Postoperative Management of the Difficult Cesarean Delivery



Postoperative Management of the Difficult Cesarean Delivery


S. Kyle Gonzales

Shae Connor

Tripp Nelson

C. David Adair



INTRODUCTION AND HISTORICAL PERSPECTIVE

Obstetrical procedures involve the spectrum of the female genitourinary tract. This chapter focuses upon complications during and following cesarean delivery and/or cesarean hysterectomy; the underlying principles will serve the accoucheur well in the provision of complicated care to the parturient patient. Obstetric and gynecology providers participate in 3 of the top 10 surgical procedures, which include cesarean section, circumcision, and hysterectomy.1

Cesarean section was generally conducted in cases of maternal death in early Roman and Christian times in an effort to bring forth the unborn child and was largely, up until the early 20th century, considered a matter of last resort. Beginning with the implementation of ether as an anesthetic by Dr. Morton and antiseptic prevention by Dr. Lister, development of surgical techniques was largely advanced in the second half of the 19th century and cesarean section became a consideration. One of the first series describing cesarean delivery in France reported a 100% maternal mortality due to either hemorrhage or infection.2 Since then, suture techniques and materials, blood transfusions, and the discovery of penicillin followed by other antibiotic developments led to a safe cesarean option. Today cesarean section is one of the most frequently conducted operations in the United States with almost 1.3 million procedures performed annually. Given the frequency of cesarean section and the other procedures, obstetricians who find themselves routinely conducting this surgery technique need care protocols for the expected complications that often accompany the procedure.


ENHANCED RECOVERY AFTER SURGERY GUIDELINES AND PRINCIPLES

Obstetric surgery has slowly made progress in improving postsurgical outcomes. Enhanced Recovery After Surgery (ERAS) guidelines for perioperative care have been published in colorectal, urologic, oncology, and gynecology.1,2,3,4 Advancements in nonobstetric surgery have shown how the use of improved surgical technique can aid in reducing postoperative complications, hospital stay, recovery time, and overall healthcare costs.5,6 By using ERAS guidelines, obstetric surgery outcomes should be capable of mirroring the improvement seen in nonobstetrical outcomes. Postoperative care after a difficult cesarean section requires specific attention to detail. We discuss ERAS guidelines and address specific issues related to obstetric surgery.



POSTOPERATIVE FLUID MANAGEMENT

Generally, balanced crystalloids are preferred to 0.9% normal saline.7 Fluids should be maintained and dosed for proper renal function. Oliguria may necessitate a fluid bolus, although gentle hydration may be required (i.e., pulmonary edema). Hypotensive patients should be managed in the proper unit, often in a critical care unit. In addition, vasopressor therapy may be indicated.

Delayed oral intake has long been a mainstay in postoperative surgical management. However, this practice has been challenged in several well-designed studies. Early oral feeds, identified as initiation of oral intake of fluid or solids within 24 hours, significantly decrease the time for bowel function to return after cesarean section without compromising gastrointestinal complications.7,8 Studies have shown that early feeds increase nausea rates but decrease vomiting, abdominal distention, and the need for nasogastric tube use.7 Chewing gum has also been suggested as a noninvasive measure to decrease the rate of postoperative ileus as well as return of bowel function.7 A Cochrane review showed a reduction in the rate of ileus as well as quicker return of bowel function with limited risks or side effects, although the authors acknowledge the level of evidence is very low to low.9 Early oral intake reduces the amount of time IV fluids are indicated. We recommend terminating IV fluids within 24 hours after surgery.


ANALGESIA

Multimodal anesthesia has been suggested to not only minimize the use of opioids but to also speed the recovery process.10 Addressed below are several options of anesthesia that exist to meet these goals. Following a difficult cesarean delivery, the optimal approach is to combine one or more of the options.11 Poor pain control is associated with increased postoperative complications, patient dissatisfaction, and development of chronic pain.7

Planned operative cases allow for the use of intrathecal agents, such as morphine sulfate. Neuroaxial opioids are more effective than systemic opioids for pain control. One benefit in a spinal injection is the quick removal of the catheter with lesser incidence of technique-related complications than epidural anesthesia.11 Combined spinal epidural may be used for cases which are expected to be prolonged beyond routine limits. This may allow for continued anesthetic control after the operation depending on the length or severity of the case. Potential systemic side effects of neuroaxial anesthesia include hypotension, systemic toxicity, pruritis, nausea and vomiting, and respiratory depression.

General anesthesia is often required and/or desired in planned cases requiring hysterectomy, such as a known placenta accreta. Postoperative opioids should be dosed for appropriate pain control without causing respiratory depression. Opioids have long been a mainstay in postoperative pain control. This may include IV patient-controlled analgesia, periodic IV control, or oral narcotics. Patient-analgesia is associated with greater patient satisfaction but included higher opioid consumption and increased complications.12 Once able to tolerate oral analgesics, intravenous patient-controlled analgesia should be stopped and pain control transitioned to oral agents.



