Junior Doctor Tips: Assessing the Post-C-Section Patient

November 4, 2023 Dr Mashal Samy SHO

As an SHO in Obstetrics & Gynaecology, you will usually be asked to assess Day 1 post-operative (C-section) patients. Mainly to determine if this post-operative recovery period has been uncomplicated, so that we can discharge the patient’s care to the midwives aka ‘Midwife Led Care.’ MLC means we won’t need to review the patients again the subsequent days unless concerns were raised by midwives. Most C-section patients can be discharged 1-2 days after their procedure. Below are some key points that should not be missed.

Prior to seeing the patient, collect some key information and document them in the notes.

1. When was the surgery performed?

To work out how many days post-op this patient is. If the patient has been an inpatient for over 3 days, you need to question what the cause for this is. Is it due to a complication?

2. Was it an Elective or Emergency C-section?

Generally, if a patient had an elective C-section, things are likely to have gone smoother as there was no maternal/foetal compromise right before the C-section. For emergency C-section, however, I always like to look for the reasons why this was decided and if there is anything I should keep an eye out for.

Such as if a patient had an emergency C-section due to prolonged rupture of membranes, I would worry about chorioamnionitis or endometritis (i.e. bacteria has been introduced into the womb due to prolonged rupture of membranes).

3. Estimated blood loss

Based on how much blood the patient has lost and their Hb levels prior to surgery, the patient would either need iron supplements or even a blood transfusion. Generally, women lose about 750-1000 mls of blood during C-sections.

If blood loss was >750ml, I would repeat the patient’s Hb levels for any significant drop in haemoglobin and correct with iron supplements (or with a blood transfusion in severe circumstances)..

4. What are the patient’s observations like? (A.K.A. MEOWS - Maternity Early Observation Warning Sign)?

Things to bear in mind are temperature – a rise in temperature (i.e. fever) could indicate infection and needs to be further investigated (taking history, exam and investigations to find the focus of the infection). Blood pressure – this is especially important to monitor for patients with gestational hypertension. In this case, blood pressure should generally improve after delivery, but their labetolol should be continued until they are reviewed by their GP post discharge.

5. Investigation results

It is important to go through recent bloods, microbiology and imaging prior to seeing the patient.

Haemoglobin – This along with EBL are important to determine whether the patient needs iron tablets/ blood transfusion. A Hb level of below 100 g/L post c-section would require iron tablets. A blood transfusion would be considered for a patient with a Hb <80g/L if they have symptoms of anaemia, and if a patient has a Hb <70g/L then a blood transfusion would be strongly indicated.

White blood cells (especially neutrophils) & CRP – These markers generally look for signs of infection which would need further investigating. It is important to note that WBC and CRP can be raised as a response to childbirth anyways, so it is important to correlate these values clinically.

ALAT, ASAT, ALP, Bilirubin, Bile acids – We look at liver enzymes & bilirubin particularly to monitor patients with gestational cholestasis (i.e. cholestasis confined to pregnancy). In gestational cholestasis, liver enzymes should improve after delivery. Bear in mind that ALP will be elevated anyway during pregnancy as it is released by the placenta. These women should have their LFTs repeated by their GP after 6 weeks.

Urea & electrolytes – It’s always good practice to look at U&Es to ascertain any electrolyte abnormalities that need correcting.

Taking a Good History

You’ve gathered info - great! Now time to see the patient and ask questions!

1. How do you feel after your surgery?

Asking an open-ended question in the beginning can signpost you to possible complications for which you can ask the patient to elaborate (some are discussed below).

2. Have you been eating alright? Were you able to pass flatus/stool?

Paralytic ileus – Transient paralytic ileus can happen after C-sections, this is due to hormones, sympathetic input, and pain medications. Symptoms include: intolerance to oral intake, inability to pass flatus/gas, and abdominal distension. Examination typically reveals a hyper-resonant and distended abdomen, generalised tenderness and reduced to absent bowel sounds.

3. When was your urinary catheter removed? Where you able to urinate?

A urinary catheter is inserted prior to surgery to decompress the bladder so that it can be retracted downwards to give a good view of the uterus.

Urinary retention - During a C-section, there could be bladder contusion, which results in bladder paralysis and urinary retention. Moreover, urinary retention is a common complication of spinal anaesthesia which is the primary type of anaesthesia used for C-sections.

