure gives mom a shot at survival,
- by relieving her aorto-caval compression, by optimizing her pulmonary mechanics, by reducing her oxygen demand. In fact, when we look at recent outcome data
- Which is a series of over 70 cases, published in 2012 in Resus, the data shows that doing RH provides a maternal survival benefit of over 30%, and a neonatal survival benefit of 50% Those are big numbers, for cardiac arrest cases. Big survival benefit There were no cases where RH worsened maternal outcome. Think about it, Mom has no pulse right now, they are both dead, we have no where to go but up here. WALK (Survival data Parry R, et al EMJ 2016:33; 224-229)
- So then someone says, but isn’t it too late? PAUSE Is it? Is it too late? Have you heard of the four-minute rule?
- The four-minute rule is decide by 4 minutes, to deliver by 5. And by this stage, we are roughly 18 minutes since this lady dropped. So should we do it or not? Hands up, if you do it…. Hands up! Woo! There are an awful lot of people on the fence in this room… Let’s fact check this. What does the evidence tell us?
- The evidence tells us that this rule is crap, people. It got into the ACLS guidelines for years, based on case report data from c-sections in the 1960’s and 70’s. Hey, and that was the best data available in the 80’s. But this is a new millennium now. We know now that there are maternal survivors reported out to 15 minutes, and fetal survivors out to 30 minutes
- In fact, when we look at recent data, what would you guess, is the mean time to delivery?? How long does RH take in real cases?
- Mean time to delivery was 16 minutes. And this is data from the cases that people are willing to publish! SMiLE So presumably there are also a bunch of worse times out there. So let’s not memorize the four minute rule. You can brain dump that bit of obsolete data. Let’s memorize “as soon as possible”, Let’s memorize that we do this emergently. Memorize “right now”
- So you want to do this as fast as possible, speed matters here. And earlier is clearly better than later. But sometimes your patient doesn’t even arrive for 10 minutes, and that doesn’t mean it’s too late. WALK OK, so we choose to go ahead. What gear do you need?
- Hum, scratch head. Do you use a lot of C-section trays in your ED? My mistake here was asking someone to go get the C-section tray. I never saw that guy again… by the time he found the tray, the resus was over. And, as a general rule, this is not a good time to ask for a tray you’ve never opened before. {And let’s get real, I don’t even know what half of that stuff is for…}
- So just use your thoracotomy tray. It has all the same gear in it. Open your tray and grab this stuff.
- Open the thoracotomy tray and pick out a scalpel, scissors and a couple kellys for the cord. That’s all you really need. Keep your life simple here. Because, let me remind you, that in the background, there is still a code going on. We are doing CPR, we are still trying and in fact failing to get an airway. Which is a whole other talk.
- We are doing lateral uterine displacement. We all need to remember that there are modifications to ACLS for maternal cardiac arrests. No more tilting the bed, right? That’s out of the 2015 AHA guidelines. Just lateral uterine displacement. Which allows the patient to remain supine for effective CPR, but lifts the uterus over and off the aorta and the cava. And so at this stage, we have our gear and we start the C-section with the classic vertical incision.
- This procedure is actually technically very easy. The harder part is making the decision. Really there are 4 basic steps, a vertical skin incision from the top of the fundus to the symphysis pubis Use your scalpel to open the uterus, extend that with your scissors, grab the baby. Hearing words alone is not good enough, let’s look at some pictures of this Let me show you pictures of this, from the marvelous Roberts and Hedges
- This is your vertical incision, with your #10 scalpel. Take a deep breath while you do this, so your hands don’t shake so much If you have retractors, great, if not, the person who was just doing uterine displacement can manually retract for you You are going through skin and peritoneum.
- Make sure you identify the uterus, which is cephalad to the bladder. Don’t open the bladder instead, there’s no baby in there, SMILE AND this is considered a rookie mistake Uterus is cephalad to bladder
- Small nick to open the uterus, don’t cut the baby, not deep, don’t stab the baby Use your blunt-edged scissors to extend the uterine incision, while using your other hand to protect the fetus inside.
- Baby is delivered, usually with some external pressure from above Once baby out, clamp cord with your Kelly’s And pass the baby off to neonatal team Deliver placenta, then do a quick uterine massage to encourage uterine contractions.
- Right? Should we review that? This is probably technically easier than a thoracotomy. Probably easier than a surgical airway. The steps aren’t complicated, but the fear factor is very high. And it’s probably exacerbated by the fact that we don’t think about this often, much less practice it often. So this is the moment to overcome that fear. To recognize that you could do these steps if you had to. This is why mental preparation for this is so critical.
- Rob Bryant, who practices in the US, kindly gave me his permission to show you this marvelous video of RH He is demonstrating the technique on live person, who has a simulated pregnancy Watch this.
- Resuscitative hysterotomy by Rob Bryant 2015
- It’s not that hard. Can you picture it? I want to show you a higher fidelity simulation, where they do this procedure quite rapidly. But what I want here, is for you to be picturing yourself doing this. What room are you in? Which side of the bed are you on? What are you holding in your hands?
- Vertical C section video - simulated
- That takes them 42 seconds, so amazing. It too Rob Bryant a little longer he clocked in at 73 seconds But this is a quick procedure. You can do this fast. Have you got the steps fixed in your mind? Let’s go back to the story…
- So in my case, we did the section, and subsequently the mom’s resuscitation was continued, but was ultimately unsuccessful, and she was pronounced.
- The baby was delivered after roughly 22 minutes mark, and handed off to the neonatal team. She had 1 minute of CPR for bradycardia and was intubated for apnea. She was transported to the ICU in a nearby hospital, and eventually was discharged home.
- We are now a few years out from this case, and she is followed by the paeds clinic at my shop, and she is a healthy thriving neurologically intact little girl. SMILE
- So learning these steps can be worth it. Let’s do a final review: Prep for RH before Mom arrives, so you can do it ASAP And if you use your time TODAY for mental preparation, you will be much further ahead when this case rolls through your doors. You can do this. SMILE
- And with that I’d like to thank you for your attention.