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Pre – Post cesarean Care

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by

Talah a.s

on 15 April 2014

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Transcript of Pre – Post cesarean Care

Pre – Cesarean Care
Assessment of
fetal pulmonary maturity .
Anesthesia.
Laboratory testing. 
Antibiotic
prophylaxis 
Thromboembolism prophylaxis. 
Fetal heart
rate monitoring. 
Fetal presentation and placental location. 
Bladder catheterization. 
Hair removal.
 
Skin preparation.  
Drapes.
Perioperative management of
medication.

Post – cesarean care
1- Single does of Cefazolin pre cesarean significantly
reduce post cesarean
fever, endometritis and wound infection.

15% True

84% False




2- Urinary cath in post C/S patient
should not be
removed
before 24hr
.


69% True

30% False



3- The
prophylactic
does of
Clexan = 40mg
SC dialy .

100%True

0% False
Evidence Based
Done by :
Tamara Alsharif Resident
Supervised by:
Dr. Iman Specialist

investigations
Take home message :
Resources:

-Uptodate.
- medscape.
- Myoclinic.

Pre – Post cesarean Care
- The cesarean delivery rate worldwide is about
15 %
of births.


-
highest
rates over
35 %
and the
lowest
is under
5 %.

Assessment of fetal pulmonary maturity 
large trial evaluated
RDS
in
term infants
delivered by
C/S
Compared with
vaginal delivery
. those delivered by scheduled C/S had a
significantly increased
risk of respiratory morbidity
before 40 weeks
..

37 weeks
10
Vs
2.8
%
38 weeks
5.1
vs
1.7
%
39 weeks
2.1
Vs
1.1
%
40 weeks
1.5
vs
1.6
%

In a randomized trial of planned cesarean delivery at
38wk
vs
39wk
, the group delivered at
39 weeks
had a
lower rate
of respiratory morbidity 6.8 vs 9.0 %.


NICU admission
within 48 hours of birth 11.9 vs13.9%

Anesthesia

- The most common
test currently in use for assessing fetal lung maturity in the USA.
Lamellar body counts
.

-
preoperative
anesthesiology
consultation





- preoperative
fasting time
of at least
2 hours
from clear liquids,
6 hours
from a light meal, and
8 hours
from a regular meal.
patients are usually asked
not to eat anything
for
12 hours
prior to the procedure.

- Massive
obesity.
-
Asthma
requiring medication.
- Severe
hypertensive
disease.
- Maternal
coagulopathy.
- History of
anesthetic complications.
- Severe facial or neck edema.
- Extremely short stature.
-
Short neck
, decreased mobility of the neck.
- Difficulty opening the mouth.
- Protuberant teeth.
-
Anatomic abnormalities
of the face, mouth, neck, or jaw.
-
Serious medical
or obstetrical conditions.
Laboratory testing 
Antibiotic prophylaxis
-meta-analysis of randomized trials that compared infection rates in women assigned to a single
pre-incision
dose of antibiotic versus
after cord clamping
.
Pre- incision prophylaxis was significantly
more effective
for prevention of
endometritis
.

- a
single IV dose
of a narrow spectrum antibiotic
(eg, cefazolin)
should be administered preoperatively to all women undergoing cesarean delivery.
Grade A1

When ?? should be administered
within 60 minutes
before making the skin incision to ensure adequate drug tissue levels.


-
avoid use of amoxicillin-clavulanic acid
because it is associated withincrease in the number of babies who developed
necrotizing enterocoli
- systematic review of randomized trials showed that
single dose
regimens were
as effective as
multiple dose regimens.


- some data suggest that
continuation
of a broad-spectrum regimen for
6 to 12 hours
postoperatively may
decrease
infectious morbidity

- For the woman in labor already
receiving antibiotics
for
GBS prophylaxis
we
do not add
further antibiotic prophylaxis, although others centers administer a
single dose of a narrow spectrum antibiotic
(eg, cefazolin).

Thromboembolism prophylaxis
- The risk of cesarean-associated thromboembolism is
0.23 %
and
more than 80 %
of
fatal puerperal pulmonary embolisms
occur after cesarean delivery.

- many obstetrical units in the US provide
mechanical prophylaxis
to all women undergoing cesarean delivery.

-
the American College of Chest Physicians (ACCP)
recommend
early ambulation
postpartum.

Fetal heart rate monitoring
- laboring patients who were
monitored
in the labor room should
continue
to be monitored after transfer to the
operating room
when surgery is
significantly delayed.
Fetal presentation and placental location
An
ultrasound
for assessment of
placental location
and
fetal presentation
,
or Leopold maneuvers to assess fetal presentation, are probably useful..
Bladder catheterization
Hair removal
- A meta-analysis found
no difference
in the rate of
surgical site infection
in non-pregnant patients who had hair removed prior to surgery and those who did not.

- If hair needs to be removed, it should be
clipped rather than shaved
, as patients who are shaved are more likely to develop surgical site infection.

