Consider the need for an emergency hysterotomy or Caesarean section as soon as a pregnant woman goes into cardiac arrest. In some circumstances immediate resuscitation attempts will restore a perfusing rhythm; in early pregnancy this may enable the pregnancy to proceed to term. Three observational studies of 154 subjects collectively provide very low quality evidence regarding the use of peri-mortem Caesarean section. Based on expert opinion, when initial resuscitation attempts fail, delivery of the fetus may improve the chances of successful resuscitation of themother and fetus. One systematic review documented 38 cases of Caesareansection during CPR, with34 surviving infants and 13 maternal survivors at discharge, suggesting that Caesarean section may have improved maternal and neonatal outcomes.
The best survival rate for infants over 24–25 weeks’ gestation occurs when delivery of the infant is achieved within 5 min after the mother’s cardiac arrest. This requires that the provider commence the hysterotomy at about 4 min after cardiac arrest. At older gestational ages (30–38 weeks), infant survival is possible even when delivery was after 5 min from the onset of maternal cardiac arrest. A case series suggests increased use of Caesarean section during CPR with team training; in this series no deliveries were achieved within 5 min after starting resuscitation. Eight of the twelve women had ROSC after delivery, with two maternal and five newborn survivors. Maternal case fatality rate was 83%. Neonatal case fatality rate was 58%.
Delivery will relieve IVC compression and may improve chances of maternal resuscitation. The Caesarean delivery also enables access to the infant so that newborn resuscitation can begin.
Decision-making for emergency hysterotomy (Caesarean section).
The gravid uterus reaches a size that will begin to compromise aorto-caval blood flow at approximately 20 weeks gestation; however, fetal viability begins at approximately 24–25 weeks.
Portable ultrasound is available in some emergency departments and may aid in determination of gestational age (in experienced hands) and positioning, provided its use does not delay the decision to perform emergency hysterotomy.
• At gestational age less than 20 weeks, urgent Caesarean delivery need not be considered, because a gravid uterus of this size is unlikely to significantly compromise maternal cardiac output.
• At gestational age approximately 20–23 weeks, initiate emergency hysterotomy to enable successful resuscitation of the mother, not survival of the delivered infant, which is unlikely at this gestational age.
• At gestational age approximately ≥24–25 weeks, initiate emergency hysterotomy to save the life of both the mother and the infant.
Uitwendige hartmassage bij zwangeren > 20 weken is eveneens nutteloos. Ongeacht of het traumatisch of non-traumatisch arrest is moet de baby er uit als er geen ROSC is binnen 4 minuten.
Het ambulanceteam kan de uitwendige reanimatiepoging voortzetten als de MMT-arts een perimortem sectio uitvoert, het enige wat nodig is is een mes, afhankelijk van de voorkeur van de operateur kan het handig zijn om het blaasblad van bijv. spreider vlgns Collin in de auto/helikopter te hebben.
Prehospitaal de buik openen kan via een verticale incisie (snel en simpel).
Ondanks dat veel mensen hier moeite mee zullen hebben moet je in staat zijn (mmt en ambulance) om het zeer laagdrempelig te doen. Ondanks dat het in Nederland zelden voorkomt hoor je regelmatig te trainen. Het zegt dus ook dat er een hervorming op gang moet komen in de prehospitale keten in Nederland, een einde maken aan de toetscultuur en beginnen met een oefen-/trainingscultuur.
ERC richtlijn 2015, sectie 4
http://www.cprguidelines.eu/http://circ.ahajournals.org/content/early/2015/10/06/CIR.0000000000000300.full.pdf+htmlhttps://www.youtube.com/watch?v=Y0jQt2OVQtk
