Gravid patient with a potentially viable fetus of ≥24 weeks’ gestational age and imminent maternal death or unresponsive to cardiopulmonary resuscitation (CPR) for 5 minutes

Survival of mother and infant is greatest when the procedure is performed within 5 minutes of maternal arrest.

CONTRAINDICATIONS

 Fetus <24 weeks’ gestational age

 Lower limit of fetal viability varies depending on institution and available resources

RISK/CONSENT ISSUES

 Verbal consent from family when possible

TECHNIQUE

 Patient Preparation

    Procedure should be performed by the most experienced person available

    Contact all essential personnel (i.e., neonatology/pediatrics, obstetrics)

    Continue CPR on maternal patient throughout the entire procedure

    Estimate fetal age (if unknown from history):

       Height of uterine fundus reaches the umbilicus at 20 weeks’ gestational age and increases 1 cm for each additional week

       Four fingerbreadths above the umbilicus is approximately 24 weeks’ gestational age

 Incision (FIGURE 20.1)

    No. 10 scalpel blade

    Make a midline vertical incision from just above the symphysis pubis extending to the umbilicus along the linea nigra/linea alba

    Incise through the abdominal wall to the peritoneal cavity

    Use retractors to retract abdominal wall and expose the uterus

 Reflect Bladder Inferiorly

    If a full bladder obstructs view of the uterus, decompress bladder with a puncture incision and deflate with either pressure or suction

    Bladder repair may be done later if mother survives

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