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Procedural Skills (SLO6)
A 24 year old woman, at 30 weeks gestation, presents unresponsive with cardiopulmonary resuscitation (CPR) in progress after a high speed motor vehicle collision (MVC). On ultrasonography, the foetal heart beat is noted at a rate of 130 beats per minute. The patient lost her vital signs 3 minutes before arrival in the emergency department. What is the most appropriate next step in the management of this patient?
Answer:
In the event of maternal cardiopulmonary arrest, perimortem caesarean section is indicated:- Perimortem caesarean delivery uses a midline incision from the level of the fundus to the pubic symphysis to gain exposure to the uterus with the use of retractors.
- Blunt dissection should be performed until the peritoneum is entered.
- A vertical incision is then made from the fundus inferiorly towards the anterior bladder reflection.
- When the uterine cavity is first entered, middle and index finger should be inserted to lift the uterine wall away from the infant while the incision is extended preferably with scissors.
- The infant should then be delivered through the hysterotomy and immediately handed to someone skilled in neonatal resuscitation while the cord is clamped.
- The placenta should be removed before closure and maternal resuscitative efforts continued.
Perimortem Caesarean Delivery
Obstetrics & Gynaecology / Procedural Skills (SLO6)
Last Updated: 14th March 2021
Perimortem caesarean delivery is a consideration for women who suffer cardiac arrest in pregnancy. When initial resuscitation attempts fail, delivery of the foetus may improve the chances of successful resuscitation of both the mother and the foetus.
Pathophysiology
Delivery relieves inferior vena cava (IVC) compression and may improve the likelihood of resuscitating the mother by permitting an increase in venous return during the CPR attempt. It also enables access to the abdominal cavity so that aortic clamping or compression is possible; internal cardiac massage may also be possible.
Once the foetus has been delivered, resuscitation of the newborn can also begin. The best survival rate for infants over 24 - 25 weeks gestation occurs when delivery of the foetus is achieved within 5 mins after the mother's cardiac arrest; this a difficult time to achieve in reality but consideration of perimortem caesarean section should be made at an early stage after cardiac arrest.
Indications
First, estimated gestational age (EGA) should be determined either based on history or fundal height. In general, the uterus reaches the level of the umbilicus at 20 weeks and grows approximately 1 centimeter for every week thereafter.
In the supine position, the gravid uterus begins to compromise blood flow in the inferior vena cava (IVC) and abdominal aorta at approximately 20 weeks gestation; however foetal viability begins at approximately 24 weeks.
Therefore, at:
- Gestational age < 20 weeks
- Do not consider emergency delivery; a gravid uterus of this size is unlikely to compromise maternal cardiac output
- Gestational age 20 - 23 weeks
- Initiate emergency delivery to permit successful resuscitation of the mother only
- Gestational age > 24 weeks
- Initiate emergency delivery to help save the life of both the mother and infant
Procedure
- Perimortem caesarean delivery uses a midline incision from the level of the fundus to the pubic symphysis to gain exposure to the uterus with the use of retractors.
- Blunt dissection should be performed until the peritoneum is entered.
- A vertical incision is then made from the fundus inferiorly towards the anterior bladder reflection.
- When the uterine cavity is first entered, middle and index finger should be inserted to lift the uterine wall away from the infant while the incision is extended preferably with scissors.
- The infant should then be delivered through the hysterotomy and immediately handed to someone skilled in neonatal resuscitation while the cord is clamped.
- The placenta should be removed before closure and maternal resuscitative efforts continued.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
