Module on “Caesarean section (Part-3)” by Dr. Vishwesh BN

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POSTOPERATIVE CARE FOLLOWING A CESAREAN SECTION

Postoperative care: Aims are:

(i) Support to restore patient’s physiological functions

(ii) Promote tissue healing

(iii) Prevention/management of complications.

Good postoperative care team involves surgical team, nursing staff, physiotherapists and dieticians.

Immediate postoperative care

On return from the theatre the patient is taken to the recovery room or ward which is usually placed adjacent to the operation suite. Patient is accompanied by a responsible person—doctor or nursing staff. The prerequisites prior to shifting include Vital signs such as pulse, respiration and blood pressure become steady. Patient recovers from anesthesia and is fully conscious. Anesthetist’s consent should be available. Fluid balance and any bleeding from the surgical site are checked.

In the Ward- First 24 hours:

Placement in the bed: The patient is gently placed on her side in the bed. This reduces the risk of inhalation of vomitus or mucous. If spinal anesthesia is given, the foot end is raised for about 12 hours.

Observation: The observation of the vital signs such as pulse, respiration and blood pressure is made half hourly in the initial period. The interval is gradually increased if these are found steady. Attention should be paid for any bleeding from the operated site.

Fluid replacement: Following any major operation fluid is replaced intravenously. The amount of fluid to be replaced is decided upon the following factors like intraoperative blood loss, operating time, urine output and the volume of fluid already replaced. Blood transfusion, if needed is given during operation and soon after. Blood transfusion should not be given unnecessarily. Urine output of at least 30 mL/hour indicates adequate fluid replacement.

On an average, after replacement of the fluid loss at operation, additional 2–2.5 liters of fluid are infused. As there is sodium retention following major surgery, the replacement is by 5 percent dextrose in water along with 0.5 to 1 liter of Ringer’s solution.

Pain control: Adequate pain control ensures deep breathing, adequate oxygenation, early mobilization; prompt wound healing, reduced pulmonary complication and less hospital stay.

Liberal analgesics should be given to relieve pain and to ensure sleep. A sedative is prescribed at night. For this purpose, intramuscular injection of pethidine hydrochloride 100 mg or morphine sulfate 10 mg is administered at an interval of 6–8 hours. Nonsteroidal anti-inflammatory agents are also effective analgesics. Nausea or vomiting may be prevented by simultaneous administration of metoclopramide 10 mg or ondansetron 4 mg IM/IV.

Antibiotics: Perioperative prophylactic antibiotics as mentioned in preoperative care are to be considered. Alternatively, routine postoperative antibiotics are prescribed. This should be administered parenterally for 48 hours followed by oral route for another 3 days.

Bladder care: Usually a Foley’s catheter is inserted before the operation. It keeps the bladder empty through- out and reduces the risk of any bladder injury. It helps to monitor urine output, reduces the risk of urinary retention and pain. Generally, it is removed on third postoperative day. Prolonged catherization is associated with urinary tract infection. Catheter is kept for 7–10 days in patients having any injury to the bladder. Following removal of catheter, postoperative urinary retention is a common problem. This is due to pain, spasm of the pelvic floor muscles, tissues edema or following regional anesthesia. Residual urine is measured after micturition with ultrasound scan or by a catheter. Recatheterization should be done if the residual urine is >100 mL. Catheter may have to be kept for 24–48 hours.

Mobilization:

The patient should be encouraged to move freely in bed and to lie in any posture comfortable to her. Deep breathing and movements of the legs and arms are encouraged to minimize leg vein thrombosis and pulmonary embolism. It is advantageous to allow the patient to sit or to stand by the side of the bed by the evening. The patient can have sips of water to relieve the thirst.

First postoperative day

General care: The patient is expected to look better and fresh. Vital signs are noted at least twice daily. Abdominal auscultation is done for appearance of peristaltic sounds. Enquiry is to be made about the passage of flatus. Vaginal plug (if any) is to be removed early in the morning. The patient is encouraged to stand or to walk few steps by the side of the bed and to sit on the bedside or on a chair. Deep breathing exercises and leg and arm movements while on bed are encouraged.

