GUIDELINE FOR PRE & POST OPERATIVE MANAGEMENT OF

PATIENTS : CAESAREAN SECTION ( CS ) / MAJOR SURGERY

PRE OPERATIVE MANAGEMENT

INFORMED WRITTEN CONSENT

Aims & benefits
Procedure
Common adverse effects
Possible major complications
Long term effects

PATIENTS AT HIGH RISK FOR CS

Trial of labour for possible CPD / VBACS / Severe pre eclampsia / APH / GDM /
Obesity / Poor progress / Pyrexia / Twins / Breech / Face / OP position /
Meconium stained liquor

HIGH RISK OF EMERGENCY CS

• At ONSET of labour : Famotidine 20mg oral +

Metoclopramide 10mg oral
OR
• At FIRST SUSPICION of possible CS :
Ranitidine 50mg im
Metoclopramide 10 mg slow iv X 2 min (or im)
(should be given as early as possible > 2hr prior to CS )

ELECTIVE CS

• Fasting : 10 hours for solids,

6 hours for clear liquids
• CS in the morning : Famotidine 20mg oral 10pm & 6 am
• CS in the afternoon : Famotidine 20mg oral +
Metochlopromide 10 mg oral 4 hrs prior to CS
• In OT : Sodium citrate ( 0.3 molar ) oral, seated position.
Fasting patients : 15 ml Others - 30 ml

BEFORE CS / MAJOR SURGERY

• Group & Rh
• Cross match blood
• Hb > 10 g / dl, PCV > 32
• Indwelling Foley catheter in OT after anaesthesia
POSTURE FOR CS

• LEFT LATERAL : All patients in labour, during journey to OT,

• OT table should be with a LEFT LATERAL TILT = 15 degrees

IN CASE OF FETAL DISTRESS

• LEFT LATERAL Position

• Oxygen inhalation intermittently

PRE OPERATIVELY

• Surgical Safety Check List

• Single IV dose : 30-60 min before skin incision

Ampicillin 2 g (or Cefuroxime 1.5 g iv)
+ Gentamicin 240 mg iv ( after delivery of baby - C. section)
+ Metronidazole 500 mg iv

• Vaginal cleaning with povidone iodine

• Skin cleansing with; surgical spirits and when dry - povidone iodine

IMMEDIATELY AFTER DELIVERY OF BABY

• Oxytocin 10 iu iv slow bolus

• Wrap baby – warm dry GS towel
• Delay clamping of cord X 2 min
(unless iso immunization+ or significant bleeding eg. Uterine tear)
• If resuscitation of baby needed – on OT table
• Controlled cord traction & examine placenta after delivery
• Uterine massage
• Delayed expulsion of cord > 5 min
- Manual removal of placenta
 POST OPERATIVE MANAGEMENT

• THREE (03) PHASES

Immediate - Theatre Recovery
Early - Ward Care ( until discharge from hospital )
Late - Home

Theatre Recovery : Modified Early Warning System Chart

Check Airway, Breathing, Circulation

All staff should have life support skills
Breast feed baby within 30 mins of CS

Ward care:
Continue MEWS chart in Ward x 4 hrs
Subjective : How does the patient feel ?
Objective : Pulse , BP, QHT, Fluid Balance
Assessment : Physical examination
Plan : For next 24hrs

MONITORING

• Watch for bleeding PV / evidence of intra-peritoneal bleeding

• 1st 2 hrs - PR, BP, RR : 15 min intervals
Next 4 hrs - PR, BP, RR : 30 min intervals
Next 6 hrs - PR, BP, RR hrly
• Inform if pulse > 100, SBP < 100
if pulse↑ >30, SBP↓ > 30
• Input output chart hrly

FLUID & ELECTROLYTE MANAGEMENT

• Most patients : N. Saline + 5 % Dextrose alternatively : 125 ml / hr
• Fluid therapy should be tailored to match additional requirements
• Volume expansion needs blood or colloids
• Blood transfusion if Hb < 8 g / dl
• Stable and asymptomatic patient with > 8g/dl do not require blood
transfusion
 PAIN MANAGEMENT

1st 24 hrs :
Pethidine 75 mg + im 6 – 8 hrly
Metoclopramide 10 mg
OR
Diclofenac Sodium supp. 100 mg pr 8 hrly

After 24 hrs
Oral Diclofenac Sodium 50mg + Oral Famotidine 20mg
8 hrly after meals
Oral Tramadol 50 mg 6 hrly
Paracetamol 1g 6 hrly

POST OPERATIVE ANTIBIOTICS – IN SPECIAL CIRCUMSTANCES

Ampicillin 1 g iv stat & 500 mg iv 6 hrly ( or Cefuroxime 1.5 g iv stat &

Gentamicin 240 mg iv 24hrly
+
Metronidazole 500mg IV 8 hrly
750 mg iv 8 hrly)
or Cefotaxime 1 G iv 8 hrly
or Ceftriaxone 1 G iv daily
or Ceftazidime 1 G iv 8 hrly
in Pseudomonas infection

CHRONIC MEDICATIONS

Should be maintained peri operatively even when ‘ Nil by mouth’

- After discussion with Consultant Anaesthetist
eg. Anti-hypertensives, Anti-arrhythmics , Anti-convulsants

FOOD INTAKE & DIET

• Oral fluids after 4 hrs of CS, if no complications

after confirmation peristalsis +
• Normal diet after 6 hrs of CS under Sp A, If no complications
• Delay fluids after major surgery till peristalsis +
• Introduce light solids prior to normal diet
 POST OPERATIVE CARE

• Early Ambulation
• Remove urinary catheter in 24 hrs if no complications
(48 hrs after VH&R)
• Remove elasto-plast dressing in 24 hrs & replace with porous dressing
• Remove drains when no longer required
• Removal of sutures (where appropriate ) in approx. 7 days

COMMON POST OPERATIVE COMPLICATIONS

• Post operative pyrexia - ( Temp. > 37 o C ) :
• D0 - D2 : commonly due to tissue damage & necrosis,
may be due to haematoma formation or blood transfusion
• D3 - D7 : may be due to wound infection , pelvic abscess formation,
bronchopneumonia or DVT
• Persistent Post operative pain - Wound haematoma,
infection or DVT
• Discharging wound - Abscess, fistula formation,
dehiscence
• Nausea & vomiting - Drugs, intestinal obstruction
• Constipation - Paralytic ileus, drugs
• Diarrhoea - Pelvic sepsis

DISCHARGE

- Planned
- Advise regarding normal recovery rates, when to return to work and
resume sexual activities
- Diagnosis card (Clear & brief, no unnecessary routine operative details)

FOLLOW UP VISITS

• Major surgery - review in clinic at 2 weeks & 6 weeks

• Caesarean section - review in PNC at 2 weeks & 6 weeks

Professor Malik Goonewardene

MBBS(Cey) , MS(Col) , FSLCOG, FRCOG (Gt. Brit ), Hon. MGS (Poland)
Senior Professor & Head, Dept. of Obstetrics & Gynaecology
University of Ruhuna 22.06.2015