Should a 32‑year‑old gravida 2 para 2 woman with fetal bradycardia and rising serum creatinine (impaired renal function) undergo immediate (stat) cesarean delivery, and how should the renal impairment be managed?

Emergency Cesarean Delivery for Fetal Bradycardia with Renal Impairment

Proceed immediately with stat cesarean delivery for fetal bradycardia regardless of rising creatinine, as fetal bradycardia represents a life-threatening emergency requiring delivery within minutes to prevent permanent neurologic injury or fetal death. 1, 2

Immediate Delivery Decision

• Fetal bradycardia is an absolute indication for immediate cesarean delivery, with optimal outcomes achieved when delivery occurs within 25 minutes of sustained bradycardia to prevent long-term neonatal neurologic damage 2
• The rising creatinine does not contraindicate emergency cesarean delivery when fetal distress is present—maternal stabilization occurs simultaneously with surgical preparation 1
• Emergency cesarean sections for fetal distress are classified as "immediate surgeries" for life-threatening conditions and take priority over non-emergent maternal medical optimization 2

Pre-Operative Preparation (Concurrent with Surgical Setup)

Anesthesia Selection

• Regional anesthesia (spinal or epidural) is strongly preferred over general anesthesia unless delivery must occur within 2-3 minutes, as regional techniques provide superior maternal hemodynamic stability—critical in a patient with renal impairment 3, 4
• General anesthesia should be reserved only for situations requiring delivery in under 2 minutes or maternal cardiac arrest 5

Fluid and Hemodynamic Management

• Avoid aggressive fluid boluses in the setting of renal impairment—use judicious 250-500 mL boluses with reassessment rather than standard 500-1000 mL boluses to prevent volume overload 5
• Obtain large-bore IV access (two 18-gauge or larger) immediately 5
• Have vasopressors readily available (norepinephrine 0.05-3.3 mcg/kg/min) for blood pressure support rather than relying solely on fluid administration 5

Blood Product Preparation

• Activate massive transfusion protocol and have blood products immediately available, as emergency cesarean for fetal distress carries higher hemorrhage risk 5, 1
• Consider cryoprecipitate over fresh frozen plasma if coagulopathy develops, to minimize volume administration in the setting of renal dysfunction 5

Intraoperative Considerations

Surgical Approach

• Proceed with standard lower uterine segment cesarean delivery unless specific anatomic factors dictate otherwise 1
• Have neonatal resuscitation team with intubation capability present in the operating room before incision, as preterm or distressed infants frequently require advanced respiratory support 3

Monitoring

• Continuous hemodynamic monitoring throughout the procedure 3, 4
• Monitor urine output intraoperatively—oliguria or anuria may indicate worsening renal function requiring postoperative nephrology consultation 5

Postoperative Renal Management

Immediate Post-Cesarean Care

• Continue hemodynamic monitoring for at least 24 hours postpartum due to autotransfusion of 300-500 mL uteroplacental blood that increases preload and can precipitate volume overload in renal impairment 3, 4
• Serial creatinine measurements every 6-12 hours to assess trajectory 6
• Strict intake/output monitoring with goal urine output >0.5 mL/kg/hour 5

Fluid Management Strategy

• Restrict maintenance fluids to 80-100 mL/hour rather than standard postoperative rates, adjusting based on urine output and clinical volume status 5
• Avoid nephrotoxic medications (NSAIDs, aminoglycosides) for postoperative pain and infection prophylaxis 6
• Use acetaminophen and opioids for analgesia instead of NSAIDs 3

Nephrology Consultation

• Obtain urgent nephrology consultation if creatinine continues rising postoperatively or if creatinine >2.0 mg/dL 6
• Investigate underlying cause of renal impairment (preeclampsia, acute tubular necrosis, obstruction, etc.) as this will guide specific management 6

Critical Pitfalls to Avoid

• Do not delay cesarean delivery to "optimize" renal function—fetal bradycardia takes absolute priority and minutes matter for neonatal neurologic outcome 2
• Do not use standard aggressive fluid resuscitation protocols—renal impairment requires modified, judicious fluid administration to prevent pulmonary edema 5
• Do not assume renal function will spontaneously improve postpartum—some causes (preeclampsia, HELLP syndrome) may worsen before improving and require intensive monitoring 6
• Avoid assuming the rising creatinine is simply "pregnancy-related"—investigate for serious underlying pathology such as preeclampsia, hemolysis, or acute kidney injury 6