Postoperative Management after Cesarean Section

I.Post Cesarean Section Orders

A.Transfer: to post partum ward when stable.

B.Vital signs: q4h x 24 hours, I and O.

C.Activity: Bed rest x 6-8 hours, then ambulate; if given spinal, keep patient flat on back x 8h. Incentive spirometer q1h while awake.

D.Diet: NPO x 8h, then sips of water. Advance to clear liquids, then to regular diet as tolerated.

E.IV Fluids: IV D5 LR or D5 ½ NS at 125 cc/h. Foley to gravity; discontinue after 12 hours. I and O catheterize prn.

F.Medications

1.Cefazolin (Ancef) 1 gm IVPB x one dose at time of cesarean section.

2.Nalbuphine (Nubain) 5 to 10 mg SC or IV q2-3h OR

3.Meperidine (Demerol) 50-75 mg IM q3-4h prn pain.

4.Hydroxyzine (Vistaril) 25-50 mg IM q3-4h prn nausea.

5.Prochlorperazine (Compazine) 10 mg IV q4-6h prn nausea OR

6.Promethazine (Phenergan) 25-50 mg IV q3-4h prn nausea

G.Labs: CBC in AM.

II.Postoperative Day #1

A.Assess pain, lungs, cardiac status, fundal height, lochia, passing of flatus, bowel movement, distension, tenderness, bowel sounds, incision.

B.Discontinue IV when taking adequate PO fluids.

C.Discontinue Foley, and I and O catheterize prn.

D.Ambulate tid with assistance; incentive spirometer q1h while awake.

E.Check hematocrit, hemoglobin, Rh, and rubella status.

F.Medications

1.Acetaminophen/codeine (Tylenol #3) 1-2 PO q4-6h prn pain OR

2.Oxycodone/acetaminophen (Percocet) 1 tab q6h prn pain.

3.FeSO4 325 mg PO bid-tid.

4.Multivitamin PO qd, Colace 100 mg PO bid. Mylicon 80

mg PO qid prn bloating.

III.Postoperative Day #2

A.If passing gas and/or bowel movement, advance to regular diet.

B.Laxatives: Dulcolax supp prn or Milk of magnesia 30 cc PO

tid prn. Mylicon 80 mg PO qid prn bloating.

IV. Postoperative Day #3

A.If transverse incision, remove staples and place steri-strips on day 3. If a vertical incision, remove staples on post op day 5.

B.Discharge home on appropriate medications; follow up in 2 and 6 weeks.

Prevention of D Isoimmunization

The morbidity and mortality of Rh hemolytic disease can be significantly reduced by identification of women at risk for isoimmunization and by administration of D immunoglobulin. Administration of D immunoglobulin [RhoGAM, Rho(D) immunoglobulin, RhIg] is very effective in the preventing isoimmunization to the D antigen.

I.Prenatal testing

A.Routine prenatal laboratory evaluation includes ABO and D blood type determination and antibody screen.

B.At 28-29 weeks of gestation woman who are D negative but not D isoimmunized should be retested for D antibody. If the test reveals that no D antibody is present, prophylactic D immunoglobulin [RhoGAM, Rho(D) immunoglobulin, RhIg] is indicated.

C.If D antibody is present, D immunoglobulin will not be beneficial, and specialized management of the D isoimmunized pregnancy is undertaken to manage hemolytic disease of

the fetus and hydrops fetalis.

II.Routine administration of D immunoglobulin

A.Abortion. D sensitization may be caused by abortion. D sensitization occurs more frequently after induced abortion than after spontaneous abortion, and it occurs more frequently after late abortion than after early abortion. D sensitization occurs following induced abortion in 4-5% of susceptible women. All unsensitized, D-negative women who have an induced or spontaneous abortion should be treated with D immunoglobulin unless the father is known to be D negative.

B.Dosage of D immunoglobulin is determined by the stage of gestation. If the abortion occurs before 13 weeks of gestation, 50 mcg of D immunoglobulin prevents sensitization. For abortions occurring at 13 weeks of gestation and later, 300mcg is given.

C.Ectopic pregnancy can cause D sensitization. All unsensitized, D-negative women who have an ectopic pregnancy should be given D immunoglobulin. The dosage is determined by the gestational age, as described above for abortion.

D.Amniocentesis

1.D isoimmunization can occur after amniocentesis. D immunoglobulin, 300 mcg, should be administered to unsensitized, D-negative, susceptible patients following firstand second-trimester amniocentesis.

2.Following third-trimester amniocentesis, 300 mcg of D immunoglobulin should be administered. If amniocentesis is performed and delivery is planned within 48 hours, D immunoglobulin can be withheld until after delivery, when the newborn can be tested for D positivity. If the amniocentesis is expected to precede delivery by more than 48 hours, the patient should receive 300 mcg of D immunoglobulin at the time of amniocentesis.