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Cesarean Section, Emergency, Emergency Medicine

Basics

- High-flow oxygen - Cardiac and BP monitoring - 2 large-bore peripheral IV lines: - Fluid resuscitation - O-negative blood if indicated

- Ensure a Foley catheter has been inserted to decompress bladder, but do not delay procedure - Perform cesarean section: - Use linea nigra as landmark 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 occasionally spontaneous circulation may return - Continue maternal resuscitation as appropriate - Suture uterus with running lock stitch using no. 0 polyglactin suture - Suture fascia and peritoneum with running stitch using no. 0 polyglactin suture - Close the skin with staples or suture - Administer broad-spectrum antibiotics

  • The sole indication for ED physician to perform emergency perimortem cesarean section is a gravid female (>24 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 arrestGoal 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
  • Do not perform emergent cesarean section if patient is <24 wk gestation

Etiology

  • Trauma (penetrating or blunt):Major cause of maternal mortality
  • Pulmonary embolus:Thromboembolism is most common cause of nontraumatic maternal mortality
  • Cerebral vascular accident
  • Amniotic fluid embolism
  • DIC
  • Placenta previa
  • Eclampsia
  • Miscellaneous medical disorders:

Diagnosis

Signs and Symptoms

History

Gravid female (>24 wk gestation determined by uterine fundal height) who is in cardiopulmonary arrest пїЅ

Physical Exam

Patient is determined to be >24 wk gestation if uterus is at least 4 finger breadths above umbilicus пїЅ

Essential Workup

  • Physical exam for apnea and pulselessness in obviously gravid female:Quickly evaluate for reversible causes of cardiopulmonary arrest:HypoxiaHypovolemiaHydrogen ion (acidosis)Hypokalemia/hyperkalemiaHypoglycemiaHypothermiaTraumaThromboembolismToxins/poisonsTension pneumothoraxTamponade (pericardial)Supine hypotension syndrome (compression of inferior vena cava by enlarged uterus)
  • Assess gestational age by uterine fundal heightDistance from pubis to fundus in centimeters is roughly equivalent to gestational age in weeks, i.e., 24 cm = 24 wk
  • US is beneficial if immediately available to assess fetus.

Diagnosis 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: пїЅ

  • Evaluate for underlying cause

Treatment

Pre-Hospital

Cautions: пїЅ

  • Minimal scene time, "scoop and run"пїЅ
  • Place the patient in the left lateral decubitus position to avoid compression of inferior vena cava (supine hypotension syndrome)
  • Trauma patient requiring spinal immobilization:Uterus can be manually displaced to leftBackboard can be wedged to keep right hip elevated 45 пїЅ

Initial Stabilization/Therapy

  • Standard resuscitation measures:Emergency intubationUse a smaller endotracheal tube (0.5-1 mm less in internal diameter compared to that used for nonpregnant women)High-flow oxygenCardiac and BP monitoring2 large-bore peripheral IV lines:Fluid resuscitationO-negative blood if indicated
  • Fetal survival correlates with maternal survival and adequacy of initial maternal resuscitation
  • If patient is at <24 wk gestation, use advanced cardiac life support (ACLS) and advanced trauma life support protocols directed at maternal resuscitationDo not perform emergent cesarean section
  • If patient is >24 wk gestation, use 4-min rule:Perform ACLS or advanced trauma life support for 4 minIf no response, proceed to immediate emergency cesarean sectionGoal is to deliver fetus within 1 minIf it is obvious there is no chance for maternal survival, begin perimortem cesarean section immediately

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 landmark for vertical midline incisionIncise abdominal wall from pubic hairline to 5 cm above umbilicus.This incision should pass through fascial and peritoneal layersRetract urinary bladder inferiorly against pubic symphysisMake small vertical incision in lower uterine segment, just cephalad to urinary bladderExtend incision cephalad with scissors:Insert your free hand into uterusLift uterine wall away from fetus to avoid fetal injuryDeliver fetusClamp umbilical cord in 2 places and cut between the 2 clampsManually deliver placentaPerform neonatal resuscitation, as indicatedImmediately reassess maternal vital signs because occasionally spontaneous circulation may returnContinue maternal resuscitation as appropriateSuture uterus with running lock stitch using no. 0 polyglactin sutureSuture fascia and peritoneum with running stitch using no. 0 polyglactin sutureClose the skin with staples or sutureAdminister 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: пїЅ

  • Treatment of underlying cause

Second Line

Neonatal resuscitation should be anticipated: пїЅ

Follow-Up

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 пїЅ

Pearls and Pitfalls

  • Only females >24 wk pregnant in cardiopulmonary arrest qualify for the procedure.
  • Decision to perform perimortem cesarean section must be made quickly (within 4 min of maternal cardiopulmonary arrest)
  • Procedure must be done quickly (<1 min).

Additional Reading

  • Atta пїЅE, Gardner пїЅM. Cardiopulmonary Resuscitation in Pregnancy. Obstet Gynecol Clin North Am. 2007;34(3):585-597.
  • Brown пїЅHL. Trauma in pregnancy. Obstet Gynecol. 2009;114:147-160.
  • Capobianco пїЅG, Balata пїЅA, Mannazzu пїЅMC, et al. Perimortem cesarean delivery 30 minutes after a laboring patient jumped from a fourth floor window: Baby survives and is normal at age 4. Am J Obstet Gynecol. 2008;198(1):e15-e16.
  • Cusick пїЅSS, Tibbles пїЅCD. Trauma in pregnancy. Emerg Med Clin North Am. 2007;25:861-872.
  • Dijkman пїЅA, Huisman пїЅCM, Smit пїЅM, et al. Cardiac arrest in pregnancy: Increasing use of perimortem cesarean section due to emergency skills training? BJOG. 2010;117:282-287.
  • Hill пїЅCC, Pickinpaugh пїЅJ. Trauma and surgical emergencies in the obstetric patient. Surg Clin North Am. 2008;88:421-440.
  • Katz пїЅV, Balderston пїЅK, DeFreest пїЅM. Perimortem cesarean delivery: Were our assumptions correct? Am J Obstet Gynecol. 2005;192:1916-1920.
  • Kue пїЅR, Coyle пїЅC, Vaughan пїЅE, et al. Perimortem Cesarean section in the helicopter EMS setting: A case report. Air Med J. 2008;27:46-47.
  • Lipman пїЅS, Daniels пїЅK, Cohen пїЅSE, et al. Labor room setting compared with the operating room for simulated perimortem cesarean delivery: A randomized controlled trial. Obstet Gynecol. 2011;118:1090-1094.
  • Muench пїЅMV, Canterino пїЅJC. Trauma in pregnancy. Obstet Gynecol Clin North Am. 2007;34:555-583.
  • Roberts пїЅJR, Hedges пїЅJR, Chanmugan пїЅAS, eds. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, PA: Saunders; 2004.
  • Suresh пїЅMS, LaToya пїЅMC, Munnur пїЅU. Cardiopulmonary resuscitation and the parturient. Best Pract Res Clin Obstet Gynaecol. 2010;24:383-400.

Codes

ICD9

  • 427.5 Cardiac arrest
  • 659.83 Other specified indications for care or intervention related to labor and delivery, antepartum condition or complication

ICD10

  • I46.9 Cardiac arrest, cause unspecified
  • O99.419 Diseases of the circ sys comp pregnancy, unsp trimester

SNOMED

  • 274130007 Emergency cesarian section (procedure)
  • 198609003 complications of pregnancy, childbirth and the puerperium (disorder)
  • 410429000 cardiac arrest (disorder)