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MAT/GUI/1109/CAESEC
MATERNITY SERVICE GUIDELINE
TITLE:
AUTHORS:
GUIDELINE LEAD:
RATIFIED BY:
ACTIVE DATE:
RATIFICATION DATE:
REVIEW DATE:
APPLIES TO:
EXCLUSIONS:
RELATED POLICIES
THIS DOCUMENT REPLACES
1.
Caesarean Section
Denise McEneaney, Supervisor of
Midwives,
Sarah Wray (Consultant
Anaesthetist)
Anita Sanghi, Consultant
Obstetrician
Anita Sanghi
Guidelines group
Dec 2009
Nov 2009 (amended Feb 2010 –
monitoring tool added)
Nov 2012
Maternity Unit Staff
None
Obstetric Analgesia and
Anaesthesia
Prophylaxis for Thromboembolism
at Caesarean Section
Cell Salvage in Obstetrics
Provision of Red Cell Units for
LSCS in Patients with Placenta
Praevia
Policy for the Labour Ward Post
Operative Recovery Unit
The Severely Ill Parturient
Vaginal Birth After Caesarean
Section (VBAC)
Guideline for Caesarean Section
November 2008 V 2.0
Antibiotic Prophylaxis for
Caesarean Section
Antacid Prophylaxis for Obstetric
Patients
INTRODUCTION/PURPOSE OF THE GUIDELINE
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This document outlines general guidance for planning either elective or emergency
caesarean sections (CS). The decision to perform a Caesarean section (CS)
should be taken after discussion with a consultant obstetrician in all but the most
urgent and clear cut situations where time is of the essence i.e. uterine rupture or
prolapsed cord with fetal decelerations before full dilation.
2.
IMPLEMENTATION
•
•
•
•
3.
ROLES AND RESPONSIBILITIES
•
•
•
•
4.
4.1
4.2
4.3
4.4
4.5
Paper copy will be attached to guideline and audit notice boards.
Emailed copies to all midwives and obstetricians.
Will be available via the trust intranet.
Circulated to guidelines folders.
Obstetric Staff – will make decision for and perform all CSs after
discussion
with a consultant obstetrician in all but the most urgent
and clear cut situations.
Midwifery Staff - will provide midwifery support and to women and their
partner and to scrub top receive the baby
Theatre Nurses – to scrub for elective and emergency CS
Maternity Care Assistants – to circulate in theatre during CS
GUIDELINE
DECISION MAKING:
The grade of obstetrician discussing the procedure with the woman should
be of appropriate seniority. As a minimum this should be Specialist Trainee
Obstetrician (ST3) level. Documentation should include grade of the doctor.
The Specialist Trainee Obstetrician should consult an Obstetric Consultant,
during the decision making process for all CS, unless doing so would be life
threatening to the woman or the fetus.
There should be midwifery input and support in this process (if there are
conflicting professional opinions, these should be resolved away from the
bedside, if necessary involving more senior input. Then an agreed plan
which all co-professionals must support is presented to the woman. Details
should be documented clearly).
All women who have had one previous CS and no subsequent vaginal birth
should be offered an appointment in the midwifery led Vaginal Birth After
Caesarean (VBAC) clinic to discuss and agree a care plan for this birth as
early as possible in the pregnancy.
Women requesting a primary CS, history of uterine surgery or who have had
at least 2 previous CS should be reviewed by a consultant obstetrician by
34 weeks at the latest to discuss mode of delivery and management plan.
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This must be clearly documented in the maternity hand held records and if a
trial of labour has been agreed.
CLASSIFICATION OF ALL CAESAREAN SECTIONS
The urgency of CS should be decided and documented using the following
standardised scheme in order to aid clear multi-professional communication
about the urgency of a CS: Grades 1. Immediate threat to the life of the woman or fetus
2. Maternal or fetal compromise which is not immediately lifethreatening
3. No maternal or fetal compromise but needs early delivery
4. Delivery timed to suit woman or staff (see Table 1)
Table 1
Classification of Caesarean sections
Grade 1
(crash /
immediate
CS)
There is immediate threat to
the life of the woman of baby.
