Chapter 26 Emergency Cesarean Section: Uterine Exposure and Infant Extraction

This chapter will discuss the technique for an emergency cesarean section. The major emphasis of this lab experience will be on standard and emergency surgical technique, pelvic anatomy, and infant extraction. Additionally, the indications and techniques for perimortem cesarean delivery will also be presented. Postpartum hemorrhage as a complication of delivery will be covered in chapter 27.

Learning Objectives

By the end of the ASSET course, participants should be able to do the following:

1. Describe indications for emergency cesarean section.
2. Describe techniques and pertinent anatomy encountered during cesarean section.
3. Demonstrate the steps of an emergency cesarean section.
4. Understand the indications and technique for perimortem cesarean delivery.

General Considerations

• Potential indications for emergency cesarean delivery are not well established but may be divided into maternal and fetal indications:
  • Maternal indications include:
    • Distress
    • Failure of labor to progress
    • Abnormal placentation with accreta or percreta
    • Prolapsed umbilical cord or fetal extremities
    • Acute cardiopulmonary or traumatic arrest
    • Cardiac/pulmonary disease, cerebral aneurysm, or active herpes simplex infection (generally elective cesarean)
  • Fetal indications include:
    • Evidence of fetal distress, such as abnormal or nonreassuring fetal heart tones
    • Breech or transverse lie
    • Uterine trauma with perforation or rupture

Female Pelvic Anatomy

• Review of female pelvic anatomy with orientation of fallopian tubes, round ligament, broad ligament, ovaries, and bladder around the gravid uterus (Figure 1).

Surgical Steps

• Anesthesia is not required for patients with acute cardiopulmonary or traumatic arrest.
• Preoperative antibiotics should be given, if possible.
• Positioning should be carefully done and the patient placed supine, with a left lateral tilt of 15–30˚ to displace the uterus off of the inferior vena cava.
• The most commonly used incision is the Pfannenstiel.
• An acute care surgeon faced with the prospect of performing an emergency cesarean may find it more expeditious (and familiar) to perform a midline incision, especially when performing a perimortem procedure.
• Landmarks for the Pfannenstiel incision are the pubic symphysis and the anterior superior iliac spine, bilaterally.
• The incision should be planned two fingerbreadths above the pubic symphysis and extending bilaterally approximately 6 cm in a semicurvilinear fashion (Figure 2).
• The incision is carried through to the underlying layer of fascia with sharp dissection. The superficial epigastric vessels will be seen in the subcutaneous layer and may need to be ligated for hemostasis (Figure 3).
• The anterior rectus fascia is cleared of any remaining subcutaneous fat and is then incised in the midline prior to making lateral extensions in the fascia.
• The fascia is elevated from the underlying rectus muscle and divided bilaterally in a transverse fashion with curved Mayo scissors (Figure 4).
• The superior fascial edge is grasped with a Kocher clamp on either side of the midline, and the fascial sheath is released from the underlying rectus muscle with sharp dissection (Figure 5). This dissection is carried down to the level of the pubic symphysis.
• Any perforating blood vessels between the fascia and the rectus muscles will need to be cauterized to achieve hemostasis.
• The rectus muscles are then separated at the midline in order to identify the underlying peritoneum. The peritoneum can then be entered (Figure 6).
• The peritoneal incision should then be extended laterally to the level of the skin edge.
• If the bladder is overlying or in close proximity to the proposed uterine incision, a “bladder flap” should be performed. This is accomplished by incising the vesicouterine serosa and digitally dissecting the bladder away from the lower uterine segment.

• The transverse uterine incision (hysterotomy) should be made approximately 1 cm below the upper margin of the bladder (Figure 7) or higher, if the patient has been laboring, to avoid the cervix and vagina.
• The hysterotomy incision is made in an exaggerated U-shape to avoid extension to the uterine arteries (Figure 7).
• The incision is carried down in a single plane, layer by layer, to the level of the amniotic membranes. Suction should be used to keep the incision clear of blood.
• The surgeon should digitally palpate the incision after each pass to evaluate remaining thickness. If bleeding obscures visualization, the incision edges can be grasped with Allis clamps and elevated away from the underlying infant.
• If sufficiently thin, the muscle can be entered digitally to avoid cutting the infant.
• Once the amniotic membranes are visualized, the incision is manually extended in the cephalad and caudal directions in order to accommodate delivery (Figure 8).

