perimortem caesarean section for the non- obstetrician - 12.15... · 2017-04-20 · section for the...
TRANSCRIPT
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Perimortem Caesarean section for the non-
obstetrician Dr. Jules Blackham
Consultant Emergency Physician, North Bristol NHS Trust
HEMS Doctor, Great Western Air Ambulance.
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Incidence
• 1: 30,000 pregnancies
• Normally young ’healthy’ adults
• 241 women during pregnancy or within 42 of end of pregnancy
• 41 coincidental• 200 maternal deaths
• 135 gave birth to 141 infants
• 253 other children left without mothers
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Maternal Mortality 2012-14
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Questions - 5 Ws (and 1 H)
•Who?
•What?
•When?
•Where?
•Why?
•How
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Who?
• IF >20 weeks (above level of umbilicus)• foetus potentially viable >24
weeks• 20-24 weeks foetus IVC
compression
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WHAT – Good resuscitation?
• Get help
• Airway management and ventilation
• CPR
• ALS cycles, drugs, IV access, monitoring
• Uterine displacement…
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Jeejeebhoy FM, Zelop CM, Lipman S, Carvalho B, Joglar J, Mhyre JM, et al. Cardiac Arrest in Pregnancy. A Scientific Statement From the American Heart Association. 2015.
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Pull rather than push
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WHAT – Good resuscitation?
• Get help!
• Airway management and ventilation
• CPR
• ALS cycles, drugs, IV access, monitoring
• Uterine displacement…
• Perimortem c-section..
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WHEN?
• Aim to deliver foetus within 5 mins of cardiac arrest• Postulated 1986
• Based on 4-6 minutes before brain damage occurs following anoxic arrest
• In some cases immediate delivery appropriate• injuries to mother unsurvivable• In cardiac arrest on arrival in dept
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Resuscitation 2012. 83(10): 1191
• 94 cases from extensive literature search
• Mean gestation 33/40 (median 35, 10-42)
• ROSC - 60%
• Mean time to delivery 16 mins (range 1-60)
• 4/94 cases delivery was in less than 4 minutes
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Maternal Survival
• 51/94 (54.3%)
• 40/51 *CPC 1 or 2
• Timing relates to outcome (p<0.001)
• Survivors: 10 minutes (1-37) (median 9)
• Deaths: 23 minutes (4-60) (median 20)
*CPC – Cerebral Performance Category
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Fetal Survival
• 42/66 (63.6%)
• Timing relates to outcome (p=0.016)
• Survivors: 14 minutes (1-47) (median 10)
• Deaths: 22 minutes (4-60) (median 20)
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‘It’s Contraindicated more than 5 minutes since cardiac arrest’ is
EXPIRED ADVICE
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WHERE?
• WHERE THE PATIENT COLLAPSES
• The woman should not be transported to an operating room for PMCD during the management of an in-hospital maternal cardiac arrest (Class IIa; Level of Evidence B).
• Specialist equipment not needed, can start with just a scalpel.
Jeejeebhoy FM, Zelop CM, Lipman S, Carvalho B, Joglar J, Mhyre JM, et al. Cardiac Arrest in Pregnancy. A Scientific Statement From the American Heart Association. 2015.
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Why Do It?
• Recruitment of utero-placental blood flow accounting for 30% of cardiac output
• More effective CPR
• Relief of IVC obstruction
• 30-80% improvement in cardiac output
• Improved maternal and fetal survival
• Small print: if resuscitation fails it gives the family the opportunity to hold the baby prior to burial/cremation
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Why Might You Not Do It?
• I haven’t done one before
• I’m not a surgeon/obstetrician
• I don’t have the right equipment
• It might be futile
• It’s brutal for the family to witness
• There’s no good reason!
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How to Do It
• Vertical midline incision with a scalpel
• Top of curve to pubic symphysis
• Down to peritoneum
• Make hole in peritoneum with fingers just below umbilicus, extend with scissors to symphysis
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Once through the peritoneum
• Expose the uterus; you can pull it out
• Vertical or LSCS incision on lower uterus with the scalpel
• Cutting the baby is not uncommon in obstetric practice. Don’t let fear of this put you off
• Suction++
• Complete with scissors
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Delivery
• Fundal pressure to extract the baby; pull it out
• Clamp and cut cord
• Hand over the baby to a colleague to resuscitate
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Third stage• Deliver placenta
• Uterus• Squash placenta between hands.
• Can pack with swabs
• Haemostatics?
• Drugs• TXA - Yes
• Oxytocin – Cardiac arrhythmias and hypotension
• Ergometerinehypertension
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In Summary
• Rapid decision required – if you’re not sure just do it
• You only need a scalpel and scissors
• Continue resuscitation throughout
• Simulate it.
• And Finally…• Look after yourself and your team
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Any Questions