Description: Cesarean section (C-section) is the delivery of the fetus through a horizontal or, less commonly, through a vertical incision in the lower uterine segment. The skin incision is made either as a Pfannenstiel’s (transverse in the crease above the pubis), a Maylard (in extremely obese patients), or vertical midline from umbilicus to pubis. The peritoneal cavity is entered as in any laparotomy. A retractor is placed inferiorly, and the reflection of visceral peritoneum from the bladder dome to the anterior lower segment of the uterus (bladder flap) is incised and may be displaced inferiorly, along with the bladder. The uterus is entered sharply and the incision extended with digital pressure and/or bandage scissors. The fetal head is elevated out of the pelvis and delivered through the uterine incision. In cases of nonvertex lie, the infant’s breech or foot is grasped and brought out of the incision. After the delivery of the fetus, the cord is double-clamped and cut, and cord blood is obtained for analysis. The placenta is removed manually and the uterine cavity cleared of all debris and clots. The uterine incision is closed with a running, interlocking stitch, followed by a 2nd imbricating layer. The bladder flap and parietal peritoneum do not require closure and the rectus muscles do not routinely require re-approximation. Finally, the fascia is closed and the skin reapproximated with staples. Classic C-section usually involves a fundal vertical uterine incision (Fig. 8.3-1). Patients with a history of prior classical C-section should be delivered abdominally via a repeat C-section, because their risk of uterine rupture with labor and vaginal delivery is ˜12%.
Usual preop diagnosis: Failure to progress in labor; elective repeat C-section; fetal distress; malpresentation
Supine with left lateral tilt. (In obese patients, the pannus may be lifted superiorly by tape or towel clips or inferiorly for a supraumbilical incision.)
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Incision
Skin: transverse low abdominal (Pfannenstiel’s) or repeat vertical. Uterus: transverse (Kerr) or low vertical (for premature infants or nonvertex lie)
Skin: Pfannenstiel’s or, more commonly, vertical midline. Uterus: vertical fundal
Special instrumentation
Bladder blade retractor; small ring forceps; bandage scissors; suction bulb; DeLee suction trap (if meconium)
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Unique considerations
[check mark] fetal heart tones before procedure. If for CPD: vaginal exam within last 15 min before procedure. If for fetal distress: continuous monitoring until skin incision.
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Antibiotics
If in labor or membranes ruptured: continue prophylactic antibiotics or cefazolin 1-2 g iv (prior to incision or 30 min prior to delivery)
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Surgical time
20-90 min
40-90 min
Closing considerations
Low transverse: closed in 2 layers. Low vertical: 2 layers; may require additional operative time for control of incision bleeding or repair of incision extension into cervix.
3-layer closure requires additional time.
EBL
750-1000 mL
1000-2000 mL
Postop care
Observation for bleeding and ↓ BP
Special attention to VS needed due to additional blood loss.
Mortality
< 0.1%
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Morbidity
Infection:
Not in labor: < 5%
In labor/ruptured membranes: 50% (antibiotics reduce incidence to 15%)
(Procedures covered: C-section; emergent obstetrical hysterectomy; repair of uterine rupture)
PREOPERATIVE
In general, patients are young and healthy, although the pregnant patient has undergone profound physiologic changes that affect the administration of anesthesia. Women present for C-section for a multitude of reasons, including failure to progress in labor, repeat cesarean delivery, breech presentation, and also for emergency cesarean delivery for nonreassuring fetal heart rate tracing and/or hemorrhage (placenta previa, abruptio placenta, and, rarely, uterine rupture).
Respiratory
The pregnant patient has a compensated respiratory alkalosis (PCO2 = 32-34), ↑ minute ventilation (MV; ↑ 50%), and ↓ FRC (↓ 20%). ↑ O2 consumption (↑ 20%) with ↓ FRC results in rapid onset of hypoxemia if ventilation is compromised. Small airway closure due to elevation of diaphragm (exaggerated by obesity and supine position) can → VQ mismatch and ↓ PaO2. ↑ MV and ↓ FRC enhance uptake of inhalational anesthetics. Mucosal capillary engorgement in upper airways may necessitate a smaller ETT and mandates careful airway suctioning to avoid bleeding. Avoid any nasal airways. Airway changes can occur in labor and necessitate an airway evaluation just prior to administration of anesthesia.
