Difference between revisions of "Cesarean section"
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{{Infobox surgical case reference | {{Infobox surgical case reference | ||
| anesthesia_type = | | anesthesia_type = General vs. Regional | ||
| airway = | | airway = ETT if GA | ||
| lines_access = | | lines_access = 2 large bore PIV | ||
| monitors = | | monitors = Standard ASA <br> | ||
| considerations_preoperative = | FHR monitor | ||
| considerations_preoperative = Full stomach precautions <br> | |||
Aspiration prophylaxis <br> | |||
Left lateral tilt | |||
| considerations_intraoperative = | | considerations_intraoperative = | ||
| considerations_postoperative = | | considerations_postoperative = | ||
}} | }} | ||
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. As of 2017, about 32% of deliveries in the United States were performed via C-section<ref>"Births: Provisional Data for 2017" (PDF). ''CDC''. May 2018. Retrieved 18 May 2018.</ref>. | |||
== Preoperative management == | == Preoperative management == | ||
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|Cardiovascular | |Cardiovascular | ||
| | | | ||
* Pregnant patients typically have decreased systemic vascular resistance, decreased diastolic pressure, decreased MAP, increased HR, and increased CO. | |||
* Left uterine tilt to minimize aortocaval compression | |||
* Evaluate for pregnancy induced hypertension (PIH) | |||
|- | |- | ||
|Respiratory | |Respiratory | ||
| | | | ||
* Pregnant patients typically have compensated respiratory alkalosis, increased minute ventilation, decreased FRC, and increased oxygen consumption. | |||
* Decreased FRC results in rapid desaturation if ventilation is compromised. | |||
* Atelectasis can occur secondary to an elevated diaphragm, thereby causing V/Q mismatch and decreased PaO<sub>2.</sub> | |||
* Increased MV and decreased FRC increase uptake of inhalational agents. | |||
* Mucosal capillary engorgement in upper airway may necessitate smaller endotracheal tube. | |||
|- | |- | ||
|Gastrointestinal | |Gastrointestinal / Hepatic | ||
| | | | ||
* Increased gastric pressure | |||
* Decreased esophageal sphincter tone | |||
* Decreased gastric motility | |||
* Full stomach precautions | |||
* Risk for aspiration | |||
* Liver enzymes may be mildly elevated | |||
** Check for HELLP | |||
|- | |- | ||
|Hematologic | |Hematologic | ||
| | | | ||
* Increased RBC mass, plasma volume, and blood volume | |||
* Leukocytosis | |||
* Iron deficiency anemia + dilutional anemia of pregnancy | |||
* Excessive blood loss possible with uterine atony, multiple gestation, previous C-section, placental pregnancy, placental abruption, pregnancy induced hypertension, or prolonged labor. | |||
* | |||
|- | |- | ||
|Renal | |Renal | ||
| | | | ||
* Increased renal blood flow, GFR, and creatinine clearance | |||
* Decreased serum creatinine and BUN | |||
* Dependent edema secondary to increased water and sodium retention | |||
|- | |- | ||
|Other | |Other | ||
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=== Labs and studies === | === 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 === | === Operating room setup === | ||
=== Patient preparation and premedication === | === 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 | |||
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | === Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | ||
* Epidural, spinal, and combined spinal-epidural (CSE) techniques are all commonly employed | |||
** Check coagulation and platelets panel prior to neuraxial anesthesia | |||
== Intraoperative management == | == Intraoperative management == | ||
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=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | === Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | ||
* Avoid nasal airways due to potential for mucosal capillary engorgement in upper airway | |||
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | === Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | ||
* Left lateral tilt (15<sup>o</sup>) to avoid aortocaval compression and supine hypotension. | |||
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | === Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | ||
* 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 | |||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | === Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ||
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|+ | |+ | ||
! | ! | ||
! | !Neuraxial | ||
! | !General | ||
|- | |- | ||
|Unique considerations | |Unique considerations | ||
| | | | ||
* Decreased BP common with spinal anesthesia | |||
* Given fluid pre-load or co-load | |||
* Be prepared to provide bolus as vasopressors as needed | |||
| | | | ||
* GA normally used with regional technique contraindicated or when there is not enough time to perform a block due to obstetric emergency | |||
* Rapid sequence induction (RSI) | |||
|- | |- | ||
|Position | |Position | ||
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== References == | == References == | ||
[[Category:Surgical | [[Category:Surgical procedures]] | ||
[[Category:Obstetric and gynecologic surgery]] |
Revision as of 11:45, 23 February 2021
Cesarean section
Anesthesia type |
General vs. Regional |
---|---|
Airway |
ETT if GA |
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. As of 2017, about 32% of deliveries in the United States were performed via C-section[1].
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
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
Intraoperative management
Monitoring and access
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
Emergence
Postoperative management
Disposition
Pain management
Potential complications
Procedure variants
Neuraxial | General | |
---|---|---|
Unique considerations |
|
|
Position | ||
Surgical time | ||
EBL | ||
Postoperative disposition | ||
Pain management | ||
Potential complications |
References
- ↑ "Births: Provisional Data for 2017" (PDF). CDC. May 2018. Retrieved 18 May 2018.