EMCrit Conference Blast Winner: Peri-Mortem C-Section

At the EMCrit 2013 Conference we had a Blast Competition. The BLAST rules are easy:

blast-rules

The winner this year was Salil Bhandari with an incredible presentation on peri-mortem caesarean section.

Here is an article:

Eur J Emerg Med. 2011 Aug;18(4):241-2. doi: 10.1097/MEJ.0b013e328344f2c5. Prehospital resuscitative hysterotomy.

Want to know more about peri-mortem c-section? Check out these insanely good posts:

And here is a simulator video:

Video on Vimeo

And the best video on the procedure I have seen on life-identical model

Update:

In one case series, 12 of 20 women had return of spontaneous circulation immediately after delivery (EMCNA, Vol. 30, pg. 949). HT to emedhome.

Now on to the Wee…

Comments

  1. Minh Le Cong says

    insanely brilliant presentation! Love the BLAST format!
    Great teaser performance at start with the sleight of hand magic tricks!

    One suggestion from me.
    Dont worry about cutting baby. It happens not too uncommonly doing C sections , even elective ones.
    Cuts heal well. hypoxic brain injury not so well.
    Interesting choice of midline vertical classic incision both to open abdo and uterus. Makes me think about choice of cut in surgical cric. horizontal vs vertical.
    I think for complete novices to abdo surgery then the vertical cut makes a lot of sense for perimortem CS and surgical cric.

    The slide images and pace of delivery was perfect.
    really enjoyed and I agree that this type of delivery for conference presentations is here to stay! Love it!

  2. says

    Fantastic presentation Salil! Certainly one of those topics that makes any sane doctor sweat.

    Perfect pace and amount of content.

    Love the blast idea Scott. There’s a lot of mileage in these and the Pecha Kucha format, can’t wait to see more!

    Oli

  3. Jonathan Henglein says

    Great presentation Salil! Great topic pick also. Thanks for putting it up there Scott. Great job once again!

    JH

  4. adam whiteside says

    I was just wondering about the insert regarding the midline incision with avoidance of the umbilicus. In the image shown, there appears to be a small hernia, so there would be concern for bowel injury. Is this what you were going for? Otherwise with no hernia, just stay midline?

    I also saw on Resus another article listed. My university does not provide access to the journals, so it would be helpful if you could provide a direct link. Thanks again.

    1.Prehospital resuscitative hysterotomy
    Eur J Emerg Med. 2011 Aug;18(4):241-2
    2.Out-of-hospital perimortem cesarean section
    Prehosp Emerg Care. 1998 Jul-Sep;2(3):206-8

      • Leon says

        As a trauma surgeon (almost done with fellowship)…..I wouldn’t worry one cent if you went through or around the umbilicus. There are benefits/drawbacks of both. Believe it or not there are a minority if surgeons who go right through middle of umbicus on elective cases all the time. If my ER colleagues had the guts to do this because I wasn’t available, I would be happy with ANY incision.

        Given such speed, I would think there is a good chance of injury to bowel no matter what so please don’t call OB to close!! Call us! If you get into bowel DONT worry it’s easily addressed/fixed. Just get in there quickly! And then quicker! ;)

  5. Kevin M says

    FEAR!
    It’s what holds us back from doing these very rare procedures where the stakes are so high.

    But when the S__T hits the fan, most of these procedures are easy. And overcoming the fear of making a mistake is the biggest obstacle we face.

    In my career, I’ve done two surgical airways, a few lateral canthotomies, a thoracotomy and each one went well.

    Get rid of the fear folks. We Can Do This!

  6. says

    Curious about the timeline — I was always taught the 4-minute rule as well, however I assume that this is based around no-flow time. If CPR (especially bomber, fast, deep, professional compressions) is ongoing, is there a longer window?

  7. matt barden says

    Running through this procedure in my head, I came to a step where I didn’t know what to do…
    After baby is out, hopefully mom gets ROSC, what now?
    Do you close her up? If so, does the placenta stay in or come out?
    Thanks,
    Matt Barden
    Loma Linda University EM2

  8. vadim keyfes says

    According to all major sources; uterine fundus at the umbilicus is 20 weeks, not 24…

  9. says

    Great video + great format: more please!

    I’m currently a med student just finishing my O&G rotation.. A couple of Q’s:
    – assumption is post-delivery NICU folk are handy for the baby’s resuscitation. Surely in that length of time if NICU can be recruited, so can the O&G reg?
    – if mother regained circulation and consciousness before being closed, would she risk going into shock from the pain of having such a major incision without analgesia or anaesthesia?

    Re the above comments, I’ve also come across the fundus at the umbilicus = 20 weeks. And agree with Minh: I’ve seen a few minor cuts on babies post C-section; no biggie.

    • SAMGHALI says

      I have a couple questions:

      1. Do we have any actual good data regarding the 5-minute timeframe for fetal prognosis?
      2. Would you agree that as long as the resuscitation is going onward–> (irrespective of fetal prognosis) baby’s coming out regardless of the timeframe of arrest in order to optimize mom’s resuscitation?

  10. Jesse Kim says

    Thanks so much for bringing topics of critically important nature to the EMCrit blogs.

    I am certainly not an expert on this but I was involved in 1 perimortem c-section and this is my observational thought.
    1. You may not have to make full incision from xyphoid to pubis, like the way Roberts and Hedges recommends, and open up the entire front of abdomen. Eric Reichman’s Emergency Medicine Procedures recommends cut from umbilicus to pubis, and it seems that that’s enough of a cut.

    2. Regarding the indications of (>24 weeks, 5 minutes from arrest as Class IIb recommendation, meaning that you can consider doing it. C-section at 4 minutes from arrest also gets the same Class IIb recommendation by the way.

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