Tests: As indicated from H&P
Cardiovascular
Typically, there is a ↓ SVR (↓ 15%), ↓ diastolic pressure and ↓ MAP (↓ 15%) with ↑ HR (↑ 20%) and ↑ CO (↑ 30-40%, higher in multifetal pregnancy, higher in labor). Use left uterine tilt (15°) to minimize aortocaval compression and supine hypotension. Immediately postpartum, 600-800 mL blood enters the central circulation, due to placental autotransfusion, with further ↑ in CO.
Tests: As indicated from H&P
Hematologic
These patients have ↑ red cell mass (↑ 300-400 mL), ↑ plasma volume (↑ 1200-1300 mL), ↑ blood volume (↑ 1500-1600 mL), ↑ more with multifetal pregnancy. WBC count may ↑ to 15,000/mm3. Iron deficiency anemia often is superimposed on the dilutional anemia of pregnancy (Hct 33%). The typical blood loss of 700-1000 mL is usually well tolerated. Excessive blood loss is possible with uterine atony, multiple gestation, previous C-section, PIH, placenta previa, abruptio placenta, and prolonged labor. Repeat C-section associated with placenta previa poses high risk for hemorrhage because of increased risk for associated placenta accreta.
Tests: Hgb/Hct
Gastrointestinal
Abnormalities, including ↑ intragastric pressure, ↓ esopageal spinchter tone, and ↓ gastric motility (after onset of labor), predisposes to aspiration pneumonitis. All parturients should be considered to have full stomachs and should receive nonparticulate antacid (e.g., 0.3 M Na citrate 30 mL) immediately prior to general or regional anesthesia. Administer iv metoclopramide 10 mg and ranitidine 150 mg or famotidine 20 mg before all C-sections.
Hepatic
Liver enzymes can be mildly elevated, alkaline phosphatase is elevated from placental source, and plasma protein concentration is diminished (↑ unbound drug levels).
Tests: As indicated from H&P
Renal
These patients have ↑ renal blood flow (↑ 50%), ↑ GFR, and ↑ creatinine clearance, and ↓ serum creatinine and ↓ BUN. Dependent edema results from increased water and Na+ retention 2° resetting of the osmotic threshold for thirst and vasopressin secretions.
Tests: As indicated from H&P
Laboratory
T&S maternal blood if risk factors for blood loss are present (e.g., third C-section). Routine cross-match unnecessary unless significant blood loss is anticipated. Routine autologous blood donation is not recommended. Coagulation studies and Plt count recommended with PIH, abnormal placentation, heavy maternal bleeding. BUN, Cr, UA, and fasting blood glucose; others as indicated from H&P.
Premedication
Agents to decrease risk of aspiration pneumonitis include a nonparticulate antacid (e.g., Na citrate 30 mL po), ranitidine 150 mg iv and metoclopramide 10 mg iv. Sedatives are not routinely administered. In extremely anxious patients, however, 0.5-1.0 mg midazolam iv is an excellent anxiolytic, without apparent effect on maternal memory or alertness or neonatal condition.
SPECIAL CONSIDERATIONS
Pregnancy-induced hypertension (PIH)
PIH is characterized by generalized vasoconstriction with relative intravascular volume depletion and, occasionally, diffuse capillary leak. There may be ↑ risk of hypotension with regional anesthesia. Cautious hydration prior to regional anesthesia is necessary to prevent hypotension or pulmonary edema. Hepatic dysfunction may be present (HELLP syndrome). Epidural, spinal, and combined spinal-epidural (CSE) are all considered safe techniques in PIH assuming normal Plt count. Cardiovascular stability is better with regional than GA, provided intravascular volume is adequate. Abnormal coagulation (↓ Plt count or dysfunctional Plt) contraindicates regional anesthesia. If GA is necessary, it is vital that precautions are taken to ↓ laryngoscopic hypertensive response. Use supplementation along with RSI technique; lidocaine (1 mg/kg), emolol (1-2 mg/kg), and/or remifentanyl (0.5-1 mg/kg). Labetalol (20 mg) or hydrolazine (5-10 mg) can be used, but beware of onset times (< 5 min and 5-15 min, respectively), so choose drugs appropriate to urgency. There is a potential for difficult intubation in PIH due to airway edema; therefore, a small ETT (6.0 mm) should be available. MgSO4 potentiates neuromuscular blocking agents; avoid defasciculating dose of muscle relaxant before induction, use smaller than normal doses of nondepolarizing agents, and monitor neuromuscular function. MgSO4 may potentiate hypotension and increase vasopressor requirements.