Diet: Oral feeding in the form of plain or electrolyte water is given in small but frequent intervals. With the appearance of bowel sounds or passage of flatus, full liquid diet is prescribed. However, early postoperative feeding is safe.

Sedative and analgesics: Parenteral analgesics are gradually replaced with oral drugs (paracetamol, aspirin and NSAIDs) in combination.

Second postoperative day and henceforth:

The patient feels comfortable and looks fresh. She moves around in the room and goes to toilet. Light solid diet of patient’s choice is given. Self-retaining catheter is removed.

Third and fourth postoperative days. Daily observation of vital signs twice daily is to be done as a routine. The diet is gradually brought to her normal. The bowels usually move normally, otherwise low enema or suppository may be given. The abdominal stitches are usually removed on the 5th day in transverse incision and on 6th day in vertical incision. The stitches are to be removed in early morning with the patient in empty stomach. The precaution is taken, so that emergency repair of the wound can be done, if burst abdomen occurs.

Discharge: There is a trend towards shorter hospital stay these days. But complete recovery of all organ functions is needed before discharge. It may take 5–7 days when she is fit for discharge. Written information is given to the patient as regard the operative procedures.

While an uniform guideline is difficult to formulate, in an otherwise uneventful postoperative recovery, the patient may be discharged by 5–7 days following operation.

Examination Prior to discharge

Abdominal wound is to be thoroughly checked for evidences of sepsis, hematoma or dehiscence. Vaginal discharge is to be noted. If the discharge is offensive, gentle vaginal exploration by a finger should be done to exclude a foreign body (gauze piece).

COMPLICATIONS OF CESAREAN SECTION

The complications are related either due to the operations (inherent hazards) or due to anaesthesia.  The complications are grouped into:  Maternal and Fetal

The maternal complications may be: Intraoperative or Postoperative

Intraoperative Complications

  • Extension of uterine incision to one or both the sides. This may involve the uterine vessels to cause severe haemorrhage, may lead to broad ligament hematoma formation.
  • Uterine lacerations at the lower uterine incision—may extend laterally or inferiorly into the vagina.
  • Bladder injury—is rare in a primary CS but may occur in a repeat procedure.
  • Ureteral injury is rare. Injury occurs during control of bleeding from lateral extensions.
  • Gastrointestinal tract injury is rare unless there is a prior pelvic/abdominal adhesion.
  • Hemorrhage may be due to uterine atony or uterine lacerations.
  • Morbid adherent placenta (placenta accreta) is commonly seen in cases with placenta previa who had prior cesarean delivery. Total hysterectomy is often needed for such a case to control hemorrhage.

Postoperative Complications

Maternal: Immediate or Remote

Immediate

  • Postpartum hemorrhage: The blood loss in cesarean section is more often underestimated. It is mostly related to uterine atony but blood coagulation disorders may rarely occur.
  • Shock: While most often it is related to the blood loss, it may occur when the operation is done following prolonged labor without correcting preexisting dehydration and ketoacidosis.
  • Anesthetic hazards: These are mostly associated in emergency operations. The hazards are related to aspiration of the gastric contents. The result may be aspiration atelectasis or aspiration pneumonitis . Others are hypotension and spinal headache.„
  • Infections: The common sites are uterus (endomyometritis), urinary tract, abdominal wound, peritoneal cavity (peritonitis) and lungs. Septic pelvic thrombophlebitis may be associated with endometritis. Risk factors for infection are prolonged duration of labor and that of rupture of membranes, repeated number of vaginal examinations. Prophylactic antibiotics reduce the risk signifcantly.
  • Intestinal obstruction: The obstruction may be mechanical due to adhesions or bands, or paralytic ileus following peritonitis. Deep vein thrombosis and thromboembolic disorders are more likely to occur following cesarean section than vaginal delivery. Septic thrombophlebitis is also a known complication.
  • Wound complications: Abdominal wound sepsis is quite common. The complications, which are detected on removal of the skin stitches, are: (1) sanguineous or frank pus (2) hematoma (3) dehiscence (peritoneal coat intact) (4) burst abdomen (involving the peritoneal coat) and (5) rarely necrotizing fasciitis.
  • Secondary postpartum hemorrhage.

