Blood loss averages 1500 mL with elective cesarean hysterectomy, although this is variable (Pritchard, 1965). Most peripartum hysterectomies are unscheduled, and blood loss in these cases is correspondingly greater. Thus, in addition to close monitoring of vital signs and urine output, the hematocrit should be determined intra-or postoperatively as indicated.
he amount of vaginal bleeding is closely monitored for at least an hour in the immediate postoperative period. he uterine fundus is also identiied frequently by palpation to ensure that the uterus remains irmly contracted. Unfortunately, as conduction analgesia fades or the woman awakens from general anesthesia, abdominal palpation is likely to produce pain. A patient-controlled analgesia (PCA) pump can be efective. Once regional analgesia begins to fade or the woman becomes fully awake following general anesthesia, criteria for transfer to the postpartum ward include minimal bleeding, stable vital signs, and adequate urine output.
Analgesia, Vital Signs, Intravenous Fluids
Several schemes are suitable for postoperative pain control. One PCA regimen uses intravenous morphine given as needed as a I-mg dose with a 6-minute lockout interval and maximum dose of 30 mg in 4 hours. An additional 2-mg booster dose is permitted for a maximum of 2 doses. Alternatively, intramuscular (1M) meperidine, 50 to 75 mg every 3 to 4 hours, or 1M morphine, 10 to 15 mg every 3 to 4 hours, is suitable. In a trial using these options, Yost and associates (2004) found that morphine provided superior pain relief to meperidine and was associated with significantly higher rates of breastfeeding and continuation of newborn rooming in. Breastfeeding can be ini tiated the day of surgery. If the mother elects not to breastfeed, a binder that supports the breasts without marked compression usually will minimize discomfort.
After transfer to her room, the woman is assessed at least hourly for 4 hours, and thereafter at intervals of 4 hours. Deep breathing and coughing are encouraged to prevent atelectasis.
Vital signs, uterine tone, urine output, and bleeding are evalu ated. The hematocrit is routinely measured the morning after surgery. It is checked sooner if there was unusual blood loss or if there is hypotension, tachycardia, oliguria, or other evidence to suggest hypovolemia. If the hematocrit is decreased signii cantly from the preoperative level, the measurement is repeated and a search is instituted to identiy the cause. If the hematocrit stabilizes, the mother can be allowed to ambulate, and if there is little likelihood of further blood loss, iron therapy is preferred to transfusion.
Postpartum, the patient begins to mobilize and excrete her physiologically expanded extravascular volume. Thus, mainte sistent oral intake is reestablished. If urine output falls below 30 mLlhr, however, the woman should be reevaluated promptly.
The cause of the oliguria can range from unrecognized blood loss to an antidiuretic efect from infused oxytocin.
Women undergoing unscheduled cesarean delivery may have pathological retention or constriction of the extracellular fluid compartment caused by severe preeclampsia, sepsis syndrome, vomiting, prolonged labor without adequate fluid intake, or increased blood loss. Women with these complications are generally observed in the recovery room until stabilization is assured.
The Foley catheter most often can be removed by 12 hours postoperatively, or more conveniently, the morning after surgery. he prevalence of urinary retention following cesarean delivery approximates 3 to 7 percent (Chap. 36, p. 660). Failure to progress in labor and postoperative narcotic analgesia are identified risks (Chai, 2008; Kandadai, 2014; Liang, 2007).