Delivery should be achieved within 30
minutes of the decision to perform a
CS.
Emergency
Examples: cord prolapse, prolonged
decelerations / bradycardia < 80bpm for
more than 12 minutes, scar rupture,
abruption with fetal heart rate changes,
scalp ph <7.20.
Grade 2
(urgent
CS)
There is maternal or fetal
compromise
which
is
not
immediately life threatening
Delivery should be achieved as soon as
possible and within 1 hour to prevent
further deterioration.
Examples: fetal heart rate changes on
CTG but not ominous
Grade 3
Grade 4 –
elective
There is no maternal or fetal
compromise but needs early
delivery
A planned procedure to suit
woman, staff, delivery suite etc.
Delivery should preferable be within 12
hours up to 24 hours.
Examples: To fit in with labour ward
workload and allow for fasting and
some degree of planning i.e. preterm,
Severe Fetal Growth Restriction/ Preeclampsia allowing for steroid therapy.
Examples include deterioration in a
mother with Pre-eclampsia,
deteriorating fetal surveillance test.
Elective caesarean sections should
routinely be carried out after 39
completed weeks gestation
(National Institute of Health and Clinical Excellence (NICE), 2004;
Royal College of Obstetricians and Gynaecologists (RCOG),2010)
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4.5
CONSENT
4.5.1 Evidence based information should be given to women, and documented in
the maternity hand held records. This will include indications for CS, what
the procedure involves, associated risks and benefits and implications for
future pregnancies and birth. Women should be given written information
where possible.
4.5.2 Support from the Maternity Health Advocates (Mon-Friday 9-5pm and Sat 912.30) should be sought. Language Line or Face to Face interpreting used
out of hours wherever possible.
4.5.3 A competent woman is entitled to refuse CS, even when the treatment would
clearly benefit her or her baby’s health. In such cases, the consultant
obstetrician and Supervisor of Midwives must be involved.
4.5.4 Documentation must contain an accurate account of discussions with the
woman. Advice can be sought from the Legal Team ext 18-4131 in office
hours or via switchboard out of hours.
4.6
PRE-OPERATIVE WORK UP
4.6.1 For elective CS, women will be referred to the pre-assessment clinic held
every 2 weeks. This clinic is led by a midwife and anaesthetist (see
Appendix 1).
4.6.2 All women should have a full blood count (FBC) and Group and Save sent
before going to theatre. In all elective cases and where possible for
emergency cases, the operator should check and document FBC and Group
results in the notes before beginning the operation. Cross matched blood
should only be requested where there is strong likelihood of excessive
bleeding i.e. Placenta Praevia or where the client is known to be anaemic
pre-operatively.
Antacid regime will be prescribed as below
Elective CS (Grade 4)
Grade 1 & 2 CS
10 pm the night before
LSCS
Oral Ranitidine 150mg
At the decision to
perform LSCS
7 am on the day of
LSCS
Oral Ranitidine 150mg
Oral Metoclopramide
10mg
IV/IM Metoclopramide 10mg
If woman has not received
ranitidine within 6 hrs, give
IM/IV ranitidine 50mg in
addition
Consider IM Glycopyrolate 0.2mg for patients prone to excessive salivation
In theatres Oral 30mls of 0.3M Sodium Citrate
immediately prior to GA
In theatres - Oral 30mls of 0.3M Sodium Citrate
immediately prior to GA.
Grade 3 – Timing of the Antacid regime will be variable.
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4.7
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ANAESTHESIA:
4.7.1 Regional nerve blockage should be used unless contraindicated or declined.
4.7.2. For general anaesthetic (GA) LSCS in out of office hours, the Obstetric
Anaesthetic Specialist Trainee (CT2) must inform the anaesthetic Senior
Specialist Trainee (Bleep 1220) when proceeding.
4.8
SURGERY
4.8.1 The grade of the Obstetrician present/scrubbed in theatre should be suitable
for the complexity of the case, and be at ST3 level at a minimum. There may
be cases where it would normally be expected for the Consultant
Obstetrician to operate for example; Jehovah's witnesses and where
placenta praevia and previous Caesarean section co-exist.