Tests: PT; PTT; Plt; TEG or bleeding time; LFTs
Eclampsia
Treat eclamptic Sz with adequate oxygenation and a small dose of either midazolam (2 mg) or propofol (20-40 mg). Intubate if necessary to protect airway. Initiate MgSO4 therapy (loading dose: 4-6 g iv over 20 min; then infuse @ 1-2 g/h). If 2nd seizure occurs during maintenance dose (rare); can administer 2nd bolus dose of 2 g over 5 min.
Massive maternal hemorrhage:
• Placenta previa
• Abruptio placenta
• Ruptured uterus
Administer massive transfusion protocol (MTP) available at institution. Insert 2 large-bore iv catheters (14-16 ga) and consider sending Hg/HCT and coagulation studies. Ensure immediate availability of cross-matched blood and if unavailable consider uncross-matched or O-negative blood. Rapidly restore intravascular volume with crystalloid, colloid, or both until blood is available. If bleeding continues, administer MTP, consisting of a transfusion of PRBC, plasma, and platelets. Induction with either ketamine (1-1.5 mg/kg) or etomidate (0.2-0.6 mg/kg) is preferred in hypovolemic or unstable patients. DIC and dilutional coagulopathy may follow abruptio placenta, amniotic fluid embolism, massive blood loss, and resuscitation. A ratio of RBC:FFP:PLT of 6:4:1 or RCB:FFP of 1:1 is currently recommended during massive transfusion.
Uterine atony is treated with oxytocin 20-40 U/L in NS @ rate sufficient to control atony (250-500 mL/h). Small boluses 1-2 U are appropriate, but avoid larger doses (risk of ↓ BP); alternatively, methylergonovine, 0.2 mg im (risk of HTN), Carboprost Tromethamine (Hemabate®; a synthetic analog of PGF2x), 0.25 mg im or intramyometrially (risk of pulmonary HTN, bronchospasm) or misoprostol (600 mg buccal or 1000 mg PR). Uterine artery embolization may be effective in controlling continued postpartum bleeding and may be considered before surgical artery ligation or hysterectomy. Emergency hysterectomy, however, may be the only solution to continued bleeding. Induction of GA may be necessary if massive bleeding occurs during regional anesthesia.
Diabetes
Diabetic patients have an increased propensity to ↓ BP following regional anesthesia. Determine blood glucose hourly and maintain at 80-100 mg/dL. Insulin requirements decrease drastically after delivery, and insulin dosage must be reduced to prevent maternal hypoglycemia.
Tests: Fasting blood glucose; UA
Response to anesthetic drugs
In pregnant patients, MAC is ↓ 30% for inhaled agents; combined with more rapid uptake, this predisposes to anesthetic overdose. Sensitivity to local anesthetics also is increased. Epidural space capacity is decreased 2° engorgement of epidural veins; this decreases requirements for local anesthetics and increases possibility of intravascular injection of drugs. Increased sensitivity to nondepolarizing muscle relaxants (especially in patients receiving MgSO4) mandates careful monitoring and use of reduced doses. Decreased protein binding may increase toxicity of highly protein-bound drugs such as bupivacaine.
INTRAOPERATIVE
Anesthetic technique: Regional (neuraxial) anesthesia has a number of materno-fetal advantages (↓ maternal morality, ↓ risks of aspiration, participation in childbirth, better pain control) than GA. Anesthetic choice in specific circumstances depends on maternal and fetal conditions and degree of urgency. Properly conducted GA or regional anesthesia probably are equally safe for the fetus.
