Difference between revisions of "Cesarean section"
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=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | === Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | ||
* | * Epidural Morphine 1-3mg for long acting post-partum pain relief<ref>{{Cite journal|last=Fuller|first=John G.|last2=McMorland|first2=Graham H.|last3=Douglas|first3=M. Joanne|last4=Palmer|first4=Lynne|date=1990-09|title=Epidural morphine for analgesia after Caesarean section: a report of 4880 patients|url=http://link.springer.com/10.1007/BF03006481|journal=Canadian Journal of Anaesthesia|language=en|volume=37|issue=6|pages=636–640|doi=10.1007/BF03006481|issn=0832-610X}}</ref><ref>{{Cite journal|last=Bollag|first=Laurent|last2=Lim|first2=Grace|last3=Sultan|first3=Pervez|last4=Habib|first4=Ashraf S.|last5=Landau|first5=Ruth|last6=Zakowski|first6=Mark|last7=Tiouririne|first7=Mohamed|last8=Bhambhani|first8=Sumita|last9=Carvalho|first9=Brendan|date=2021-05|title=Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean|url=https://journals.lww.com/10.1213/ANE.0000000000005257|journal=Anesthesia & Analgesia|language=en|volume=132|issue=5|pages=1362–1377|doi=10.1213/ANE.0000000000005257|issn=0003-2999}}</ref> | ||
* IT Morphine 50-150mcg for long acting post-partum pain relief if spinal performed<ref>{{Cite journal|last=Bollag|first=Laurent|last2=Lim|first2=Grace|last3=Sultan|first3=Pervez|last4=Habib|first4=Ashraf S.|last5=Landau|first5=Ruth|last6=Zakowski|first6=Mark|last7=Tiouririne|first7=Mohamed|last8=Bhambhani|first8=Sumita|last9=Carvalho|first9=Brendan|date=2021-05|title=Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean|url=https://journals.lww.com/10.1213/ANE.0000000000005257|journal=Anesthesia & Analgesia|language=en|volume=132|issue=5|pages=1362–1377|doi=10.1213/ANE.0000000000005257|issn=0003-2999}}</ref> | |||
* IV acetaminophen | * IV acetaminophen | ||
* Ibuprofen PO post-op | * Ibuprofen PO post-op |
Revision as of 09:42, 21 June 2021
Cesarean section
Anesthesia type |
Neuraxial or general |
---|---|
Airway |
ETT if general |
Lines and access |
2 large bore PIV |
Monitors |
Standard ASA |
Primary anesthetic considerations | |
Preoperative |
Full stomach precautions |
Intraoperative | |
Postoperative | |
Article quality | |
Editor rating | |
User likes | 2 |
A cesarean section (also known as C-section) is a surgical procedure where the baby is delivered through an incision in the uterus. C-sections are typically performed when a vaginal delivery would put the mother or baby at risk. In the USA, about 32% of deliveries are via Cesarean section[1], and worldwide the figure is approximately 21%[2].
Preoperative management
Patient evaluation
System | Considerations |
---|---|
Neurologic | |
Cardiovascular |
|
Respiratory |
|
Gastrointestinal / Hepatic |
|
Hematologic |
|
Renal |
|
Other |
Labs and studies
- T&S
- T&C only if significant blood loss anticipated
- Coagulation panel
- Chemistry panel
- Complete Blood Count (CBC)
- Other tests as indicated by H&P
Operating room setup
Patient preparation and premedication
- Full stomach precautions
- Nonparticulate oral antacid (e.g. sodium citrate) immediately prior to general or regional anesthesia
- Intravenous promotility agent (eg. metoclopramide)
- Intravenous antacids (e.g. ranitidine, famotidine)
- Anxiolysis not typically used unless patient is extremely anxious
- Elevate the right hip to provide left uterine displacement
- Adjunctive azithromycin 500mg IV to standard beta-lactam antibiotics shown to reduce the incidence in endometriosis and wound infection occurring in the first 6 weeks after Cesarean Section[4].
Regional and neuraxial techniques
- Epidural, spinal, and combined spinal-epidural (CSE) techniques are all commonly employed
- Check coagulation and platelets panel prior to neuraxial anesthesia
- Post-operative transversus abdominal block (TAP block) or quadratus lumborum block.
Intraoperative management
Monitoring and access
Standard ASA monitors
Induction and airway management
- Avoid nasal airways due to potential for mucosal capillary engorgement in upper airway
Positioning
- Left lateral tilt (15o) to avoid aortocaval compression and supine hypotension.
Maintenance and surgical considerations
- Anticipate EBL of 700-1000 mL
- Be prepared for excessive blood loss if underlying risk factors
- Immediately post-partum, ~600-800 mL of blood will enter the central circulation (placental autotransfusion), which will increase cardiac output
- Tranexamic acid 1g administered over 30-60 seconds during the first 3 minutes after birth, and after the uterotonic agent has been administered (e.g. oxytocin) is shown to reduce the incidence of post-operative blood loss > 1000 mL by POD #2 or RBC transfusion[5].
