• Post delivery monitoring reduces the incidence of maternal morbidity and mortality
• All women who receive obstetric anaesthesia or analgesia should be reviewed by the anaesthetic team after delivery
• Any delay in epidural or spinal block regression should be referred early to the anaesthetic team
• Management of pain after delivery requires a multimodal approach
• Withholding oral fluids after uncomplicated caesarean section has no benefit.
11.1 Monitoring and observations—what to look for
All women should be observed and monitored following delivery of the baby. The intensity of observations depends not only on the type of delivery but also on the anaesthetic and surgical intervention. Women with uncomplicated vaginal delivery often require minimal monitoring after delivery in contrast to those having emergency caesarean section or post partum haemorrhage.
All women who receive anaesthesia or regional labour analgesia should be reviewed by the anaesthetic team sometime between 18–36 hours after delivery. During the review, enquiries should be made about the effectiveness of the anaesthetic intervention and maternal satisfaction, whether there is any anaesthetic related morbidity, e.g. headache (associated with a post dural tap), nausea and vomiting, backache and whether the mother has adequate pain control. It is also important to confirm that the mother has made a full neurological recovery after regional anaesthesia, is mobilizing and able to pass urine. It is useful to review that her vital signs are normal and have been charted as required. Appropriate action should be taken when abnormal recordings are found.
Basic observations include monitoring of the vital signs, i.e. heart rate, blood pressure, respiratory rate, temperature, and where available pulse oximetry, sedation scores, and pain scores. These observations are required for all women. Uncomplicated vaginal delivery, with or without labour analgesia, should be monitored for the first few hours after delivery and then 12 hourly until discharge, but women delivered by caesarean section require closer observations. In the immediate postoperative period, observations should be performed every 15 minutes. Observations should be continued until full recovery from general anaesthesia is obtained. Monitoring every 2 hours is then required for the first 24 hours. Deliveries that are complicated with large blood loss or severe pre-eclampsia may need hourly observations for 24 hours or until their condition is stable with additional observation such as oxygen requirements, blood gases, blood count, urea and electrolytes, urine output, and fluid balance. A higher level of care may be needed if the patients’ condition deteriorates. Women receiving long acting intrathecal/epidural opioids (morphine and diamorphine) and patient controlled analgesia (PCA) are at increased risk of respiratory depression and their observations must be performed every two hours for 24 hours. The coloured early warning observation chart (Chapter 15, Figure 15.1) has been introduced in some countries as a track and trigger tool. This is to help nurses and midwifery staff to identify sick women during the antenatal and postnatal periods. Early identification of these women then requires a timely response from the medical or surgical team before significant deterioration occurs.
11.1.2 Block regression
Block regression after spinal anaesthesia starts one hour following the injection of the standard surgical dose of bupivacaine. Larger doses may prolong the block. Epidural block, however, starts to regress approximately 2 hours following bupivacaine 0.5%. Most neuraxial blocks wear off completely after 12 hours and women are able to mobilize. However, if repeated doses of long acting local anaesthetic (such as bupivacaine) are used, full neurological recovery may be delayed up to 24 hours. Women should be observed closely following spinal and epidural blocks and any delay in neurological recovery should be referred to the anaesthetic team.
The block regresses in the following order: motor nerves recover first, then sensory and finally the autonomic nerves, with bladder sensation recovering last. All women should be reviewed at 24 hours to ensure full neurological recovery and women must not attempt to walk until motor block has recovered. When a woman is mobilizing for the first time, this should be aided by a nurse, midwife, or relative.
Bladder sensation is the last function to recover following neuraxial blockade. The ability to micturate is especially prolonged if spinal or epidural opioids are administered. An indwelling urinary catheter is required for at least 12 hours to reduce the risk of bladder wall damage due to urine retention.
After the urinary catheter is removed, the women’s ability to pass urine should be monitored. She should be encouraged to drink in order to maximize urine production and if after 6 hours the woman has not passed urine, it is important to determine whether this is due to urine retention or simply because of dehydration. The bladder should be palpated or an ultrasound scan performed, if available, to determine bladder volume. If there is evidence of urine retention, the bladder must be re-catheterized.
