Anesthesiologist's Manual of Surgical Procedures, 4th ed.

Obstetric/Gynecologic Surgery

Chapter 8.3

Obstetric Surgery

  1. Mark Taslimi MD

Surgeon

Yasser El-Sayed MD

Surgeon

Brendan Carvalho MBBCh, FRCA

Anesthesiologist

Lee Coleman MD

Anesthesiologist

P.818

Cesarean Section—Lower Segment and Classic

Surgical Considerations

Description: Cesarean section (C-section) is the delivery of the fetus through a horizontal or, more commonly, through a vertical incision in the lower uterine segment. The skin incision is made either as a Pfannenstiel's (transverse in the crease above the pubis), a Maylard (in extremely obese patients), or vertical midline from umbilicus to pubis. The peritoneal cavity is entered as in any laparotomy. A retractor is placed inferiorly and the reflection of visceral peritoneum from the bladder dome to the anterior lower segment of the uterus (bladder flap) is incised and displaced inferiorly, along with the bladder. The uterus is entered sharply and the incision extended with digital pressure and/or bandage scissors. The fetal head is elevated out of the pelvis and delivered through the uterine incision. In cases of nonvertex lie, the infant's breech or foot is grasped and brought out of the incision. After the delivery of the fetus, the cord is double-clamped and cut, and cord blood is obtained for analysis. The placenta is removed manually and the uterine cavity cleared of all debris and clots. The uterine incision is closed with a running, interlocking stitch, followed by a 2nd imbricating layer. The bladder flap and parietal peritoneum do not require closure. Finally, the fascia is closed and the skin reapproximated with staples. Classic C-section usually involves a fundal vertical uterine incision (Fig. 8.3-1). Patients with a history of prior classical C-section should be delivered abdominally via a repeat C-section, because their risk of uterine rupture with labor and vaginal delivery is ~12%.

Usual preop diagnosis: Failure to progress in labor; elective repeat C-section; fetal distress; malpresentation

 

Figure 8.3-1. Typical C-section incisions. A: Classic incision, in upper uterine segment. B: Low transverse incision.

Summary of Procedures

 

Lower-Segment C-Section

Classic C-Section

Position

Supine with left lateral tilt. (In obese patients, the pannus may be lifted superiorly by tape or towel clips.)

Incision

Skin: transverse low abdominal (Pfannenstiel's) or repeat vertical. Uterus: transverse (Kerr) or low vertical (for premature infants or nonvertex lie)

Skin: Pfannenstiel's or, more commonly, vertical midline. Uterus: vertical fundal

Special instrumentation

Bladder blade retractor; small ring forceps; bandage scissors; suction bulb; DeLee suction trap (if meconium)

Unique considerations

[check mark] fetal heart tones before procedure. If for CPD: vaginal exam within last 15 min before procedure. If for fetal distress: continuous monitoring until skin incision.

Antibiotics

If in labor or membranes ruptured: continue prophylactic antibiotics or cefazolin 1–2 gm iv (prior to incision or 30 minutes prior to delivery)

Surgical time

20–90 min

40–90 min

Closing considerations

Low transverse: closed in 2 layers. Low vertical: 2 layers; may require additional operative time for control of incision bleeding or repair of incision extension into cervix.

3-layer closure requires additional time.

EBL

750–1,000 mL

1,000–2,000 mL

Postop care

Observation for bleeding and ↓ BP

Special attention to VS needed due to additional blood loss.

Mortality

< 0.1%

Morbidity

Infection:
   Not in labor: < 5%
   In labor/ruptured membranes: 50% (antibiotics reduce incidence to 15%)
Small-bowel obstruction (SBO): Rare





Pain Score

4

7

P.819

Patient Population Characteristics

Age range

14–45 yr

Incidence

10–30%

Etiology

Failure to progress (30%); repeat C-section (30%); fetal anomaly/other (20%); abnormal presentation (10%); fetal distress (10%)

Associated conditions

Preeclampsia/eclampsia; DIC; hemolysis, elevated liver enzyme, low Plt count (HELLP) syndrome; obstetrical hemorrhage/shock; chorioamnionitis

Anesthetic Considerations

(Procedures covered: C-section; emergent obstetrical hysterectomy; repair of uterine rupture)

Preoperative

In general, patients are young and healthy, although the pregnant patient has undergone profound physiologic changes that affect the conduct of anesthesia. Patients present for emergency C-section for nonreassuring fetal heart rate tracing and/or hemorrhage (placenta previa, abruptio placenta, and, rarely, uterine rupture).

Respiratory

The pregnant patient has a compensated respiratory alkalosis (PCO2 = 32–34), ↑ minute ventilation (MV) (↑ 50%), and ↓ FRC (↓ 20%). ↑ O2 consumption (↑ 20%) with ↓ FRC results in rapid onset of hypoxemia if ventilation is compromised. Small airway closure due to elevation of diaphragm (exaggerated by obesity and supine position) can → shunting and ↓ PaO2. ↑ MV and ↓ FRC enhance uptake of inhalational anesthetics. Mucosal capillary engorgement in upper airways may necessitate a smaller ETT and mandates careful airway suctioning to avoid bleeding.
Tests: As indicated from H&P.

Cardiovascular

Typically, there is a ↓ SVR (↓ 15%), ↓ diastolic pressure and ↓ MAP (↓ 15%) with ↑ HR (↑ 20%) and ↑ CO (↑ 30–40%, higher in multi-fetal pregnancy, higher in labor). Use left lateral tilt to minimize aortocaval compression and supine hypotension. Immediately postpartum, 600–800 mL blood enters the central circulation, due to placental transfusion, with further ↑ in CO.
Tests: As indicated from H&P.

Hematologic

These patients have ↑ red cell mass (↑ 300–400 mL), ↑ plasma volume (↑ 1,200–1,300 mL), ↑ blood volume (↑ 1,500–1,600 mL), ↑ more with multifetal pregnancy. WBC count may ↑ to 15,000/mm3. Iron deficiency anemia often is superimposed on the dilutional anemia of pregnancy (Hct 33%). The typical blood loss of 500–800 mL is usually well tolerated. Excessive blood loss is possible with multiple gestation, previous C-section, PIH, placenta previa, abruptio placenta, prolonged labor, and uterine atony. Repeat C-section associated with placenta previa poses high risk for hemorrhage because of placenta accreta.
Tests: Hgb/Hct

Gastrointestinal

Abnormalities, including ↓ gastric motility (after onset of labor), gastroesophageal reflux, raised intragastric pressure, and gastric hyperacidity, predisposes to aspiration pneumonitis. All parturients should be considered to have full stomachs and should receive clear antacid (e.g., 0.3 M Na citrate 30 mL) immediately prior to general or regional anesthesia. Administer iv metoclopramide 10 mg and ranitidine 50 mg before emergent C-section. Before elective C-section, parturients at high risk for aspiration (e.g., planned or potential GA, difficult airway, or any patient with esophageal reflux or obesity) should receive an H2-blocker (e.g., ranitidine 150 mg po) the night before and the morning of surgery.

Hepatic

Liver enzymes can be mildly elevated and plasma protein concentration is diminished (↑ unbound drug levels).
Tests: As indicated from H&P

Renal

These patients have ↑ renal blood flow (↑ 50%), ↑ GFR, and ↑ creatinine clearance, and ↓ serum creatinine and ↓ BUN. Dependent edema results from increased water and Na+ retention 2° resetting of the osmotic threshold for thirst and vasopressin secretions.
Tests: As indicated from H&P.

Laboratory

T&S maternal blood if risk factors for blood loss are present (e.g., third C-section). Cross-match unnecessary unless significant blood loss is anticipated. Routine autologous blood donation is not recommended. Coagulation studies and Plt count recommended with PIH, abruptio placenta, heavy maternal bleeding. BUN; Cr; UA; fasting blood glucose; others as indicated from H&P.

Premedication

Agents to decrease risk of aspiration pneumonitis include a clear antacid (e.g., Na citrate 30 mL po), ranitidine 50 mg iv and metoclopramide 10 mg iv. Sedatives are not routinely administered. In extremely anxious patients, however, 0.5–1.0 mg midazolam iv is an excellent anxiolytic, without apparent effect on maternal memory or alertness or neonatal condition.

P.820

Special Considerations

Pregnancy- induced hypertension (PIH)

PIH is characterized by generalized vasoconstriction with relative intravascular volume depletion and, occasionally, diffuse capillary leak. There may be ↑ risk of hypotension with regional anesthesia. Cautious hydration prior to regional anesthesia is necessary to prevent hypotension or pulmonary edema. Hepatic dysfunction may be present (HELLP syndrome). Epidural, spinal, and combined spinal-epidural (CSE) are all considered safe techniques in PIH. Cardiovascular stability is better with regional than GA, provided intravascular volume is adequate. Abnormal coagulation (↓ Plt count or dysfunctional Plt) contraindicates regional anesthesia. If GA is necessary, control BP with small doses of labetalol (5–20 mg iv over 3–5 min) and/or low doses of a short-acting opioid (e.g., fentanyl 50–100 mcg) prior to induction to blunt hypertensive response to laryngoscopy. There is a potential for difficult intubation in PIH due to airway edema; therefore, a small ETT (6.0 mm) should be available. MgSO4 potentiates neuromuscular blocking agents; avoid defasciculating dose of muscle relaxant before induction, use smaller than normal doses of nondepolarizing agents, and monitor neuromuscular function.
Tests: PT; PTT; Plt; TEG or bleeding time; LFTs

Eclampsia

Treat eclamptic Sz with adequate oxygenation and a small dose of STP (50–100 mg) or diazepam (5 mg). Intubate if necessary to protect airway. Initiate MgSO4 therapy (loading dose: 4–6 g iv over 20–30 min; then infuse @ 1–2 g/h).

Massive maternal hemorrhage:

·         Placenta previa

·         Abruptio placenta

·         Ruptured uterus

Insert 2 large-bore iv catheters (14–16 ga). Assure immediate availability of cross-matched blood. Rapidly restore intravascular volume with crystalloid, colloid, or both. Induction of GA with ketamine (1–1.5 mg/kg) is preferred in hypovolemic patients. DIC can follow abruptio placenta or amniotic fluid embolism. Dilutional thrombocytopenia following massive blood loss might require Plt transfusion. Uterine atony is treated with oxytocin 20–40 U/L in NS @ rate sufficient to control atony (risk of ↓ BP with boluses); methylergonovine, 0.2 mg im (risk of HTN); or 15-methyl prostaglandin F2-alpha, 0.25 mg im or intramyometrially (risk of pulmonary HTN, bronchospasm). Uterine artery embolization is often effective in controlling continued postpartum bleeding and may be considered before surgical artery ligation or hysterectomy. Emergency hysterectomy, however, may be the only solution to continued bleeding. Induction of GA may be necessary if massive bleeding occurs during regional anesthesia.

