Rapid recovery after caesarean section
The article was prepared by: Dmytro Shadlun, Medical Director of the Leleka Maternity Hospital, Doctor of Medical Science; Evgen Grizhymalskyi, Head of the Anesthesiology and Intensive Care Department; Andrii Harha, Candidate of Medical Science, Anesthesiologist
The constant search for effective methods of recovery after caesarean section, the desire to reduce the risks of postoperative complications and shorten the length of hospital stay made us implement the modern concept of rapid recovery of female patients in this category.
In daily practice, Leleka Maternity Hospital is already using a program of rapid recovery after a caesarean section. At the same time, the positive results of its implementation in obstetric practice are due to the need to update the traditional approach to organizing preoperative preparation.
Key recommendations to prepare for surgery
Preoperative fasting. The last intake of solid food is 6-8 hours before the caesarean section, clear liquid — 2 hours before surgery.
This approach reduces the risk of aspiration and perceptions of hunger and thirst. The American Society of Anesthesiologists recommends 6-8 hours of preoperative fasting, depending on the type of food taken: light food (such as toast and clear liquid) or milk can be taken 6 hours before elective surgery requiring general or regional anesthesia or sedation.
Longer fasting (≥ 8 h) before surgery may be required if the female patient took fried, fatty foods or meat. When determining the length of the fasting period, both the amount and type of food should be taken into account. Beverages high in carbs without solids reduce the incidence of hypoglycemia and metabolic stress in a woman in labor.
The benefits of complex carbohydrate beverages taken before C-section have not been defined, and their effects on the fetus is unknown. It would be logical to avoid them if a woman in labor suffers from diabetes mellitus. Beverages high in carbs without solids should last be taken 2 hours before the caesarean section (in the absence of diabetes mellitus). We recommend 45 g of carbohydrates.
Optimization of Hb level. All pregnant women should undergo laboratory tests to detect the presence and cause of anaemia. In addition to prenatal vitamins, patients with iron-deficiency anaemia should be additionally prescribed with iron supplements.
Co-working between obstetricians and anaesthesiologists during examination before the elective surgery is necessary to explain to the patient the importance of optimizing Hb level and the need to correct antenatal anaemia. Anaemia a woman in labor is a key predictor of postpartum anaemia associated with depression, cognitive impairment and fatigue. Iron-deficiency anaemia during pregnancy is associated with an increased risk of low birth weight, preterm birth and perinatal mortality.
Recommendations during surgery
Optimization of infusion therapy.
The fluid volume is < 3,000 mL for routine C-section.
Prevention and treatment of arterial hypotension during spinal anesthesia.
The aim is to prevent intraoperative nausea and vomiting (IONV) after spinal anesthesia, as well as to maintain utero-placental perfusion. Optimal treatment is prophylactic infusion of such vasopressors as phenylephrine (mesatonum) or norepinephrine. Arterial hypotonia associated with spinal anesthesia is primarily a physiological phenomenon caused by decreased afterload. It is necessary to change the mode of administration of vasopressors in women in labor with pre-eclampsia, since arterial hypotension caused by spinal anesthesia may be less severe than in women in labor without pre-eclampsia.
Maintenance of normothermia.
It is necessary to maintain active warming of the patient. It begins before surgery and maintains the optimal ambient temperature in the operating room.
Optimization of the administration of uterotonic drugs.
It is recommended to use the lowest effective dose of uterotonic drugs which are necessary to achieve adequate uterine tone and minimize side effects.
Antibiotic prophylaxis. Administration of antibiotics into the skin incision.
Treatment and prevention of intraoperative nausea and vomiting. To reduce the degree of arterial hypotonia, accompanied by IONV, prophylactic infusion of vasopressors is used. The removal of the uterus from the small pelvis and washing the abdominal cavity with solutions are limitedly performed. At least two prophylactic antiemetics with different mechanisms of action are prescribed (for example, ondansetron 4 mg, dexamethasone 4 mg, metoclopramide 10 mg).
The removal of the uterus from the small pelvis, which is associated with IONV and delayed recovery of bowel function, should be avoided (limited). The use of saline to irrigate the abdominal cavity can cause both IONV and PONV. Dexamethasone is an effective drug to prevent PONV, but not IONV, due to the delayed onset of action.
In contrast, metoclopramide is effective to prevent IONV, but not PONV. Multimodal analgesia consists of the neuraxial administration of long-acting anesthetics. Non-opioid analgesia is performed in the operating room, unless contraindicated, and should ideally begin before the onset of pain. Moreover, local anesthesia, continuous wound infiltration or regional blocks (e.g., TAP or QL block) are used. Pain relief is considered adequate if pain at rest does not exceed 2 points, and 4 points when coughing and moving.
Recommendations after surgery
The early meal. The transition to regular meals can ideally be within 4 hours after C-section (in the absence of nausea and vomiting). The early meal helps to accelerate the recovery of bowel function, shorten the length of hospital stay.
Blood glucose monitoring. Pregnant women with diabetes mellitus should be placed first in the daily surgery schedule. It is necessary to maintain normoglycemia. Early activation. Activation should begin soon after restoration of lower-limb motor function. Early removal of the urethral catheter. The urethral catheter should be removed 6-12 hours after childbirth. You may read the full text of the article by clicking the link.