4.8.2 Antibiotic prophylaxis should be administered to all women - Augmentin
1.2G Intravenous (IV) after delivery of baby. If allergic follow the Trust policy.
4.8.3 Thromboprophylaxis should be considered in all cases – see Royal College
of Obstetricians and Gynaecologist (2009) Guideline.
4.8.4 Pubic hair must not be shaved - this will be clipped just prior to the operation
by the case midwife.
4.8.5 Paired umbilical cord gases should be sampled. Results must be written in
the Birth notes and the printed results slips must be filed in the marked
envelope in the Maternity Notes.
4.8.6 The position and timing of cord clamping should be deliberate, allowing
adequate length for umbilical catheterization of the baby should this be
required.
4.8.7 Women will be given Syntocinon 5 IU IV for delivery of the placenta and
membranes. A further 5 units may be required in some circumstances to
contract the uterus.
4.8.8 Oxytocin infusion (40 units/500mls Normal Saline / 4 hours) following the CS
will be prescribed based on clinical need, i.e. risk of haemorrhage.
4.9
ELECTIVE CAESAREAN SECTION
4.9.1 Providing there is no documented clinical reason to the contrary, elective
caesarean sections should be performed in the morning, aiming to complete
all booked work by noon. The elective lists on Wednesday and Thursday
should always be filled first before booking another day in the week.
4.9.2 In the event of a delay of 12 hours or more from fasting, an IV infusion of
Hartmanns liters/8 hours via a wide bore cannula prescribed to maintain
hydration. The on call consultant obstetrician must review the women and
explain the circumstances regarding the delay.
4.9.3 Delays in start time or between cases should be coded on the appropriate
audit form in theatre and reported through trust risk reporting process.
4.10 ELECTIVE CAESAREAN FOR MATERNAL REQUEST
4.10.1 Maternal request is not on its own an indication for CS
4.10.2 If requested in the absence of an identifiable reason, the risks and benefits
of CS compared with vaginal birth should be discussed at obstetric
consultant level and documented in the maternity records
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4.10.3 If a woman has a fear of childbirth, she should be offered counselling.
4.10.4 The consultant is able to refuse to conduct a CS in the absence of an
identifiable indication.
4.10.5 The woman’s decision however should be respected and further opinion
then be sought from a senior midwife/supervisor of midwives and obstetric
consultant colleague so that a management plan is constructed. Once this
has been done, all consultants are required to respect & if necessary assist
with the implementation of the recommendation.
4.11 NEONATOLOGY INPUT
4.11.1 A Neonatologist does not need to be present for elective CS under regional
anaesthesia if there is no evidence of fetal compromise.
4.11.2 Staff attending CS must be sufficiently trained to undertake resuscitation of
the newborn.
4.12. Skin to Skin Contact
4.12.1 In all cases where the baby is born in good condition and the mother is well
and agrees, the baby should be handed directly to the mother and skin to
skin contact actively encouraged.
4.12.2 The baby can be checked, dried and identity bands applied whilst on the
mother’s chest and covered with a warm towel to keep warm.
4.13 EMERGENCY CAESAREAN SECTION:
4.13.1 In labour, any such decision not supported by fetal blood sampling (FBS)
should be justified and documented by the operating obstetrician.
4.13.2 Continuous cardiotocograph (CTG) monitoring must continue until skin
preparation prior to knife to skin.
4.13.3 All CS must be graded according to Table 1. The timing of the decision for
the CS, timing of consent, if there is significant delay and timing of ‘knife to
skin’ together with the grade of urgency of the procedure should be clearly
documented in the obstetric case notes, together with the reasons for any
delay in delivering the baby
4.14
Documentation expectation
i.Operative details
The Birth Notes “Operative Details” must be fully completed. For Grade 1
and 2 CSs this must include reason for performing the CS by the person
making the decision. If for any reason, the person making the decision is
not present throughout the surgery, the above must be documented in the
main maternity records.
ii.Reminder: If there is a significant delay, the timing of consent, and timing
of ‘knife to skin’ together with the grade of urgency of the procedure should
be clearly documented in the “Birth Notes”, together with the reasons for
any delay in delivering the baby. An incident form must be raised in the
instance.
iii.Cord samples for gases
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The results must be written in the page 20 of “Birth notes” and the printed
results slips must be filed in the marked envelope in the Maternity and
Baby’s records.
