If cesarean delivery is scheduled, a sedative may be given at bedtime the night before surgery. In general, no other sedatives, narcotics, or tranquilizers are administered until after the fetus is born. In one small randomized trial, no benefits were gained from a presurgical enema (Lurie, 2012). Solid food intake is stopped at least 6 to 8 hours before the procedure. Uncomplicated patients may have moderate amounts of clear liquids up to 2 hours before surgery (American Society of Anesthesiologists, 2016). his comports with Enhanced Recovery After Surgery (ERAS) protocols that strive to maintain anabolic homeostasis and advocate clear carbohydrate drinks up to 2 hours before scheduled surgery and early postoperative feeding (Ljungqvist, 2017). Although evidence supports an ERAS approach for many procedures, data specifically addressing this for cesarean delivery are scarce (Wrench, 2015).
The woman scheduled for repeat cesarean delivery typically is admitted the day of surgery and evaluated by the obstetrical and anesthesia teams. Recently performed hematocrit and indirect Coombs test are reviewed. If the latter is positive, then availability of compatible blood must be ensured.
As discussed in Chapter 25 (p. 490), regional analgesia is preferred for cesarean delivery. An antacid is given shortly before regional analgesia or induction of general anesthesia. One example is Bicitra, 30 mL orally in a single dose. This minimizes the lung injury risk from gastric acid aspiration. Once the woman is supine, a wedge beneath the right hip and lower back creates a left lateral tilt to aid venous return and avoid hypotension. Data are insuicient to determine the value of fetal monitoring before scheduled cesarean delivery in women without risk factors. Our practice is to obtain a 5-minute tracing prior to elective cases. At minimum, fetal heart sounds should be documented in the operating room prior to surgery.
Of urther preparations, hair removal at the surgical site does not lower surgical site infection (SSI) rates (Kowalski, 2016). However, if hair is obscuring, it is removed the day of surgery by clipping, which is associated with fewer SSIs than shaving (Tanner, 2011). Chemical depilation the night before surgery compared with clipping has similar SSI rates (Lefebvre, 2015). An electrosurgical grounding pad is placed near the surgical incision and typically on the lateral thigh. n indwelling bladder catheter is typically placed at Parkland Hospital to collapse the bladder away from the hysterotomy incision, to avert urinary retention secondary to regional analgesia, and to allow accurate postoperative urine measurement. Small studies show that catheterization may be withheld in hemodynamically stable women to minimize urinary infections (Abdel-Aleem, 2014; Li, 2011; Nasr, 2009).
he risk of venous thromboembolism is increased with pregnancy and almost doubled in those undergoing cesarean delivery Oames, 2006). Accordingly, for all women not already receiving thromboprophylaxis, the American College of Obstetricians and Gynecologists (2017d) recommends initiation of pneumatic compression hose before cesarean delivery. These are usually discontinued once the woman ambulates. Recommendations between organizations vary, and the American College of Chest Physicians suggests only early ambulation for women without risk factors who are undergoing cesarean delivery (Bates, 2012). For women already receiving prophylaxis or those with increased risk factors, they support escalation of prophylaxis. Last, the Royal College of Obstetricians and Gynaecologists (2015) are the most conservative and suggest pharmacological prophylaxis for the largest proportion of patients. hese various methods and recommendations are discussed in Chapter 52 and are shown in Table 52-6 (p. 1020).