What is the best course of action for a 29-year-old female (G2P1) with contractions every 3 minutes, scheduled for a cesarean section (C-section) due to her history of a previous twin pregnancy, now nearing her due date of November 16?

Management of 29-Year-Old Female with Contractions Every 3 Minutes Before Scheduled Cesarean Section

The patient should be immediately transported to the hospital for urgent cesarean section due to her history of previous twin pregnancy and current active labor with contractions every 3 minutes, despite her due date being November 16. 1

Assessment and Initial Management

• Establish intravenous access immediately, as this is essential for fluid management and potential medication administration during emergency cesarean section 1
• Perform rapid assessment of maternal and fetal status, including continuous fetal monitoring to evaluate for signs of fetal distress 2
• Notify the multidisciplinary team including obstetricians, anesthesiologists, and neonatal specialists to prepare for urgent cesarean delivery 2
• Consider administration of antacid prophylaxis (sodium citrate) immediately before induction of anesthesia to reduce the risk of aspiration 2

Anesthetic Considerations

• Regional anesthesia (epidural or spinal) is the preferred method for cesarean section if there are no contraindications, as it allows the mother to remain awake and reduces risks associated with general anesthesia 2
• If general anesthesia becomes necessary, use rapid sequence induction with proper positioning in the "ramped" position to optimize laryngoscopic view 1
• Take precautions to avoid hypotension during anesthesia administration, which is particularly important in patients with cardiac conditions 2
• Ensure proper monitoring of vital signs throughout the procedure, with special attention to blood pressure and heart rate 2

Surgical Approach

• Given the history of previous twin delivery, the surgical team should be prepared for potential adhesions or other complications related to the prior cesarean section 3
• A long U-shaped incision using scissors is recommended to avoid thick vessels on the uterine lateral wall 3
• Consider the increased risk of postpartum hemorrhage and have oxytocin prepared before starting the cesarean section 3
• Monitor for excessive bleeding, as not all bleeding may be recognized in the operation field, and be prepared for blood transfusion if necessary 3

Special Considerations for Previous Twin Pregnancy

• Women with previous multiple gestations may have increased risk of uterine atony during subsequent deliveries, requiring vigilant monitoring for postpartum hemorrhage 3
• The surgical team should be aware that the previous cesarean for twins may have resulted in a larger uterine incision, potentially affecting the current procedure 4
• There may be increased risk of placental abnormalities in women with previous cesarean deliveries, requiring careful assessment during surgery 1

Postoperative Care

• Close clinical monitoring for at least 72 hours postpartum is recommended to detect early signs of complications 2
• Early mobilization should be encouraged to reduce the risk of venous thromboembolism, which is higher after cesarean section (2.6 per 1000 cesarean births) 1
• Provide appropriate thromboprophylaxis based on risk factors, including mechanical methods such as pneumatic compression devices 1
• Monitor for signs of infection, as postpartum fever occurs in approximately 6.7% of cesarean deliveries compared to 1.1% in vaginal deliveries 1

Potential Complications to Watch For

• Increased risk of postpartum hemorrhage due to uterine atony, particularly with history of previous cesarean section 3
• Higher risk of wound infection and separation, particularly in women with more than 2 cm of subcutaneous fat 1
• Venous thromboembolism risk is elevated following cesarean section 1
• Postoperative complications are more common after emergency cesarean delivery (relative risk 4.17) compared to elective procedures 1