Tag Archives: Cesarean section

Trauma In Pregnancy 7: C-Section – Technique (with video)

Your preparation. You should already have full personal protective gear on, right? Right? Your existing gear is just fine. You do not need to change to sterile gown and gloves. The time wasted is probably not worth the low risk of infection in the rare event that the mother survives.

You need at least one assistant, preferably two. They will pass you instruments and provide retraction. Continue CPR throughout the procedure.

At the same time, call your OB and neonatal colleagues, if you haven’t already. If you don’t have any at your hospital, don’t sweat it. If you do, don’t wait for them to arrive.

Patient preparation. Have someone quickly insert a foley catheter.

Do not use sterile technique. It just slows things down. The bladder needs to be empty so you can quickly and easily get to the uterus.

The procedure. Here’s the blow by blow:

  • Splash some betadine on the skin. The mother is probably not going to survive, so infection is not a concern.
  • Make a midline, vertical incision from mid-epigastrium to pubis. Extend down to the midline fascia.
  • Enter the peritoneal cavity near the umbilicus. Extend the incision along the full length of the skin incision using scissors.
  • Use the scalpel to make a 4cm vertical incision near the top of the uterus. Insert your 2nd and 3rd fingers into the uterus, directed downwards. Use them to protect the fetus from the scissors as you use them to extend the uterine incision downwards.
  • Rupture the membrane with a clamp and deliver the baby. Remember, the membrane is tough! Insert your hand deep into the lower uterus under the baby’s head. Flex the body as you gently push upwards to deliver the head first. Suction the mouth and nose, then deliver the shoulders and body.
  • Cut and clamp the cord. Hand off the baby to another team for suctioning and resuscitation.
  • Continue to try to revive the mother. If circulation is restored, move immediately to an OR for delivery of the placenta, control of the bleeding that was killing her in the first place, and hopefully, closure.

Here’s a video that shows how quickly the procedure can be done (with a few edits). Just watch the first 47 seconds!

YouTube player

Trauma In Pregnancy 6: C-Section – Tools

Most emergency departments do not have a separate perimortem C-section pack sitting on the shelf. And when you finally need it, that is not the time to make one up. Most emergency departments have some type of major cutdown or mini-laparotomy tray available. Here is the absolute minimum required. Make sure these are on your existing tray.

  • Large scalpel – note that this should be a disposable type that is opened and dropped onto the tray
  • 3 large retractors for the helpers
  • Toothed forceps
  • Metzenbaum scissors
  • Heavy scissors
  • Multiple large clamps and hemostats

Yup, that’s all the heavy equipment you really need!

Trauma In Pregnancy 5: C-Section – When?

The perimortem C-section (PMCS) is a heroic procedure designed to salvage a viable fetus from a moribund mother. Interestingly, in some mothers, delivery of the fetus results in return of spontaneous circulation.

The traditional teaching is that PMCS should be started within 4-5 minutes of the mother’s circulatory arrest. The longer it is delayed, the (much) lower the likelihood that the fetus will survive.

The reality is that it takes several minutes to prepare for this procedure because it is done so infrequently in most trauma centers. Recent literature suggests the following management for pregnant patients in blunt traumatic arrest (BTA):

  • Cover the usual BTA bases, including securing the airway, obtaining access and rapidly infusing crystalloid, decompressing both sides of the chest, and assessing for an unstable pelvis
  • Assess for fetal viability. The fundus must measure at least 23 cm.
  • Assess for a shockable vs non-shockable rhythm. If shockable, do two cycles of CPR before beginning the PMCS. If non-shockable, move straight to this procedure.

Bottom line: Any time you receive a pregnant patient in blunt arrest, have someone open the C-section pack while you assess and try to improve the mother’s viability. As soon as you complete the three tasks above, start the procedure! You don’t need to wait 4 minutes!