Symptoms of urinary retention include inability to pass urine, pain and distension of lower abdomen.

The condition usually resolves within 1-2 weeks, however, the patient may need to be catheterised in the interim.

4. Have you experienced any (vaginal) discharge? If so, what type of discharge (how would you describe it and what colour is it)? How often do you have to change your pads?

Lochia – is the term used for vaginal discharge after birth. In your early post-natal review, patient should have lochia rubra which looks basically like their ‘period blood’ with some clots. It is important to ask how heavy the bleeding is and if we should be alarmed about post-partum haemorrhage needing intervention. Infected lochia – ask if the lochia is foul smelling or has an unusual greenish colour, this could indicate infection in the womb (A.K.A. endometritis).

5. How are you coping with abdominal pain after your surgery?

All post C-section patients should be receiving a basic level of analgesia:

Paracetamol
Ibuprofen
Dihydrocodeine.

If they are really struggling with pain despite this, this should prompt us to think of the reasons why. Not only do we have to take a pain history, we should also manage and alleviate their symptoms by adding additional pain killers such as tramadol or oramorph (oral morphine).

If they are coping with the post-op pain, they can be sent home with dihydrocodeine (+ lactulose for constipation caused by dihydrocodeine), for a few days.

6. Have you thought about contraception for when you get discharged?

You need to emphasise that their bodies need time to recover before conceiving again. This is because the sites of surgery are weak points for rupture / herniation if adequate scar tissue is not formed yet. You can briefly tell them of the different contraceptive options available: Pills, Subdermal implants, Coils.

(P.S. Some midwives on the ward can insert subdermal implants for post-partum women before they get discharged if they wish to have one!)

Examination:

You’ve read through their notes and taken a thorough history - now on to the physical examination!

1. General abdomen

The abdomen should be soft, and mildly tender. If there is severe pain even on superficial palpation, then the patient should not be discharged, and senior review (registrar and above) should be sought.

Things to consider:

Paralytic ileus - Examination typically reveals a hyper-resonant and distended abdomen, generalized tenderness and reduced to absent bowel sounds. Correlate if patient states they are unable to pass any flatus.
Bladder contusion or cystitis – Pain will be felt in the lower hypogastric region on palpation. Associated symptoms of urinary discomfort may be present too.

2. Uterus

In the first 24 hours after birth, the fundus of the uterus should contract to the level of the umbilicus. In the subsequent days the uterus will contract further and will be felt lower down in the abdomen.

3. C-Section incision site

The C-section scar should appear ‘clean’ no significant bleed, or discharge from the incision site. The surrounding tissue should not be red, hot or swollen.

4. Calves

The calves should be examined to exclude deep vein thrombosis (DVT). The patient should also be wearing TED stocking throughout entirety of their hospital stay and using anticoagulants prophylactically (e.g. Dalteparin).

Management

For an uncomplicated post C-section patient, we normally transfer the patient’s care to the Midwives i.e. Midwife-Led Care (MLC). Their usual medication regimen would (for TTOs) include:

o Dihydrocodeine 30 mg (to supplement OTC paracetamol and ibuprofen for pain)

o Lactulose 15 mLs (to aid constipation brough on by dihydrocodeine

o Dalteparin for 10 days or 6 weeks (to prevent blood clots in post c-section patients

The dose of Dalteparin will depend on the patient’s weight
The duration of Dalteparin for prophylaxis is normally 10 days - 6 weeks —> this depends on the patient’s VTE risk (a VTE assessment should have been completed prior to their C-section).

Medications started during pregnancy

o Labetalol - If the patient was started on Labetalol during pregnancy for gestational hypertension and their blood pressure is stable, then this is to be continued after discharge until reviewed by GP.

o Aspirin – If the patient was started on low-dose Aspirin during pregnancy due to high BMI, this is to be stopped. However, if they were started on aspirin due to a cardiac event or TIA/stroke, this should continue.

o Ursodeoxycholic acid – If the patient was started on Ursodeoxycholic acid because of obstetric cholestasis, then this is to be stopped after delivery. It is expected for liver enzymes to improve after delivery. Repeat liver enzymes should be performed at their GPs after 6 weeks.

Further management will depend on any significant findings discovered during our review. For example, iron tablets or blood transfusion based on the level of anaemia; antibiotics for infections and so on.

References