Spinal anesthesia is preferred for elective or semielective C-section (unless patient has an existing epidural) when no contraindications to regional anesthesia exist (e.g., patient refusal, coagulopathy, active neurological disease, elevated ICP, hypovolemia, infection at site of insertion). With the use of a pencil-point needles (e.g., Sprotte, Whitacre), the risk of headache is low (0.5-2%). Advantages of spinal over epidural anesthesia include technical ease, rapid onset of block, and more reliable anesthesia. ↓ BP, however, is more common with spinal anesthesia. Fluid (1-1.5 L crystalloid/500 mL colloid) preloading or coloading (at time of the spinal), leg wrapping (e.g., compression stockings), and vasopressors infusions (phenylephrine 25-50 mcg/min) reduce the incidence and severity of ↓BP, but do not eliminate it. Additional boluses of vasopressors (e.g., phenylephrine [50-100 mcg] or ephedrine [5-10 mg]), should be used as appropriate to treat ↓ BP. Phenylephrine should be considered the vasopressor of choice due to its rapid onset, efficacy in treating ↓ SVR, and limited placental transfer. Ephedrine may be associated with ↑ fetal acidosis. Atropine (0.4 mg iv) should be used to treat ↓ HR. Consider using epinephrine (50-100 mcg iv) if other vasopressors are unsuccessful in reversing severe ↓ BP or profound ↓ HR.
General anesthesia normally is used when regional anesthesia is contraindicated or when there is inadequate time to institute regional blockade. Obstetric emergencies for which rapid induction of GA may be indicated include severe maternal hemorrhage, prolapsed umbilical cord, severe fetal bradycardia, severe persistent fetal decelerations, or the need for intrauterine manipulation. Less dire situations often permit the performance of a quickly placed spinal or extension of a functioning epidural block with an agent having a rapid onset (e.g., 15-20 mL 3% 2-chloroprocaine or 2% lidocaine with epinephrine 1:200,000 and bicarbonate). Continuous monitoring of the fetal heart rate (FHR) in the OR may allow use of regional anesthesia if the FHR tracing is reassuring. Constant communication with the obstetrician regarding maternal and fetal condition is essential. Although situations exist in which a GA is preferable to regional, the risks must be weighed against the benefits for patients with greater potential for complications. If difficult intubation is anticipated, rapid-sequence induction of GA with cricoid pressure should not be undertaken. Alternative approaches include awake intubation, regional anesthesia, or local infiltration by the obstetrician. Sometimes, a nonreassuring FHR pattern is diagnosed as “fetal distress.” Fetal distress is an imprecise and nonspecific term with little positive predictive value. The severity of any FHR abnormality should be considered when the urgency of delivery and type of anesthesia are determined. C-section performed for a nonreassuring FHR pattern does not necessarily preclude the use of regional anesthesia.
Regional anesthesia:
Epidural
Apply monitors, fluid load, and place the patient in the sitting or lateral decubitus position. Locate the epidural space with a 17-18 ga Tuohy needle and LOR to saline (preferable) or air technique. A 3 mL test dose of 1.5-2% lidocaine (45-60 mg) with 1:200,000 epinephrine (15-20 mcg) is given through the epidural needle or catheter to exclude intravascular injection (Sx: tachycardia, palpitations, dizziness, tinnitus, new taste in mouth) or subarachnoid placement (motor/sensory block in lower extremities, rapid onset of pain relief). After 3-5 min, inject 15-20 mL 2% (300-400 mg) lidocaine with 1:200,000 epinephrine (75-100 mcg) incrementally over 5-10 min. Sodium bicarbonate, 1 mEq/10 mL lidocaine, hastens onset of block and improves the block quality, but increases risk of ↓ BP. Bupivacaine, levobupivacaine, or ropivacaine 0.5%, 15-20 mL (75-100 mg), with or without epinephrine 1:200,000 and/or fentanyl (50-100 mcg), or 2-chloroprocaine (450-600 mg) or 2% lidocaine with epinephrine should produce adequate surgical anesthesia within 5-10 min.
Left uterine displacement is best achieved by evaluating the right hip with a wedge or towel. Administer O2 by mask or nasal cannula, and continue to monitor FHR prior to abdominal prep. Monitor BP every min until stable, then every 3-5 min. Treat ↓ in BP with further uterine displacement, additional fluids, and vasopressors as outlined earlier. Maintain BP at baseline levels to optimize placental perfusion. For inadequate anesthesia, give additional epidural local anesthetic, 50-100 mcg fentanyl iv or epidurally, 50% N2O/O2, ketamine 10-20 mg iv, midazolam 1-2 mg iv, and/or infiltrate with local anesthetic. The patient must remain conscious to avoid risk of aspiration. If anesthesia is still inadequate, induce GA (see below).
After delivery of infant and placenta, rapidly infuse oxytocin 10-20 U/hr. Monitor for excessive blood loss, recognizing that significant blood loss can occur quickly and outside of direct observation, and is often underestimated. Chest pain, mild oxyhemoglobin desaturation, and SOB after delivery may be due to irritation of diaphragm by blood or packs, too high or inadequate level of anesthesia, or venous air or amniotic fluid embolization. Transient S-T segment changes on ECG may occur, but do not usually signify myocardial ischemia.
