Surgical Complications in Obstetrics

Intraop Hemorrhage & Shock - Red Alert Crisis

MOH: >1.5L loss / shock. Activate "Code Red"; multidisciplinary team.

• Initial Actions (HEMOSTASIS 📌 Mnemonic):

  • Help: Call seniors (OB, Anesthesia), Blood Bank.
  • Establish IVs: Two large-bore (14-16G).
  • MTP activation.
  • Oxygen: High flow.
  • Samples: X-match, FBC, Coags, Fibrinogen.
  • TXA: 1g IV (within 3 hrs).
  • Assess etiology (4 T's).
  • IV fluids: Crystalloids (max 2L), then blood.
  • Shock: Target SBP >90, UO >0.5mL/kg/hr.

• Etiology & Management (The 4 T's 📌):

  • Tone (Atony, ~80%): Massage, Uterotonics (Oxytocin, Ergometrine, Carboprost, Misoprostol).
    • Refractory: Bakri, B-Lynch, ligation/embolization, hysterectomy.
  • Trauma (Lacerations, Rupture): Repair.
  • Tissue (Retained): Evacuate.
  • Thrombin (Coagulopathy): FFP, Cryo, Platelets. Ratio PRBC:FFP:Platelets 1:1:1.

⭐ TXA (1g IV) within 3 hrs of PPH onset significantly reduces bleeding mortality (WOMAN trial).

Intraop Organ & Nerve Injuries - Collateral Damage

• Urological:
  • Bladder: Most common (CS). Recog: hematuria, defect, dye. Repair: 2-layer, Foley 7-14d.
  • Ureter: Rare (near uterine art./IP lig.). Risk: anatomy distortion, emerg. hyst. Recog: delayed, IV dye. Repair: stent, reimplant, anastomosis.
• Bowel: Risk: adhesions. Recog: defect. Repair: primary; rare stoma.
• Nerves: Cause: position/retractors.
  • Femoral (L2-L4): Hyperflexion. Quads weak, ↓patellar reflex.
  • Obturator (L2-L4): Sidewall compress. Adductor weak, medial thigh sense loss.
  • Common Peroneal: Fibular head. Foot drop.
  • Sciatic (L4-S3): Prolonged lithotomy. Foot drop, hamstring weak.
  • Mgmt: Conservative, prevent.

⭐ Bladder injury is the most common urological injury during obstetric surgery, particularly during Cesarean section with adhesions.

Postop Infections & Sepsis - Febrile Foes

• Definition: Temp ≥38°C (≥2 occasions, >24h post-op).
• Key Causes & Timeline (📌 The "Ws"):
  • Wind (Atelectasis/Pneumonia): Day 1-2. CXR.
  • Womb (Endometritis): Day 2-5. Uterine tenderness, foul lochia. Common post-CS. Tx: Clindamycin + Gentamicin.
  • Water (UTI): Day 3-5. Urine culture.
  • Wound (SSI): Day 5-7+. Erythema, discharge. Prophylaxis: Cefazolin.
  • Walking (DVT/PE): Day 7+. Leg swelling, dyspnea.
  • Wonder Drugs: Drug fever.
• Sepsis: Organ dysfunction from infection. qSOFA.
  • Tx: Early antibiotics, fluids, source control.

⭐ Endometritis is the most common cause of persistent fever after childbirth, especially post-Caesarean section.

Postop Wound & VTE Issues - Healing Hurdles

• Wound Complications:
  • Hematoma/Seroma: Localized fluid collection. Small: observe; Large/symptomatic: drain.
  • Surgical Site Infection (SSI): Erythema, discharge, fever. Prophylactic antibiotics crucial. Management: antibiotics, drainage, debridement.
  • Dehiscence/Evisceration: Wound separation. Risks: infection, obesity, poor nutrition. Urgent resuturing for evisceration.
• Venous Thromboembolism (VTE): DVT & PE.
  • Risks: Virchow's triad (hypercoagulability, stasis, endothelial injury), CS, obesity, immobility.
  • 📌 VTE Prophylaxis is KEY:
    • Early ambulation for all.
    • Mechanical: Sequential Compression Devices (SCDs).
    • Pharmacological (LMWH, e.g., Enoxaparin 40mg SC daily) for high-risk patients.
  • Diagnosis: Doppler US (DVT), CTPA (PE).
  • Treatment: Therapeutic anticoagulation (LMWH).

⭐ Cesarean delivery increases VTE risk approximately 4-fold compared to vaginal delivery.

High‑Yield Points - ⚡ Biggest Takeaways

• PPH: Leading maternal death cause; uterine atony is #1. AMTSL is crucial.
• Uterine Rupture: Highest risk with prior classical C-section. Watch for fetal distress, shock.
• Bladder Injury: Most common urogenital injury in C-section. Repair in layers.
• Ureteric Injury: Often near uterine artery ligation. Suspect with post-op flank pain/fever.
• Surgical Site Infections (SSI): Prevent with asepsis, prophylactic antibiotics.
• Venous Thromboembolism (VTE): Significant post-op risk. Early ambulation, LMWH prophylaxis key.