Remote: Gynecological ,General surgical and Future pregnancy

Gynecological:

  • Menstrual excess or irregularities, chronic pelvic pain or backache.

General surgical:

  • Incisional hernia, intestinal obstruction due to adhesions and bands.

Future pregnancy:

  • There is risk of scar rupture.

FETAL:

Iatrogenic prematurity and development of RDS is not uncommon following cesarean

delivery. This is seen when fetal maturity is uncertain. Accidental scalpel injury to the baby may occur.

Maternal and perinatal mortality:

Maternal: The causes of death are:

(1) Hemorrhage and shock

(2) Anzesthetic hazards

(3) Infection

(4) Thromboembolic disorders.

Fetal: The causes of death are:

(1) Asphyxia may be preexisting

(2) RDS

(3) Prematurity

(4) Infection

(5) Intracranial hemorrhage— attempting breech delivery through a small incision.

Cesarean hysterectomy:

Cesarean hysterectomy refers to an operation where cesarean section is followed by removal of the uterus. The common conditions are:

(1) Morbid adherent placenta

(2) Atonic uterus and uncontrolled postpartum hemorrhage

(3) Big fibroid (parous women)

(4) Extensive lacerations due to extension of tears with broad ligament hematoma

(5) Grossly infected uterus

(6) Rupture uterus.

Peripartum hysterectomy is the surgical removal of the uterus either at the time of cesarean delivery or in the immediate postpartum period. Subtotal hysterectomy is commonly done as an emergency (unplanned) procedure. Benefits of subtotal hysterectomy are:  Less operating time, less blood loss, less risk of injury to other organs (bladder, ureter) and less postoperative morbidity.

Questions/ Assessment:

  1. What are the prerequisites before a patient of caesarean delivery is shifted fom the OT?

The prerequisites prior to shifting include – Vital signs such as pulse, respiration and blood pressure become steady. Patient recovers from anesthesia and is fully conscious. Anesthetist’s consent should be available. Fluid balance and any bleeding from the surgical site are checked.

  1. What is the normal protocol followed for the fluid replacement following a caesarean delivery?

Following any major operation fluid is replaced intravenously. The amount of fluid to be replaced is decided upon the following factors like intraoperative blood loss, operating time, urine output and the volume of fluid already replaced. Blood transfusion, if needed is given during operation and soon after. Blood transfusion should not be given unnecessarily. Urine output of at least 30 mL/hour indicates adequate fluid replacement.On an average, after replacement of the fluid loss at operation, additional 2–2.5 liters of fluid are infused. As there is sodium retention following major surgery, the replacement is by 5 percent dextrose in water along with 0.5 to 1 liter of Ringer’s solution.

  1. How is pain controlled following a caesarean delivery?

Adequate pain control ensures deep breathing, adequate oxygenation, early mobilization; prompt wound healing, reduced pulmonary complication and less hospital stay. Liberal analgesics should be given to relieve pain and to ensure sleep. A sedative is prescribed at night. For this purpose, intramuscular injection of pethidine hydrochloride 100 mg or morphine sulfate 10 mg is administered at an interval of 6–8 hours. Nonsteroidal anti-inflammatory agents are also effective analgesics.

  1. Comment on the antibiotic coverage following a caesarean delivery.

Perioperative prophylactic antibiotics as mentioned in preoperative care are to be considered. Alternatively, routine postoperative antibiotics are prescribed. This should be administered parenterally for 48 hours followed by oral route for another 3 days.