5.
IMMEDIATE POSTNATAL CARE
In addition to general postnatal care, women who have had a CS should be
provided with “one to one” care in Recovery after CS.
5.1
ANALGESIA
• In the post operative period, the woman should be prescribed for regular
analgesia of Paracetamol and Diclofenac sodium.
• Encourage the woman to take these regularly. Additional pain relief such
as opiates is prescribed as p.r.n. If the woman reports inadequate
analgesia, discuss with the anaesthetic team.
5.2
MATERNAL AND NEONATAL WELL-BEING
• Care of the newborn will be addressed in the “Immediate Care of the
Newborn” guideline
• The Recovery observations plan is addressed in the “Recovery” guideline
• Following Recovery period, unless there is a clinical indication, the
woman should have temperature, pulse, respiration and blood pressure
check every four hours for the first 24 hours. Please refer to the
“Severely Ill Parturient” guideline if there is a clinical indication to monitor
observations frequently.
• Full postnatal assessment with particular attention to wound and vaginal
loss must be performed to ensure early identification of complications
such as secondary haemorrhage or infection.
• Intravenous fluid may be prescribed to address fluid balance but the
woman may start drinking and eating according to obstetric advice.
All observations must be documented in the Modified Early Obstetric
Warning Score (MEOWS) chart. Fluid balance chart must be used until the
woman is able to drink and eat normally.
5.3
WOUND CARE
I. Remove the dressing 24 hours after the CS. If non absorbable sutures
are used, these are removed on day 5 if first CS, or Day 7 if subsequent
CS.
II. The wound should be observed for signs of infection or dehiscence.
III. Women should be advised to shower daily and gently clean and dry the
wound daily and be encouraged to wear loose, comfortable clothes and
cotton underwear
5.4
BLADDER CARE
I. The urinary catheter should be removed once the woman is mobile, and
at least 8 hours after regional anaesthetic.
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II. Observe for urinary symptoms for signs of urinary tract infection, stress
incontinence (occurs in about 4% of women after CS), urinary tract injury
(occurs in about 1 per 1000 CS). Refer to “Bladder Care” guideline for
further management.
5.6
THROMBOPROPHYLAXIS
I. Women who have had CS are at increased risk of venous
thromboembolic (VTE) disease (both deep vein thrombosis and
pulmonary embolism).
II. All women should be encouraged to mobilise. Risk assessment for VTE
must be carried out to individualise the VTE plan. Graduated
compression stockings should be wore, if thromboprophylaxis is
contraindicated.
5.7
PLANNING FUTURE PREGNANCIES
I. Women should have the opportunity to discuss the rational for the CS
and implications for future pregnancies.
II. Ideally this is performed on the postnatal ward before transfer home or
may be discussed at a planned outpatient appointment approximately 6
weeks post birth prior to discharge from maternity services.
6.
DOCUMENTATION EXPECTATION
All postnatal care must be documented in the mother and baby’s sets of
postnatal notes. Ensure all loose charts are filed securely in the maternity
record.
7.
BREACH OF GUIDELINE
The incident will be reviewed within the risk management framework. The
impact of this incident will be reviewed by the appropriate lead clinician and
feedback/training be given to staff as required.
8.
MONITORING COMPLIANCE
Compliance will be monitored via continuous audit of implementation and
classification of all Grade 1 and 2 CS. Findings will be reviewed by the Audit
Committee and circulated to maternity staff.
REFERENCES
Confidential Enquiry into Maternity and Child Health (CEMACH) (2007)
Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood
safe – 2003-2005. London: RCOG Press
National Institute of Health and Clinical Excellence (NICE) (2004).
