Perioperative management - Cesarean section

Maternal:

• in severe cases of preeclampsia/eclampsia
• threat of uterine rupture
• Abnormal placentation: Placenta previa partial or total, Placenta accreta spectrum, Vasa previa
• Arrest of labor.
• Mechanical obstruction to delivery: Fibroids, severe pelvic fractures, fetal macrocephaly or other fetal malformations
• Severe infections (e.g., active genital herpes or HIV without antiretroviral combination therapy and viral load >50 copies/ml).
• Previous extensive transmyometrial uterine surgeries: large myomectomy, reconstructive uterine surgeries

Fetal:

• Pathological CTG
• Breech presentation when vaginal delivery is not possible.
• Twins or multiples with unfavorable position.
• Preterm birth with unfavorable fetal conditions.
• Cord prolapse
• Suspected macrosomia: Macrosomia ≥5000 g, Macrosomia ≥4500 g with diabetes.
• Positions incompatible with delivery: Transverse lie, mentoposterior face presentation, nasoposterior brow presentation, posterior parietal bone presentation (exaggerated posterior asynclitism, exaggerated Litzmann obliquity), persistent high straight position

• Patients should continue their regularly taken medications as usual, unless contraindications exist (e.g., antihypertensives, insulin for gestational diabetes).
• Pause low-dose heparin (e.g., enoxaparin) 12 hours before surgery.
• Clear fluids (e.g., water, tea, apple juice) are allowed up to two hours before surgery.
• Avoid solid food at least six hours before surgery; fatty meals should be avoided eight hours prior.
• A preoperative appointment with the anesthesiologist is recommended, especially for high-risk patients (e.g., obesity, anemia, coagulation disorders).
• Avoidance of bowel preparations
• Laboratory: Blood count and coagulation parameters, crossmatch in case of medium to high risk of bleeding
• Documentation of fetal heart rate upon admission to the delivery room; continuous monitoring for patients in labor as far as possible.
• Preoperative ultrasound examination: placental location, fetal position, estimated weight if necessary

Reason for Cesarean Section:

• Medical necessity (e.g., placenta previa, fetal macrosomia, transverse lie).
• Specific risks with vaginal delivery (e.g., uterine rupture after previous cesarean section).
• Discuss alternatives, clarification if a vaginal delivery would be safely possible.

Surgical Procedure:

• Skin incision (usually a horizontal incision in the bikini area).
• Opening of the uterus (usually a transverse incision in the lower uterine segment).
• Delivery of the child, removal of the placenta, and suture closure.
• Duration: Usually 30-60 minutes.

Anesthesia

• Preoperative consultation in anesthesia
• Regional anesthesia (preferred): Spinal or epidural anesthesia for pain relief and remaining awake during the operation.
• General anesthesia: Only in emergencies or contraindications for regional anesthesia.
• Complications: Risk of hypotension, headache, nausea, or rarely neurological damage.

Risks and Possible Complications

Maternal Risks:

• Blood loss (in rare cases, blood transfusion necessary).
• Infections (e.g., endometritis, wound infection).
• Thrombosis or embolism (hence thrombosis prophylaxis necessary).
• Injury to adjacent organs (e.g., bladder, bowel, ureter).
• Uterine rupture in subsequent pregnancies.
• Wound healing disorder

Fetal Risks:

• Breathing problems (e.g., tachypnea) in premature infants or children without prior labor.
• Very rare: Injuries from the skin incision.

Long-term Effects

• Future pregnancies:
  • Increased risk of placenta previa or placenta accreta.
  • Risk of uterine rupture in vaginal birth after cesarean.
• Scar formation: Possibility of adhesions that can cause long-term pain or fertility problems.

Expectations and Postoperative Care

Expectations

• Possibility to see the baby immediately after birth (bonding).
• Breastfeeding is usually possible immediately after birth.

Postoperative Care

• Pain management (combination of acetaminophen, NSAIDs, and possibly opioids).
• Early mobilization to prevent thrombosis.
• Monitoring for bleeding or infections.
• Hospital stay: Typically 3-5 days.

Legal Aspects of Informed Consent

• The information must be provided in understandable language.
• Adequate time must be allowed for questions and concerns.
• Written consent is required.
• In emergencies, detailed information can be omitted if the life of the mother or child is at risk.

• Monitoring of fetal heart rate during delays between anesthesia placement and skin incision.
• Hair removal only if necessary; clipping is recommended instead of shaving to minimize skin irritation and infection risks.
• Administer spinal anesthesia or epidural catheter if possible, otherwise general anesthesia.
• Antibiotic prophylaxis before skin incision.
• Placement of a urinary catheter.
• Bonding: Skin-to-skin contact between mother and child immediately after birth.
• Facilitation of breastfeeding directly in the operating room.

• Postoperative monitoring (usually in the delivery room):
  • Vital signs: blood pressure, pulse, oxygen saturation.
  • Uterine tone and bleeding: monitoring of lochia and the incision site.
  • Urine output: ensuring adequate output and monitoring for urinary retention.
  • Tachycardia >120/min and hypotension <90 mmHg are considered warning signs for potential complications such as hemorrhage or infection.
• Pain management: administer paracetamol and NSAIDs regularly, opioids if necessary.
• Thrombosis prophylaxis: low-dose heparin or enoxaparin at the latest 6-12 hours after surgery, depending on bleeding risk.
• Encouragement of mobilization approximately four hours after surgery
• Early oral intake
• Remove the urinary catheter as soon as possible
• Skin-to-skin contact and breastfeeding should be initiated directly in the operating room or immediately after surgery, if clinically possible.

• Discharge on 3-4 days postoperatively
• Wound care: Removal of the dressing within 6-24 hours.
• Showering: Possible from 24-48 hours after surgery.
• Avoidance of heavy lifting (>6 kg) for 4-6 weeks.
• Resumption as soon as the patient feels ready, usually after 6-8 weeks.
• Light activity from the first day, gradually increasing load.

Additional Notes

• Early mobilization: In addition to pharmacological prophylaxis, starting approximately 4–8 hours postoperatively.
• Neuraxial anesthesia: Depending on the timing of catheter removal, start of LMWH prophylaxis at least 12 hours after the last dose and 24 hours after spinal anesthesia.
• Type of Medication:
  • Standard: Enoxaparin (40 mg daily) or Dalteparin (5000 IU daily).
  • Increased Risk: Increase dosage or switch to therapeutic anticoagulation in case of current or very high VTE risk.