Not So Bored When You’re the Obstetrician for the Night

You decide to take a break from the city and moonlight in a small rural hospital. You think you’ll be chilling for the night seeing urinary tract infections, or maybe you’ll finally see that snake bite you never thought you’d see. The night starts off slowly with a steady stream of patients complaining of abdominal pain and children with upper respiratory infections. Just when you were getting into the new groove of slow and steady for a change, you get a notification…

A 31-year-old gravid woman has sustained a gunshot wound to the head and neck. You are in a small rural hospital with no obstetrics service and no Neonatal ICU.

 

This image pops into your head and you think: if only it were this easy. Instead, you roll up your sleeves and snap back to reality, wondering how the night could suddenly have ended up like a mix between Grey’s Anatomy and Cloverfield.

The patient arrives.

Vital signs: BP 90/60, HR 140, RR 12, Pox 98% on room air

You start your evaluation with the primary trauma survey.

Airway: Intact, minimal swelling to the right side of the neck, no expanding hematoma

Breathing: Bilateral breath sounds with good chest rise

Circulation: Tachycardia, cool and clammy extremities, decreased capillary refill

Disability/Neurologic Assessment: Dilated left pupil, withdrawing to painful stimuli, unresponsive to verbal commands, GCS 6.

The patient is noted to have bleeding gunshot wounds to the left occipital region and right eye. Suddenly, her breathing becomes agonal. You intubate the patient as another member of the team activates the massive transfusion protocol. Two large-bore peripheral IV lines are placed and 1 L Lactated Ringer’s solution is started as O negative blood is being sent from blood bank. The patient becomes hypotensive (systolic BP 60s), bradycardic, and she exhibits decerebrate posturing.

Bedside sonogram reveals an IUP with a fetal heart rate.

Q1: When is the ideal time to perform perimortem caesarian section?
A perimortem caesarean delivery (C-section) should be performed within 5 minutes of maternal cardiac arrest to maximize survival chances for both the fetus and mother

Q2: When is perimortem C-section indicated?
Perimortem C-section is indicated only If gestational age is ≥ 24 weeks (in a setting of maternal cardiac arrest). If gestational age is < 24 weeks, continue maternal resuscitation

Q3: What factors are associated with an increased chance of fetal survival?
• Gestational age > 28 weeks • Fetal weight > 1kg • Short interval time between maternal cardiac arrest and delivery • Cause of maternal death not related to chronic hypoxia • Healthy fetal status prior to maternal death • Availability of neonatal intensive care facilities • Quality of maternal resuscitation

Q4: How do you perform a perimortem C-section?
   

Q5: How can you determine that gestational age is ≥ 24 weeks on physical exam?
By 20 weeks, the uterine fundus is palpable at the umbilicus; from 20-32 weeks the fundal height in cm approximates the gestational age

 

 

In your patient, the uterine fundus is palpable 6 cm above the level of the umbilicus, corresponding to an estimated gestational age of 26 weeks. Your patient further deteriorates into cardiac arrest. ACLS is started, and O neg RBC are given with rapid infusion, but after three minutes, there is no return of spontaneous circulation. CPR is continued on the mother as your attending makes the call to perform a c-section. On the field are your scalpel, mayo scissors, clamps, and everything else in the emergency c-section kit you’d never thought you’d open. Your attending looks over and hands you the scalpel. She says, “You’re a Kings County resident, you can handle this, right?” You make a vertical incision through the abdominal wall. The rest is history. The mother does not make it, but the baby survives.

For more reading check out the link below on neonatal resuscitation:

Neonatal Resuscitation

An Ob/Gyn attending shows up an hour later and offers you a spot in a nearby Ob/Gyn residency program as a PGY-2, but you politely decline.

References:

  1. Lanoix et al. Perimortem Cesarian Section: Case Reports and Recommendations. Acad. Emerg. Med. 1995; 2:1063-1067.

  2. http://adelaideemergencyphysicians.com/2016/03/thinking-about-perimortem-caesarean-section/

  3. https://www.acep.org/clinical—practice-management/time-is-critical-for-success-in-perimortem-c-section/

  4. AJOG 2005;192:1916-21. http://www.ncbi.nlm.nih.gov/pubmed/15970850

  5. Tintinalli’s Emergency Medicine

  6. Roberts & Hedges Clinical Procedures in Emergency Medicine 6ed

 

 

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sahmad

PGY1 clinical monster in training/EMIM resident/improviser