- Start oxytocin 30U in 500mL fluid over 3 hours after clamping of umbilical cord
- Monitor for hemodynamic variance after starting oxytocin
- Additional uterotonics may be requested by surgeon if uterine tone is not adequate
Emergence
Postoperative management
Disposition
- L&D PACU
- Operating room PACU
Pain management
- Epidural Morphine 1-3mg for long acting post-partum pain relief[6][7]
- IT Morphine 50-150mcg for long acting post-partum pain relief if spinal performed[8]
- IV acetaminophen
- Ibuprofen PO post-op
- ± ketoralac (dependent upon surgeon preference and total blood loss)
- ± Wound infiltration
- ± Transversus abdominal block (TAP block) or quadratus lumborum block (for patients undergoing general anesthesia or neuroaxial without intrathecal opioid administration)
- ± Continuous local anesthetic pain pump
Potential complications
- Ureteral injury
- Post-partum hemorrhage
Procedure variants
Neuraxial | General | |
---|---|---|
Unique considerations |
|
|
Position | Left lateral tilt | Left lateral tilt |
Surgical time | 45-90min | 30-45min (given emergency delivery indications) |
EBL | 500-1000mL | 500-1000mL |
Postoperative disposition | L&D PACU | L&D or OR PACU |
Pain management | 4 | 6 |
Potential complications | Post-dural-puncture headache |
|
References
- ↑ "FastStats". www.cdc.gov. 2021-03-24. Retrieved 2021-05-27.
- ↑ Boerma, Ties; Ronsmans, Carine; Melesse, Dessalegn Y.; Barros, Aluisio J. D.; Barros, Fernando C.; Juan, Liang; Moller, Ann-Beth; Say, Lale; Hosseinpoor, Ahmad Reza; Yi, Mu; Neto, Dácio de Lyra Rabello (2018-10-13). "Global epidemiology of use of and disparities in caesarean sections". The Lancet. 392 (10155): 1341–1348. doi:10.1016/S0140-6736(18)31928-7. ISSN 0140-6736. PMID 30322584.
- ↑ Buley, R. J.; Downing, 4 W.; Brock-Utne, J. G.; Cuerden, C. (1977-10). "Right versus left lateral tilt for Caesarean section". British Journal of Anaesthesia. 49 (10): 1009–1015. doi:10.1093/bja/49.10.1009. ISSN 0007-0912. PMID 921864. Check date values in:
|date=
(help) - ↑ Tita, Alan T.N.; Szychowski, Jeff M.; Boggess, Kim; Saade, George; Longo, Sherri; Clark, Erin; Esplin, Sean; Cleary, Kirsten; Wapner, Ron; Letson, Kellett; Owens, Michelle (2016-09-29). "Adjunctive Azithromycin Prophylaxis for Cesarean Delivery". New England Journal of Medicine. 375 (13): 1231–1241. doi:10.1056/NEJMoa1602044. ISSN 0028-4793. PMC 5131636. PMID 27682034.CS1 maint: PMC format (link)
- ↑ Sentilhes, Loïc; Sénat, Marie V.; Le Lous, Maëla; Winer, Norbert; Rozenberg, Patrick; Kayem, Gilles; Verspyck, Eric; Fuchs, Florent; Azria, Elie; Gallot, Denis; Korb, Diane (2021-04-29). "Tranexamic Acid for the Prevention of Blood Loss after Cesarean Delivery". New England Journal of Medicine. 384 (17): 1623–1634. doi:10.1056/NEJMoa2028788. ISSN 0028-4793.
- ↑ Fuller, John G.; McMorland, Graham H.; Douglas, M. Joanne; Palmer, Lynne (1990-09). "Epidural morphine for analgesia after Caesarean section: a report of 4880 patients". Canadian Journal of Anaesthesia. 37 (6): 636–640. doi:10.1007/BF03006481. ISSN 0832-610X. Check date values in:
|date=
(help) - ↑ Bollag, Laurent; Lim, Grace; Sultan, Pervez; Habib, Ashraf S.; Landau, Ruth; Zakowski, Mark; Tiouririne, Mohamed; Bhambhani, Sumita; Carvalho, Brendan (2021-05). "Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean". Anesthesia & Analgesia. 132 (5): 1362–1377. doi:10.1213/ANE.0000000000005257. ISSN 0003-2999. Check date values in:
|date=
(help) - ↑ Bollag, Laurent; Lim, Grace; Sultan, Pervez; Habib, Ashraf S.; Landau, Ruth; Zakowski, Mark; Tiouririne, Mohamed; Bhambhani, Sumita; Carvalho, Brendan (2021-05). "Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced Recovery After Cesarean". Anesthesia & Analgesia. 132 (5): 1362–1377. doi:10.1213/ANE.0000000000005257. ISSN 0003-2999. Check date values in:
|date=
(help)