  1. How is the bladder care done during a caesarean delivery?

Usually a Foley’s catheter is inserted before the operation. It keeps the bladder empty through- out and reduces the risk of any bladder injury. It helps to monitor urine output, reduces the risk of urinary retention and pain. Generally, it is removed on third postoperative day. Prolonged catherization is associated with urinary tract infection. Catheter is kept for 7–10 days in patients having any injury to the bladder. Following removal of catheter, postoperative urinary retention is a common problem. This is due to pain, spasm of the pelvic floor muscles, tissues edema or following regional anesthesia. Residual urine is measured after micturition with ultrasound scan or by a catheter. Recatheterization should be done if the residual urine is >100 mL. Catheter may have to be kept for 24–48 hours.

6. Name some Intraoperative Complications of a caesarean delivery.

Extension of uterine incision involving the uterine vessels to cause severe haemorrhage, Uterine lacerations at the lower uterine incision, Bladder injury, Ureteral injury , rarely gastrointestinal tract injury or hemorrhage due to uterine atony or uterine lacerations and morbid adherent placenta requiring a total hysterectomy.

7. Name some Immediate maternal postoperative complications following a caesarean delivery.

Postpartum hemorrhage, shock, anesthetic hazards like hypotension, spinal headache etc, infections of the uterus, urinary tract, abdominal wound, peritoneal cavity etc intestinal obstruction, Septic thrombophlebitis etc are some of the Immediate maternal postoperative complications following a caesarean delivery.

8. What are certain Wound complications following a caesarean delivery?

Abdominal wound sepsis is quite common. The complications, which are detected on removal of the skin stitches, are sanguineous or frank pus, hematoma,dehiscence (peritoneal coat intact), burst abdomen (involving the peritoneal coat) and rarely necrotizing fasciitis.

9. What are the causes of Maternal and perinatal mortality following a caesarean delivery?

Some causes of Maternal death are hemorrhage and shock, anzesthetic hazards,  infection, thromboembolic disorders etc and of Fetal death include asphyxia , RDS, Prematurity, Infection  or Intracranial hemorrhage during the process.

Reading Resources/ References:

  1. Sung S, Mahdy H. Cesarean Section. [Updated 2020 May 5]. In: StatPearls [Internet]. Treasure Island (FL): Stat Pearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK546707
  2. Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for cesarean delivery. Am. J. Obstet. Gynecol. 2005 Nov;193(5):1607-17.
  3. Cecilia Bottomley and Janice Rymer. 100 cases in Obstetrics and Gynaecology. 2nd edition. Series editor: Janice Rymer. CRC Press: Taylor & Francis Group; 2015.
  4. Andrew T. Raftery, Michael S. Delbridge, Marcus J.D. Wagstaff and Katherine I. Bridge, Editors: Churchill’s Pocketbooks Surgery. 5th Elsevier; 2017
  5. Hiralal Konar Editor: Textbook of DC Dutta’s obstetrics. 8th New Delhi: Jaypee Brothers Medical Publishers; 2015.
  6. Hiralal Konar Editor: Dutta’s Bedside Clinics and Viva-Voce in Obstetrics and Gynecology. Sixth Edition. New Delhi: Jaypee Brothers Medical Publishers; 2016.
  7. Sakshi Arora. Pre Neet Obstetrics and Gynaecology. First Edition. New Delhi: Jaypee  Brothers Medical Publishers; 2013.
  8. Narendra Malhotra, Pratap Kumar, Jaideep Malhotra, Neharika Malhotra Bora and Parul Mittal M. Revised and updated. Jeffcoate’s Principles Of Gynaecology. Eighth Edition New Delhi: Jaypee Brothers Medical Publishers; 2014.
  9. Sarala Gopalan, S.Rathnakumar and Vanita Jain editors. Mudaliar and Menons Clinical Obstetrics. 7th Revised Edition. Orient Longman, Bombay.
  10. Keith Edmonds. Editor .Dewhurst’s Textbook of Obstetrics & Gynaecology. Seventh edition, Blackwell Publishing; 2007.

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