Cesarean Hysterectomy Periprocedural Care

Consent begins when a mother is admitted for childbirth. Getting consent from admitted patients for intrapartum and postpartum care is standard. The mother should be aware of the potential complications of childbirth such as hemorrhage and the measures typically used to stop hemorrhage, including hysterectomy in severe situations. When abnormal placentation is suspected earlier in pregnancy, discussion about potential cesarean hysterectomy should begin during antenatal visits. Mothers undergoing planned cesarean hysterectomy should be counseled in the office regarding risks of surgery and indications. They should be aware that they cannot carry future children after hysterectomy.

Surgical preparation

Preoperative laboratory studies

Most mothers have a complete blood cell (CBC) count and blood type obtained upon routine admission. If a hysterectomy is planned, additional laboratory work may be obtained, including coagulation studies and basic metabolic panel, and the hospital blood bank should be called to prepare blood products matched specifically for that mother.

Venous access

Venous access is extremely important for surgery so that fluids and blood products (red blood cells [RBCs], platelets, fresh frozen plasma) may be transfused to resuscitate a mother in the event of massive bleeding. If hemorrhage is a preoperative concern, anesthesiologists usually prefer 2 sites of peripheral intravenous access (far away from the heart, such as in hands or arms) but may prefer larger intravenous access sites (central lines) to allow more rapid infusion of vital fluids. If the decision is made during cesarean surgery to proceed with hysterectomy, additional intravenous access is usually secured by anesthesiologists. The surgeon must actively communicate with the anesthesiologist as the mother’s situation changes.

Blood product availability

Blood products including packed RBCs, fresh frozen plasma, and platelets should be immediately available for a planned or suspected cesarean hysterectomy. Most labor and delivery units have a massive transfusion protocol that can be activated in the event of unexpected obstetric hemorrhage such as that which can prompt cesarean hysterectomy.

In a 2014 report, rates of intraoperative/postoperative RBC transfusion for cesarean hysterectomy were similar for women with placenta increta and those with placenta percreta, as were rates of transfusion with fresh frozen plasma or platelets. ^[5] However, perioperative outcomes were worse for women with placenta percreta, including a higher proportion who underwent cystostomy and postoperative mechanical ventilation.

Cell salvage of autologous blood may be an option for transfusion in women undergoing cesarean hysterectomy for placenta accreta. ^[6] In a 2013 prospective observational study comprising 15 of 20 women with an antenatal diagnosis of placenta accreta who underwent cesarean hysterectomy and received autologous blood after cell salvage, 13 (86.7%) did not require allogeneic RBC transfusion. No intraoperative or postoperative amniotic fluid embolism, hypotension, sepsis, or coagulopathy occurred. ^[6]

Appropriate medical facilities

If abnormal placentation is diagnosed prior to delivery and a cesarean hysterectomy is planned, surgery should take place at a tertiary care center with a blood bank, dedicated obstetric anesthesiologists, surgical subspecialists including gynecologic oncologists, and an interventional radiology suite. A multidisciplinary care team dedicated to cesarean hysterectomy may improve maternal outcomes.

Additional instruments should be added to the cesarean surgical field when a hysterectomy is undertaken. Various self-retaining retractors are available to increase exposure to organs near the uterus, and the choice of retractor is surgeon-dependent. Heavy-duty clamps such as the Heaney or Haney-Ballantine are needed and are frequently contained in a surgical tray specifically loaded for an abdominal hysterectomy. Newer handheld electronic vessel-sealing devices, adapted for abdominal surgery from minimally invasive laparoscopic surgery, may also be used at the surgeon’s discretion if available.

Anesthesia

The anesthesiologist is a crucial member of the care team for a mother undergoing cesarean hysterectomy. Venous access must be secured as above. Additionally, a mother who has an epidural or spinal may need to receive general anesthesia (via intubation or breathing tube) if the surgical conditions change and the anesthesiologist is concerned about a mother’s airway or breathing capacity. Pregnant women in general have an airway that is more edematous than normal, and maintaining an open airway is paramount for oxygen delivery to a mother.

Positioning

Cesarean deliveries normally are performed with the mother in dorsal supine position (laying down with legs flat on table). A pillow wedge is usually placed under the mother’s right torso, producing a leftward tilt, which alleviates pressure from the uterus on a large vein (inferior vena cava), increasing blood return to the heart and thus oxygen delivery to both mother and fetus. A hysterectomy can be performed in this position; however, if imaging of the urinary tract is required at the end of a hysterectomy or access to the vagina is required, the mother must be carefully moved into the dorsal lithotomy position during the procedure. Therefore, if a hysterectomy is planned or suspicion is high, place the mother in dorsal lithotomy position (laying down with legs in padded stirrups) prior to the procedure so the vagina or urethra are accessible during surgery if necessary.

Position the mother properly before starting the surgery because once skin cleansing and draping occurs, repositioning the mother without contaminating the sterile field is difficult. A drape with a collecting bag may be placed under the patient to collect blood loss from the vagina. This assists in a more accurate assessment of blood loss.

The pace of diet resumption depends on what was encountered during surgery. If the bowel is damaged during surgery, a mother’s diet is slowly advanced. Usually, mothers after surgery start with a liquid diet and then progress to solid food when they can tolerate a liquid diet without any nausea or vomiting. Surgeons prefer passage of flatus (gas) prior to discharge home though a bowel movement is not necessary prior to discharge.

If nausea with or without vomiting develops while the mother is recovering in the hospital, she may be evaluated for an ileus or small bowel obstruction using abdominal radiography or CT scanning. Ileus occurs when the bowels slow down or stop working from manipulation during surgery or from narcotics, and small bowel obstruction can occur after ileus or from scarring or adhesions inside the abdomen from surgery. A nasogastric tube (NGT) may need to be placed through a mother’s nose, down the esophagus and into the stomach, to help decompress the bowels and remove fluid in event of an ileus or bowel obstruction.

Discharge medications

When a mother is discharged home, she is usually given prescriptions for narcotic and nonsteroidal anti-inflammatory drug (NSAID) medications to assist with the pain relief that is expected after major abdominal surgery. If a mother remains anemic prior to discharge home, she may additionally be prescribed ferrous sulfate (iron).

Care after discharge from hospital

Mothers are asked to present to the outpatient office for a postoperative evaluation, usually by 6 weeks postpartum but possibly sooner depending on the mother’s clinical situation. For example, a mother with postpartum depression should be seen sooner, as should a mother who has complications after surgery. Assistance with lactation may be offered either in the hospital or as an outpatient in the form of a lactation consultant.