Diabetes

Diabetic patients have an increased propensity to ↓ BP following regional anesthesia, with the fetus becoming more acidotic than normal as a result. Determine blood glucose hourly and maintain at 80–100 mg/dL. Insulin requirements decrease drastically after delivery, and insulin dosage must be reduced to prevent maternal hypoglycemia.
Tests: Fasting blood glucose; UA

Response to anesthetic drugs

In pregnant patients, MAC is ↓ 40% for inhaled agents; combined with more rapid uptake, this predisposes to anesthetic overdose. Sensitivity to local anesthetics also is increased. Epidural space capacity is decreased 2° engorgement of epidural veins; this decreases requirements for local anesthetics and increases possibility of intravascular injection of drugs. Increased sensitivity to nondepolarizing muscle relaxants (especially in patients receiving MgSO4) mandates careful monitoring and use of reduced doses. Decreased protein binding may increase toxicity of highly protein-bound drugs such as bupivacaine.

P.821

Intraoperative

Anesthetic technique: General considerations involve primarily the choice of anesthetic. Compared with regional anesthesia, the risks of aspiration and difficult intubation with GA increase maternal morbidity and mortality. Anesthetic choice in specific circumstances depends on maternal and fetal conditions and degree of urgency. Properly conducted GA or regional anesthesia probably are equally safe for the fetus.

Spinal anesthesia is preferred for elective or semielective C-section (unless patient has an existing epidural) when no contraindications to regional anesthesia exist (e.g., patient refusal, coagulopathy, active neurological disease, hypovolemia, sepsis). With the use of a pencil-point needles (e.g., Sprotte, Whitacre), the risk of headache is low (1–2%). Advantages of spinal over epidural anesthesia include: technical ease, rapid onset of block, and more solid anesthesia, and less shivering. ↓BP, however, is more common with spinal anesthesia. Fluid loading (1–1.5 L crystalloid/500 mL colloid), leg wrapping (e.g., compression stockings), and vasopressors reduce the incidence and severity of ↓ BP, but do not eliminate it. Pressors (e.g., ephedrine [5–10 mg], phenylephrine [50–100 mcg], and atropine [0.4 mg iv]) should be used as appropriate to treat ↓ BP and ↓ HR. Ephedrine, even in large doses, may not reverse severe ↓ BP, and may ↑ fetal acidosis. Consider using epinephrine (50–100 mcg iv) if other pressors/fluids are unsuccessful.

P.822

General anesthesia normally is used when regional anesthesia is contraindicated or when there is inadequate time to institute regional blockade. Obstetric emergencies for which rapid induction of GA may be indicated include: severe maternal hemorrhage, prolapsed umbilical cord, severe fetal bradycardia, severe persistent fetal decelerations, or the need for intrauterine manipulation. Less dire situations often permit the performance of a “quick spinal” or extension of a functioning epidural block with an agent having a rapid onset (e.g., 15–20 mL 3% 2-chloroprocaine or 2% lidocaine with epinephrine). Continuous monitoring of the fetal heart rate (FHR) in the OR may allow use of regional anesthesia if the FHR tracing is reassuring. Constant communication with the obstetrician regarding maternal and fetal condition is essential. Although situations exist in which a GA is preferable to regional, the risks must be weighed against the benefits for patients with greater potential for complications. If difficult intubation is anticipated, rapid-sequence induction of GA should not be undertaken. Alternative approaches include awake intubation, spinal anesthesia, or local infiltration by the obstetrician. Sometimes, a nonreassuring FHR pattern is diagnosed as “fetal distress” and the fetus is delivered immediately. Fetal distress is an imprecise and nonspecific term with little positive predictive value. The severity of any FHR abnormality should be considered when the urgency of delivery and type of anesthesia are determined. C-section performed for a nonreassuring FHR pattern does not necessarily preclude the use of regional anesthesia.

Regional anesthesia:

Epidural

Apply monitors, fluid load, and place the patient in the sitting or lateral decubitus position. A 3 mL test dose of 1.5–2% lidocaine (45–60 mg) with 1:200,000 epinephrine (15–20 mcg) is given through the epidural needle or catheter to exclude intravascular injection (Sx: tachycardia, palpitations, dizziness, tinnitus, new taste in mouth) or subarachnoid placement (motor/sensory block in lower extremities). After 3–5 min, inject 15–20 mL 2% (300–400 mg) lidocaine with 1:200,000 epinephrine (75–100 mcg) incrementally over 5 min. Sodium bicarbonate, 1 mEq/10 mL lidocaine, hastens onset of block, but increases risk of ↓ BP. Bupivacaine, levobupivacaine, or ropivacaine 0.5%, 15–20 mL (75–100 mg), with or without epinephrine 1:200,000 and/or fentanyl (50–75 mcg), or 3% 2-chloroprocaine, 15–20 mL (450–600 mg) can also be used. To ensure a T4 level of anesthesia throughout surgery, additional local anesthetic often is needed. If a functioning epidural catheter is in place and an urgent C-section becomes necessary, 15–20 mL 3% 2-chloroprocaine (450–600 mg) or 2% lidocaine with epinephrine should produce adequate surgical anesthesia within 5–10 min.
Tilt table or use left hip elevation. Administer O2 by mask or nasal cannula, and check FHR prior to abdominal prep. Monitor BP every min until stable, then every 3–5 min. Treat ↓ 20% in BP or SBP < 95–100 mmHg with further uterine displacement, additional fluids, and ephedrine 5–10 mg or phenylephrine 50–100 mcg iv. For inadequate anesthesia, give additional epidural local anesthetic, 50–100 mcg fentanyl iv or epidurally, 50% N2O/O2, ketamine 5–10 mg iv and/or infiltrate with local anesthetic. The patient must remain conscious to avoid risk of aspiration. If anesthesia is still inadequate, induce GA (see below).
After delivery of infant and placenta, rapidly infuse oxytocin 20–30 U/L. Observe for excessive blood loss. Chest pain, mild oxyhemoglobin desaturation, and SOB after delivery may be due to irritation of diaphragm by blood or packs, too high or inadequate level of anesthesia, or venous air or amniotic fluid embolization. S-T segment changes on ECG occur, but do not usually signify myocardial ischemia.

Spinal

Apply monitors, administer fluid, and position as for epidural anesthesia. Metoclopramide 10 mg iv, 5–10 min prior to block decreases intraop N/V. Insert 24–25-ga pencil-point needle and verify free flow of CSF. In urgent situations, a larger pencil-point needle (e.g., 22-ga Sprotte) is easier and faster to place with minimal increase in headache. Inject hyperbaric 0.75% spinal bupivacaine 11.25–12.0 mg (1.5–1.6 mL) ± fentanyl 10–15 mcg and preservative-free morphine 0.1–0.2 mg, and position the patient with left uterine displacement. Monitor and treat ↓ BP as for epidural. Adjust operating table position to insure a T4 level of anesthesia. If anesthesia is inadequate and time permits, consider repeating block with CSE, repeat spinal (caution with dosing), or placement of an epidural catheter. Treat persistent inadequate anesthesia as for epidural. Induce GA if other measures fail.

Combined spinal- epidural (CSE)

An alternative technique combining the rapid onset and density of spinal anesthesia with the flexibility of continuous epidural anesthesia (e.g., if necessary to extend the duration or intensity of the block). Apply monitors, administer fluid, and position as for spinal/epidural. The most common technique is the needle-through-needle. When the epidural space is located with a 17-ga Tuohy needle, insert a 26–27 ga pencil-point spinal needle through it and administer 11.25–12 mg of spinal bupivacaine. Secure the epidural catheter and use if needed. (An epidural test dose is advisable.)

P.823

General anesthesia:

Induction

 

Tilt table or use left hip displacement and administer 500–750 mL dextrose-free crystalloid before induction. Preoxygenation for 3 min is optimal; however, 4 maximal inspiratory breaths in 30 sec is a satisfactory substitute in an emergency. Place patient in maximal “sniff” position with elevation of shoulders, if necessary, to optimize position for intubation. After patient is prepped and draped and obstetric team is ready to begin, perform rapid-sequence induction with cricoid pressure. Administer STP 4–5 mg/kg or propofol 2–3 mg/kg (or ketamine 1–1.5 mg/kg in hypovolemic patients) and succinylcholine 1–1.5 mg/kg to induce GA and facilitate intubation. Inflate cuff of ETT and verify tracheal placement by ETCO2 waveform and auscultation of bilateral breath sounds.

Failed intubation

 

If tracheal intubation is unsuccessful, monitor O2 sat and mask ventilate, maintaining cricoid pressure. Summon experienced help and quickly decide whether surgery must proceed. The risks of continuing with mask GA and cricoid pressure must be weighed against the risk of allowing the mother to awaken. If mask ventilation is impossible, quickly attempt ventilation with an LMA. If this succeeds, either continue to use throughout the case or place an ETT (6 mm ID) through LMA blindly or with FOL; alternatively, use an intubating LMA. A Pro-seal LMA has been used in this situation and may negate the necessity for ET intubation. If LMA fails to allow ventilation, attempt emergency transtracheal ventilation using a 12–14 ga iv catheter and appropriate tubing to connect to a high-pressure O2 source (e.g. jet ventilator). If these measures are unsuccessful, an emergency cricothyrotomy or tracheostomy should be performed by experienced personnel. Planning for a failed intubation must occur before it actually happens. A difficult-intubation tray, including equipment for emergency jet ventilation, must be immediately accessible in or very near the delivery room.

Maintenance

 

50% N2O/O2 with isoflurane or sevoflurane (limit MAC < 1.5 to prevent uterine atony). Control ventilation, avoiding extreme hypocapnia (PCO2 < 30 mmHg), which decreases umbilical blood flow. After delivery, substitute an opioid (e.g., fentanyl 50–100 mcg) for volatile agent and increase concentration of N2O to 70%. Administer small doses of muscle relaxants (e.g., vecuronium 2–3 mg) as needed. Reverse with neostigmine 0.05 mg/kg and glycopyrrolate 0.01 mg/kg or atropine 0.02 mg/kg. Midazolam (1–2 mg), given after delivery, helps avoid maternal awareness, which occasionally occurs with this anesthetic technique.

