Preoperative Orders and Postoperative Orders Care Plan for Lower Segment Caesarean Section (LT C/S) [Cesarean Section]

Standing Order: Preoperative & Postoperative Care for Term Pregnancies Undergoing LT C/S

Patient Details:

• Gestational Age: Term pregnancy (≥37 weeks usually 39 weeks)
• Indication for Surgery: Any medical or obstetric condition requiring LT C/S (e.g., CPD, breech presentation, fetal distress, placenta previa, prior C/S, etc.)

Preoperative Orders

1. Patient Preparation
   • Clean and shave the abdomen and perineum.
   • Administer Unison enema.
   • NPO (nothing by mouth) from 0.00 o'clock is considered 12am (midnight) onward. usually, we need 8 hours of NPO time.
2. IV Fluid Management
   • 5% Dextrose in Normal Saline (D/N/2) 1,000 mL IV drip at 100 mL/hr.
3. Laboratory & Blood Preparation
   • Complete Blood Count (CBC) before delivery.
   • Prepare blood: GMT/S/PRC unit as per clinical judgment.
4. Antibiotic Prophylaxis
   • Cefazolin 2 g IV drip 30 minutes before surgery.
5. Catheterization
   • Insert and retain Foley’s catheter with a urine bag.
6. Neonatal Preparation
   • Notify pediatrician (กุมารแพทย์).
   • Administer Vitamin K 1 mg IM to the newborn.
   • Administer Hepatitis B vaccine 0.5 mL IM to the newborn.

Postoperative Orders

1. Vital Signs & Monitoring
   • Monitor vital signs until stable, then transfer to the ward.
   • Observe uterine contractions (UC) and vaginal bleeding.
   • Record intake/output (I/O).
2. Fluid & Uterotonic Therapy
   • 5% Dextrose in Normal Saline (D/N/2) 1,000 mL IV + Syntocinon 20-40 units IV drip at 120 mL/hr.
   • Followed by 5% D/N/2 1,000 mL IV drip.
3. Pain Management
   • Pethidine (dose to be determined by anesthesiologist).
   • Voignon 50 mg IV every 6 hours for pain.
   • Morphine 3 mg IV PRN every 4 hours for severe pain.
   • Administer additional pain medication per the anesthesiologist’s order.
4. Postoperative Nausea & Vomiting (PONV) Management
   • Plasil (Metoclopramide) 1 amp IV PRN every 6 hours for nausea/vomiting.
5. Hemostasis & Bleeding Control
   • Transamine 250 mg IV every 6 hours.
6. Urinary & Hydration Management
   • Retained Foley’s catheter with a urine bag.
7. Diet & Mobilization
   • Begin sips of water after ..... we need a 6-hour gap.
   • Encourage early ambulation to prevent DVT.

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1. Immediate Postoperative Monitoring

1.1 Vital Signs (V/S) Monitoring

• Frequency:
  • Every 15 minutes for the first hour.
  • Every 30 minutes for the next 2 hours.
  • Every hour for the next 4 hours.
  • Then proceed to routine postoperative or ward-level monitoring (e.g., every 4–6 hours) once stable.
• Parameters:
  • Blood Pressure (BP), Heart Rate (HR), Respiratory Rate (RR), SpO₂, and Temperature.
  • Observe for signs of hypotension, tachycardia, tachypnea, hypoxia, or fever.

1.2 Uterine Contractions (UC)

• Palpate the fundus regularly to ensure effective uterine contraction and involution.
• A well-contracted uterus should feel firm and midline at or slightly below the umbilicus in the immediate postpartum period.
• Rationale: Adequate uterine contraction is essential to minimize postpartum hemorrhage (PPH).

1.3 Vaginal Bleeding (Lochia)

• Monitor lochia amount, color, and consistency:
  • Rubra (red) for the first few days postpartum.
  • Assess for excessive bleeding (e.g., saturation of more than one pad per hour, presence of large clots).
• Rationale: Early detection of hemorrhage is key to prompt intervention and prevention of hypovolemia and shock.

1.4 Transfer to Ward

• After stabilizing vital signs, ensuring adequate pain control, and confirming no acute complications, transfer the patient from the recovery area to the postpartum ward with thorough handoff communication.

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2. Fluid & Uterotonic Management

2.1 Intravenous Fluids

• 5% Dextrose in Normal Saline (D/N/2) 1,000 mL at a rate of approximately 120 mL/hour or as ordered, depending on the patient’s fluid and electrolyte balance.
• Rationale: Maintains adequate hydration and electrolyte balance, especially when oral intake is not yet fully established.

2.2 Uterotonics

• Syntocinon (Oxytocin) 20–40 units is typically added to the IV drip:
  • Infusion rate: ~120 mL/hr, though rate can be adjusted as per uterine tone and institutional protocols.
• Rationale: Oxytocin is critical in preventing postpartum hemorrhage by promoting uterine contractions. Continuous administration during the immediate postoperative period helps maintain adequate uterine tone.

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3. Pain Management

Effective pain control promotes early mobility, facilitates bonding with the newborn, and reduces the risk of postoperative complications such as atelectasis or thromboembolism.

3.1 Opioid Analgesics

• Pethidine (dosage as per institutional policy) may be used for moderate to severe pain.
• Morphine 3 mg IV every 4 hours as needed (PRN) for breakthrough pain.
  • Rationale: Morphine is more potent and is given intravenously for quick relief of severe pain.

3.2 Non-Opioid Analgesics (NSAIDs)

• Voignon 50 mg IV every 6 hours for pain (likely Diclofenac or a similar NSAID).
  • Rationale: Multimodal analgesia reduces the total requirement of opioids, minimizing opioid-related side effects such as respiratory depression or sedation.