Spinal
Apply monitors, administer fluid, and position as for epidural anesthesia. Metoclopramide 10 mg iv, 5-10 min prior to block decreases intraop N/V. Insert 25-27-ga pencil-point needle and verify free flow of CSF. If technical difficulties or urgent situations are encountered, a larger pencil-point needle (e.g., 22-ga Sprotte) may be considered. Inject hyperbaric 0.75% spinal bupivacaine 11.25-12.0 mg (1.5-1.6 mL) ± fentanyl 10-20 mcg and preservative-free morphine 0.1-0.2 mg, and position the patient with left uterine displacement. Monitor and treat ↓ BP as for epidural. Adjust operating table position to insure a T4 level of anesthesia. If anesthesia is inadequate and time permits, consider repeating block with CSE, spinal (caution with dosing), or epidural catheter. Treat persistent inadequate anesthesia as for epidural. Induce GA if other measures fail.
Combined spinal-epidural (CSE)
An alternative technique combining the rapid onset and density of spinal anesthesia with the flexibility of continuous epidural anesthesia (e.g., if necessary to extend the duration or intensity of the block). Apply monitors, administer fluid, and position as for spinal/ epidural. The most common technique is the needle-through-needle. When the epidural space is located with a standard 17-18 ga Tuohy needle, insert a 25-27 ga pencil-point spinal needle through it and administer either a standard C-section spinal dose of bupivacaine and narcotics as described for spinal or reduced dose if indicated (e.g., repeated block after failed spinal or epidural; maternal cardiac disease or short stature). Secure the epidural catheter and use if needed. Appreciate that the epidural catheter is untested and an epidural test dose is advisable prior to dosing.
General anesthesia:
Induction
Elevate the right hip (wedge or towel) to provide left uterine displacement. Preoxygenation for 3-5 min is optimal; however, 4-8 maximal inspiratory breaths in 30 sec is a satisfactory substitute in an emergency. Head up and CPAP may improve oxygenation in obese parturients. Place patient in maximal “sniff” position (ramp patient if necessary), to optimize position for intubation. After patient is prepped and draped and obstetric team is ready to begin, perform rapid-sequence induction with cricoid pressure. Administer propofol 2-3 mg/kg (or ketamine 1-1.5 mg/kg or etomidate 0.2-0.6 mg/kg in hypovolemic or cardiovascularly unstable patients) and succinylcholine 1-1.5 mg/kg to induce GA and facilitate intubation. Inflate cuff of ETT and verify tracheal placement by ETCO2 waveform and auscultation of bilateral breath sounds.
Failed intubation
If tracheal intubation is unsuccessful, oxygenation and mask ventilation must become a priority, and numerous attempts to intubate should be avoided. Summon experienced help and quickly decide whether surgery must proceed. The risks of continuing with mask GA and cricoid pressure must be weighed against the risk of allowing the mother to awaken. If mask ventilation is impossible, quickly attempt ventilation with an LMA. If this succeeds, either continue to use throughout the case or place an ETT (6 mm ID) through LMA blindly or with FOL; alternatively, use an intubating LMA. A Pro-seal LMA has been used successfully as a rescue supraglottic airway device in this situation and may negate the necessity for ET intubation. Cricoid pressure may interfere with mask ventilation or LMA placement and should be released if necessary. If LMA fails to allow ventilation, attempt emergency transtracheal ventilation using a 12-14 ga iv catheter (or specific cricothyroid airway device) and appropriate tubing to connect to a high-pressure O2 source (e.g., jet ventilator). If these measures are unsuccessful, an emergency cricothyrotomy or tracheostomy should be performed by experienced personnel. Planning for a failed intubation must occur before it actually happens. A difficult-intubation tray, including video laryngoscopes, supraglottic airways, and equipment for emergency jet ventilation, must be immediately accessible in or very near the delivery room.
