Preoperative management Guidelines recommend a minimum preoperative fasting time of at least 2 hours from clear liquids, 6 hours from a light meal, and 8 hours from a regular meal.[6] However, patients are usually asked not to eat anything for 12 hours prior to the procedure.[7] The following are also included in preoperative management: Placement of an intravenous (IV) line Infusion of IV fluids (eg, lactated Ringer solution or saline with 5% dextrose) Placement of a Foley catheter (to drain the bladder and to monitor urine output) Placement of an external fetal monitor and monitors for the patient’s blood pressure, pulse, and oxygen saturation Preoperative antibiotic prophylaxis (decreases risk of endometritis after elective cesarean delivery by 76%, regardless of the type of cesarean delivery [emergent or elective])[8] Evaluation by the surgeon and the anesthesiologist Laboratory testing The following laboratory studies may be obtained prior to cesarean delivery: Complete blood count Blood type and screen, cross-match Screening tests for human immunodeficiency virus, hepatitis B, syphilis Coagulation studies (eg, prothrombin and activated partial thromboplastin times, fibrinogen level) Imaging studies In labor and delivery, document fetal position and estimated fetal weight. Although ultrasonography is commonly used to estimate fetal weight, a prospective study reported the sensitivity of clinical and ultrasonographic prediction of macrosomia, respectively, as 68% and 58%.[9] Cesarean delivery The technique for cesarean delivery includes the following: Laparotomy via midline infraumbilical, vertical, or transverse (eg, Pfannenstiel, Mayland, Joel Cohen) incision Hysterotomy via a transverse (Monroe-Kerr) or vertical (eg, Kronig, DeLee) incision Fetal delivery Uterine repair Closure Postoperative management Routine postoperative assessment Monitoring of vital signs, urine output, and amount of vaginal bleeding Palpation of the fundus IV fluids; advance to oral diet as appropriate IV or intramuscular (IM) analgesia if patient did not receive a long-acting analgesic or had general anesthesia; analgesia is usually not needed if patient received regional anesthesia, with/without a long-acting analgesic Ambulation on postoperative day 1; advance as tolerated If patient plans to breastfeed, initiate within a few hours after delivery; if patient plans to bottle feed, she may use a tight bra or breast binder in the postoperative period Discharge on postoperative day 3 or 4, if no complications Discuss contraception as well as refraining from intercourse for 4-6 weeks postpartum Complications Approximately 2-fold increase in maternal mortality and morbidity with cesarean delivery relative to a vaginal delivery[10] : Partly related to the procedure itself, and partly related to conditions that may have led to needing to perform a cesarean delivery Infection (eg, postpartum endomyometritis, fascial dehiscence, wound, urinary tract) Thromboembolic disease (eg, deep venous thrombosis, septic pelvic thrombophlebitis) Anesthetic complications Surgical injury (eg, uterine lacerations; bladder, bowel, ureteral injuries) Uterine atony Delayed return of bowel function
Posted on: Mon, 15 Sep 2014 21:03:56 +0000
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