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)

Only if epidural working appropriately.

Initial Dose

• 0.5% Bupivacaine ( 15-20ml, increments of 5ml ) or 2% Lidocaine + 1:200,000 Adrenaline ( 15-20ml )
• and
• fentanyl ( 50-100mcg, epidural )

Monitoring

• NIBP 2 min cycles initially
• ECG
• Pulse oximetry

Infusions

• phenylephrine ( Titrate to effect )

Antibiotics

• Cefuroxime ( 1.5g )
• Metronidazole ( 500mg )

Uterotonics (Check contraindications)

• Carbetocin ( 100mcg ) or Oxytocin ( 5 IU )
• Once baby delivered + cord clamped

Analgesia

• Diamorphine ( 3mg, Epidural )
• Diclofenac ( 100mg, PR )

Additional If Required

Analgesia

• Paracetamol ( 1g )

Anti-emetics

• ondansetron ( 4-8mg )
• prochlorperazine ( 12.5mg SC )

Uterotonics

• ergometrine ( 500mcg, IM ) - Avoid in pre-eclampsia / hypertension
• carboprost / Hemabate ( 250mcg, IM, Every 15 mins, max 2mg ) - Avoid in asthma
• misoprostol ( 4 x 200mcg, PR )

Other

• Tranexamic acid ( 1g )

Prescriptions

• Paracetamol ( 1g, QDS )
• Ibuprofen ( 400mg, TDS )
• Dihydrocodeine ( 30mg, QDS )
• Dihydrocodeine ( 30mg, QDS PRN )
• Morphine ( PO, PRN )
• Ondansetron ( 4mg )
• Laxative
• LMWH 6 hours post-op
• TEDS
• Fluids

Follow-Up

• Check for block recovery (Able to raise legs 4 hours post block)

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