Maintenance
50% N2O/O2 with isoflurane, sevoflurane, or desflurane (limit MAC < 1.5 to prevent uterine atony). Propofol infusion for maintenance negates the uterine relaxant effect of the halogenated agents but may lead to more neonatal depression. Avoid hypocapnia during controlled ventilation which may ↓ umbilical blood flow. After delivery, NDMR rarely required, additional opioid (e.g., fentanyl 150-250 mcg) and increase volatile and N2O concentrations if necessary. Administer small doses of muscle relaxants (e.g., vecuronium 2-3 mg or rocuronium 10-20 mg) if needed. Reverse with neostigmine 0.05 mg/kg and glycopyrrolate 0.01 mg/kg or atropine 0.02 mg/kg. Consider titrating longer-acting opioids (e.g., hydromorphone 1-2 mg) for postpartum analgesia. Midazolam (1-2 mg), given after delivery, helps avoid maternal awareness, which occasionally occurs with this anesthetic technique. Consider TAP (transversus abdominus plane) blocks preemergence.
Emergence
Delay extubation until patient is fully awake and muscle strength has returned to normal.
Blood and fluid requirements
Moderate blood loss
IV: 16-18 ga × 1 (additional larger
IV access if hemorrhage)
NS/LR 1-3 L typical replacement
Infuse 1-2 L dextrose-free crystalloid (± colloid 500 mL) immediately prior to regional anesthesia. Typical blood loss = 700-1000 mL. A rapid-fluid infuser and blood warmer should be available in the event that large-volume blood transfusion is required.
Arterial BP monitoring via automated BP device, or arterial line for severe or labile HTN. CVP useful in PIH for oliguric patients unresponsive to fluid challenges. Occasionally, a PA catheter is indicated (e.g., for pulmonary edema, unresponsive oliguria).
Positioning
Left uterine displacement (blanket under right hip and/or table tilt)
Minimizes aortocaval compression.
Complications
Amniotic fluid embolism
Rare cause of hemodynamic instability, hypoxemia, and DIC. Often fatal. Rx: supportive: 100% O2, PEEP, and vasopressors. Correct Plt, clotting factors, and metabolic disturbances. CPB has been used successfully.
POSTOPERATIVE
Complications
VTE
Postpartum hemorrhage
Pregnancy and C-section increases risk of venous thromboembolism. DX: pleuritic chest pain, cough, hypoxemia, ↑ RR, ↑ HR, ↑ A-a gradient. Rx: supportive: 100% O2, volume expansion, and vasopressors. See p. B-8.
See Anesthetic Considerations for Removal of Retained Placenta, p. 855.
Pain management
Epidural: 2-4 mg (preservativefree) morphine after delivery.
Intrathecal: Morphine (preservative-free) 0.1-0.2 mg given with spinal local anesthetic.
Chloroprocaine may interfere with analgesia from epidural opioids
Common side effects include: pruritus 70%, nausea 30-40%, and, rarely, respiratory depression. Nalbuphine (5-10 mg) and naloxone (0.1-0.4 mg) are used for reversal of these side effects. Metoclopramide (10 mg iv) and/or ondansetron (4 mg iv) may be needed for persistent nausea. Risk of delayed respiratory depression in healthy patients is small; however, adequately trained nursing staff and a protocol for treatment of complications are mandatory if neuraxial opioids are used. These patients should not routinely receive sedatives or other systemic opioids for 12 h, and close monitoring of RR and level of consciousness every hour is necessary for 12 h then every 2 h for the next 12 h. Pulse oximetry and monitors of ventilation (e.g., ETCO2) should be considered in high-risk patients, including those with obstructive sleep apnea, morbid obesity, and patients receiving additional sedatives.
Parenteral opioids: iv opioids (e.g., fentanyl 50-100 mcg, hydromorphone 0.1-0.2 mg) boluses prn or PCA instituted in recovery room. NSAIDS (e.g., ketorolac): iv either in OR at end of case or in PACU or if unable to take orally post surgery. Acetaminophen: iv 1000 mg in OR or in PACU.
Oral analgesics: NSAIDs (e.g., ibuprofen) and acetaminophen around-the-clock dosing for 48-72 postcesarean. Oxycodone or Hydromorphone (or equivalent oral opioid), for breakthrough pain management. TAP block is a beneficial rescue analgesic option in select patients.
Tests
As indicated
Suggested Readings
1. American Society of Anesthesiologists Task Force on Obstetric Anesthesia: Practice guidelines for obstetric anesthesia: an updated report by the ASA Task Force on Obstetric Anesthesia. Anesthesiology 2007; 106:281-7.
