The Pregnant Surgical Patient

Introduction:

When necessary, non-obstetric surgery may be performed during pregnancy. During or after these procedures, the patient may experience miscarriage, hemorrhage, infection, aspiration, untoward reactions to the anesthetic, or preterm labor and delivery. Although fetal needs may conflict with those of the patient, maternal physiologic integrity takes priority.

The second trimester, when formation of the organs is complete, is the optimal time for non-obstetric surgical procedures because preterm contractions and spontaneous abortion are least likely.

All pregnant women are considered to be at risk for aspiration and require a secured airway for procedures. Sedation should be used with extreme caution, the patient must be alert enough to protect her own airway.

All pregnant women need to have abdominal shielding, if possible, to minimize the exposure to radiation. Radiation time should be kept as short as possible.

Notification:

  • All notification should happen well in advance of the scheduled procedure, exceptions are emergency cases.
  • Email (as soon as procedure is scheduled) with procedure, medical record number, date of service, gestational age and other pertinent information sent to:
  • CVC Charge RN to call OB Charge RN (720-848-3450) the day prior to procedure to verify monitoring
  • Notify the neonatal intensive care units (NICU charge nurse 83465) of the potential for preterm birth, if the fetus is viable (usually 24 weeks or greater, but this can vary.)
  • Emergent: If the patient has a non-obstetric, life threatening medical or surgical condition requiring emergency surgery or an emergency procedure, obstetrical consultation should be obtained as soon as possible by contacting the MFM attending at 720-848-3447 and/or to the OB charge nurse 720-848-3450. Depending on the condition and gestational age of the pregnancy, delivery of the baby may provide needed intraoperative exposure and enhance maternal survival and may require neonatology notification if the pregnancy is viable.

Monitoring:

  • Making the decision to monitor the fetus is determined in collaboration with the anesthesiologist, obstetrician, and surgeon. Consider gestational age, maternal and gestational history, the nature and urgency of the surgery, and available facilities when determining which, if any, techniques to use for preoperative, intraoperative, and postoperative fetal monitoring and evaluation:
  • Before 10 weeks' gestation, don't perform fetal monitoring. The findings from fetal assessment at this stage of gestation don't impact the managementplan or fetal outcome. Before 10weeks' gestation, the products of conception are known as an embryo and are highly susceptible to early death and miscarriage. Embryo cardiac activity is visible on ultrasonography but isn't audible with a fetoscope.
  • From 10 weeks' to 24 weeks' gestation, monitor fetal heart rate (FHR) before and after surgery using a fetoscope, a Doppler or other ultrasound device, or other techniques. Intraoperative monitoring is not routinely performed or recommended; solely on a case by case basis if feasible and will change management.
  • After 24 weeks' gestation, use intraoperative continuous fetal monitoring for heart rate and uterine contraction when feasible, depending on the nature of the procedure and the availability of a practitioner to take action based on the FHR pattern.
  • During the recovery period, as the patient's condition becomes stable and she regains consciousness, change continuous fetal assessment to intermittent auscultation of FHR. This timing will be determined by the obstetric provider.

Clinical alert: Uterine contraction monitoring is performed during surgery only if documentation of the contractions would change operative management.

Special Considerations:

  • After 18 to 20 weeks' gestation, all patients need lateral uterine displacement during induction of anesthesia and for the surgical procedure to avoid decreased uterine blood flow and maternal hypotension.Never place the patient in the supine position.
  • Closely monitor the patient's hemodynamic status because a comprehensive evaluation of fetal condition depends on understanding the mother's hemodynamic status. In particular, a decrease in maternal hematocrit greater than 50% from baseline or a decrease in maternal mean blood pressure of 20% or a maternal partial pressure of arterial oxygen less than 60 mm Hg (oxygen saturation less than 90%) may result in fetal hypoxia, acidosis, and compromise.
  • The surgeon, obstetrician, anesthesiologist, and neonatologist must collaborate to select and use medications and anesthetic agents that pose the lowest risk to the fetus.
  • The obstetric and surgical nurses must also collaborate to coordinate fetal monitoring by gestational age.

References:

  1. Norwitz, E. R., et al. Management of the pregnant patient undergoing nonobstetric surgery. (2015). In: UpToDate, Hepner, D. L., et al. (Eds.). Accessed December 2015 via the Web at
  2. American College of Obstetricians and Gynecologists (ACOG). (2011, reaffirmed 2013). ACOG committee opinion number 474: Nonobstetric surgery during pregnancy. Obstetrics & Gynecology, 117, 420–421. Accessed December 2015 via the Web at
  3. Davis, J., & Shay-Zapien, G. (Eds.). (2012). Templates for protocols and procedures for maternity services (3rd ed.). Washington, DC: Association of Women's Health, Obstetric and Neonatal Nurses.
  4. (Rating System for the Hierarchy of Evidence for Intervention/Treatment Questions)American College of Obstetricians and Gynecologists. (2014). Practice bulletin number 145: Antepartum fetal surveillance. Obstetrics and Gynecology, 124, 182–192.
  5. Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). (2011). Perioperative care of the pregnant woman: Evidence-based clinical practice guideline. Washington, DC: AWHONN.
  6. Stewart, M. K., & Terhune, K. (2015). Management of pregnant patients undergoing general surgical procedures. Surgical Clinics of North America, 95, 429–442.