Can I give IV metoclopramide (intravenous metoclopramide) during a cesarean section if the patient is not nil per os (NPO)?

Metoclopramide Administration During Cesarean Section in Non-NPO Patients

Intravenous metoclopramide can be safely administered during cesarean section even if the patient is not nil per oral (NPO), as it is an effective antiemetic that reduces the incidence of intraoperative nausea and vomiting without significant adverse effects on mother or neonate. 1, 2

Rationale for Metoclopramide Use During Cesarean Section

Nausea and vomiting are common complications during cesarean section under neuraxial anesthesia, affecting up to 80% of patients without prophylaxis. Metoclopramide is specifically recommended for:

• Preventing intraoperative nausea and vomiting during cesarean section
• Providing antiemetic prophylaxis in obstetric patients
• Safe use regardless of NPO status

Efficacy of Metoclopramide

Metoclopramide (10 mg IV) has been shown to:

• Reduce intraoperative nausea by 57% to 14% compared to placebo 2
• Decrease the overall incidence of nausea and vomiting during cesarean section 3
• Provide effective prophylaxis without adverse effects on maternal or neonatal outcomes 2

Timing of Administration

The optimal timing for metoclopramide administration during cesarean section is:

• Before surgical procedures: As part of aspiration prophylaxis 1
• After umbilical cord clamping: To minimize fetal exposure while maintaining efficacy 4

Safety Considerations

Metoclopramide is considered safe during cesarean section because:

1. No increased risk of congenital defects has been reported 1
2. No significant adverse effects on neonatal acid-base status or neurobehavioral outcomes 2
3. Side effects like extrapyramidal symptoms are rare at the standard 10 mg dose 3

Enhanced Efficacy with Combination Therapy

For high-risk patients or those with persistent symptoms, consider combining metoclopramide with:

• Dexamethasone 8 mg IV: Provides complementary antiemetic effects 5, 6
• Propofol (1 mg/kg/h): The combination significantly reduces nausea (21% vs 63% with placebo) and vomiting (7% vs 33% with placebo) 7

Practical Recommendations for Non-NPO Patients

For cesarean section patients who are not NPO:

1. Administer metoclopramide 10 mg IV as part of a multimodal antiemetic approach
2. Consider timing the administration after cord clamping if concerned about fetal exposure
3. Monitor for rare side effects such as drowsiness, dizziness, or dystonia
4. For high-risk patients, combine with dexamethasone for enhanced efficacy

Potential Pitfalls and Caveats

• Metoclopramide may be less effective than ondansetron for preventing nausea (43% vs 24% incidence) but similarly effective for preventing vomiting 4
• Sedation scores may be higher with metoclopramide compared to ondansetron or placebo 4
• Extrapyramidal side effects, though rare, should prompt immediate discontinuation 1

The evidence clearly supports the use of IV metoclopramide during cesarean section regardless of NPO status, as its benefits in reducing nausea and vomiting outweigh potential risks, with no documented adverse effects on maternal or neonatal outcomes.