Cesarean Section

Aka: Cesarean Section, C-Section, Cesarean Section Postoperative Management, C-Section Postoperative Management

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II. Epidemiology

  1. Incidence: 32.9% of deliveries (U.S., 2009)
    1. Associated with an increased primary C-Section rate and decreased VBAC rate
    2. Contrast with a 4.5% C-Section rate in U.S. in 1965
    3. Contrast with the lowest developed world rates in Saudi Arabia (13%), Japan (17.4%), France (18.8%)
    4. Contrast with the highest developed world rates in Brazil (45.9%), Italy (38.2%) and Mexico (37.8%)
    5. Menacker (2010) NCHS Data Brief (35):1-8 +PMID:20334736 [PubMed]

III. Indications

  1. Common
    1. Elective repeat cesarean delivery or ERCD (30%)
    2. Labor Dystocia (30%)
    3. Malpresentation such as Breech Presentation (11%)
    4. Non-reassuring Fetal Heart Tracings suggesting Fetal Distress (10%)
  2. Other indications
    1. Active genital HSV
      1. See Genital Herpes in Pregnancy
    2. Maternal HIV Infection
      1. See HIV in Pregnancy
    3. Maternal comorbidity
      1. Cardiopulmonary disease
      2. Thrombocytopenia
    4. Emergent condition
      1. Placenta Previa
      2. Placental Abruption
      3. Vasa Previa
      4. Umbilical Cord Prolapse
      5. Perimortem Cesarean Section
    5. Structural Pelvis anomaly
      1. Contracted Pelvis (congenital, prior Pelvic Fracture)
      2. Obstructive pelvic tumor
      3. Vaginal reconstruction
    6. Fetal indications
      1. Congenital Anomaly
      2. Conjoined twin

IV. History: Rounds

  1. Abdominal and perineal Pain
  2. Lochia
  3. Flatus or Bowel Movement

V. Exam: Rounds

  1. Cardiopulmonary exam
  2. Abdominal examination
    1. Fundal height
    2. Uterine tenderness
    3. Bowel sounds
    4. Incision clean and dry
  3. Extremity exam
    1. Calf tenderness
    2. Homan's sign

VI. Labs: Postpartum

  1. Complete Blood Count (or Hemoglobin And Hematocrit) in morning
  2. Maternal Blood Type Indications for Cord Blood
    1. Mother Rh Negative

VII. Management: Emergency C-Section

  1. Local Anesthesia (non-intubated mother)
    1. Anesthesia
      1. Lidocaine 0.5% with Epinephrine (100 cc)
        1. Anesthetize all tissue layers
        2. May use bupivicaine for longer activity
    2. Pre-delivery Sedation
      1. If general Anesthesia used, delivery must proceed rapidly to prevent adverse infant outcome
      2. Nitrous Oxide 2 L/min at low dose to keep patient in semi-awake state
    3. Incisions
      1. Midsagittal skin incision
      2. Classic uterine incision
    4. Post-delivery sedation
      1. Ketamine 1-2 mg/kg IV every 10 minutes prn
  2. References
    1. (2016) CALS manual, 14th ed, 1:64

VIII. Management: Postpartum General Measures

  1. Transfer to postpartum ward when stable
  2. Vital Signs
    1. Obtain hourly for 4 hours, then every 4 hours for 24 hours, then every 8 hours
    2. Uterine massage at time of Vital Signs and report excessive lochia
    3. Monitor intake and output every 4 hours for 24 hours
  3. Activity
    1. Patient may be up as able and encouraged to ambulate three times daily
    2. Cough and deep breath hourly
  4. Drains and Tubes
    1. Foley Catheter to closed drainage
    2. Discontinue Foley Catheter on first postoperative morning or when ambulating well
  5. Early Solid Diet Protocol
    1. Initiate after Nausea resolves
    2. Solid food within 8 hours of uncomplicated C-Section
      1. Contrast with older, standard diet of NPO for 8 hours then advance
    3. Well tolerated and resulted in faster bowel function return
    4. Shortened hospital stay by 24 hours
    5. Patolia (2001) Obstet Gynecol 98:113-6 [PubMed]
  6. Contact physician for
    1. Temperature > 100.4
    2. Systolic Blood Pressure <90 mmHg or >140 mmHg
    3. Diastolic Blood Pressure >90 mmHg or <50 mmHg
    4. Heart Rate >130 or <60
    5. Respiratory Rate >32 or <8
    6. Urine Output
      1. Foley Catheter in place: <60 cc in 2 hours
      2. Intermittent Urine collection: <300 cc per shift
  7. Dressing care
    1. Remove abdominal dressing after 24 hours

