Are you prepared to handle a post-mortem C-section?
Are you prepared to handle a post-mortem C-section?
When a pregnant woman has arrested and a post-mortem cesarean may be needed, it’s one of the most challenging situations you can encounter, stresses Renee Holleran, RN, PhD, chief flight nurse and clinical nurse specialist at Cincinnati Medical Center.
"The most important issue to emphasize with the pregnant patient who has suffered a cardiac arrest is that in order to save the baby, the mother needs to be cared for," she says. (See stories on critical incident stress management and specific steps to take, p. 116.) Here are ways to effectively manage this scenario:
• Focus efforts toward caring for the mother.
When a pregnant woman has arrested, the child’s survival is dependent upon the mother’s survival, Holleran stresses. "All efforts should be directed at providing an airway, oxygenation, and circulation to the mother."
The fetus is absolutely dependent on maternal blood flow for life, so resuscitation of the mother is the priority, says Cindy Jimmerson, RN, trauma/ transport outreach coordinator for Community Medical Center in Missoula, MT. "If resuscitation fails, then CPR, mechanical ventilation, heart compressions of the mother, and immediate C-section are the only steps that will offer the fetus a chance of survival," Jimmerson says.
• Consider the cause of arrest.
The causes of maternal arrest influence the infant’s outcome, notes Holleran. "Years ago, chronic illness such as tuberculosis was a cause of arrest," she says. "Today, embolus or trauma are more common causes."
Since trauma is the No. 1 cause of death in women of childbearing age, a pregnant patient is always at risk for a traumatic injury, says Holleran. The most common mechanism of injury are motor vehicle crashes, she says, adding that ED nurses can use that information to educate pregnant patients who are being discharged from the ED.
"ED nurses need to ensure that the pregnant patient knows how to fasten their seat belt appropriately," Holleran says.
Lap belt should be low
According to Janet Lassman, RN, BS, national instructor trainer for Alexandria, VA-based Emergency Nurses Care (EN CARE), pregnant women should wear seat belts with the lap belt low on the pelvis and the shoulder harness across the clavicle and chest. "The belt should be snug and away from the mass of the baby, and the seat positioned away from the airbag," she says.
EN CARE is a not-for-profit organization affiliated with the Emergency Nurses Association. Its mission is to reduce preventable injuries and deaths by educating the public to increase awareness and promote healthy lifestyles.
• Know increased risks of domestic violence.
Research has shown an increase in domestic violence against pregnant women, notes Holleran. Make pregnant women aware of community resources for support related to domestic violence, she advises.
Penetrating trauma such as gunshot wounds or stabbing injuries is a common problem with domestic disputes and might contribute to the need for emergency cesarean, Jimmerson says.
• Know indications for the procedure.
Cessation of maternal vital signs within five minutes is an indication for this procedure, says Holleran.
"However, the effects of prolonged hypotension prearrest on the mother and child must be taken into consideration," she advises.
The mother’s body will divert circulation from the fetus to sustain the mother, says Holleran. "Many times, manifestation of maternal stress from illness or injury is manifested first in the fetus generally by a change in the baby’s heart rate [tachycardia-bradycardia]."
Unsuccessful cardiac resuscitation might be another indication for a perimortem section, says Holleran.
Age of fetus critical
• Determine the age of the fetus.
The fetal age should be greater than 20 weeks for the child to have a chance of survival, says Holleran. "It is a good idea to have a chart available that indicates the age of the fetus by looking at the mother’s abdomen."
Other ways of determining fetal age include asking family members when the baby is due or the date of the mother’s last period, or having an ultrasound machine available to determine the gestational age of the fetus, says Holleran.
• Have equipment readily available.
You’ll need neonatal resuscitation equipment including airway management equipment-resuscitation bag and endotracheal tubes based on infant size, advises Holleran.
• Obtain all necessary information.
Gather the facts relative to pregnancy and the event that helps make the decision, says Jimmerson. This includes mechanism of injury, CPR or pulselessness in the field prior to ED arrival, gestation of the fetus, presence and quality of fetal heart tones, she adds. Contact the patient’s obstetrician, particularly if they are locally available, she adds.
• Give adequate oxygen and fluid resuscitation.
The mother needs a significant amount of oxygen and fluid resuscitation in the form of crystalloids and blood products," Jimmerson says. "During the third trimester of pregnancy, placental flow is approximately 700cc/minute," she says. "Potential for blood loss with injury is massive, and correction of hypovolemia is essential for fetal survival."
For more information about management of post-mortem cesareans, contact:
• Renee Holleran, RN, PhD, University of Cincinnati Medical Center, P.O. Box 670736, Cincinnati, OH 45267. Telephone: (513) 594-7522. Fax: (513) 584-4533. E-mail: hollerre @Healthall.com.
• Cindy Jimmerson, RN, Community Medical Center, 2827 Fort Missoula Road, Missoula, MT 59804. Telephone: (406) 327-4074. Fax: (406) 327-4505. E-mail: [email protected].
• Janet Lassman, RN, EN CARE, 205 S. Whiting St., Suite 403, Alexandria, VA 22304. Telephone: (703) 370-4050. Fax: (703) 370-4005. E-mail: [email protected].
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