It is very important to differentiate post dural puncture headache from other types of headaches. Post dural puncture headache is usually severe, postural in nature and often associated with evidence of dural puncture with the epidural needle or multiple attempts at spinal anaesthesia (see Chapter 9).
Back pain is a very common symptom after delivery. Back pain during pregnancy may extend into the postnatal period and may take several weeks to resolve. New backache may develop after regional anaesthesia either as a localized or more generalized ache. Localized tenderness is common at the site of needle insertion and is related to local soft tissue haematoma. More generalized back pain may be due to musculoskeletal spasm. The mother should be reassured that this back pain is common and should resolve within a few days. Women should also be reassured that spinal or epidural anaesthesia is not associated with long-term back problems.
Although rare, if back pain is associated with other symptoms suggestive of epidural haematoma or abscess, urgent radiological examination and a neurosurgical opinion will be required.
11.1.6 Nausea and vomiting
There are many reasons why a mother may have nausea and vomiting after delivery, particularly if she had a caesarean section. Hypotension following regional anaesthesia, opioid use, antibiotic prophylaxis, and uterotonic infusions may all contribute to her symptoms. Occassionally, an ileus develops after delivery, especially after caesarean section. Persistent vomiting with abdominal distension should be managed with IV fluids, IV anti-emetics, and kept nil by mouth until the abdomen is soft.
Postoperative fluid administration aims to ensure adequate intravascular volume to maintain optimal organ perfusion. Postoperative fluid management should take into account the pre-operative deficit, blood loss during delivery and daily maintenance requirements.
Hypovolemia and dehydration following delivery may not only lead to maternal fatigue but could precipitate renal failure. Fluid overload, on the other hand, can be harmful as increased lung water leads to pulmonary oedema and increases the risk of pneumonia. Fluid overload also reduces gastric emptying and prolongs post-operative ileus.
If blood loss is more than 1000 ml, an intravenous fluid infusion should be started to replace the blood loss in addition to early oral intake. There is no evidence of benefit from withholding oral fluids after uncomplicated caesarean section. The incidence of nausea and vomiting is not increased by early fluid intake. Complicated caesarean sections (e.g. massive haemorrhage) may require further anaesthesia and therefore the patient should not be fed orally until reviewed by an obstetrician. Early oral fluid intake is associated with earlier first food intake, earlier return of bowel sounds and function and reduced abdominal distension. Women should therefore be encouraged to drink immediately following normal delivery and caesarean section and eat whenever they feel hungry.
11.2 Pain control
The severity of pain post delivery does not only depend on the mode of delivery but also on the type of anaesthetic used if any. It is best to use a multimodal approach (combination of paracetamol, NSAIDs and opioids) as this improves the efficacy of analgesia and allows reduced doses of individual agents.
11.2.1 Vaginal delivery
Pain after vaginal delivery is minimal, unless associated with an episiotomy or perineal tear. Regular paracetamol (1g 6 hourly) and NSAID (diclofenac 50mg 8 hourly or Ibuprofen 400mg 8 hourly) should provide adequate analgesia. More severe pain (3rd and 4th degree tears) can be controlled by adding codeine phosphate (60mg 6 hourly) or tramadol (50–100mg every 4–6 hours).
11.2.2 Caesarean section
22.214.171.124 After regional anaesthesia
The effect of morphine (100mcg intrathecally or 4mg epidurally) can last up to 18–24 hours and that of diamorphine (250mcg intrathecally or 5mg epidurally) can last up to 8–12 hours. If long-acting spinal opioids are used, further systemic opioids should be avoided in the first 12–24 hours following delivery. Oral or intravenous tramadol or codeine can be used during this period for breakthrough pain.
The combination of paracetamol and NSAID (if not contraindicated) is very efficacious and should be given immediately after caesarean delivery and on a regular basis.