- Use of a
depilatory cream
is also preferable to shaving.
Skin preparation

- The overall rate of surgical-site infection was significantly
lower
in the
chlorhexidine-alcohol
group than in the povidone-iodine group
9.5 vs16.1 %.
Drapes
- The surgical site is draped with
nonadhesive drapes
, as they appear to be associated with a
lower rate
of wound infection than adhesive drapes.
Perioperative management of medication
Diabetic patient:
Type 2 diabetes on
oral hypoglycemic
agents
continue
medications until the morning of surgery.

Type 1 or
insulin
treated type 2 diabetes:
continue
with subcutaneous insulin perioperatively.

_
Aspirin :
stop at
36wk
,
7 days
before OR.

_
clexan :
stop
24hr
before OR.
- Analgesia.
- oral intake.
- investigations.
- wound care.
- Discharge and follow up.
-
Early ambulation
, clexan
40mg
SC.

- In the
recovery room
, vital signs are taken

Q15 min
. for the
first 1-2 hours
, and
urine output
is monitored
hourly
.

- Then, Vital signs should be taken
Q 1hr
for at least the
first 4 hours
.

-
The bladder catheter
can be removed
12-24 hours
postoperatively once the patient is
ambulatory
.
Analgesia
-
opioid analgesia
followed by oral
NSAID
drugs provides adequate pain relief for most women.
oral intake
- Oral intake within
6 hours
of delivery are encouraged.

- 2 hr after spinal anasthesia.
- In a 2013 systematic review,
early oral intake
after C/S was well tolerated and had
no adverse effects
on time to bowel action/passing flatus or frequency of nausea, vomiting,
paralytic ileus, or analgesic use.

-
Early oral intake
may
enhance
the return of bowel function by
stimulating the gastrocolic reflex.
- Routine postoperative
hemoglobin testing
is
not necessary
in
asymptomatic
patients after planned cesarean delivery

- the blood count is checked
12-24 hours after surgery
, or
sooner
if a
greater than average
blood loss has occurred.

Discharge and follow up
- The American College of Obstetricians and Gynecologists (ACOG) recommends that, in cases of postpartum
discharge after 48 hrs
.

- An
early postpartum visit
at
one to two weeks
.

- A
baseline hemoglobin
is recommended .

- A
normal value
obtained within
one month
of surgery probably does
not need
to be repeated preoperatively in
uncomplicated pregnancies
.

- blood type and antibody screen , cross match.
- HIV , HBV, VDRL .
- coagulation profile.
- A
guideline
developed by the
American Society of Health-System Pharmacists (ASHP)
, the
Infectious Diseases Society of America (IDSA)
, the
Surgical Infection Society (SIS)
, and the
Society for Healthcare Epidemiology of America (SHEA)
recommends
2 grams cefazolin
for patients
<120 kg and 3 grams for patients ≥120 kg table.

-
clindamycin
and an
aminoglycoside

(gentamicin or tobramycin) in women with
beta-lactam allergy
.
-systematic review that compared infection outcomes after both scheduled cesarean delivery
with or without
the use of prophylactic antibiotics.

-Antibiotic prophylaxis significantly
reduced the incidence
of postoperative fever,
endometritis
, wound infection, UTI, and serious maternal infectious complications compared to controls receiving no antibiotic treatment.

- patients at
low risk of intraoperative
complications can be asked to void shortly before the procedure, and an indwelling catheter can be inserted
intraoperatively
and
removed as early as possible.
Dear Doctors…
We would greatly appreciate your cooperation in filling out this Questioner about
pre and post cesarean care…

( ) Resident ( ) specialist ( ) consultant

1- Single does of Cefazolin pre cesarean significantly reduce post cesarean fever, endometritis and wound infection.
( ) True ( ) False

2- Urinary cath in post C/S patient should not be removed before 24hr.
( ) True ( ) False

3- The prophylactic does of Clexan = 40mg SC dialy .
( ) True ( ) False

4- Oral intake is recommended 6hr after C/S .
( ) True ( ) False.

5- Skin prepration before C/S with iodine is better than chlorhexidine.
( ) True ( ) False




Thank you …


4- Oral intake is recommended
6hr after C/S
.

53% True

46% False.



5- Skin prepration before C/S with
iodine is better than chlorhexidine.

96% True

30% False
- Caesarean section rates
have increased
significantly in recent years.
- our protocol and quality standard should focuses on reducing
potential risks
or
complications
for the woman and the baby.
good,
better,
best

Never let it rest untill your
good is better
and your
better is the best.
Thank you
- Planned cesarean delivery should be scheduled for
≥39 wk
.
pre admission consultation with an anesthesiologist :
wound care
In a clean surgical wound, the
epithelial cells migrate
downward to
meet deep in the dermis
. this is normally completed
within 48 hours
of surgery.

- This superficial layer of epithelium creates a
barrier
to bacteria and other foreign bodies. However, it is very thin,
easily traumatized
, and gives little tensile strength

- The
dressing
can be
removed 12-24 hours
after surgery and can be left open after that time.

-
Hold the abdomen
near the incision d
uring sudden movements
, such as coughing, sneezing or laughing.

- A large randomized trial found that preoperative cleansing of the patient's skin with
chlorhexidine-alcohol
was
superior to
cleansing with
povidone-iodine
for preventing surgical-site infection after .
Full transcript