After recovery from anaesthesia observations (respiratory rate, heart rate, blood pressure, pain and sedation) should be continued every half hour (or quarter hourly) for two hours and hourly thereafter provided that the observations are stable or satisfactory. If these observations are not stable, more frequent observations and medical review are recommended. After Caesarean delivery, women should be observed on a one-to-one basis by a properly trained member of staff until they have regained airway control and cardiorespiratory stability and are able to communicate.26 Intravenous fluids (usually 5% dextrose / saline 500mls over 4 hours, to alternate with 5% dextrose water 500mls over 4 hours, unless otherwise indicated) should be continued until patients tolerates orally.
2.3.1 Pain Management after Caesarean Delivery
Intrathecal analgesia, patient controlled analgesia or parenteral opioids like pethidine and pentazocine, local anaesthetic wound infiltration and non-steroidal anti-inflammatory agents are commonly used for analgesia post-Caesarean delivery.26 An antiemetic, such as promethazine,
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25 mg, usually is given along with the opioids.1 It has been recommended that diamorphine (0.3–
0.4 mg intra-thecally) should be used for intra- and post-operative analgesia because it reduces the need for supplemental analgesia after a Caesarean delivery.34 Epidural diamorphine (2.5–5 mg) is a suitable alternative. Patient controlled analgesia using opioid analgesics should be offered after Caesarean delivery where facilities are available as it improves pain relief.26
Suitable opioids commonly used include intravenous or intramuscular pentazocine (30mg given 4-6 hourly) which is usually given with promethazine (25mg) to counter its emetic effect; and pethidine (50mg 6 hourly). Providing there is no contraindication, non-steroidal anti-inflammatory drugs (NSAIDS like intramuscular diclofenac – 75mg 12 hourly) should be offered post-Caesarean delivery as an adjunct to other analgesics, because they reduce the need for opioids.26 Also acetaminophen (paracetamol) should be used because of its excellent analgesic and anti-pyretic activity and its weak anti-inflammatory activity.45 These parenteral analgesics are mostly only necessary during the first 24 to 48 hours after surgery, then the oral forms of the NSAIDS and paracetamol may suffice for the next few days, when oral intake has been established.
2.3.2 Early Ambulation
In encouraging early ambulation, after bed rest for the first 6 hours post-operative, the woman should sit out of bed within 12 hours post-operative and walk around the room within 24 hours post-operative. In most instances, by the day after surgery, a woman should get briefly out of bed with assistance at least twice to walk.1 Ambulation can be timed so that a recently administered analgesic will minimize the discomfort. By the second day, she may walk around without
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assistance.1,26 Early ambulation lowers the risk of venous thrombosis and pulmonary embolism.1 Women undergoing Caesarean delivery have a two- to 20-fold increased risk of pulmonary embolism compared with those delivering vaginally.1 Risks include age ≥ 35; body mass index ≥ 30; parity ≥3; emergency Caesarean delivery; Caesarean hysterectomy; concurrent infection, major illness, pre-eclampia, or gross varicosities; recent immobility; and prior deep-venous thrombosis or thrombophilia.1
2.3.3 Early Eating after Caesarean Delivery
Most Caesarean deliveries are performed under regional anaesthesia, requiring little intestinal manipulation, short operating time, and typically involve young patients. Early oral feeding after Caesarean deliveries should not result in any complications, and has other benefits, such as early ambulation and a shorter hospital stay.14,26 It has been indicated that the early feeding after uncomplicated Caesarean delivery had reduced the rate of ileus symptoms and offer potential benefits such as associated shorter interval to bowel movement, intravenous fluid administration, and length of hospital stay.46 However, management of post-operative feeding requires proper counselling on details of both regimens and flexibilities should be provided to accommodate early feeding when requested by the patients.26,46
Delayed initiation of oral fluids and food may be uncomfortable for women in the post-operative period. Women who have regional anaesthesia for Caesarean delivery may be more comfortable with taking oral fluids and food early. However, established hospital routines often restrict early intake of food and fluids for the fear of abdominal distension and possible vomiting. It has been recommended that women who are recovering well and who do not have complications after Caesarean delivery can eat and drink when they feel hungry or thirsty.1,26
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Nevertheless, a number of factors may influence the decision regarding early or late initiation of fluids and food. These include: the type of abdominal incision, peritoneum closure, the extent of bowel irritation and use of other operative procedures during the Caesarean section. Low midline skin incision, swab packing during operation or cleaning amniotic fluid or blood in the abdominal cavity and closure of the peritoneum may also affect the return of bowel function.14,26 The above events may delay return of bowel function. Oral intake should be introduced in a graded fashion starting with water/plain fluids, then other fluids, semisolids and then solid diet.
2.3.4 Other Aspects of Post-operative Management
Removal of the urinary bladder catheter should be carried out once a woman is mobile after a regional anaesthetic and not sooner than 12 hours after the last epidural ‘top up’ dose.26 Routine respiratory physiotherapy does not need to be offered to women after a Caesarean delivery under general anaesthesia, because it does not improve respiratory outcomes such as
coughing, phlegm, body temperature, chest palpation and auscultatory changes.26 The wound should be inspected, and the dressing removed (depending on the unit protocol), from the second post-operative day. Women who have had a Caesarean delivery should be offered the opportunity to discuss with their healthcare providers the reasons for the Caesarean delivery and implications for the child or future pregnancies.11,26