What is included in preoperative monitoring prior to cesarean delivery (C-section)?

Updated: Dec 14, 2018
  • Author: Hedwige Saint Louis, MD, MPH, FACOG; Chief Editor: Christine Isaacs, MD  more...
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A blood pressure cuff is placed. Monitors are also placed to allow the patient’s blood pressure, pulse, and oxygen saturation to be monitored before administration of anesthesia through the initial postoperative period in the recovery room.

Before surgery, a Foley catheter is placed so that the bladder can be drained during the procedure and urine output can be monitored to help evaluate fluid status. After regional anesthesia, patients are unable to void spontaneously for as long as 24 hours.

A review by Li et al suggests that nonuse of indwelling urinary catheters in caesarean delivery is associated with fewer urinary tract infections and no increase in urinary retention or intraoperative difficulties. [64] Further trials are necessary to confirm this finding among patients who receive spinal or epidural anesthesia for uncomplicated cesarean delivery.

Preoperative antibiotic prophylaxis decreases the risk of endometritis after elective cesarean delivery by 76% (relative risk [RR], 0.24; 95% confidence interval [CI], 0.25-0.35), regardless of the type of cesarean delivery (emergent or elective). [13]

Mackeen et al compared the effects of cesarean antibiotic prophylaxis administered preoperatively versus after neonatal cord clamp on postoperative infectious complications for the mother and the neonate. They searched the Cochrane Pregnancy and Childbirth Group's Trials Register and reference lists of retrieved papers for randomized controlled trials focused on this comparison. They included 10 studies (12 trial reports), from which 5041 women contributed data for the primary outcome. Based on high quality evidence from studies whose overall risk of bias is low, they found evidence that intravenous prophylactic antibiotics for cesarean administered preoperatively significantly decrease the incidence of composite maternal postpartum infectious morbidity as compared with administration after cord clamp. There were no clear differences in adverse neonatal outcomes reported. The authors conclude that women undergoing cesarean delivery should receive antibiotic prophylaxis preoperatively to reduce maternal infectious morbidities. Further research may be required to elucidate short- and long-term adverse effects for neonates. [65]

Single-dose therapy is recommended for its effectiveness, lower cost, decreased potential toxicity, and decreased development of resistance. A first-generation cephalosporin is the first-line antibiotic of choice. In women with penicillin or cephalosporin allergy (ie, anaphylaxis, angioedema, respiratory distress, or urticaria), the alternative is a combination of clindamycin with an aminoglycoside. Recent studies have shown that adding azithromycin 500mg continuous IV to cefazolin about an hour prior to surgery further reduce the risk of endometriosis and wound infection. [66] Prolonged surgery, excessive blood loss, and maternal obesity may require repeat or higher dosing. [67]

A meta-analysis of three randomized trials supports the use of antibiotic prophylaxis for cesarean delivery administered up to 60 minutes before skin incision rather than after umbilical cord clamping. [68, 67]

There is no benefit from oral antibiotics for eradication of MRSA colonization among patients in the health care setting, and oral antibiotics are not currently routinely recommended for the purpose of MRSA decolonization. Routine screening of obstetric patients for MRSA colonization is not recommended. For obstetric patients known to be MRSA colonized, a single dose of vancomycin can be added to the antibiotic prophylaxis regimen. Vancomycin alone does not provide sufficient coverage for surgical prophylaxis. [67]

Infective endocarditis prophylaxis is not recommended for vaginal delivery or cesarean delivery. Patients at highest potential risk for adverse cardiac outcomes who are undergoing vaginal delivery may benefit from prophylaxis. Those at highest risk are women with cyanotic cardiac disease, recently repaired cyanotic heart disease, residual defects after repair, prosthetic valves, history of bacterial endocarditis, or history of heart transplant. Mitral valve prolapse is not considered a lesion that ever needs infective endocarditis prophylaxis. [69]

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