Emergence

 

Delay extubation until patient is fully awake and muscle strength has returned to normal.

Blood and fluid requirements

Moderate blood loss
IV: 16–18 ga × 1
NS/LR 1–3 L typical replacement

Infuse 1–2 L dextrose-free crystalloid (± colloid 500 mL) immediately prior to regional anesthesia. Typical blood loss = 500–800 mL. A rapid-fluid infuser and blood warmer should be available in the event that large-volume blood transfusion is required.

 

Monitoring

Standard monitors (seep. B-1)
FHR monitor
±CVP or PA catheter
±arterial line

Arterial BP monitoring via automated BP device, or arterial line for severe or labile HTN. CVP useful in PIH for oliguric patients unresponsive to fluid challenges. Occasionally, a PA catheter is indicated (e.g., for pulmonary edema, unresponsive oliguria).

 

Positioning

Left uterine displacement (blanket under right hip and/or table tilt)

Minimizes aortocaval compression.

 

Complications

Amniotic fluid embolism

Rare cause of hemodynamic instability, hypoxemia, and DIC. Often fatal. Rx: supportive: 100% O2, PEEP, and vasopressors. Correct Plt, clotting factors, and metabolic disturbances. CPB has been used successfully.

 

P.824

Postoperative

Complications

VTE

DX: pleuritic chest pain, cough, hypoxemia, ↑ RR, ↑ HR, ↑ A-a gradient. Rx: supportive: 100% O2, volume expansion, and vasopressors. See p. B-7.

Postpartum hemorrhage

See Anesthetic Considerations for Removal of Retained Placenta, p. 825.

Pain management

Epidural: 4–5 mg preservative-free morphine in 10 mL after delivery.
Intrathecal: Morphine (preservative-free) 0.1–0.2 mg given with spinal local anesthetic.
Chloroprocaine interferes with analgesia from epidural opioids

Common side effects include: pruritus 70%, nausea 30–40%, and, rarely, respiratory depression. Nalbuphine (5–10 mg) and naloxone (0.1–0.4 mg) are used for reversal of these side effects. Metoclopramide (10 mg iv) and/or ondansetron (4 mg iv) may be needed for persistent nausea. Risk of delayed respiratory depression in healthy patients is small; however, adequately trained nursing staff and a protocol for treatment of complications are mandatory if intraspinal opioids are used. These patients should not routinely receive sedatives or other systemic opioids for 12 h, and close monitoring of RR every hour and level of consciousness is necessary. Pulse oximetry is recommended in high-risk patients.

Parenteral opioids: iv or im opioids or PCA instituted in recovery room. Oral analgesics:NSAIDs (e.g., ibuprofen), acetaminophen ±codeine (or equivalent oral narcotics), after the patient can tolerate oral medication.

 

Tests

As indicated

 

Suggested Readings

  1. Carvalho B, Roland LM, Chu LF, et al: Single-dose, extended-release epidural morphine (DepoDur) compared to conventional epidural morphine for post-cesarean pain. Anesth Analg2007; 105(1):176–83.
  2. Chadwick HS: An analysis of obstetric anesthesia cases from the American Society of Anesthesiologists closed claims project database. Int J Obstet Anesth1996; 5:258–63.
  3. Cunningham FG, MacDonald PC, Gant NF, et al., eds: Cesarean delivery and postpartum hysterectomy. In: Williams Obstetrics, 22nd edition., Appleton & Lange, Stamford: 2005, 587–606.
  4. Ezri T, Szmuk P, Evron S, et al: Difficult airway in obstetric anesthesia: a review. Obstet Gynecol Surv2001; 56(10):631–41.
  5. Hawkins JL, Koonin LM, Palmer SK, et al: Anesthesia-related deaths during obstetric delivery in the United States, 1979–1990. Anesthesiology1997; 86:277–84.
  6. Macarthur A, Riley ET: Obstetric anesthesia controversies: vasopressor choice for postspinal hypotension during cesarean delivery. Int Aneshtesiol Clin2007; 45(1):115–32.
  7. McLintic AJ, Pringle SD, Lilley S, et al: Electrocardiographic changes during cesarean section under regional anesthesia. Anesth Analg1992; 74(1):51–6.
  8. Mercier FJ, Riley ET, Frederickson WL, et al: Phenylephrine added to prophylactic infusion during spinal anesthesia for elective cesarean section. Anesthesiology2001; 95(3):668–74.
  9. Morgan PJ, Halpern SH, Tarshis J: The effects of an increase of central blood volume before spinal anesthesia for cesarean delivery: a qualitative review. Anesth Analg2001; 92(4):997–1005.
  10. Richardson MG: Regional anesthesia for obstetrics. Anesthesiol Clin North America2000;18(2):383–406.
  11. Vedantham S, Goodwin SC, McLucas B, et al: Uterine artery embolization: an underused method of controlling pelvic hemorrhage. Am J Obstet Gynecol1997; 176(4):938–48.

P.825

Medical and Surgical Management of Postpartum Hemorrhage

Surgical Considerations

Description: The most common indication for postpartum uterine devascularization and hysterectomy is intractable postpartum hemorrhage (PPH). PPH is clinically defined as any uncompensated postpartum blood loss → tissue hypoperfusion. There are four major causes of PPH: retained products of conception (POC), laceration of the genital tract, uterine atony, and coagulopathies. Inherited coagulopathies include von Willebrand's disease, hemophilia, and factor XI deficiency. Acquired coagulopathies are most often related to thrombocytopenia 2° preeclampsia/eclampsia, hypofibrinogenemia 2° long-standing fetal demise, placental abruption, and DIC related to massive blood loss.

Postpartum blood loss can be reduced by prophylactic use of oxytocin, methylergonovine, or prostaglandins and these same agents are used as the first line of treatment for PPH. A concentrated oxytocin infusion (e.g., 80–100 U in 500 mL over 30 min) may be used. Methylergonovine should be given im only (0.2 mg q 2–4 h up to 1 mg), since iv infusion has been reported to cause acute HTN, stroke, and Sz. Ergot derivatives are contraindicated in patients with Hx of HTN, asthma, Raynaud's syndrome, or migraine. PGF (Hemabate) may be injected im (intramyometrial) at a dose of 0.25 mg, up to a total of 2 mg. Misoprostol, an inexpensive PGE, may be given rectally (up to 800 mcg).

Simultaneously, the surgeon should explore the cause of PPH and apply a specific treatment. If PPH is not controlled with treatment of uterine atony, and after volume replacement and correction of any coagulopathy, temporizing measures should be applied while preparing the patient for definitive invasive treatments. Temporizing measures include packing of uterine cavity with a long gauze and use of balloon tamponade. Extensive experience on non-pneumatic anti-shock garment (ASG) on non-pregnant patients is applied to post partum patients with remarkable success in temporizing hypovolemic shock from abdominal and pelvic bleeding. ASG can be applied quickly and results in an immediate 1,500–2,000 mL autotransfusion. ASG should not be used with fetus in situ or thoracic site of hemorrhage. After stabilization, patient should be transferred to Radiology for uterine artery embolization under fluoroscopic control where uterine arteries are selected and absorbable Gelfoam pledgets are introduced. Treatment may be repeated until bleeding is stopped. In known cases of placenta accreta, in anticipation of PPH, catheters have been placed in uterine arteries before C-section.

If selective embolization is not available, or fails to stop hemorrhage, more invasive surgical intervention should be employed, including uterine compression sutures, iliac artery ligation, uterine devascularization, and hysterectomy. The decision for surgical intervention is made when other options (i.e., medical, interventional radiology) have not been successful in decreasing the hemorrhage. Volume and coagulation factor replacement should continue while proceeding with surgery.

The technique for an emergent obstetrical hysterectomy is largely similar to a hysterectomy for other indications. Of note is the engorged and prominent nature of the vessels supplying the gravid uterus. The edematous tissues surrounding the uterus are very friable and may bleed profusely if improperly manipulated. A supracervical or total hysterectomymay be performed. Through a midline or Pfannenstiel's incision, the uterus is elevated out of the abdominal cavity. The round ligaments are clamped, transected, and ligated; and the anterior leaf of the broad ligament is incised bilaterally from the transected round ligaments to the vesicouterine reflection. The posterior leaf of the broad ligament adjacent to the uterus is entered at a level just below that of the fallopian tubes and uteroovarian ligaments. These are then clamped, transected, and ligated. Next, incision of the posterior leaf of the broad ligament toward the cardinal ligaments is performed. With gentle blunt dissection, the bladder and attached vesicouterine peritoneal flap are dissected off the lower uterine segment. The ascending uterine arteries and veins are identified bilaterally, then clamped, transected, and ligated. If a subtotal hysterectomy is planned, the body of the uterus is amputated at this level, and the cervical stump is closed with interrupted sutures. If a total hysterectomy is planned, dissection of the bladder off the cervix is continued until the cervicovaginal margin is identified. The cardinal and uterosacral ligaments are clamped, transected, and ligated, with clamps placed as close to the cervix as possible without including cervical tissue. After the level of the lateral vaginal fornix is reached, a clamp is swung below the cervix, across the lateral vaginal fornix. The cervix is then amputated off the vaginal cuff. Throughout the procedure, it is vital to clamp and ligate any bleeding vessels and to take extra care to avoid damage to the ureter or bladder. Following removal of the uterus and cervix, the vaginal cuff angles are sutured to the ipsilateral cardinal ligament stumps, and the vaginal cuff is closed with a running locked stitch. The abdominal wall is closed in layers.

P.826

Usual preop diagnosis: Intractable postpartum bleeding; rupture of gravid uterus

Summary of Procedures

Position

Supine, with left lateral tilt

Incision

Pfannenstiel's or midline longitudinal

Unique considerations

Monitoring of coagulation parameters and correction of DIC. Consider central venous hemodynamic monitoring. Pediatrics team present, if indicated.

Antibiotics

Cefazolin 1 g iv q 8 h; total 3 doses

Surgical time

2–3 h

Closing considerations

Subcutaneous intraperitoneal drains, if indicated.

EBL

3,000–4,000 mL

Postop care

ICU if blood loss severe; patient may require continued intubation and mechanical ventilatory support. Monitor for infectious morbidity and acute renal failure.

Mortality

< 1%

Morbidity

Hemorrhage
Postop febrile morbidity
DIC
Wound infection
Sheehan's syndrome
Bladder injury
Intraperitoneal bleeding requiring reoperation
Vesicovaginal fistula
Ureterovaginal fistula
Transfusion-related complications

Pain score

7

Patient Population Characteristics

Age range

Reproductive age

Incidence

0.11% of obstetric patients

Etiology

Unknown

Associated conditions

Placenta accreta; uterine atony nonresponsive to medical or other surgical intervention; extension of cervical tear to lower uterine segment; placenta previa; uterine rupture; uterine inversion

Anesthetic Considerations

See Anesthetic Considerations following Cesarean Section, p. 819.