126.96.36.199 After general anaesthesia
Caesarean sections performed under general anaesthesia often require intra-operative morphine, IV/PR paracetamol, IV/PR diclofenac and wound infiltration with local anaesthetic. Ideally, morphine PCA should be prescribed for postoperative pain, but a good alternative is IM morphine (10mg up to every 2 hours). Bilateral ilioinguinal nerve block or transverse abdominis plane block (performed before waking the woman up) are associated with lower pain scores and also reduce morphine requirement post delivery.
Paracetamol is a very safe drug during and after pregnancy and delivery. The dose is 1 g orally 4–6 hourly (maximum 4 g/24 hours). It is safe in therapeutic doses for women who are breast-feeding. An adjustment in dose is recommended in severe liver insufficiency.
188.8.131.52 Non steroidal anti inflammatory drugs (NSAIDs)
NSAIDs are very effective especially in combination with paracetamol, local anaesthetic blocks, and opioids. Diclofenac (oral, rectal, and IV) is the most commonly used agent and ibuprofen is a useful alternative. The suppository form is easy to administer and ideal in women suffering nausea and vomiting. It should be given at the end of the caesarean section if not contra-indicated. The IV form is ideal for caesarean section under general anaesthesia and after delivery of the baby. Usual doses are diclofenac 50–75mg PO/PR 8–12 hourly to a maximum of 150mg in 24 hours. It is safe in therapeutic doses for women who are breast-feeding. NSAIDs are contra-indicated in renal impairment, severe pre-eclampsia and major haemorrhage and are best avoided in women with history of peptic ulceration. If administered in therapeutic doses in the third trimester of pregnancy, NSAIDs can lead to premature closure of patent ductus arteriosus in the neonate and should not be given.
Opioids are not routinely prescribed after vaginal delivery, but women who deliver by caesarean section under regional anaesthesia may receive intrathecal or epidural opioids to cover the postoperative period and are less likely to require additional opioids. After caesarean section under general anaesthesia, regular postoperative opioids are often required. Depending on availability and the local unit protocol, opioids can be given orally, intramuscularly (IM) or intravenously (IV). Oral morphine preparations are very effective and widely available. The oral route may not be ideal if the woman is experiencing nausea and vomiting, while the IM route is painful and requires administration by a nurse or midwife. Women should be monitored closely for 24 hours after intrathecal opioids and while receiving intravenous opioids. Naloxone should be prescribed and available on the maternity ward, and staff should be trained to use it if the mother’s respiratory rate falls below 8 breaths/min.
184.108.40.206 Patient controlled intravenous analgesia (PCIA)
PCIA is an excellent method of pain relief especially after general anaesthesia for caesarean section. It is more effective than the oral or IM route and is associated with higher maternal satisfaction. Morphine is preferred over fentanyl because of its longer duration of action and over pethidine because of its minimal neonatal effects. Norpethidine is the active metabolite of pethidine and it accumulates in both the mother and the breastfed infant. Newborn babies exposed to pethidine may have impaired behaviour, increased risk of respiratory depression and seizures. A common dose for PCIA morphine is 1mg bolus with a lock out period of 5 minutes.
220.127.116.11 Local anaesthetic blocks
Wound infiltration with local anaesthetics provides excellent analgesia after caesarean section especially those performed under general anaesthetic. Bilateral ilioinguinal, iliohypogastic, and subcostal nerve blocks provide postoperative analgesia for caesarean section by blocking somatosensory fibres of T12 and L1. Bilateral transversus abdominis plane (TAP) blocks are also very effective. Local anaesthetic blocks can be performed at the end of the caesarean delivery or in the postoperative period. These blocks are more effective when combined with administration of NSAIDs and paracetamol.
18.104.22.168 Postoperative epidural analgesia
This can be employed for women who deliver by caesarean section under epidural or combined spinal-epidural technique. Although it is usual for an epidural catheter to be removed at the end of the caesarean delivery, this method of postoperative analgesia may be usefully employed in selected cases (e.g. women who may be allergic to morphine).
This can be used either as continuous infusion or as patient controlled epidural analgesia (PCEA). The same low dose solution used for labour analgesia can be used for postoperative analgesia.