3.3 Additional Orders

• “แก้ปวดตาม order วิสัญญีแพทย์” – Pain management per the anesthesiologist’s orders.
  • This may include epidural analgesics or other adjunctive medications (e.g., acetaminophen, ketorolac, etc.) depending on the anesthesia team’s assessment.

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4. Postoperative Nausea & Vomiting (PONV) Management

• Metoclopramide (Plasil) 1 amp IV every 6 hours as needed for nausea and vomiting.
  • Rationale: Metoclopramide is a prokinetic agent that helps speed gastric emptying and reduce PONV, which is common after anesthesia and opioid use.

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5. Hemostasis & Bleeding Control

• Tranexamic Acid (Transamine) 250 mg IV every 6 hours:
  • Rationale: Tranexamic acid helps reduce blood loss by inhibiting fibrinolysis, thus stabilizing clot formation. Often used prophylactically or therapeutically in patients at risk of postpartum hemorrhage.

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6. Antibiotic Prophylaxis

• Cefazolin (dosage and frequency per institutional protocol) is commonly administered postoperatively:
  • Rationale: A first-generation cephalosporin effective against common skin flora and potential contaminants during surgery, helps prevent surgical site infections (SSI) and endometritis.

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7. Urinary & Input/Output (I/O) Monitoring

7.1 Foley Catheter

• A Foley catheter is typically placed intraoperatively and may be retained for the first 12–24 hours post-LT C/S or as per the obstetrician’s protocol.
• Rationale: Prevents urinary retention, enables accurate measurement of urine output, and reduces the risk of bladder distension that can interfere with uterine contraction.

7.2 Input/Output Recording

• Monitor and record all fluid input and output:
  • IV fluids, oral intake, urine output, drainage (if any).
  • Rationale: Early detection of oliguria or excessive fluid retention, ensuring renal perfusion and balanced fluid management.

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8. Diet & Mobilization

8.1 Dietary Progression

• Start with sips of water after 22:00 (or at least 4–6 hours post-op), advancing to a full diet as tolerated.
• Rationale: Gradual reintroduction of oral intake helps prevent ileus and nausea. Early but careful resumption of diet promotes healing and recovery.

8.2 Early Ambulation

• Encourage gradual mobilization (e.g., sitting up in bed, dangling legs, short walks) once the patient is hemodynamically stable and pain is controlled.
• Rationale: Early mobilization reduces risk of deep vein thrombosis (DVT) and respiratory complications, and speeds overall recovery.

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9. Additional Considerations

9.1 Postpartum Hemorrhage (PPH) Surveillance

• Continue close observation for excessive vaginal bleeding, hypotension, and tachycardia.
• Rationale: Timely detection and management of postpartum hemorrhage are life-saving.

9.2 Infection Control

• Watch for signs of infection:
  • Fever (temperature > 38°C).
  • Uterine or wound tenderness.
  • Foul-smelling lochia.
• Rationale: Postoperative infections may arise from surgical incisions, the uterine cavity (endometritis), or the urinary tract.

9.3 Monitoring for Thromboembolic Events

• Assess for signs of deep vein thrombosis (DVT):
  • Unilateral leg swelling, pain, warmth, or redness.
• In high-risk cases, prophylactic anticoagulation or mechanical measures (compression stockings) may be prescribed.
• Rationale: Pregnancy and the postoperative state both increase hypercoagulability, raising DVT risk.

9.4 Psychosocial Support

• Provide emotional support, especially if the mother had a stressful or unexpected LT C/S.
• Encourage skin-to-skin contact and breastfeeding support if the infant’s condition permits.
• Rationale: Emotional well-being and early bonding support maternal mental health and infant well-being.

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Sample Nursing Checklist for Bedside Implementation

1. Vital Signs & Observations
   •  V/S q15min ×1hr → q30min ×2hr → q1hr ×4hr → routine.
   •  Check uterine fundus firmness and position.
   •  Observe lochia amount, color, odor.
2. IV Fluids & Medications
   •  Ensure correct Oxytocin dosage in IV fluids (20–40 units per 1,000 mL).
   •  Administer IV fluids as per order, check flow rate and IV site.
   •  Administer Tranexamic Acid, Antibiotics, and any PRN medications as ordered.
3. Pain Control
   •  Assess pain level using a standardized pain scale (e.g., 0–10).
   •  Administer Pethidine, Morphine, or NSAIDs per protocol.
   •  Reassess pain after each intervention.
4. PONV Management
   •  Give Metoclopramide IV if the patient reports nausea or vomiting.
   •  Reassess in 30 minutes; document effectiveness.
5. Urine Output Monitoring
   •  Ensure Foley catheter is patent; record urine output hourly initially.
   •  Check for signs of hematuria or decreased output (<30 mL/hr).
6. Mobilization & Diet
   •  Help patient sit up gradually; encourage short, assisted walks.
   •  Progress diet from clear fluids to normal diet as tolerated.
7. Documentation & Communication
   •  Document all findings in the patient chart.
   •  Notify the obstetrician/anesthesiologist of any abnormal findings (e.g., excessive bleeding, uncontrolled pain, abnormal V/S).

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Conclusion

Postoperative care following an LT C/S for CPD centers on vigilant monitoring, adequate pain control, maintenance of fluid balance, prevention of infection, and the promotion of early mobility. By following a structured care plan—encompassing frequent vital signs monitoring, uterine tone assessment, fluid and uterotonic therapy, analgesic and antiemetic management, and thoughtful progression of diet and activity—healthcare providers can significantly reduce postoperative complications. This multidisciplinary approach ensures a safe, comfortable, and prompt recovery for the new mother, supporting her well-being and facilitating the best possible start to motherhood.