Suggested Readings

  1. AbdRabbo SA: Stepwise uterine devascularization: a novel technique for management of uncontrolled postpartum hemorrhage with preservation of the uterus. Am J Obstet Gynecol1994; 171:694–700.
  2. B-Lynch C, Coker A, Lawal AH, et al: The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported.Br J Obstet Gynecol1997; 104:372–5.
  3. Bukowski R, Hankins GDV: Managing postpartum hemorrhage. ContemporaryOB/GYN 2001; 9:92–105.
  4. Cho JH, Jun HS, Lee CN: Hemostatic suturing technique for uterine bleeding during cesarean delivery. Obstet Gynecol2000; 96(1):129–31.
  5. Cunningham FG, MacDonald PC, Gant NF, et al: Cesarean delivery and cesarean hysterectomy. In Williams Obstetrics, 22nd edition. Appleton & Lange, Stamford: 2005.
  6. Hansch E, Chitkara U, McAlpine J, et al: Pelvic arterial embolization for control of obstetric hemorrhage: a five-year experience. Am J Obstet Gynecol1999; 180(6):1454–60.

P.827

  1. Hensleigh PA: Anti-shock garment provides resuscitation and haemostasis for obstetric haemorrhage. BJOG2002; 109(12):1377–84.
  2. Mousa H, Walkinshaw S: Major postpartum hemorrhage. Curr Opin Obstet Gynecol2001; 13(6):595–603.
  3. Oyelese Y, Scorza W, Mastrolia R, et al: Postpartum hemorrhage. Obstet Gynecol Clin North Am2007; 34(3):421–41.
  4. Tamizian O, Arulkumaraqn S: The surgical management of postpartum hemorrhage. Curr Opin Obstet Gynecol2001; 13(2):127–31.

Repair of Uterine Rupture

Surgical Considerations

Description: Rupture of the gravid uterus is considered a true obstetric emergency and can be catastrophic, with significant maternal and fetal mortality. The classic symptoms are “shearing” pain, cessation of uterine contractions, loss of fetal heart tones, and the onset of vaginal bleeding. Unfortunately, these warning symptoms occur only in a minority of uterine rupture cases. Extrusion of the placenta through the uterine rupture may result in late decelerations due to uteroplacental insufficiency. Extrusion of the umbilical cord may be manifested by recurrent variable decelerations. Suprapubic pain as the only symptom has not been associated with uterine rupture. Causes of uterine rupture include breakdown of a previous uterine scar, obstructed labor, or uterine trauma. In cases where the uterine rupture occurs at the site of a prior uterine scar, the clinical course is usually less severe and the blood loss less than in cases of primary rupture of an intact uterus. The incidence of uterine rupture at the site of the old scar is 0.5% for lower-uterine transverse C-sections, and 12% for classic C-sections.

Total abdominal hysterectomy (see p. 804), or supracervical hysterectomy (p. 825), is the definitive therapy; however, depending on the clinical situation and the patient's wishes for future fertility, a uterine repair may be undertaken. This consists of a 2- to 3-layered closure of the defect, using synthetic absorbable sutures. A transverse abdominal incision is made ~3 cm above the symphysis pubis and carried to the anterior rectus fascia. The fascia is incised and the muscles of the anterior abdominal wall separated sharply and bluntly from the midline. The peritoneum is elevated and entered sharply. Because of the emergent nature of this condition and the possible massive blood loss associated with rupture of a gravid uterus, the anesthesiologist must act quickly. Prompt O2 administration, together with aggressive iv fluid resuscitation, is indicated. Serious consideration should be given to the use of unmatched O(-) or type-specific blood until cross-matched blood becomes available. Intraop hypogastric or uterine artery ligation may help minimize blood loss. Patient's coagulation parameters must be monitored, because hypoxia and massive blood loss are associated with DIC.

Usual preop diagnosis: Uterine rupture

Summary of Procedures

Position

Supine with left-lateral tilt

Incision

Pfannenstiel's (low, transverse abdominal) or midline longitudinal

Unique considerations

Pediatrics team present for infant resuscitation, if necessary. Thorough surgical exploration of the urinary tract (bladder and ureters), because ~10% of cases are associated with bladder lacerations. Cell Saver may be helpful.

Antibiotics

Cefazolin 1 gm iv q 8 h × 3 doses

Surgical time

1–2 h

EBL

500–3,000 mL

Postop care

ICU if blood loss severe; continued intubation and mechanical ventilatory support if aggressive fluid resuscitation results in pulmonary edema. Acute renal failure may occur 2° hypoxic and hypovolemic renal injury at time of acute uterine rupture with massive bleeding; monitor UO and serial renal function tests.

Mortality

Fetal : 35–45%
Maternal: 5%

Morbidity

Blood transfusion > 5 U: 58%
Postop wound infection: 33%
Pelvic abscess: 8%
Repeat uterine rupture with subsequent pregnancies: 5%

Pain score

6

P.828

Patient Population Characteristics

Age range

Reproductive age

Incidence

1/1,400 deliveries

Etiology

Prior uterine surgery; grand multiparity; obesity; manual removal of placenta; injury from tools of abortion; direct or indirect violence; oxytocin use; intraamniotic or vaginal prostaglandins; breech extractions; internal or external version; forceps rotation; shoulder dystocia; fundal pressure; neglect (cephalopelvic disproportion, etc.); congenital uterine anomaly; cornual pregnancy; gestational trophoblastic neoplasia; placenta percreta; abruptio placenta

Anesthetic Considerations

See Anesthetic Considerations following Cesarean Section. p. 819.

Suggested Readings

  1. Chazotte C, Cohen WR: Catastrophic complications of previous cesarean section. Am J Obstet Gynecol1990; 163(3):738–42.
  2. Cunningham FG, MacDonald PC, Gant NF, et al: Surgical sterilization. In Williams Obstetrics, 22nd edition. Appleton & Lange, Stamford: 2005.
  3. Eden RD, Parker RT, Gall SA: Rupture of the pregnant uterus: a 53-year review. Obstet Gynecol1986; 68(5):671–74.
  4. Kaczmarczyk M, Sparen P, Terry P, et al: Risk factors for uterine rupture and neonatal consequences of uterine rupture: a population-based study of successive pregnancies in Sweden. BJOG2007; 114(10):1208–14.
  5. Plauche WC, VonAlmen W, Muller R: Catastrophic uterine rupture. Obstet Gynecol1984; 64(6):792–97.
  6. Sawyer MM, Lipshitz J, Anderson GD, et al: Third-trimester uterine rupture associated with vaginal prostaglandin E2Am J Obstet Gynecol1981; 140(6):710–11.
  7. Walsh C, Baxi L: Rupture of the primigravid uterus: a review of the literature. Obstet Gynec Surv2007; 62(5):327–34.

Postpartum Tubal Ligation

Surgical Considerations

Description: Postpartum tubal ligation (PPTL) is female surgical sterilization performed at the time of cesarean section (C-section) after delivery of the infant and repair of the uterine incision or within the first several days after a vaginal delivery. Although PPTL can be performed immediately postpartum, problems in the neonate may not be immediately evident, and a delay in surgery may be appropriate. If performed after a vaginal delivery, a small infraumbilical incision is made in the skin and carried down through the parietal peritoneum. The fallopian tubes are identified and brought out of the incision. It is important to identify the fimbriated end of the tube to ensure that the structure ligated is not the round ligament. A midsegment portion of the tube over an avascular portion of mesosalpinx is selected and tubal patency is disrupted by a variety of methods (Pomeroy, Parkland, Irving, Uchida, etc.). The Pomeroy, or a modification of it, is the most common technique used. The segment of tube grasped is ligated with absorbable suture and the knuckle of tube formed is excised. The cut ends of the tubes should be hemostatic before replacing the tubes into the abdomen. The wound is closed in layers in the usual fashion.

The consent for sterilization requires special consideration. The procedure is strictly elective and voluntary and must be considered permanent, even though reversal may be possible. Some patients will eventually regret the decision to undergo permanent sterilization. The risk of sterilization failure and an increased risk of ectopic pregnancy in

P.829

case of failure must be reviewed. The full range of alternatives to PPTL, including an interval sterilization procedure (sterilization performed remote from pregnancy) must also be considered.

Usual preop diagnosis: Desire for permanent sterilization

Summary of Procedures

Position

Supine; steep Trendelenburg often required to allow bowel to fall away for exposure.

Incision

Infraumbilical

Special instrumentation

Small Richardson and Army/Navy retractors; Babcock clamps; vein retractor

Unique considerations

A special consent form for sterilization must be signed by the patient in advance of the surgery. The bladder must be drained prior to the procedure.

Antibiotics

None recommended

Surgical time

15–25 min (Uchida technique may ↑ operative time)

EBL

10 mL

Postop care

Routine postpartum care after recovery from anesthesia

Mortality

3/100,000

Morbidity

Hemorrhage
Infection
Incidental damage to bowel or bladder

Pain score

3

Patient Population Characteristics

Age range

Reproductive age

Incidence

The most common contraceptive procedure in the United States.

Anesthetic Considerations

Preoperative

Optimal timing of tubal ligation is controversial. The patient with a functioning epidural catheter may benefit from having surgery immediately after delivery. Many surgeons, however, favor waiting 8–24 h, when adequate assessment of the neonate should be complete and risk of maternal hemorrhage lessened. Alternatively, the epidural catheter can be left in place and reinjected later (successful epidural reactivation within 24 h is possible in > 92% of patients). Because pulmonary aspiration remains a theoretical risk, initiation of GA or spinal anesthesia often is delayed 8–24 h until the acute GI changes of pregnancy have regressed. There is no benefit to delaying surgery beyond this time. Shorter hospital stays after vaginal delivery are encouraging more tubal ligations during the first 12 h after delivery. It is unknown whether this will affect morbidity or mortality.

Respiratory

FRC returns to normal almost immediately after delivery. Laryngeal edema may persist in preeclamptic and postpartum patients after protracted expulsive efforts during labor → requirement for a small ETT.
Tests: As indicated from H&P.

Cardiovascular

The physiologic changes of pregnancy return to normal at varying intervals after delivery. For example, risk of aortocaval compression disappears immediately. Blood volume returns to pre-pregnant values over several days. Postpartum hemorrhage can occur without warning.
Tests: As indicated from H&P.