IX. Management: Postpartum Medications

  1. Intravenous Fluids
    1. Initial: D5LR with 20 units Pitocin per liter administered 1 L/hour for 2 hours
    2. Maintenance: D5LR at 125 cc/hour
    3. Saline lock IV when tolerating fluids
    4. Discontinue IV when if no signs of Postpartum Hemorrhage
  2. Antibiotic prophylaxis (all patients undergoing Cesarean Section)
    1. Reduces postpartum infection rate from 85% to 5%
    2. Cefazolin (Ancef) 1 gram IV after Umbilical Cord clamped for single dose OR
    3. Ampicillin 2 g IV after Umbilical Cord clamped for single dose
  3. Nausea
    1. Ondansetron (Zofran) 4-8 mg orally every 4-6 hours as needed
  4. Initial Parenteral analgesia
    1. Patient-controlled analgesia (PCA)
      1. Morphine 1 mg bolus with 6 minute lockout, max of 10 mg hourly, and optional 1 mg/h infusion
      2. Dilaudid 0.1 mg bolus with 6 minute lockout, max of 1.5 mg hourly, and optional 0.1 mg/h infusion
    2. Intermittent dosing
      1. Morphine 2-4 mg IV every 1-2 hours as needed
      2. Dilaudid 0.2 to 0.5 mg every 1-2 hours as needed
  5. Later analgesia
    1. Ibuprofen 600-800 mg orally every 6-8 hours with scheduled dosing for the first several days
    2. Acetaminophen-Hydrocodone (Vicodin) 325/5 mg orally every 6 hours as needed
    3. Acetaminophen-Oxycodone (Percocet) 325/5 mg orally every 6 hours as needed for pain
  6. Immunizations (if indicated, prior to discharge)
    1. RubellaVaccine 0.5 cc SQ
    2. Hepatitis B Vaccine
    3. Tdap Vaccine
  7. Mother Rh Negative
    1. Blood Type and Indirect Coombs
    2. Cord blood sent to lab
    3. RhoGAM indicated for Rh Positive infant
  8. Other Medications
    1. Iron Sulfate dosing based on Postpartum Anemia
    2. Prenatal Vitamin orally daily
    3. Colace 100 mg PO twice daily or 200 mg orally at bedtime

X. Management: VTE Prophylaxis after cesarean

  1. Low risk protocol: Early ambulation
    1. Uncomplicated pregnancy and cesarean delivery and no additional risk factors
  2. Moderate risk protocol: Low Molecular Weight Heparin OR Compression Stockings
    1. Age over 35 years old
    2. Body Mass Index (BMI) > 30
    3. More than three deliveries (Parity)
    4. Significant varicosities
    5. Current infection or major illness
    6. Pregnancy Induced Hypertension
    7. Immobility for >4 days after surgery
    8. Emergency cesarean delivery
  3. High risk protocol: Low Molecular Weight Heparin OR Compression Stockings
    1. More than two risk factors from the moderate risk indications
    2. Cesarean Hysterectomy
    3. Previous Deep Vein Thrombosis or Hypercoagulable state
  4. References
    1. Marik (2008) N Engl J Med 359(19): 2025-33 [PubMed]

XI. Complications: Immediate and early postoperative complications

  1. Infection (within first 10 days of delivery)
    1. Postpartum Endometritis
      1. Presents with fever (two >100.0 F), Leukocytosis and uterine tenderness >24 hours after delivery
      2. Treated with broad spectrum IV Antibiotics (e.g. Gentamicin and Clindamycin)
    2. Urinary Tract Infection
      1. Common after indwelling Urinary Catheter
    3. Infected wound dehiscence (see below)
  2. Wound dehiscence (5%)
    1. Wound Infection (66% of wound dehiscense sites)
      1. Presents with erythema, tenderness, purulent drainage, fever
      2. Start broad spectrum oral Antibiotics
      3. Consult surgery for possible wound exploration and packing
    2. Facial dehiscence (6% of dehiscence sites)
      1. Presents with large amounts of discharge and possibly bowel protrusion
      2. Cover bowel with sterile moist gauze
      3. Emergent surgical Consultation
  3. Gastrointestinal complications
    1. Ileus
    2. Small Bowel Obstruction
  4. Vascular complications
    1. Thromboembolism
      1. Three to five fold increased risk after Cesarean Section (compared with Vaginal Delivery)
      2. See VTE prevention above
    2. Septic Thrombophlebitis
      1. Clinical diagnosis with fever, no source and typically normal Ultrasound
  5. Maternal Mortality
    1. Intraoperative complications account for 50% of mortality
      1. Other causes include Pulmonary Embolism, Amniotic Fluid Embolism, Postpartum Hemorrhage
      2. Pregnancy Induced Hypertension is also responsible for perioperative mortality
    2. Primary Cesarean Section: 8 per 100,000 births
    3. Elective repeat Cesarean Section: 13.4 per 100,000 births

XII. Prevention: Primary Cesarean

  1. Childbirth classes
  2. Induction of labor should be based on standard indications (not convenience)
  3. Avoid Amniotomy prior to active labor
  4. Continuous Labor Support (e.g. doula)

XIII. Disposition

  1. Staple Removal
    1. Horizontal incision
      1. Remove staples on Day 3-4 and place tape strips (e.g. steri-strips)
    2. Vertical incision
      1. Remove staples on Day 5-7
  2. Home instructions
    1. No specific lifting, stair climbing or Exercise restrictions
      1. Exercise caution with straining (valsalva), forceful coughing and rising from supine position
      2. Pre-Cesarean Section Exercise levels may be resumed as tolerated
    2. Driving has no specific limitations
      1. Avoid driving after taking Opioid Analgesics
      2. Avoid driving until steering and use of the brake does not exacerbate pain
    3. Vaginal intercourse may be initiated when comfortable
      1. Vaginal Lubricants are recommended
    4. Return to work
      1. No fixed timing for return to work
      2. Gradual return is recommended
  3. Follow-up in clinic
    1. Status post Cesarean Section at 2 weeks
    2. Postpartum visit at 6 weeks

XIV. References

  1. Quinlan (2015) Am Fam Physician 91(3): 178-84 [PubMed]

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