• If the hysterotomy is not large enough to allow delivery, sharp extension can be done with scissors to create a J-incision (Figure 9).
• In the case of a cephalic (head towards hysterotomy wound) presentation, the surgeon’s hand should cup the infant’s head, then elevate the infant to the level of the hysterotomy, while the assistant provides pressure on the fundus (Figure 10).
• After the head is delivered, any nuchal cord (any portion of the umbilical cord that is wrapped around the infant’s neck) should be reduced. The anterior shoulder is delivered using downward traction, followed by upward traction to deliver the posterior shoulder and the rest of the infant.
• If the infant presents breech, the hips/ sacrum of the infant should be elevated to the hysterotomy and the legs delivered. Fundal pressure is used to help deliver the infant to the level of the scapula. The infant arm is delivered, and the infant is rotated 180° for delivery of the other arm. Once the arms are delivered, the head is stabilized and delivered (Figure 11).
• Following delivery of the infant, the umbilical cord should be double-clamped and then cut.
• Gentle traction should then be put on the umbilical cord to the placenta, with internal uterine massage to facilitate placental separation (Figure 12).

• After delivery of the placenta, the uterus should be exteriorized into the wound. The fundus is wrapped in a moist lap sponge, and manual uterine massage is continued.
• The contents of the uterus are cleared with a dry lap sponge wrapped around the surgeon’s hand (Figure 13).
  • In the event of significant uterine hemorrhage, the uterus should be packed and manually compressed, as discussed in chapter 27.
• Closure of the hysterotomy is done with absorbable sutures in a running locked fashion anchored at either apex (Figure 14). An additional imbricating layer can be used if needed.
• Any remaining areas of bleeding can be over sewn with figure-of-eight sutures as needed.
• The uterus is returned to the abdomen, and the rectus muscles are allowed to return to their original position. The anterior rectus fascia is closed using a running suture.

Perimortem Cesarean Delivery (PMCD) Considerations

• Perimortem cesarean delivery (PMCD), when appropriately applied, can save the life of both the mother and the infant.
• The most common indications for PMCD are traumatic or nontraumatic cardiopulmonary arrest of the mother.
• Several factors must be considered in deciding whether to undertake PMCD:
  • The estimated gestational age (EGA) of the fetus:
    • A fetus with EGA of less than 24 weeks is unlikely to survive.
    • EGA can be difficult to obtain in an emergency. Fundal height is used as a crude measure, and a fundal height of 4 cm above the umbilicus is consistent with an EGA of 24 weeks.
  • The time from maternal arrest:
    • To increase the likelihood of infant survival, the procedure should be performed as soon after maternal arrest as possible.
    • Best outcomes are achieved if PMCD is initiated within four minutes of maternal arrest when resuscitative measures have failed.
    • PMCD should be attempted even in the face of prolonged maternal downtime if circumstances suggest that the fetus is potentially viable.
• When previous maternal resuscitative efforts have failed, cesarean delivery is beneficial to both the infant and the mother. Emptying the uterus improves maternal physiology and the effectiveness of cardiopulmonary resuscitation.

Perimortem Cesarean Delivery (PMCD) Technique

• PMCD should be performed by the available physician with the most surgical experience.
• If possible, a neonatologist should also be in attendance.
• The mother should be supine with a left lateral tilt.
• Prepping and draping are not necessary and should not delay the procedure.
• Maternal resuscitation efforts should not be interrupted and should continue while PMCD is being done.
• A vertical midline incision is indicated, as this will allow evaluation and control of any other traumatic intra-abdominal injuries the mother may have sustained.
• Also unlike in an elective cesarean section, in PMCD the uterine incision is made vertically, from the fundus to just above the anterior reflection of the bladder.
• When the uterus is entered, insert the index and middle fingers to lift the uterine wall away from the fetus, and extend the incision as needed.
• Deliver the infant, clamp and divide the umbilical cord, and hand the infant immediately to someone trained in resuscitation.
• A length of cord should be clamped at each end and saved for later cord gas evaluation.
• The placenta should be removed and the uterus massaged.
• If the resuscitation team believes that the mother has a chance of survival, a careful, layered closure should be undertaken, as previously described.
• Other life-threatening injuries should be addressed, as indicated by damage control principles.