Gastrointestinal

Postpartum patients continue to be at risk for acid aspiration, although it is not known exactly when normal GI function returns. If elective PPTL is planned within 8 h of delivery, patient should have no oral intake of solid foods during labor and the postpartum period. Precautions for prevention of acid aspiration should be followed as discussed in Cesarean Section, p. 820.

Neurological

Local anesthetic requirements for spinal anesthesia remain decreased after delivery but are greater than for pregnant patients.

Laboratory

Hct; other tests as indicated from H&P.

Premedication

Precautions should be taken to ↓ risk of aspiration pneumonitis, as discussed in Cesarean Section, p. 820.

P.830

Intraoperative

Anesthetic technique: Spinal anesthesia is preferred, if a functioning epidural catheter is not in place. Epidural catheters frequently become dislodged after a patient becomes ambulatory. GA is acceptable if patient has a strong preference or if contraindications to regional anesthesia exist. These patients may be at risk for aspiration of gastric contents at least 8–24 h postdelivery.

Regional anesthesia:

Spinal

For technique and monitoring for spinal anesthesia, see Cesarean Section, p. 822. Hyperbaric bupivacaine (7.5–12 mg) ± fentanyl (10–25 mcg). With the patient supine, adjust position of the operating table to obtain a T6 level of anesthesia. Sedate patient as necessary with small doses of iv midazolam 0.5–1.0 mg or opioid.

Epidural

A 3 mL epidural test dose, followed after 3–5 min by 15–20 mL of 1.5–2% lidocaine with 1:200,000 epinephrine injected incrementally. Additional local anesthetic as needed to ensure adequate level of anesthesia.

General anesthesia:

Induction

 

Rapid-sequence induction with STP (4–5 mg/kg) or propofol (1.5–2 mg/kg) and succinylcholine (1 mg/kg) for ET intubation.

Maintenance

Standard maintenance (p. B-2)

 

 

Emergence

 

Extubation should be delayed until patient is fully awake and protective airway reflexes have returned.

Blood and fluid requirements

Minimal blood loss
IV: 18 ga × 1
NS/LR @ 2–4 mL/kg/h

1–1.5 L dextrose-free crystalloid immediately prior to regional anesthesia

 

Monitoring

Standard monitors (p. B-1)

 

 

Positioning

[check mark] and pad pressure points
[check mark] eyes

 

 

Complications

None specific

 

 

Postoperative

Complications

Minimal bleeding

 

Pain management

Intraspinal opioids 10–25 mcg fentanyl
Parenteral opioids: IV or im opioids (e.g., morphine 2–4 mg iv up to 20 mg), or meperidine 10–20 mg iv q 10–15 min, titrated to RR and patient's level of pain and instituted in the recovery room.

Intrathecal fentanyl 10–25 mcg, given with spinal local anesthetic, enhances intraop anesthesia, particularly with low doses of bupivacaine, and provides several h postop analgesia.

Tests

None routinely indicated.

 

P.831

Suggested Readings

  1. Abouleish El: Postpartum tubal ligation requires more bupivacaine for spinal anesthesia than does cesarean section. Anesth Analg1986; 65(8):897–900.
  2. American College of Obstetricians and Gynecologists: ACOG Committee Opinion, Committee on Ethics: Sterilization of women, including those with mental disabilities. No 371, 2007 (replaces No 63, 1988, No 73, 1989, and No 216 1999). Obstet Gynecol2007;110(1):217–20.
  3. American College of Obstetricians and Gynecologists: ACOG Committee Opinion, Committee on Obstetrics, Maternal and Fetal Sterilization: Postpartum tubal sterilization. No 105, 1992. Int J Gynaecol Obstet1992; 39(3):244.
  4. American College of Obstetricians and Gynecologists: ACOG technical bulletin. Benefits and Risks of Sterilization. No 46, 2003 (replaces No 222, 1996 and No 113, 1988). Obstet Gynecol2003; 102(3):647–58.
  5. Bucklin BA: Postpartum tubal ligation: timing and other anesthetic considerations. Clin Obstet Gynecol2003; 46(3)657–66.
  6. Cunningham FG, MacDonald PC, Grant NF, et al., eds: Surgical sterilization. In Williams Obstetrics, 22nd edition. Appleton & Lange, Stamford: 2005.
  7. Goodman EJ, Dumas SD: The rate of successful reactivation of labor epidural catheters for postpartum tubal ligation surgery. Reg Anesth Pain Med1998; 23(3):258–61.
  8. Hampl KF, Schneider MC, Pargger H, et al: A similar incidence of transient neurologic symptoms after spinal anesthesia with 2 percent and 5 percent lidocaine. Anesth Analg1996; 83:1051–54.
  9. Hughes SC, Levinson G, Rosen MA, et al., eds: Shnider and Levinson's Anesthesia for Obstetrics, 4th edition. Lippincott Williams & Wilkins, Philadelphia: 2002.
  10. Practice Guidelines for Obstetrical Anesthesia: A report by the American Society of Anesthesiologists' Task Force on Obstetrical Anesthesia. Anesthesiology1999; 90:600–11.
  11. Viscomi CM, Rathmell JP: Labor epidural reactivation or spinal anesthesia for delayed postpartum tubal ligation: a cost comparison. Anesthesiology1994; 81:A1160.
  12. Wheeless CR Jr: Atlas of Pelvic Surgery, 2nd edition. Lea & Febiger, Philadelphia: 1988, 282–8.

Repair of Vaginal/Cervical Lacerations

Surgical Considerations

Description: Vaginal and cervical lacerations may occur 2° trauma of spontaneous and operative vaginal delivery. Adequate repair requires optimal surgical assistance, exposure, and patient comfort. Repair may be performed in a birthing bed, or may require patient positioning, lighting, anesthesia, or monitoring capabilities available only in an OR. Vaginal and cervical lacerations can extend into the perineum, rectum, urethra, bladder, lower uterine segment, broad ligament, or peritoneal cavity.

Lacerations of the lower vagina generally are easy to identify and repair. Small, superficial lacerations that do not bleed often do not need repair, whereas larger ones should be approximated. Deep lacerations may cause profuse bleeding; if it persists despite placement of multiple stitches, brief tamponade may be adequate to achieve hemostasis or vaginal packing may be required. Lacerations involving the perineum are classified as follows: First degree—involves break in mucosa and skin. Second degree—involves deeper tissue (bulbocavernosus and levator ani fascia and muscle). Third degree—involves anal sphincter. Fourth degree—extends into rectal mucosa. First- and second-degree lacerations are repaired in layers with continuous or interrupted stitches. The skin usually is closed with a subcuticular stitch. When the anal sphincter is lacerated, it often retracts. The ends are grasped with Allis clamps and approximated with multiple stitches. When the laceration extends into the rectum, the rectal mucosa usually is

P.832

closed in two layers, with the second layer imbricating the first. With periurethral lacerations, a catheter may need to be placed in the urethra to prevent passing a stitch through it. A laceration involving the urethra or bladder should be closed in multiple layers, followed by bladder drainage for several days.

Lacerations of the upper vagina are often difficult to visualize. Uterine bleeding and the umbilical cord of an undelivered placenta can obscure the field, and it can be difficult to determine if bleeding is vaginal or uterine. It is helpful to deliver the placenta and control uterine bleeding before proceeding. After visualization is adequate, it is important to place the first stitch above the apex of the laceration to control bleeding from vessels that may have retracted. Again, vaginal packing may be required if oozing of blood persists.

Superficial lacerations of the cervix occur with most deliveries but usually do not require treatment. Deep lacerations can cause significant blood loss, especially when they involve larger branches from the uterine artery or extend into the lower uterine segment. Again, the first stitch must be placed above the apex of the laceration to control bleeding from vessels that may have retracted. A laparotomy may be necessary if a laceration extends into the lower uterine segment or broad ligament and is causing significant bleeding that cannot be controlled otherwise. Alternatively, uterine artery embolization may be considered.

Usual preop diagnosis: Vaginal or cervical laceration

Summary of Procedures

Position

Dorsal lithotomy

Incision

None (unless exploratory laparotomy is performed)

Special instrumentation

Right-angle retractors; ring forceps; Allis clamps; Gelpi retractor; vaginal packing

Antibiotics

May be used for lacerations involving entry into the peritoneal cavity or the rectal mucosa.

Surgical time

10–45 min (possibly longer if exploratory laparotomy is performed)

EBL

Variable. Possible need for transfusion. Areas that persistently ooze after repeated placement of suture may be managed with vaginal packing.

Postop care

PACU ↑ ward

Mortality

Rare

Morbidity

Hemorrhage
Hematoma
Infection
Rectovaginal fistula
Vesicovaginal fistula

Pain score

3

Patient Population Characteristics

Age range

Reproductive age

Incidence

Not uncommon

Etiology

Trauma 2° spontaneous or operative vaginal delivery (98%); other vaginal/pelvic trauma (2%)

Associated conditions

Major blood loss possible; with non-obstetric etiology, the possibility of sexual assault needs to be explored.

Anesthetic Considerations

Preoperative

Vaginal and cervical lacerations may go undetected until considerable blood loss has occurred. Patients should be examined carefully for Sx of hypovolemia with appropriate volume resuscitation prior to anesthesia.

P.833

Respiratory

FRC returns to normal almost immediately after delivery.
Tests: As indicated from H&P.

Cardiovascular

The physiologic changes of pregnancy return to normal at varying intervals after delivery. For example, risk of aortocaval compression disappears immediately. Blood volume returns to pre-pregnant values over several days. Postpartum hemorrhage can occur without warning. Ensure adequate fluid resuscitation prior to induction of GA or regional anesthesia.
Tests: As indicated from H&P.

Gastrointestinal

Postpartum patients continue to be at risk for acid aspiration, although it is not known exactly when normal GI function returns. Precautions for prevention of acid aspiration should be followed as discussed in Cesarean Section, p. 820.

Neurological

Local anesthetic requirements for spinal anesthesia remain decreased after delivery.

Laboratory

Hct; other tests as indicated from H&P.

Premedication

Precautions should be taken to ↓ risk of aspiration pneumonitis, as discussed in Cesarean Section, p. 820.

Intraoperative

Anesthetic technique: In many patients, a functioning epidural catheter will be in place, and supplemental doses of anesthetic may be given to provide adequate analgesia for the surgery. If no epidural is placed and the patient is hemodynamically stable, a spinal anesthetic may be satisfactory. Occasionally, GA may be required.

