Resuscitation AlgorithmsProcedure Guide

Resuscitative Hysterotomy

Rapid procedure walkthrough focused on maternal arrest decision points and emergency operative steps.

Query: How to perform resuscitative hysterotomy

Summary

Resuscitative hysterotomy is performed during maternal cardiac arrest (in patients ≥20–24 weeks gestation) when ROSC is not achieved within 4 minutes. The goal is to relieve aortocaval compression, improve venous return, and enhance the efficacy of CPR while also rescuing the fetus ^1^2.

Indications
  • Maternal cardiac arrest without ROSC within 4 minutes in a gravid patient (≥20–24 weeks)
  • Evidence of aortocaval compression (uterine fundus at or above the umbilicus)
  • Arrest in settings where prolonged resuscitation is unlikely to improve maternal outcomes without decompression
Contraindications
  • ROSC achieved within 4 minutes of arrest
  • Gestational age clearly <24 weeks (using fundal height)
Complications
  • Post-procedural hemorrhage and potential uterine atony
  • Injury to the bladder or adjacent structures
  • Fetal trauma during extraction

Equipment

  • Essential: Large scalpel (e.g., 10-blade), blunt scissors (Mayo or bandage scissors), cord clamps/hemostats, retractors, sponges/towels, suction
  • Optional: Surgical gown and additional sterile drapes, skin stapler

Positioning and Landmarks

  • Position: Supine on the ED stretcher with ongoing CPR and manual left uterine displacement (LUD)
  • Landmarks/US: Identify the uterine fundus at the level of the umbilicus (≥20 weeks), and use the linea nigra as a midline guide for the vertical incision from the pubic symphysis to the uterine fundus

Analgesia/Sedation

OptionWhenKey note
Not applicableAs procedure occurs during cardiac arrestFocus remains on lifesaving decompression and resuscitation ^5

Steps

  1. Continue CPR: Maintain high-quality CPR with manual LUD; assign a team member to perform consistent displacement.
  2. Prepare the Field: Quickly expose the abdomen at the bedside; if possible, perform rapid skin prep (but do not delay the incision).
  3. Abdominal Incision: Using the large scalpel, make a midline vertical incision from the pubic symphysis upward toward the uterine fundus along the linea nigra.
  4. Enter the Peritoneum: Dissect through subcutaneous tissue, fascia, and peritoneum; reflect the bladder inferiorly.
  5. Uterine Incision: With the scalpel, create a small (2–5 cm) vertical incision in the lower uterine segment until amniotic fluid gushes out.
  6. Uterine Extension: Insert your non-dominant finger between the fetus and the anterior uterine wall to protect the fetus, then use blunt scissors to extend the incision vertically toward the fundus.
  7. Delivery: Gently extract the fetus, clamp the umbilical cord twice, cut between clamps, and pass the neonate to the neonatal team.
  8. Placenta and Packing: Deliver the placenta with gentle traction; pack the uterine cavity with sponges to minimize bleeding.
  9. Continue Resuscitation: Resume and maintain maternal CPR; further definitive surgical repair can be deferred to obstetric/surgical teams once ROSC is achieved.

Post-procedure

  • Confirm: Monitor for improved maternal hemodynamics and verify that decompression is effective.
  • Aftercare: Pack the abdomen, control any post-ROSC hemorrhage with uterotonic agents (caution with oxytocin given potential hypotension), and transfer for definitive surgical management.
  • Re-check: Continuous reassessment of maternal circulation and surgical site to monitor for bleeding

^1 ^2 ^3 ^4 ^5

References