Obstetrics 10: Emergency Cesarean Section Portal
Emergency Cesarean Section
Many obstetric emergencies will eventually require an emergency Cesarean section. Despite its critical end-point, little literature is written about this topic.
Patients most commonly develop complications requiring a C-section in the OB ward; however, clinic, ED, or street emergencies occur, thus the system must be well prepared and flexible to rapidly recognize an OB emergency and activate the emergency C-section protocols.
Evaluating your facility, identifying key players, and listing their roles, is the start of putting together a “C-section Team.” Note that teams from smaller facilities often have overlapping roles. For instance, a physician helping with the C-section may need to assume the role of leading the neonatal resuscitation if the infant develops complications.
The following pages display the design of a C-section team that applies to a small, rural facility. After the C-section team has been defined, test the system by using an actual timed scenario to determine the facility’s preparedness. This approach will benefit not only the Obstetrics department but also all members of the hospital healthcare team.
Finally, take the time to debrief after each crisis. Many lessons are learned in a positive fashion simply by asking what could have been done differently. The fastest way to encounter a similar crisis is to fail to prepare for it the first time it is encountered.
| Team Role | Responsibility |
| Recorder | A floor nurse may be appointed by the charge nurse to accurately record events and times of interventions. |
| C/S MD | Rapid scrub – double glove. Update by obstetric provider. Immediate assessment of fetal heart tones. Placement of spinal anesthetic/local. Emergent C/S. Back-up MD may scrub out if need for neonatal resuscitation. Act as Team Leader for all available staff until anesthesia, OR staff arrive. |
| Anesthesia | Manage maternal airway and fluids. Provide regional or general anesthesia. Neonatal intubation if needed. Start difficult IVs. |
| OR Personnel | Help transfer patient to the OR bed. Start IVs. Apply warm blankets. Place and maintain sitting or lying positioning for spinal anesthetic. Rapid abdominal prep. Foley catheter placement. Apply needed equipment (ie, Bovie, suction). Assist in providing warmed fluids and blood products utilizing blood warmer and/or Bair-Hugger. Circulate to assist scrub tech and physicians. |
| Neonatal Team |
Turn on warmer and test equipment; ready medications. Review prenatal and antepartum course for dating of pregnancy, risks for prematurity, infection, hypoglycemia, or narcotic respiratory depression. Provide Neonatal protocols. Consider triage/transfer decisions for the neonate. |
| ER MD | Manage maternal airway and blood pressure to assure
proper oxygenation and perfusion of mother. Apply monitors – EKG, BP, pulse oximetry. Perform RSI (intubation) as needed. Assist with ordering blood products. Consider changing to neonatal role when anesthesia arrives. |
| OB Nursing | Place “STAT C/S” call Administer 100% oxygen, stop Pitocin, change maternal position. Apply fetal scalp lead (if membranes have ruptured). Consider terbutaline 0.25 mg SQ if contractions are close or hypertonic. Unplug fetal scalp cable from monitor, coil, and place on OB bed. Have assistant help transport OB bed to the OR. (Do not move patient to a cot for transport.) Bring prenatal and OB worksheet/ER record to OR. Appoint floor nurse to direct family to waiting room. Fathers are not to go to OR unless notified by MD. Assist in transfer of patient to OR bed. Attach fetal scalp lead to OR monitor, and turn up volume for audible heart rate. Assist with starting of IVs; insert Foley catheter. Give verbal report of labor to MDs. Remove fetal scalp lead once uterine incision is made. Move to neonatal role if needed. |
| Laboratory | Provide blood products (type-specific or O-negative). Reassess need for further supplies. |
Post Mortem Cesarean Section
The American Heart Association's guidelines for Advanced Cardiac Life Support recommend emergency cesarean section for women in cardiac arrest who are near-term pregnant and have not been resuscitated within 4 to 5 minutes of arrest. Women who are moribund from trauma and are near term are also candidates for emergency cesarean section in the ED. When the top of the uterus is well above the umbilicus, fetal viability is probable.
Using a #21 or #10 scalpel, make a long midline abdominal incision starting just below the xiphoid process and down almost to the pubis. Expose the fascia just below the umbilicus and incise it. Open the fascia, properitoneal fat, and peritoneum using heavy straight Mayo scissors.
With a #10 scalpel, open the wall of the uterus, exposing the fetal membranes or the fetus. Amniotic fluid will flood out of the uterus when the fetal sac is entered. Insert fingers in the uterus and open it longitudinally with bandage scissors.
With the edge of your palm, scoop out the baby. If the head is engaged in the pelvis, use Mauriceau’s maneuver (fingers in the mouth and on the malar prominances) as in a breech vaginal delivery to deliver the head out of the pelvis. Someone may need to push up the baby's head by inserting a hand in the vagina. Divide the cord about 4 to 6 inches from the baby's abdomen and hand off the baby for resuscitation.
Deliver the placenta. Close the uterus with 2 running sutures. Approximate the abdominal wound edges using towel clips pending surgical exploration and lavage if the mother survives.