Regional anesthesia:

Epidural

Supplemental doses of local anesthetic (2-chloroprocaine or 1.5–2% lidocaine 10–15 mL) injected incrementally with patient in sitting position (if tolerated) to promote perineal anesthesia.

Spinal

Hyperbaric bupivacaine 0.75% 7.5–10 mg with patient in sitting position, if tolerated. 24–25 ga pencil-point needle (e.g. Sprotte or Whitacre) to ↓ incidence of spinal headache. Anesthesia to T10 is usually adequate. Repair of more extensive lacerations may require a higher level and, consequently, a higher dose of anesthetic.

Combined spinal-epidural (CSE)

An alternative technique combining the rapid onset and density of spinal anesthesia with the flexibility of continuous epidural anesthesia (e.g., if necessary to extend the duration or intensity of the block). Apply monitors, administer fluid, and position as for spinal/epidural. The most common technique is the needle-through-needle. When the epidural space is located with a 17-ga Tuohy needle, insert a 26–27 ga pencil-point spinal needle through the Tuohy needle and administer 7.5–10 mg of spinal bupivacaine. Secure the epidural catheter and use if needed. (An epidural test dose is advisable.)

General anesthesia:

Induction

 

Rapid-sequence induction (see p. B-4) with STP (4–5 mg/kg) or propofol (2–3 mg/kg) and succinylcholine (1 mg/kg) for ET intubation. If significant blood loss, ketamine 1.5 mg/kg is preferred for induction.

Maintenance

 

Standard maintenance (see p. B-2).

Emergence

 

Extubation should be delayed until patient is fully awake and protective airway reflexes have returned.

Blood and fluid requirements

IV: 16–18 ga × 1
NS/LR @ 2–4 mL/kg/h

1–1.5 L dextrose-free crystalloid immediately prior to regional anesthesia. Blood loss may be extensive until laceration is repaired.

 

Monitoring

Standard monitors (see p. B-1)

 

 

Complications

Bleeding

 

 

Positioning

[check mark] and pad pressure points
[check mark] eyes

* NB: peroneal nerve compression at lateral fibular head → foot drop.

 

P.834

Postoperative

Complications

Bleeding
Peroneal nerve injury (2° lithotomy position)


Nerve injury manifests as foot drop and loss of sensation over dorsum of foot.

Pain management

Intraspinal opioids: 10 mcg fentanyl
Parenteral opioids: iv or im opioids (e.g., morphine 2–4 mg iv analgesia up to 20 mg, or meperidine 10–20 mg iv q 10–15 min up to 100 mg) instituted in the recovery room.

Intrathecal fentanyl given with spinal local anesthetic enhances intraop anesthesia and provides 3–4 h postop analgesia.

Tests

Hct

 

Suggested Readings

  1. American College of Obstetricians and Gynecologists: ACOG Educational Bulletin: Postpartum hemorrhage. No 76, 2006 (replaces No 243, 1998 and No 143, 1990). Obstet Gynecol2006;108(4):1039–47.
  2. Cunningham FG, MacDonald PC, Grant NF, eds: Obstetrical hemorrhage. In Williams Obstetrics, 22nd edition. Appleton & Lange, Stamford: 2005.
  3. Golan A, David MP: Repair of birth injuries. In Operative Perinatology: Invasive Obstetric Techniques. Iffy L, Charles D, eds. MacMillan, New York: 1984, 730–50.
  4. Zuspan P, Quilligan EJ, eds: Douglas-Stromme: Operative Obstetrics, 5th edition. Appleton & Lange, New York: 1988.

Cervical Cerclage-Elective and Emergent

Surgical Considerations

Description: Cervical cerclage is the reinforcement of the cervix to prevent premature cervical dilation in a patient with an incompetent cervix. With cervical incompetence, there is painless dilation of the cervix in the midtrimester of pregnancy. The membranes bulge through the cervix and rupture, followed by delivery of a severely premature infant.

An elective cerclage is performed prophylactically before pregnancy or usually after the first trimester of pregnancy on a patient with a Hx of cervical incompetence. If cerclage is performed before pregnancy, it may need to be removed because of spontaneous abortion or fetal anomalies. It generally is performed between 14–16 wk gestation, but may be performed as early as 10 wk gestation. An emergent (rescue) cerclage is performed in a patient who presents in the second trimester with painless cervical dilation and/or effacement. Ultrasound is performed before the procedure to confirm viability and to r/o major congenital anomalies. An emergent cerclage should not be performed if there is advanced cervical dilation or any evidence of infection, contractions, or uterine bleeding.

There are two types of cerclage procedures generally performed: the McDonald and the Shirodkar. The McDonald cerclage is technically easier, and the one most commonly performed. A purse-string stitch with nonabsorbable monofilament suture is placed high around the cervix near the level of the internal os and tied at the twelve o'clock position. The end of the suture is cut long to facilitate removal. The cerclage is removed electively at term or earlier if there is rupture of membranes, persistent contractions, bleeding, or evidence of infection. The Shirodkar cerclage involves incising the cervix transversely, anteriorly, and posteriorly, and advancing the bladder off the cervix. A nonabsorbable monofilament suture is placed submucosally between the incisions, and the mucosa is closed, burying

P.835

the stitch. A Shirodkar cerclage may be left for future pregnancies if abdominal delivery is performed. If the cervix cannot be adequately accessed through the vagina, cerclage may be attempted through laparotomy or laparoscopy.

Usual preop diagnosis: Cervical incompetence

Summary of Procedures

Position

Dorsal lithotomy, with use of cane stirrups. Left lateral pelvic tilt (if performed during pregnancy); Trendelenburg

Incision

None with McDonald cerclage; transverse cervical with Shirodkar cerclage

Special instrumentation

Right-angle retractors; monofilament, nonabsorbable stitch

Unique considerations

For emergent cerclage, when prolapsing membranes are present, they may be reduced by filling the bladder and/or possibly removing amniotic fluid transabdominally.

Antibiotics

None recommended.

Surgical time

30 min–1 h (may be longer for Shirodkar cerclage)

EBL

25–50 mL (may be higher with the Shirodkar cerclage)

Postop care

PACU → ward; tocolysis with indomethacin or other agent can be considered.

Mortality

Rare

Morbidity

Morbidity is increased for emergent cerclage, especially when performed later in 2nd trimester. The McDonald cerclage is associated with less trauma and bleeding than the Shirodkar cerclage.
Cervical trauma
Rupture of membranes
Chorioamnionitis
Preterm labor
Spontaneous abortion

Pain score

McDonald—2; Shirodkar—3

Patient Population Characteristics

Age range

Reproductive age

Incidence

Not uncommon

Etiology

Cervical trauma from previous vaginal delivery; cervical trauma at time of previous D&C; previous treatment for cervical dysplasia (laser therapy, cryotherapy, loop electrosurgical excision procedure [LEEP]/large loop excision of transitional zone [LLETZ], cone biopsy); congenital anomalies; idiopathic

Anesthetic Considerations

Preoperative

This is a generally fit and healthy patient population. Little will need to be done other than routine tests, unless otherwise indicated. Cerclage is usually performed between 14–24 wk of pregnancy. When performed after 20 wk, relevant physiologic changes are as discussed under Cesarean Section, p. 819. Patient may receive drugs such as β-sympathomimetics (e.g., terbutaline), nifedipine, or indomethacin to decrease uterine irritability.

Laboratory

Hct; other tests as indicated from H&P.

Premedication

None usually. If >18 wks gestation, precautions should be taken to decrease risk of aspiration pneumonitis, as discussed in Cesarean Section, p. 820.

P.836

Intraoperative

Anesthetic technique: Drug exposure during the critical period of organogenesis (15–56 d) should be minimized, although no particular anesthetic techniques or agents have proven teratogenic in humans. Through an action on vitamin B12, N2O inhibits methionine synthase, which is involved in thymidine and methionine synthesis. This may explain why N2O is teratogenic in rodents. There is no evidence, however, that N2O is teratogenic when used for cervical cerclage or other operations in humans. Large, retrospective analysis has shown no increase in congenital abnormalities following surgery under anesthesia. Avoid diazepam during the period of organogenesis (may ↑ cleft lip). Ensure adequate uteroplacental perfusion and fetal oxygenation by maintaining normal maternal BP and oxyhemoglobin saturation. Use left uterine displacement after 20 wk gestation. Maternal hyperventilation and IPPV may diminish uteroplacental and umbilical blood flow. Monitoring FHR may permit optimization of fetal well-being by adjustment of anesthetic technique or patient position. Spinal anesthesia is ideal as it minimizes fetal drug exposure and provides good operating conditions. Risk of headache is low with the use of small gauge pencil-point needles (e.g., Sprotte, Whitacre). Epidural anesthesia is an appropriate alternative for this procedure. GA may be used if regional anesthesia is contraindicated.

Regional anesthesia:

Spinal

Hyperbaric bupivacaine 7–10 mg ± fentanyl 10–15 mcg. Position patient to obtain T8 block. Monitor BP every min until stable, then every 3–5 min. Treat >20% ↓ in BP or SBP < 95–100 mmHg with additional fluids and ephedrine 5–10 mg iv.

General anesthesia:

Induction

 

Standard induction (see p. B-2). If > 18 wk gestation, rapid-sequence induction is indicated (see p. B-4).

Maintenance

 

Standard maintenance (p. B-2). If < 15–18 wk gestation, use of LMA or mask anesthesia with O2/N2O/volatile agent/opioid is appropriate. If > 18 wk gestation, ET intubation will be necessary.

Emergence

 

If > 18 wk gestation, extubate patient when fully awake and protective airway reflexes have returned.

Blood and fluid requirements

Minimal blood loss
IV: 18 ga × 1
NS/LR @ 4 mL/kg/h

1–1.5 L dextrose-free crystalloid immediately prior to regional anesthesia

   

Monitoring

Standard monitors (see p. B-1)
±FHR monitor


Consider FHR monitoring for viable fetuses and in earlier gestation, as the FHR may indicate inadequate placental perfusion and can guide BP management.

   

Positioning

Left uterine displacement, if > 20 wk gestation
[check mark] and pad pressure points
[check mark] eyes

Left uterine displacement with a wedge under mattress should be used for pregnant patients.
* NB: peroneal nerve compression at lateral fibular head → foot drop.

   

Postoperative

Complications

Preterm labor

Observe for preterm labor in recovery area.

Maternal dysrhythmias Hypotension

Tocolytic agents β-adrenergic agents) given to inhibit uterine contractions can cause maternal dysrhythmias or ↓BP.