Oral Analgesics

Most oral analgesics are safe for women who choose to breastfeed. Acetaminophen and NSAIDs (ibuprofen and diclofenac) are considered safe for most women. The use of NSAIDs in newborns with a ductal-dependent lesion (e.g., hypoplastic left heart) should be avoided.13 Given the concern for opioid dependence as well as passage in breast milk, we prefer to use other oral analgesics as first-line options, with oral opioids as second-options. Due to concern for opioid passage into breast milk, we recommend providers avoid the use of codeine, hydrocodone, tramadol, and meperidine in breastfeeding women. The American Academy of Pediatrics prefers the use of morphine, hydromorphone, or butorphanol.13

The use of NSAIDs has been shown to decrease overall opioid use and subsequently decrease opioid-related side effects.14 Given their benefit, NSAIDs should be considered as first-line pain control over opioids. Traditionally, it has been recommended that NSAIDs be avoided in the hypertensive postpartum patient.15 Newer data have suggested NSAID usage may be safe for this subset of women.16,17 The addition of IV acetaminophen with NSAIDs has been shown to improve patient satisfaction.7


Transversus Abdominis Plane Blocks

Transversus abdominis plane (TAP) blocks require a large volume of local anesthetic injected between muscle layers, often under ultrasound guidance. The use of TAP blocks in nonobstetric and gynecologic surgery is mounting which appears to reduce overall opioid usage. These may be considered for large surgeries or in patients where some of the above modalities are contraindicated. Multimodal pain management that decreases opioid consumption and resultant opioid-induced side effects, limited perioperative fluid administration, epidural analgesia, and transverse abdominis plane (TAP) block have all been proven to decrease rates of ileus.18,19,20,21


VENOUS THROMBOEMBOLISM PREVENTION

Thromboembolic events are uncommon in pregnancy but remain significantly elevated above the general population risk. An operative delivery increases the risk of a venous thromboembolism (VTE) two- to threefold above a vaginal delivery and is increased for emergent cesarean deliveries.22,23 All women undergoing a cesarean section should have placement of pneumatic compression devices prior to incision, and we recommend continuation in the immediate postpartum period with continuation until fully ambulatory. The addition of graduated compression stockings has been shown to reduce the rate of VTE when combined with other methods.24 Individuals with additional risk factors, such as morbid obesity, prolonged immobility, or prolonged surgery, may require anticoagulants such as low-molecular-weight heparin in combination with pneumatic compression devices.25 When indicated, we recommend low-molecular-weight heparin 40 mg subcutaneous daily, or weight based (1 mg/kg daily) for women with a BMI >35 kg/m2.



MOBILIZATION

Early mobilization is widely recommended among ERAS bundles across surgical specialties.1,2,3,26 Benefits potentially include reduced time to return of bowel function, decreased use of opioids, and reduced risk of thromboembolism. No well-designed study has statistically proven these benefits. In the setting of a difficult cesarean section, pain and postoperative healing may inhibit mobilization for some time, but any form of mobilization, such as moving to a chair, may be beneficial. Foley catheters, IV poles, and poor pain control have been cited as barriers to mobilization, and by following an ERAS protocol, early mobilization may be more feasible.7 We encourage mobilization within 24 hours after surgery.


FOLEY CATHETER AND DRAINS

Removal of a Foley catheter as soon as possible is recommended in the postoperative period. However, after a difficult operation, the Foley allows for proper fluid balance and maintenance. This should be removed as early as possible after a complicated delivery. Time to ambulation after cesarean decreases when the catheter is removed early.27 Prolonged placement may be required after bladder injuries. Prophylactic antibiotics are not indicated in either of these settings, and if infection is suspected, removal or replacement is recommended. Catheter-associated infection (CAUTI) is associated with prolonged hospital stay and increased morbidity and mortality.28

Routine placement of drains is not indicated.29,30 Historically, intraperitoneal drains have been placed for monitoring of bleeding or urinary leaks. As noted in gynecologic oncology literature, while drain placement has been shown to diagnose anastomotic leaks sooner, drain placement did not improve outcomes, and the lack of drainage output did not rule out an anastomotic leak.29 If drains are indicated, then we recommend removal as early as clinically indicated.


GLUCOSE CONTROL

Perioperative hyperglycemia impairs wound healing, increases morbidity and mortality, increases hospital stay, and increases postoperative infection.31 Physiologic response to surgery involves activation of the hypothalamic-pituitary-adrena (HPA) axis, increasing cortisol, leading to peripheral insulin resistance.32 Therefore, when hyperglycemia is expected, we recommend routine glucose monitoring with goal values <160 to 180 mg/dL. Values may be treated with intermittent insulin injection or an insulin drip. In a randomized study in a nonobstetric setting comparing sliding scale regular insulin versus basal-bolus insulin regimen, the basal-regimen showed lower mean glucose levels and significantly lower composite outcome (wound infection, pneumonia, bacteremia, respiratory failure, and acute renal failure).33 When individuals are planned to continue basal-bolus regimens in the prolonged setting, we recommend initiating this dosing as soon as tolerated. Iatrogenic hypoglycemia is a known risk of tight control and frequent glucose monitoring is paramount.



