What are the immediate management steps for a female patient of childbearing age, undergoing a cesarean section (C-section) under spinal anesthesia, who starts vomiting after the uterus is forced back into the abdominal incision during closure?

Immediate Management of Intraoperative Vomiting During Cesarean Section Under Spinal Anesthesia

Stop all surgical manipulation immediately, ensure adequate oxygenation, and administer antiemetic therapy while ruling out life-threatening complications such as high spinal block, aspiration, or cardiovascular collapse. 1

Immediate Assessment and Stabilization

Critical First Steps (Within 60 Seconds)

• Assess airway patency and oxygenation - Apply supplemental oxygen via face mask, monitor oxygen saturation continuously, and prepare suction equipment immediately 1
• Check hemodynamic status - Measure blood pressure and heart rate urgently, as hypotension from high spinal block or aortocaval compression can trigger vomiting 1, 2
• Evaluate level of anesthesia - Assess sensory level to rule out high or total spinal block, which presents with respiratory difficulty, upper limb weakness, or loss of consciousness 1
• Position the patient appropriately - Ensure left uterine displacement is maintained to prevent aortocaval compression, turn head to side to prevent aspiration 3

Rule Out Life-Threatening Complications

• High/total spinal block - Check for ascending sensory level above T4, respiratory distress, bradycardia, or altered consciousness requiring immediate airway management 1
• Aspiration risk - Vomiting during cesarean section under spinal anesthesia carries significant aspiration risk, with nearly 30% of adverse anesthetic events occurring at emergence or recovery 1
• Severe hypotension - Administer ephedrine 5-10 mg IV bolus or phenylephrine if systolic blood pressure drops below 90 mmHg or >20% from baseline 2
• Uterine manipulation trauma - Forcing the contracted uterus back into the abdomen can cause uterine angle tears, broad ligament extensions, or vascular injury leading to hemorrhage 1

Pharmacologic Management of Vomiting

First-Line Antiemetic Therapy

Administer ondansetron 4-8 mg IV immediately as first-line treatment for intraoperative vomiting during cesarean section under spinal anesthesia. 4, 5

• Ondansetron 4-8 mg IV - Provides rapid antiemetic effect within 5-10 minutes, safe for breastfeeding mothers 4, 5
• Add dexamethasone 4-8 mg IV - Combination therapy with ondansetron achieves 98% complete response rate versus 83% with ondansetron alone 5
• Consider midazolam 1 mg IV - Subhypnotic doses (1 mg bolus) are equally effective as propofol for preventing further emetic episodes without causing sedation 4, 6

Combination Therapy for Refractory Vomiting

• Ondansetron 8 mg + midazolam 30 μg/kg IV - Superior to single-agent therapy at 6 hours postoperatively, reducing both incidence and severity of nausea/vomiting 4
• Granisetron 3 mg + dexamethasone 8 mg IV - Achieves 98% complete response rate for both intraoperative and 24-hour postoperative periods 5

Surgical Management Considerations

If Uterus Cannot Be Replaced Easily

Never force the contracted uterus back into the abdomen - this causes uterine angle tears, broad ligament extensions, and vascular injury. 1

• Allow uterus to relax - Wait 2-3 minutes for uterine contraction to subside before attempting replacement 1
• Administer uterotonic agents cautiously - Oxytocin should be given as slow IV infusion (not bolus) to avoid hypotension and reflex vomiting 3
• Consider tocolytic if needed - Nitroglycerin 50-100 μg IV can provide temporary uterine relaxation to facilitate replacement (use only if bleeding is controlled) 1
• Avoid simultaneous abdominal pressure - Pushing on the uterine lower segment or angles during replacement increases risk of tears and hemorrhage 1

Anesthetic Adjustments

• Maintain volatile anesthetic if needed - Sevoflurane does not impair uterine contraction and can be added via face mask for anxiolysis 1
• Avoid propofol boluses - While effective antiemetic, propofol causes uterine relaxation which may worsen bleeding if already present 1

Monitoring and Prevention of Complications

Continuous Monitoring Requirements

• Oxygen saturation - Maintain SpO2 >95% throughout, prepare for intubation if aspiration suspected 1
• Blood pressure every 2 minutes - Hypotension is the most common cause of intraoperative nausea/vomiting during cesarean section 2, 6
• Fetal heart rate monitoring - Continue until delivery if not yet completed 1
• Assess for aspiration - Listen for bronchospasm, check for oxygen desaturation, observe for pink frothy secretions 1

Common Pitfalls to Avoid

• Delaying antiemetic administration - Vomiting during cesarean section increases aspiration risk exponentially; treat immediately, not after "waiting to see" 1
• Forcing uterine replacement - This outdated practice causes lateral extensions to uterine arteries and inferior extensions to cervical vessels, leading to massive hemorrhage 1
• Ignoring hypotension - Intraoperative nausea/vomiting has pooled prevalence of 36% during cesarean section under spinal anesthesia, primarily from hypotension 2
• Inadequate left uterine displacement - Aortocaval compression from supine positioning causes hypotension and vomiting 3

Post-Event Management

If Aspiration Suspected

• Immediate intubation - Secure airway with rapid sequence intubation if respiratory distress, bronchospasm, or significant desaturation occurs 1
• Bronchoscopy and lavage - Perform therapeutic bronchoscopy if particulate matter aspirated 1
• Chest radiograph - Obtain within 2 hours to assess for infiltrates 1
• ICU admission - Transfer for mechanical ventilation and monitoring if significant aspiration confirmed 1

Documentation and Follow-Up

• Document the event thoroughly - Record timing of vomiting, interventions performed, medications given, and patient response 1
• Postoperative visit mandatory - All patients who experience vomiting during cesarean section require follow-up assessment for aspiration pneumonitis 1
• Inform patient - Explain what occurred, why it happened, and signs/symptoms requiring urgent return (fever, cough, dyspnea) 1