What precautions should be taken for a second stage arrest cesarean section?

Precautions for Second Stage Arrest Cesarean Section

Second stage arrest cesarean sections require specific precautions to minimize maternal and fetal morbidity and mortality, including proper positioning with left uterine displacement, adequate surgical preparation, and readiness for increased blood loss and surgical complications.

Maternal Positioning and Preparation

• Position the parturient with left uterine displacement to avoid aortocaval compression, which is essential for maintaining maternal hemodynamics and fetal perfusion 1
• Administer intravenous antibiotics within 60 minutes before skin incision; for women in labor or with ruptured membranes, add azithromycin to the first-generation cephalosporin for additional reduction in postoperative infections 1
• Use chlorhexidine-alcohol for abdominal skin preparation and consider povidone-iodine solution for vaginal preparation to reduce post-cesarean infections 1
• Implement measures to prevent hypothermia, including forced air warming, intravenous fluid warming, and increased operating room temperature 1

Anesthesia Considerations

• Regional anesthesia is preferred over general anesthesia as part of an enhanced recovery protocol 1
• Be prepared for a potentially difficult airway, as this is common in pregnancy; have the most experienced provider available for airway management 1
• Maintain euvolemia with crystalloid fluids (20 ml/kg, repeated as needed) for optimal maternal and neonatal outcomes 1

Surgical Techniques and Complications Management

• Be prepared for increased blood loss compared to first-stage cesarean sections (average 552 ml vs. 410 ml) 2
• Anticipate longer operation time (average 37.5 minutes vs. 31.1 minutes for first-stage cesareans) 2
• Be vigilant for uterine incision extensions, which occur more frequently in second-stage cesareans 3, 2
• Consider blunt expansion of the uterine hysterotomy to reduce surgical blood loss 1
• Close the hysterotomy in 2 layers to potentially reduce the risk of future uterine rupture 1
• Reapproximate subcutaneous tissue if ≥2 cm thick 1
• Use subcuticular suture for skin closure to reduce wound separation 1

Specific Complications to Anticipate

• Be prepared for atonic postpartum hemorrhage, which occurs more frequently in second-stage cesareans 4, 2
• Have blood products readily available, as the need for transfusion is higher compared to first-stage cesareans 3
• Monitor for postoperative fever and wound infections, which are more common after second-stage cesareans 4
• Be prepared for potential need for hysterectomy in cases of severe hemorrhage 3, 2

Neonatal Considerations

• Delay cord clamping for at least 1 minute at term delivery when possible 1
• Be prepared for increased risk of meconium-stained amniotic fluid (34.2%) and neonatal intensive care unit admissions 4
• Have neonatal resuscitation team present, as there is increased risk of low Apgar scores and neonatal complications 3
• Maintain neonatal body temperature between 36.5°C and 37.5°C after birth 1

Emergency Situations

• If maternal cardiac arrest occurs, immediately activate the emergency cesarean section team 1
• Consider emergency cesarean section within 4 minutes of maternal cardiac arrest if there is no return of spontaneous circulation 1
• Team planning should be done in collaboration with obstetric, neonatal, emergency, anesthesiology, intensive care, and cardiac arrest services 1
• For perimortem cesarean section, delivery within 5 minutes of maternal cardiac arrest offers the best chance for fetal survival 5, 6