Peroneal nerve injury

Nerve injury manifests as foot drop and loss of sensation over dorsum of foot.

Pain management

Intraspinal opioids: 10–15 mcg fentanyl
Parenteral opioids: iv or im opioids (e.g., morphine 2–4 mg iv up to 20 mg or meperidine 10–20 mg q 15 min up to 100 mg) instituted in the recovery room.
Oral analgesics: NSAIDS (e.g., ibuprofen), acetaminophen ± codeine (or equivalent oral narcotics), once patient can tolerate oral medication.

Intrathecal fentanyl given with spinal improves intraop analgesia and provides short-period postop analgesia. Risk of delayed respiration depression minimal in healthy patients.

P.837

Suggested Readings

  1. Aboujaoude R, Maloof P, Alvarez M, et al: A novel method for laparoscopic abdominal cerclage utilizing minimally invasive hydrodissection: a case report. J Reprod Med2007; 52(5):428–30.
  2. Aldridge LM, Tunstall ME: Nitrous oxide and the fetus. A review and the results of a retrospective study of 175 cases of anaesthesia for insertion of a Shirodkar suture. Br J Anaesth1986; 58(12):1348–56.
  3. American College of Obstetricians and Gynecologists: Cervical Cerclage, Prophylactic. ACOG Criteria, Set 17. American College of Obstetricians and Gynecologists, Washington: 1996.
  4. American College of Obstetricians and Gynecologists: Cervical Cerclage, Therapeutic. ACOG Criteria, Set 18. American College of Obstetricians and Gynecologists, Washington: 1996.
  5. American College of Obstetricians and Gynecologists: Cervical insufficiency. ACOG Practice Bulletin No 48. Int J Gynecol Obstet2004; 85:81–9.
  6. Barmat L, Glaser G, Davis G, et al: Da Vinci-assisted abdominal cerclage. Fertil Steril2007; 88(5):1437.
  7. Crawford IS, Lewis M: Nitrous oxide in early human pregnancy. Anaesthesia1986; 41(9):900–5.
  8. Czeizel AE, Pataki T, Rockenbauer M: Reproductive outcome after exposure to surgery under anesthesia during pregnancy. Arch Gynecol Obstet1998; 261(4):193–9.
  9. Gilstrap LC, Cunningham FG, Vandorsten JP, eds. Operative procedures on the Cervix. In Operative Obstetrics. McGraw-Hill, New York: 2002:503–22.
  10. Goodman S: Anesthesia for nonobstetric surgery in the pregnant patient. Semin Perinatol2002; 26(2):136–45.
  11. Levinson G: Anesthesia for surgery during pregnancy. In Hughes SC, Levinson G, Rosen MA, eds. Shnider and Levinson's Anesthesia for Obstetrics, 4th ed. Lippincott Williams & Wilkins, Philadelphia: 2002.
  12. Mazze RI, Kallen B: Reproductive outcome after anesthesia and operation during pregnancy: a registry study of 5405 cases. Am J Obstet Gynecol1989; 161(5):1178–85.
  13. Naughton NN, Cohen SE: Non-obstetric surgery during pregnancy. In Chestnut D, ed. Obstetric Anesthesia: Principles and Practice, 3rd ed. Mosby, St. Louis: 2004.
  14. Rosen MA: Management of anesthesia for the pregnant surgical patient. Anesthesiology1999; 91:1159–63.
  15. Safra MJ, Oakley GP Jr: Association between cleft lip with or without cleft palate and prenatal exposure to diazepam. Lancet1975; 2(7933):478–84.

Removal of Retained Placenta

Surgical Considerations

Description: In most deliveries, the placenta is easily removed with gentle cord traction and uterine massage. If, after 30 min, the placenta remains undelivered, manual removal,following either parenteral analgesia or GA, must be initiated. NTG (100–200 mcg iv or 0.4 mg sublingually) may induce uterine relaxation during manual removal. A possible alternative to manual removal involves injection of 10 mL of oxytocin (10 U/mL) into the umbilical vein; however, the success of this procedure is unpredictable. A retained placental fragment may cause immediate or late postpartum hemorrhage. An ultrasound evaluation of the uterus may help in the detection of a retained fragment. If retained products are found, curettage is recommended. Frequently, the retained product will already have been flushed out of the uterus by brisk bleeding. In such cases, iv oxytocin, rectal misoprostol, im prostaglandins or methylergonovine may be administered to contract the uterus prior to curettage.

Bleeding from a retained placenta or fragment is frequently brisk, so the anesthesiologist must be ready to administer iv fluids and O2, and to correct any coagulopathy. Cross-matched blood must be available. Placenta accreta, if extensive, can cause profuse bleeding at delivery, and a hysterectomy is often necessary.

P.838

Oxytocin 20–40 U in 1,000 mL of LR should be administered at a rate sufficient to maintain uterine tone after manual removal of the placenta or after sharp/suction curettage of a retained placental fragment.

Usual preop diagnosis: Retained placenta

Summary of Procedures

Position

Dorsal lithotomy

Incision

None

Special instrumentation

Banjo curette/suction cannula

Unique considerations

IV fluids; use of blood and blood products, as needed; monitoring of VS

Antibiotics

Cefazolin 1 g iv q 8 h; 3 total doses

Surgical time

30 min

EBL

300–900 mL

Postop care

PACU → ward. Monitor for infection and further bleeding.

Mortality

Rare

Morbidity

Hemorrhage
Endometritis
Uterine perforation 2° curettage
Asherman's syndrome
Transfusion-related morbidity (hepatitis, HIV, transfusion reactions)

Pain score

5

Patient Population Characteristics

Age range

Reproductive age

Incidence

0.25–0.8% of vaginal deliveries

Etiology

Unknown

Associated conditions

Placenta accreta; avulsed cotyledon; succenturiate lobe

Anesthetic Considerations

Preoperative

The degree of urgency associated with these patients may vary dramatically. Some patients may be hemodynamically unstable as a result of continued bleeding in the postpartum period; others may have a retained placenta with minimal bleeding. Patient's volume status should be carefully assessed.

Respiratory

FRC returns to normal almost immediately after delivery.
Tests: As indicated from H&P.

Cardiovascular

Restore intravascular volume prior to institution of analgesia or anesthesia. Extension of existing lumbar epidural blockade may aggravate hypovolemia and should proceed with caution. Consider possibility of placenta accreta (placental villi are attached to myometrium).

Gastrointestinal

Postpartum patients continue to be at risk for acid aspiration, although it is not known exactly when normal GI function returns. Precautions for prevention of acid aspiration should be followed as discussed in Cesarean Section, p. 820.

Neurological

Local anesthetic requirements for neuraxial anesthesia remain decreased after delivery.

Hematologic

Coagulopathy can develop with retained placenta if bleeding is severe and persistent.
Tests: Hct, PT, PTT, Plt, FSP, as indicated.

Laboratory

Other tests as indicated from H&P. T&C for 2 U+ if time permits. Emergency transfusion with Type O(-) or type-specific blood may be necessary.

Premedication

Precaution should be taken to decrease risk of aspiration, as discussed in Cesarean Section, p. 820.

P.839

Intraoperative

Anesthetic technique: Anesthesia for the removal of a retained placenta may vary from MAC to GA performed as an emergency. In the multiparous patient, MAC may be sufficient to enable the obstetrician to empty the uterus. If better analgesia and additional uterine relaxation are needed, however, then GA may be required. The incidence of retained placenta is about 1%. If intravascular volume has been restored and an existing epidural catheter is in place, the block can be extended to provide adequate anesthesia. Initiating spinal anesthesia is also an option if intravascular volume status is adequate, there is no active bleeding, and uterine relaxation is not required. Small doses of opioids and midazolam sometimes provide sufficient analgesia and sedation to allow removal of a retained placenta without compromising maternal safety. If this proves inadequate or hemorrhage is severe, however, GA with ET intubation is required. Anecdotal experience indicates that NTG in 100–200 mcg iv boluses or sublingual NTG 400 mcg provides uterine relaxation and delivery of a retained placenta in normovolemic patients receiving iv analgesia.

Regional anesthesia:

Spinal

For technique and monitoring of spinal anesthesia, see Cesarean Section, p. 822. Hyperbaric bupivacaine 8–10 mg; adjust the position of operating table to obtain T8 level of anesthesia.

Epidural

For technique and monitoring, see Cesarean Section, p. 822. Administer increments of 3% 2-chloroprocaine or 2% lidocaine with 1:200,000 epinephrine and bicarbonate until block level adequate. Additional local anesthetic as needed to ensure adequate level of anesthesia.

MAC

Titrate small doses of opioids (e.g., fentanyl 25–50 mcg) and midazolam 0.5–1.0 mg or ketamine 0.1 mg/kg. Sedation and analgesia should be titrated carefully, due to the potential risk of pulmonary aspiration in the parturient with an unprotected airway. Ensure patient is awake and responsive throughout. Consider NTG 100–200 mcg iv for uterine relaxation, repeated as necessary to obtain the desired effect. Transient ↓ BP may follow vasodilation due to NTG, and should be treated with volume and pressors if necessary.

General anesthesia:

Induction

 

Preoxygenation, rapid-sequence induction with cricoid pressure (see p. B-4), and hydration, as discussed in Cesarean Section (p. 823). Ketamine (1 mg/kg) is preferred for induction of hypotensive patient; but, in larger doses (> 1.5 mg/kg), it theoretically may increase uterine tone and make removal of placenta more difficult. Anesthesia with N2O/O2 + opioid (but no volatile agent) often permits delivery of the placenta.

Maintenance

 

If uterine relaxation is necessary, administer volatile agent (> 1 MAC) or NTG (see above) until uterine tone decreases.

Emergence

 

Extubation should be delayed until patient is fully awake and protective airway reflexes have returned.

Blood and fluid requirements

Anticipate large blood loss
IV: 16–18 ga × 1–2
NS/LR @ 6–8 mL/kg/h

Infuse crystalloid solution (1–1.5L) to maintain BP prior to regional anesthesia. Treat ↓ BP with fluids and ephedrine, and by decreasing concentration of volatile agent. Surgery is usually brief; additional muscle relaxation not usually necessary.

 

Monitoring

Standard monitors (seep. B-1)

 

 

Complications

Bleeding

Uterine atony: Rectal misoprostol, concentrated oxytocin infusion, 277–1667 mU/min. (50–300 U in 500 mL 1/2 normal saline over 3 h), uterine massage, ± methylergonovine 0.2 mg im (may →↑ BP), or PGF (Hemabate) 250 mcg iv/im/intrauterine (may → cardiovascular collapse/bronchospasm).