2. Bloom SL, Spong CY, Weiner SJ, et al: Complications of anesthesia for cesarean delivery. Obstetric Gynecol 2005; 106:281-7.
4. Hawkins JL, Koonin LM, Palmer SK, et al: Anesthesia-related maternal mortality in the United States: 1979-2002. Obstetric Gynecol 2011; 117:69-74.
5. Ngan Kee WD, Khaw KS, Tan PE, et al: Placental transfer and fetal metabolic effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. Anesthesiology 2009; 111:506-12.
6. Rollins M, Lucero J: Overview of anesthetic considerations for cesarean delivery. British Medical Bulletin 2012; 101:105-25.
7. Silver RM, Landon MB, Rouse DJ, et al: Maternal morbidity associated with multiple cesarean deliveries. Obstetric Gynecol 2006; 107:1226-32.
8. Soltanifar S, Russell R: The National Institute for Health and Clinical Excellence guidelines for caesarean section, 2011 update: implications for the anesthetist. Int J Obstet Anesth 2012; 21:264-72.
9. Wray S, Plaat F: Regional anesthesia for caesarean section and what to do when it fails. Anesth Intensive Care Med 2007; 8(8): 320-22.
MEDICAL AND SURGICAL MANAGEMENT OF POSTPARTUM HEMORRHAGE
SURGICAL CONSIDERATIONS
Description: The most common indication for postpartum uterine devascularization and hysterectomy is intractable postpartum hemorrhage (PPH). PPH is clinically defined as any uncompensated postpartum blood loss → tissue hypoperfusion. There are four major causes of PPH: retained products of conception (POC), laceration of the genital tract, uterine atony, and coagulopathies. Inherited coagulopathies include von Willebrand’s disease, hemophilia, and factor XI deficiency. Acquired coagulopathies are most often related to thrombocytopenia 2° preeclampsia/eclampsia, hypofibrinogenemia 2° long-standing fetal demise, placental abruption, and DIC related to massive blood loss.
Postpartum blood loss can be reduced by prophylactic use of oxytocin, methylergonovine, or prostaglandins, and these same agents are used as the first line of treatment for PPH. A concentrated oxytocin infusion (e.g., 80-100 U in 500 mL over 30 min) may be used. Methylergonovine should be given im only (0.2 mg q 2-4 h up to 1 mg) because iv infusion has been reported to cause acute HTN, stroke, and Sz. Ergot derivatives are contraindicated in patients with Hx of HTN, asthma, Raynaud’s syndrome, or migraine. PGF2α (Hemabate) may be injected im (intramyometrial) at a dose of 0.25 mg, up to a total of 2 mg. Misoprostol, an inexpensive PGE, may be given rectally (up to 800 mcg).
Simultaneously, the surgeon should explore the cause of PPH and apply a specific treatment. If PPH is not controlled with treatment of uterine atony, and after volume replacement and correction of any coagulopathy, temporizing measures should be applied while preparing the patient for definitive invasive treatments. Temporizing measures include packing of uterine cavity with a long gauze and use of balloon tamponade. Extensive experience on nonpneumatic antishock garment (ASG) on nonpregnant patients is applied to postpartum patients with remarkable success in temporizing hypovolemic shock from abdominal and pelvic bleeding. ASG can be applied quickly and results in an immediate 1500-2000 mL autotransfusion. ASG should not be used with fetus in situ or thoracic site of hemorrhage. After stabilization, patient should be transferred to radiology for uterine artery embolization under fluoroscopic control where uterine arteries are selected and absorbable Gelfoam pledgets are introduced. Treatment may be repeated until bleeding is stopped. In known cases of placenta accreta, in anticipation of PPH, catheters have been placed in uterine arteries before C-section.
If selective embolization is not available or fails to stop hemorrhage, more invasive surgical intervention should be employed, including uterine compression sutures, iliac artery ligation, uterine devascularization, and hysterectomy. The decision for surgical intervention is made when other options (i.e., medical, interventional radiology) have not been successful in decreasing the hemorrhage. Volume and coagulation factor replacement should continue while proceeding with surgery.