SPECIFIC POSTOPERATIVE COMPLICATIONS


Anesthesia-Related Complications

In the United States, anesthesia complications account for approximately 2% to 3% of maternal deaths. Aspiration of gastric contents is one of the most common causes of death from general anesthesia.34 Injury from aspiration can occur either by obstruction of the airway or chemical insult to the bronchial epithelium. Pulmonary edema, hypoxia, and rarely cardiovascular collapse and death can occur.35 Animal studies suggest that the mechanism of death in aspiration is the release of proinflammatory cytokines, especially tumor necrosis factor (TNF)-alpha and interleukin (IL)-8.36 The risk of aspiration is greatest during induction with endotracheal intubation and with extubation at emergence, but it can happen at any point in the postoperative period. The incidence of aspiration is three to four times higher in emergent anesthesia situations compared to elective surgeries, and the risk is particularly increased in pregnant women due to decreased lower esophageal sphincter tone.37 Although most experts recommend rapid sequence intubation in all pregnant women, this technique is not supported by the available evidence.38 Aspiration pneumonitis can have a fulminant course and result in respiratory compromise quickly. The primary treatment goal is respiratory support. Animal studies have shown therapeutic benefit from positive-pressure ventilation and intravenous high-molecular-weight colloids.39,40


Urinary Retention

Urinary retention is a common complication of both pelvic surgery and neuraxial anesthesia. Spinal anesthesia blocks both afferent and efferent nerve signals to the bladder, resulting in decreased sensation of fullness and impaired detrusor contractility.41 During a difficult cesarean or hysterectomy, extensive dissection of the parametrial tissues may disrupt the pelvic splanchnic nerves that supply the bladder, usually resulting in a hypotonic bladder and urinary retention. An indwelling catheter, sometimes for a prolonged interval, is required to decompress the bladder and allow it to regain its normal tone.


Postdural Puncture Headache

Postdural puncture headache (PDPH), or spinal headache, is another common complication of obstetric anesthesia characterized by a positional headache that is worse when upright. The incidence of PDPH after spinal anesthesia is between 3% and 9%, depending on the type and size of needle used. More commonly, PDPH results from inadvertent puncture of the dura during placement of an epidural catheter.42 An epidural needle has a larger diameter than a spinal needle, and PDPH is thought to result from decreased cerebrospinal fluid (CSF) pressure due to leakage of CSF through the hole in the dura. Although fewer than 6% of epidural placements are complicated by inadvertent dural puncture, the rate of PDPH in these instances is up to 88%.43 Mild PDPH is usually treated with supportive therapy, including bed rest as needed, oral analgesics, and antiemetics. Aggressive oral and/or intravenous hydration is often encouraged in postpartum patients.44 For patients with severe or debilitating symptoms that prevent them from carrying out activities of daily living, an epidural blood
patch should be offered as definitive treatment. A blood patch involves injection of autologous blood through an epidural needle into the epidural space. Epidural blood patch has been shown to reduce the duration and intensity of PDPH compared with both conservative treatment and sham procedure in a recent systematic review based on the results of three randomized controlled trials.45,46,47,48 The blood patch procedure usually provides immediate relief within seconds to minutes, with reported success rates between 65% and 98%.46,49


Spinal Epidural Hematoma and Central Nervous System Infection

Spinal epidural hematoma and central nervous system (CNS) infection are rare but potentially life-threatening complications of neuraxial anesthesia. Spinal epidural hematoma results from hemorrhage into the neuraxis. Although the incidence of spinal epidural hematoma appears to be significantly lower in obstetric patients than in other populations, the risk is increased in the setting of coagulopathy or anticoagulation therapy.50 Hematoma is less likely with a spinal needle than with an indwelling epidural catheter.51 The concealed nature of the bleeding necessitates a high index of suspicion in patients with progressive motor and sensory blockade and/or bladder and bowel dysfunction. CNS infection is also exceedingly rare but must be considered in patients with fever, back pain, and neurologic deficits. Epidural abscess is more likely to occur with placement of epidural catheters, whereas meningitis is more common after dural puncture. The incidence of postdural puncture meningitis after spinal anesthesia ranges from 0.2 to 1.3 per 10,000 procedures.52 Epidural abscess following placement of epidural catheters is more common, with incidence ranging from 0.5% to 3%.53,54,55 Diagnosis is confirmed with lumbar puncture or magnetic resonance imaging (MRI).

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Apr 13, 2020 | Posted by in GYNECOLOGY | Comments Off on Postoperative Management of the Difficult Cesarean Delivery

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