Caesarean Section. London: RCOG press
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National Institute for Health and Clinical Effectiveness (NICE) (2005)
Intraoperative blood cell salvage in obstetrics. London: NICE
Royal College of Obstetricians and Gynaecologists (RCOG) (2007) Birth
after previous caesarean section. London: RCOG
Royal College of Obstetrics and Gynaecologists (2009) Thrombosis and
embolism during pregnancy and puerperium, reducing the risk (Green-top
37). London: RCOG.
RCOG (2010) Good Practice 11 Classification of Urgency of CS – a
continuum of risk. London. RCOG Press.
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APPENDIX 1
Care pathway for women requiring Elective CS (ELLSCS)
Consultant Led AN appointment
Consultant Obstetrician agrees ELLSCS
Obstetrician completes consent form and women signs –
file in Antenatal Maternity Notes.
Give leaflet – Planned Caesarean Section
Request CS date via ext
2474 (Labour Ward
Clerk)
Pre-Assessment Clinic - woman
to see midwife and anaesthetist
Midwife led session
Anaesthetist led session
Request appointment in
pre-assessment clinic
group session (alternate
Tuesday afternoons
12.30pm or 14.00pm)
ANC support staff to prep notes preceding Friday or
Monday (print results, collate forms etc)
DVD shown – 16 minutes ‘Your Anaesthetic for CS’
Group session re taking pre medication
MRSA swabs shown how to take (not required if already
done within last 2 weeks). Request generated day
before.
Give blood forms for FBC, Clotting, Group and Save
requested (woman attends phlebotomy on ground floor
OPD)
Weight recorded on anaesthetic chart
Give BLT information leaflet - Planned Caesarean
section
Midwife available during Anaesthetic appointments and
leads unstructured session with women addressing
further queries
Individual assessment with each woman. Risk
assessment and discussion of risks/benefits of
spinal/general anaesthesia
Prescribe pre med oral Ranitidine 150mg and
Metoclopramide 10mg
Confirm with woman date/time to attend Labour ward for
ELCS (morning of CS)
Record significant medical history on anaesthetic chart
If decision for CS made and pre-assessment clinic appointment not available – obstetrician to consent
woman as usual and prescribe pre-medication.
ANC midwife to organise:
MRSA swabs, FBC, Clotting, Group and Save requested (woman attends phlebotomy on ground floor
OPD)
Give Information leaflet
Woman to attend LW morning of CS and anaesthetist to complete anaesthetic risk assessment and
discussion of risks/benefits of spinal/general anaesthesia
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APPENDIX 2
MONITORING TOOL
Element to be monitored
Lead
Monitoring
Tool
Agreed Classification used
Audit and
Quality
Midwife/
HDU Lead
Midwife
Proforma
Decision to delivery interval for CS
Documentation of reasons for
performing grade 1 and 2 CS by
the person who makes the
decision
Consultant involvement in the
decision [unless doing so would
be life threatening to the woman or
the fetus]
Documentation of reasons for
delay in undertaking the CS
Administration of prophylactic
Augmentin or substitute if the
woman is allergic to Penicillin
Documentation of minimum
observations in first 24 hours post
operative.
Documentation of that a
discussion has been had with the
woman regarding implications for
future pregnancies prior to
discharge
Frequency
Reporting
arrangements
Acting on
recommendations and
Lead (s)
Change in practice
and lessons to be
shared
All Grade 1 & 2
caesarean sections
Labour Ward Forum,
(multidisciplinary team)
review quarterly results
and recommendations
Labour ward forum will
undertake recommendations.
Quarterly report will be
circulated it all relevant
clinical areas
Quarterly report
produced
Results of report
shared quarterly
This process with be
documented in the
meetings minutes
Maternity and Gynaecology
Governance Board will receive
an annual audit report and
completed /outstanding action
plans.
Emailed to all relevant
staff groups
Required changes to
practice will be
identified and actioned
within a specific time
frame, at the Labour
ward forum.
A labour ward forum
(LWF) member will be
identified to take each
change forward.
Lessons will be shared
with the relevant staff
groups
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