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Trauma is the leading cause of death in women of reproductive age and accounts for 25 to 50 percent of maternal morbidity. Major maternal injury is associated with a 45 to 50 percent fetal loss rate. The primary goal in the management of the severely injured pregnant patient is maternal assessment and stabilization. Prompt attention to the needs of the gravid patient can save the life of both the fetus and the mother. Nonetheless, there are occasions when emergent cesarean delivery of the fetus is necessary to save the fetus, and sometimes, the mother. This procedure is best performed by a qualified Surgeon in the Operating Room. However, there are circumstances that may necessitate the performance of this procedure in the Emergency Department. These include the possibility of uterine rupture, placental abruption, fetal distress, and imminent maternal demise.


There are several simple principles to keep in mind. Quickly establish that the mother is deceased or that no further intervention is possible. Quickly open the abdominal wall and uterus with vertical incisions. The use of aseptic technique is not required and only wastes valuable time. Deliver the fetus and begin resuscitation. Manually remove the placenta. Close the uterus and abdominal wall with running sutures.


Maternal Physiology


The performance of adequate CPR in the gravid patient at or near term is extremely difficult. Adequate CPR produces a cardiac output equivalent to 30 percent of normal under ideal circumstances. The enlarged uterus lies anterior to the inferior vena cava and suppresses venous return in the gravid patient. Place the patient in 15 degrees of left lateral tilt to adequately relieve the obstruction of the inferior vena cava by the uterus. Evacuation of the uterus by cesarean section may save the fetus and, by enabling adequate maternal resuscitation, save the mother as well. The pregnant patient has a decreased tolerance for anoxic brain injury. The fetus can tolerate anoxic injury slightly longer than the mother.


Evaluation for Perimortem Cesarean Section


Quickly determine the fetal age using ultrasonography, the last known menstrual period, the history of term gestation by family members, or fundal height. Perform ultrasonography only if the unit is immediately available and if the operator is experienced in obstetric ultrasound. Note the time of the maternal arrest. Immediately consider performing a perimortem cesarean section in the resuscitation of a pregnant patient with an estimated gestational age of 24 weeks or greater and with cardiac arrest that has not responded to aggressive resuscitation within four minutes from onset. The single most important prognostic factor for neonatal outcome is the time from maternal arrest to delivery. Delivery of the fetus can also maximize maternal resuscitation efforts and minimize the risk of maternal brain injury. Delay the initiation of vasopressor agents until after adequate volume replacement. However, they should not be withheld if needed to resuscitate the patient. Place a wedge under the patient’s right ...

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