We do these quite frequently because of our large OB volume and we do TONS of repeat C-Sections, and as you know, the risk for abnormal placental implantations rises with each C-Section. I recently did three of these in less than a month. We are strictly private practice, no residents. BTW, these cases should not come as a big surprise, unless your practice has a large number of patients with poor pre-natal care. Most of ours are diagnosed ahead of time.
We now do almost all of these with GETA from the start. We've tried being optimistic and going with epidurals but invariably these patients end up being put to sleep anyway. I haven't seen anyone mention DIC and/or dilutional coagulopathies, but that's certainly reason enough not to do a neuraxial technique. A boggy uterus is pretty much a given with these cases anyway, so GA really isn't contraindicated.
Two big IV's are a must, and if you really think it's going to hit the fan, it sure is nice having that introducer in place pre-induction instead of trying to do it under the drapes after you've already stepped in it. We generally go without the a-line.
Don't even consider just a type and screen with these cases. We type and cross for at least 4-6 units, and make sure the blood bank has more typed blood, FFP, pooled platelets, and cryo readily available. I will not start the case unless at least 4 units of blood are in the OR in a cooler. We transfuse early, and as soon as we do, we order the FFP and platelets and stay at least 4 units ahead on crossmatching more blood. These cases bleed like stink. Assume they will, treat it early, and most do pretty well.
These are not one-person cases either. We will usually have at least two anesthesia providers in the room the entire time, and it's not uncommon to have one or two more if necessary.
