Resuscitative Hysterotomy

Indication

• Maternal cardiac arrest where the uterus is palpable at or above the level of the umbilicus — a proxy for a gestation of approximately 20 weeks or more, at which point the gravid uterus can meaningfully compress the aorta and inferior vena cava.
• The primary purpose is maternal resuscitation: emptying the uterus relieves aortocaval compression, improving venous return and the effectiveness of chest compressions. Fetal survival is a secondary, welcome benefit, not the primary indication.

Timing

• Traditional teaching: begin the procedure at 4 minutes of maternal cardiac arrest with the aim of delivering the fetus by 5 minutes, based on the point at which permanent maternal neurological injury becomes increasingly likely.
• Modern emphasis (RCUK/international resuscitation guidance): perform resuscitative hysterotomy as soon as feasible once maternal cardiac arrest is confirmed and initial resuscitation has not achieved ROSC — do not wait to hit an arbitrary 4-minute mark before starting preparations.
• Do not abandon the procedure if the 4–5 minute window has passed — resuscitative hysterotomy can still improve maternal haemodynamics and outcome even later in an arrest, and has been performed successfully well beyond this window.

Team activation & ongoing resuscitation

• Call for obstetric, neonatal/paediatric and anaesthetic help immediately — but do not wait for them to arrive if they cannot get there in time; this is a procedure any appropriately trained emergency clinician may need to perform.
• Continue high-quality chest compressions and manual left uterine displacement throughout preparation and, where feasible, during the procedure itself.
• Continue standard maternal ALS in parallel — the hysterotomy does not replace resuscitation drugs, defibrillation or airway management.
• Perform the procedure where the arrest is happening — do not transport the patient to theatre first; moving a patient in cardiac arrest costs time this procedure cannot afford.

Minimum equipment

Technique for non-obstetricians

1. Continue compressions and displacement

   Maintain chest compressions and manual left uterine displacement up until, and where possible during, the incision.

2. Midline vertical incision

   Make a large midline vertical laparotomy incision from just above the symphysis pubis toward the umbilicus — a vertical incision is generally taught for speed and better exposure without needing detailed anatomical knowledge.

3. Enter the abdomen and identify the uterus

   Continue through subcutaneous tissue and peritoneum bluntly where possible to reach the uterus quickly.

4. Classical vertical uterine incision

   Make a vertical incision into the uterus (classical incision), extending it with fingers or blunt scissors to avoid injuring the fetus.

5. Deliver the fetus

   Deliver the baby through the incision, clamp and cut the cord, and hand immediately to the neonatal team for resuscitation.

6. Deliver the placenta and pack

   Remove the placenta, and pack the uterus and abdomen with gauze to control bleeding — definitive haemostasis is not the priority at this stage.

7. Continue maternal resuscitation

   Resume or continue chest compressions (now far more effective without aortocaval compression) and ongoing ALS.

Incision landmarks

Aftermath

• If maternal ROSC is achieved, transfer urgently to theatre for formal surgical closure and haemostasis, and full obstetric/anaesthetic care.
• Ensure the neonatal team documents and manages the baby fully, regardless of maternal outcome.
• Careful, contemporaneous documentation: time of arrest, time procedure started, time of delivery, personnel involved, and rationale for the decision.
• Hold a hot debrief for the team as soon as practicable — this is one of the highest-acuity, lowest-frequency procedures in emergency medicine, and staff welfare needs active attention regardless of outcome.

Pitfalls & pearls

• The commonest error is delay — waiting for a full surgical set, a specific specialist, or transfer to theatre. None of these should hold up the incision.
• Do not stop chest compressions for longer than necessary to make the incision.
• This is fundamentally a resuscitation procedure — think of it as "delivering the compressions" as much as delivering the baby.
• Even outside the classic 4–5 minute window, performing the procedure remains worthwhile — do not abandon it on the basis of elapsed time alone.

References