 

Positioning

[check mark] and pad pressure points
[check mark] eyes

*NB: peroneal nerve compression at lateral fibular head → foot drop.

 

P.840

Postoperative

Complications

Peroneal nerve injury (2° lithotomy position)
Bleeding

Nerve injury manifested as foot drop and loss of sensation over dorsum of foot.
See uterine atony, above.

Pain
management

IV or im opioids, titrated to effect, as usual, instituted in recovery room.

 

Tests

Hct

 

Suggested Readings

  1. Chedraui P, Insuasti D: Intravenous nitroglycerin in the management of retained placenta. Gynecol Obstet Invest2003; 56(2):61–4.
  2. Clark SL: Placenta previa and abruptio placentae. In Maternal-Fetal Medicine: Principles and Practice,5th edition. Creasy RK, Resnik R, eds. WB Saunders, Philadelphia: 2003.
  3. Cunningham FG, MacDonald PC, Gant NF, eds: Obstetrical hemorrhage. In Williams Obstetrics,22nd edition. Appleton & Lange, Stamford: 2005.
  4. Decherney AH, Pernoll ML, ed: Current Obstetric and Gynecologic Diagnosis and Treatment,9th edition. Appleton & Lange, Stamford: 2006.
  5. Desimone CA, Norris MC, Leighton BL: Intravenous nitroglycerin aids manual extraction of a retained placenta [Letter]. Anesthesiology1990; 73(4):787.
  6. Gilstrap LC, Cunningham FG, Vandorsten JP: Operative Obstetrics. New York: McGraw-Hill, 2002: 397–419.
  7. Hughes SC, Levinson G, Rosen MA, et al., eds: Shnider and Levinson's Anesthesia for Obstetrics,4th edition. Lippincott Williams & Wilkins, Philadelphia: 2002.
  8. Jha S, Chiu J, Yeo I: Intravenous nitroglycerine versus general anaesthesia for placental extraction–a sequential comparison. Med Sci Monit2003; 9(7):CS63–6.
  9. O'Grady JP, Gimovsky ML, McIlhargie, eds: Operative Obstetrics.Williams & Wilkins, Baltimore: 2002, 503–4.
  10. Owen J, Hauth JC: Concentrated oxytocin plus low-dose prostaglandin E2 compared with prostaglandin E2 vaginal suppositories for second-trimester pregnancy termination.Obstet Gynecol1996;88:110–3.
  11. Practice Guidelines for Obstetrical Anesthesia: An updated report by the American Society of Anesthesiologists' Task Force on Obstetrical Anesthesia. Anesthesiology2007; 106(4)843–63.
  12. Riley ET, Flanagan B, Cohen SE, et al: Intravenous nitroglycerin: a potent uterine relaxant for emergency obstetrical procedures. Report of 3 cases and review of literature.Int J Obstet Anesth1996; 5:264–8.

Management of Uterine Inversion

Surgical Considerations

Description: Uterine inversion is associated with fundal implantation of the placenta whereby a thinning of the uterine wall, together with placental separation, causes an invagination of the myometrium, resulting in inversion. Vigorous fundal pressure or cord traction also can contribute to uterine inversion, which can be complete or

P.841

incomplete. Complete inversion results in the inverted fundus extending beyond the cervix and appearing at the vaginal introitus, whereas in an incompletely inverted uterus, the fundus does not extend beyond the external cervical os. Uterine inversion can cause hemorrhage and shock out of proportion to observed bleeding, and must be managed as an obstetrical emergency. An anesthesiologist must be called to the delivery room as soon as a diagnosis of uterine inversion is made. The ready availability of GA is paramount. IV access with two infusion systems and appropriate fluid resuscitation must be initiated emergently. Blood and blood products should be available for administration as indicated.

Frequently, uterine replacement can be accomplished with iv tocolytics, such as terbutaline, MgSO4, and, more recently, NTG; however, GA with a volatile agent may be necessary. Three primary methods for uterine replacement are the Johnson, Huntington and Haultain procedures. Normally, the Johnson method is attempted first. Persistent pressure applied to the fundus is used to elevate the uterus into the vagina. The placenta, if attached, is not removed until iv resuscitation has been initiated, and iv tocolytics (or anesthesia) have been administered. Oxytocin is given when the uterus has been replaced. Laparotomy must be performed if uterine replacement with the Johnson method is unsuccessful. TheHuntington procedure involves grasping the round ligaments and applying upward traction on them, while an assistant exerts upward pressure on the uterus via a hand in the vagina. If the inverted uterus is trapped below the cervical ring, the Haultain procedure is used. This procedure involves making a longitudinal fundal incision posteriorly to allow easier reinversion of the fundus. Hydrostatic and laparoscopic reduction of uterine inversion have also been described.

Usual preop diagnosis: Uterine inversion

Summary of Procedures

 

Manual Reinversion

Huntington/Haultain

Position

Dorsal lithotomy

Supine

Incision

None

Pfannenstiel's or midline longitudinal

Unique considerations

Prompt O2 and iv fluid resuscitation; use of blood and blood products as necessary.

Antibiotics

Cefazolin 1 g iv q 8 h; total 3 doses

Surgical time

30 min

1–2 h

EBL

150–4,000 mL

Postop care

±ICU. ARDS may necessitate mechanical ventilation. Monitor for acute renal failure 2° hypoxia and hypovolemia.

Mortality

Rare

Morbidity

Febrile morbidity
Clinical shock
Infectious morbidity from blood transfusion



Pain score

5

7

Patient Population Characteristics

Age range

Reproductive age

Incidence

1/2,000–6,000 deliveries

Etiology

Unknown

Associated conditions

Fundal implantation of the placenta; primiparity; intrapartum oxytocin; placenta accreta; therapy of preeclampsia with MgSO4; macrosomic fetus

P.842

Anesthetic Considerations

Preoperative

These patients often present in shock out of proportion to blood loss; and immediate resuscitation may be necessary. Since patient condition will improve as soon as the uterus is replaced, however, surgical treatment should not be delayed.

Respiratory

FRC returns to normal almost immediately after delivery.
Tests: As indicated from H&P.

Cardiovascular

Massive hemorrhage and pain usual with complete inversion. Prior to induction, insert large-bore iv and rapidly infuse fluids, including colloid, to treat ↓ BP. Blood transfusion may be necessary, although is seldom available until after surgery.

Gastrointestinal

Postpartum patients continue to be at risk for acid aspiration, although it is not known exactly when normal GI function returns. Precautions for prevention of acid aspiration should be followed as discussed in Cesarean Section, p. 820.

Neurological

Local anesthetic requirements for neuraxial anesthesia remain decreased after delivery.

Laboratory

Hct; Plt; other tests as indicated from H&P. T&C for 2 U; keep 2 U ahead.

Premedication

Na citrate 30 mL po within 30 min of induction. If time permits, other agents to decrease risk of aspiration pneumonitis, as discussed in Cesarean Section, p. 820.

Intraoperative

Anesthetic technique: Attempted uterine replacement and induction of anesthesia should not await intravascular volume replacement. Bleeding usually stops when uterus is replaced. IV NTG (50–200 mcg) is very effective in providing uterine relaxation to facilitate replacement, and can be given immediately in the patient's room. Other tocolytics, such as terbutaline or Mg++, also may help. Do not give oxytocin before uterine replacement. Sometimes, however, GETA is required, often with increasing concentrations of volatile agents to facilitate uterine replacement. If regional anesthesia (e.g., epidural or spinal) was used for delivery, replacement of uterus may be accomplished with little further anesthetic intervention, with or without NTG. If regional anesthesia was not used for delivery, iv analgesia with small doses of fentanyl (25–50 mcg iv) occasionally allows reduction.

Induction

 

Rapid-sequence induction (see p. B-4) with ketamine (1.0 mg/kg) preferred. Higher dose may adversely increase uterine tone.

Maintenance

 

Halothane, isoflurane and sevoflurane are all effective uterine relaxants, but sevoflurane is most rapidly eliminated. ↓ BP should be treated with fluids + vasopressors.

Emergence

 

Extubation should be delayed until patient is fully awake and protective airway reflexes have returned.

Blood and fluid requirements

Significant blood loss
IV: 16–18 ga × 1 or 2

Possible continued blood loss after reduction of uterus due to uterine atony.

   

Monitoring

Standard monitors (see p. B-1)

Arterial line may be useful, if time allows.

   

Positioning

[check mark] and pad pressure points
[check mark] eyes

 

   

Complications

Uterine atony
Massive blood loss

Rx:↓ volatile anesthetic concentrations. Oxytocin infusion, uterine massage, ±methylergonovine 0.2 mg im (may ↑ BP), PGF (Hemabate) 250 mcg iv/im/intrauterine (may →cardiovascular collapse/bronchospasm)

   

P.843

Postoperative

Complications

Bleeding

Pain management

Parenteral opioids, titrated to effect, as usual, instituted in recovery room.

Tests

Hct

Suggested Readings

  1. American College of Obstetricians and Gynecologists: ACOG practice bulletin: postpartum hemorrhage. No 76, 2006 (replaces No 243, 1998 and No 143, 1990). Obstet Gynecol2006; 108(4)1039–47.
  2. Bowes W: Clinical aspects of normal and abnormal labor. In Maternal-Fetal Medicine: Principles and Practice,5th edition. Creasy RK, Resnik R, Bralow L, eds. WB Saunders, Philadelphia: 2003.
  3. Cunningham FG, MacDonald PC, Gant NF, eds: Williams Obstetrics,22nd edition. Appleton & Lange, Stamford: 2005.
  4. Hostetler DR, Bosworth MF: Uterine inversion: a life threatening obstetric emergency. J Am Board Fam Pract2000; 13(2): 120–3.
  5. Hughes SC, Levinson G, Rosen MA, et al., eds: Shnider and Levinson's Anesthesia for Obstetrics,4th edition. Lippincott Williams & Wilkins, Philadelphia: 2002.
  6. Riley ET, Flanagan B, Cohen SE, et al: Intravenous nitroglycerin: a potent relaxant for emergency obstetrical procedures. Review of literature and reports of 3 cases. Int J Obstet Anesth1996; 5:264–8.
  7. Tan KH, Luddin NS: Hydrostatic reduction of acute uterine inversion. Int J Gynaecol Obstet2005; 1:63–4.
  8. Vijayaraghavan R, Sujutha Y: Acute postpartum uterine inversion with haemorrhagic shock: laparoscopic reduction: a new method of management? BJOG2006; 9:1100–2.