Difference between revisions of "Cesarean section"

From WikiAnesthesia
(Additional evidence regarding azithromycin and tranexamic acid use in C-Section.)
m (Morphine dosing for epidural and spinal analgesia for CS)
(8 intermediate revisions by 4 users not shown)
Line 1: Line 1:
{{Infobox surgical case reference
{{Infobox surgical case reference
| anesthesia_type = General vs. Regional
| anesthesia_type = Neuraxial or general
| airway = ETT if GA
| airway = ETT if general
| lines_access = 2 large bore PIV
| lines_access = 2 large bore PIV
| monitors = Standard ASA <br>
| monitors = Standard ASA <br>
FHR monitor
Fetal heart rate monitor
| considerations_preoperative = Full stomach precautions <br>
| considerations_preoperative = Full stomach precautions <br>
Aspiration prophylaxis <br>
Aspiration prophylaxis <br>
Line 11: Line 11:
| 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. In the USA, about 32% of deliveries are via Cesarean section<ref>{{Cite web|date=2021-03-24|title=FastStats|url=https://www.cdc.gov/nchs/fastats/delivery.htm|access-date=2021-05-27|website=www.cdc.gov|language=en-us}}</ref>, and worldwide the figure is approximately 21%<ref>{{Cite journal|last=Boerma|first=Ties|last2=Ronsmans|first2=Carine|last3=Melesse|first3=Dessalegn Y.|last4=Barros|first4=Aluisio J. D.|last5=Barros|first5=Fernando C.|last6=Juan|first6=Liang|last7=Moller|first7=Ann-Beth|last8=Say|first8=Lale|last9=Hosseinpoor|first9=Ahmad Reza|last10=Yi|first10=Mu|last11=Neto|first11=Dácio de Lyra Rabello|date=2018-10-13|title=Global epidemiology of use of and disparities in caesarean sections|url=https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31928-7/abstract|journal=The Lancet|language=English|volume=392|issue=10155|pages=1341–1348|doi=10.1016/S0140-6736(18)31928-7|issn=0140-6736|pmid=30322584}}</ref>.
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 ==
Line 28: Line 27:
|
|
* Pregnant patients typically have decreased systemic vascular resistance, decreased diastolic pressure,  decreased MAP, increased HR, and increased CO.
* 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
* Left uterine tilt to minimize aortocaval compression<ref>{{Cite journal|last=Buley|first=R. J.|last2=Downing|first2=4 W.|last3=Brock-Utne|first3=J. G.|last4=Cuerden|first4=C.|date=1977-10|title=Right versus left lateral tilt for Caesarean section|url=https://pubmed.ncbi.nlm.nih.gov/921864/|journal=British Journal of Anaesthesia|volume=49|issue=10|pages=1009–1015|doi=10.1093/bja/49.10.1009|issn=0007-0912|pmid=921864}}</ref>
* Evaluate for pregnancy induced hypertension (PIH)
* Evaluate for pregnancy induced hypertension (PIH)
|-
|-
Line 94: Line 93:
* Epidural, spinal, and combined spinal-epidural (CSE) techniques are all commonly employed
* Epidural, spinal, and combined spinal-epidural (CSE) techniques are all commonly employed
** Check coagulation and platelets panel prior to neuraxial anesthesia
** Check coagulation and platelets panel prior to neuraxial anesthesia
* Post-operative transversus abdominal block (TAP block) or quadratus lumborum block.


== Intraoperative management ==
== Intraoperative management ==


=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
Standard ASA monitors


=== 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. --> ===
Line 113: Line 114:
* Immediately post-partum, ~600-800 mL of blood will enter the central circulation (placental autotransfusion), which will increase cardiac output
* 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<ref>{{Cite journal|last=Sentilhes|first=Loïc|last2=Sénat|first2=Marie V.|last3=Le Lous|first3=Maëla|last4=Winer|first4=Norbert|last5=Rozenberg|first5=Patrick|last6=Kayem|first6=Gilles|last7=Verspyck|first7=Eric|last8=Fuchs|first8=Florent|last9=Azria|first9=Elie|last10=Gallot|first10=Denis|last11=Korb|first11=Diane|date=2021-04-29|title=Tranexamic Acid for the Prevention of Blood Loss after Cesarean Delivery|url=http://www.nejm.org/doi/10.1056/NEJMoa2028788|journal=New England Journal of Medicine|language=en|volume=384|issue=17|pages=1623–1634|doi=10.1056/NEJMoa2028788|issn=0028-4793}}</ref>.   
* 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<ref>{{Cite journal|last=Sentilhes|first=Loïc|last2=Sénat|first2=Marie V.|last3=Le Lous|first3=Maëla|last4=Winer|first4=Norbert|last5=Rozenberg|first5=Patrick|last6=Kayem|first6=Gilles|last7=Verspyck|first7=Eric|last8=Fuchs|first8=Florent|last9=Azria|first9=Elie|last10=Gallot|first10=Denis|last11=Korb|first11=Diane|date=2021-04-29|title=Tranexamic Acid for the Prevention of Blood Loss after Cesarean Delivery|url=http://www.nejm.org/doi/10.1056/NEJMoa2028788|journal=New England Journal of Medicine|language=en|volume=384|issue=17|pages=1623–1634|doi=10.1056/NEJMoa2028788|issn=0028-4793}}</ref>.   
* 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<!-- 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. --> ===
Line 119: Line 123:


=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
* L&D PACU
* Operating room PACU


=== 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
* 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<!-- List and/or describe any potential postoperative complications for this case. --> ===
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
* Ureteral injury
* Post-partum hemorrhage


== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
Line 143: Line 162:
|-
|-
|Position
|Position
|
|Left lateral tilt
|
|Left lateral tilt
|-
|-
|Surgical time
|Surgical time
|
|45-90min
|
|30-45min (given emergency delivery indications)
|-
|-
|EBL
|EBL
|
|500-1000mL
|
|500-1000mL
|-
|-
|Postoperative disposition
|Postoperative disposition
|
|L&D PACU
|
|L&D or OR PACU
|-
|-
|Pain management
|Pain management
|
|4
|
|6
|-
|-
|Potential complications
|Potential complications
|[[Post-dural-puncture headache]]
|
|
|
* Aspiration
* Difficult Airway
|}
|}



Revision as of 10:42, 21 June 2021

Cesarean section
Anesthesia type

Neuraxial or general

Airway

ETT if general

Lines and access

2 large bore PIV

Monitors

Standard ASA
Fetal heart rate monitor

Primary anesthetic considerations
Preoperative

Full stomach precautions
Aspiration prophylaxis
Left lateral tilt

Intraoperative
Postoperative
Article quality
Editor rating
Comprehensive
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
  • 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[3]
  • Evaluate for pregnancy induced hypertension (PIH)
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 PaO2.
  • Increased MV and decreased FRC increase uptake of inhalational agents.
  • Mucosal capillary engorgement in upper airway may necessitate smaller endotracheal tube.
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
  • 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
  • Increased renal blood flow, GFR, and creatinine clearance
  • Decreased serum creatinine and BUN
  • Dependent edema secondary to increased water and sodium retention
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
  • 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 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
  • Aspiration
  • Difficult Airway

References

  1. "FastStats". www.cdc.gov. 2021-03-24. Retrieved 2021-05-27.
  2. 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.
  3. 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)
  4. 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)
  5. 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.
  6. 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)
  7. 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)
  8. 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)