LSCS (Epidural Top-Up)

• One / both arms out of gown (enables better skin to skin later)
• 3-way octopus to cannula (Fluid + Phenylephrine infusion + Spare port)

Starting Dose

• 0.5% Bupivacaine15-20ml, increments of 5ml or 2% Lidocaine + 1:200,000 Adrenaline15-20ml
• and
• fentanyl50-100mcg, epidural

Monitoring

• NIBP 1-2 min cycles initially
• ECG
• Pulse oximetry

Infusions

• phenylephrineTitrate to effect

Antibiotics

• Cefuroxime1.5g
• Metronidazole500mg

Uterotonics (Check contraindications)

• Carbetocin100mcg or Oxytocin5 IU
• Once baby delivered + cord clamped

Analgesia

Anti-emetics

• ondansetron4mg

Uterotonics

• ergometrine500mcg, IM : Avoid in pre-eclampsia / hypertension
• carboprost / Hemabate250mcg, IM : Avoid in asthma. Every 15 minutes up to 8 doses.
• misoprostol4 x 200mcg, PR

Other

• Tranexamic acid1g

Analgesia

• Paracetamol1g, QDS
• Ibuprofen400mg, TDS
• Dihydrocodeine30mg, QDS
• Dihydrocodeine30mg, QDS PRN
• MorphinePO, PRN

Anti-emetic

• Ondansetron4mg

Other

• Laxative
• LMWH 6 hours post-op
• TEDS
• Fluids

Follow-Up

1. Pfannenstiel / Joel-Cohen incision (transverse lower abdomen)
2. Dissection through skin, fascia, rectus sheath, rectus muscle, peritoneum -> to reveal uterus
3. Bladder retraction
4. Uterine incision
5. Fundal pressure from assistant
6. Delivery (+/- delayed cord clamping)
7. Placental delivery (controlled cord traction)
8. Closure of uterine cavity (2 layers), rectus sheath, skin

• Labour Pains