The technique for an emergent obstetrical hysterectomy is largely similar to a hysterectomy for other indications. Of note is the engorged and prominent nature of the vessels supplying the gravid uterus. The edematous tissues surrounding the uterus are very friable and may bleed profusely if improperly manipulated. A supracervical or total hysterectomy may be performed. Through a midline or Pfannenstiel’s incision, the uterus is elevated out of the abdominal cavity. The round ligaments are clamped, transected, and ligated; and the anterior leaf of the broad ligament is incised bilaterally from the transected round ligaments to the vesicouterine reflection. The posterior leaf of the broad ligament adjacent to the uterus is entered at a level just below that of the fallopian tubes and uteroovarian ligaments. These are then clamped, transected, and ligated. Next, incision of the posterior leaf of the broad ligament toward the cardinal ligaments is performed. With gentle blunt dissection, the bladder and attached vesicouterine peritoneal flap are dissected off the lower uterine segment. The ascending uterine arteries and veins are identified bilaterally, then clamped, transected, and ligated. If a subtotal hysterectomy is planned, the body of the uterus is amputated at this level, and the cervical stump is closed with interrupted sutures. If a total hysterectomy is planned, dissection of the bladder off the cervix is continued until the cervicovaginal margin is identified. The cardinal and uterosacral ligaments are clamped, transected, and ligated, with clamps placed as close to the cervix as possible without including cervical tissue. After the level of the lateral vaginal fornix is reached, a clamp is swung below the cervix, across the lateral vaginal fornix. The cervix is then amputated off the vaginal cuff. Throughout the procedure, it is vital to clamp and ligate any bleeding vessels and to take extra care to avoid damage to the ureter or bladder. Following removal of the uterus and cervix, the vaginal cuff angles are sutured to the ipsilateral cardinal ligament stumps, and the vaginal cuff is closed with a running locked stitch. The abdominal wall is closed in layers.
Usual preop diagnosis: Intractable postpartum bleeding; rupture of gravid uterus
▪ SUMMARY OF PROCEDURE
Position
Supine, with left lateral tilt
Incision
Pfannenstiel’s or midline longitudinal
Unique considerations
Monitoring of coagulation parameters and correction of DIC. Consider central venous hemodynamic monitoring. Pediatrics team present, if indicated.
Antibiotics
Cefazolin 1 g iv q 8 h; total 3 doses
Surgical time
2-3 h
Closing considerations
Subcutaneous intraperitoneal drains, if indicated.
EBL
3000-4000 mL
Postop care
ICU if blood loss severe; patient may require continued intubation and mechanical ventilatory support. Monitor for infectious morbidity and acute renal failure.
Mortality
< 1%
Morbidity
Hemorrhage
Postop febrile morbidity
DIC
Wound infection
Sheehan’s syndrome
Bladder injury
Intraperitoneal bleeding requiring reoperation
Vesicovaginal fistula
Ureterovaginal fistula
Transfusion-related complications
Pain score
7
▪ PATIENT POPULATION CHARACTERISTICS
Age range
Reproductive age
Incidence
0.11% of obstetric patients
Etiology
Unknown
Associated conditions
Placenta accreta; uterine atony nonresponsive to medical or other surgical intervention; extension of cervical tear to lower uterine segment; placenta previa; uterine rupture; uterine inversion
ANESTHETIC CONSIDERATIONS
See Anesthetic Considerations following Cesarean Section, p. 835.
Suggested Readings
1. AbdRabbo SA: Stepwise uterine devascularization: a novel technique for management of uncontrolled postpartum hemorrhage with preservation of the uterus. Am J Obstet Gynecol 1994; 171:694-700.
2. B-Lynch C, Coker A, Lawal AH, et al: The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. Br J Obstet Gynecol 1997; 104:372-5.
4. Cho JH, Jun HS, Lee CN: Hemostatic suturing technique for uterine bleeding during cesarean delivery. Obstet Gynecol 2000; 96(1):129-31.
5. Cunningham FG, MacDonald PC, Gant NF, et al: Cesarean delivery and cesarean hysterectomy. In: Williams Obstetrics, 22nd edition. Appleton & Lange, Stamford: 2005.
6. Hansch E, Chitkara U, McAlpine J, et al: Pelvic arterial embolization for control of obstetric hemorrhage: a five-year experience. Am J Obstet Gynecol 1999; 180(6):1454-60.
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SURGICAL CONSIDERATIONS
ANESTHETIC CONSIDERATIONS
PREOPERATIVE
INTRAOPERATIVE
POSTOPERATIVE
SURGICAL CONSIDERATIONS
ANESTHETIC CONSIDERATIONS
