EMEREGENCY CESAREAN SECTION

Detailed Process Outline with Suggestions for os!ital Guidelines

Definitions"
Stat Cesarean Deli#er$" A cesarean delivery performed due to impending fetal or maternal death, where every
effort is made to minimize the time from decision to delivery of the baby.
%rgent Cesarean Deli#er$" A timely cesarean delivery performed due to deteriorating maternal or fetal
condition, but where there is no imminent risk of fetal/maternal compromise. This category includes
indications for which there is wide variation in timeliness of response. Safety, including that of patient and
providers must always be considered. This includes labor arrest disorders, non-reassuring fetal heart rate
tracings etc.
%nscheduled Non&%rgent Cesarean Deli#er$" esarean delivery performed where there is no evidence of
deteriorating maternal or fetal condition. This includes cesarean deliveries performed due to malpresentations
in early labor, refused trial of labor.
Scheduled Cesarean Deli#er$" Self e!planatory.
Personnel" This protocol uses three nurses to get the pregnant woman delivered and to stabilize the situation.
This is #ust one suggestion of how to perform the critical tasks, and other e!cellent models e!ist. $or hospitals
using this paradigm, we anticipate that roles may be reassigned once the situation is stabilized. The primary
labor nurse takes the patient to the %&, stays at the head of the bed to help anesthesia and then becomes the
baby's nurse if needed.
(. The first responder in the room helps the primary nurse transport the patient, becomes the )bottom)
nurse and then becomes the circulator.
*. The scrub nurse is the scrub nurse.
E#ent'Action'Role Details Ideas for discussion
+atient with potential
need for stat cesarean
section
+ossible ,ndicators"
Abnormal $-&T
./A
Twins
-eavy /leeding
0alpresentation in early labor
Abnormal labor progress
1hat is your culture2
ould a nurse initiate the c/s2
1ho starts calling personnel in and
notifying teams.
onsent for possible
cesarean section
.erbal consent at minimum Typically it is the 03 who obtains
consent.
Ask about planned tubal ligation
(
4otify Teams of
+otential for esarean
Section.
+ersonnel to notify"
%perative Assistant
harge 4urse
4ursing Supervisor
Anesthesia
%& team
+ediatrician
Any other group/person who is part
of your stat c/s protocol
o 53 03
o &espiratory
o 6ab
o 7-ray
1ho does notification2
&4 to &4
03 to 03
3o you call at home at night2 This
should be a multidisciplinary
discussion. Set a time before which
calls are e!pected.
Always call if personnel in house and
awake, regardless of time.
,f no calls at night, consider a policy
that everyone is home after (( pm,
unless they notify the unit.
All of the personnel on your notify list
should be involved in drills.
-ave posters in bright colors regarding
who to notify.
Spell out who will notify each group.
-ave it on the poster.
1hat is the information communicated2
,ndication
-ow STAT
8estational Age
0a#or 0edical/+regnancy problems
0eds in labor
Allergies
8rease /oard in %& with critical
details.
Standard information sheet at desk
with details written on it.
+repare for possibility
of stat c/s
+artial %& set up" trays in room,
including stat tray, but not opened
0ay put all e9uipment including
gloves on a table or infant warmer etc
right outside of room.
reate a list of what needs to be done
in %&.
0ay choose to open the trays, but
technically someone is supposed to be
in the %& with an open tray at all
times.
Anesthesia machine set up with drugs
out, record started.
ould starting an anesthesia record on a
patient count as a consultation2
&adiant warmer set up in %& for
possible resuscitation, but left off.
&oles assigned" who will scrub,
circulate, move patient
Should happen with every shift turn over
+atient room streamlined for rapid
transport" ords untangled
+atient 3elivers Take everyone off alert
1ho do you take off alert on off hours2 4o call backs after (: pm
Ask each person at home what they
want2
*
3ecision to perform
emergency cesarean
section
an be made by &4, 03, 40 &emember this is for getting everyone
in. ;ou can change your mind.
reate a culture that is non-punitive if
the decision is made to call off the
cesarean section.
Typical ,ndications"
$etal distress <prolonged
bradycardia, repetitive severe
decelerations with decreased
variability=,
ord prolapse,
0assive hemorrhage,
0alpresentation with rapidly
progressing labor,
&apidly deteriorating maternal
condition, including cardio-
pulmonary arrest.
Suspected uterine rupture
Second twin with one of the above
issues.
/e clear if it is stat or urgent See above definitions.
4otify >nit 5mergency all button in room, so don't
need to leave patient's side
0ust include nursing supervisor
3ecide what to call the emergency button,
create unit culture around it
Train using the call button? make sure
everyone knows what it means and what it
does.
onsider testing buttons 9uarterly.
3o you have call backs2 all /acks
all backs decrease response times.
1ithout call backs, how do you know
everyone is on their way in2
;ou could call back a beeper and put
your beeper number into the beeper
you paged. That would let the person
leading the effort know you are on
your way. ;ou could do this from a
cell phone, or have a family member
do it for you as you are leaving home.
5very institution needs a method of
testing/simulating the notification system.

@
1ho places all the pages2 >se a special code, so that folks know
it is a stat <ie A((=
onsider dedicated stat pagers that
never change and that can be accessed
through a computer program.
Switch board" They have a list of
who is on call.
4ursing supervisor.
0ed/Surg oordinator" list of who is
on call with pagers.
Beep a list of all the pagers.
,f you don't have a stat pager system,
you should have daily paging lists
0ust have daily paging lists.
5very institution needs a method of
testing/simulating the notification
system.
This should be done at least monthly.
6arge systems may consider doing it
daily.
1hat priority do you page personnel in"
%/ attending, anesthesia attending, %&
team, assistant, +edi2
onsider +edi prior to assistant
onsider going by distance form
hospital
53 doc, 7-ray, 6ab last
6abor nurse stays with
patient, at head and
moves patient to %&
,s chief communicator to other services
%/ +rovider
Anesthesia
+ediatricians
&esponders
Assigns roles
0ay give updates to the family once the
baby is delivered.
onsider who talks with family. This
could be the 03 as the patient is being
assessed. Some one needs to give
them updates after the baby is out...
this could be a nurse.
1ho assigns roles... or are they
scripted2. The labor nurse could
assign them as responders come in.
0oves patient to %&, staying at head of
bed
aps all ,.'s
aps 5pidural
Takes everything off pumps
&aises bed all the way up with side
rails up.
3etaches monitor leads from
machine #ust prior to transfer
1hat is the 9uickest route to %&
3o you need to call elevators2 ,f so
who does this2
1alk in a controlled pace. ,f you rush
you can break e9uipment and it will
take longer.
8ives patient bicitra in %& Tape to pillow in %& or to +edi
warmer, top of anesthesia cart.
0ake stocking /icitra part of the
routine for cleaning the %&.
C
+erforms anesthesia related tasks, until
relieved by anesthesia.
+uts o!ygen on patient
-angs ,. fluids
+ulse o!imetry
/+ uff
58 leads
Turns on 0achine, if off
+erforms ricroid pressure if needed
omforts patient
,ndication for c/s
1e are moving very 9uickly
5!plains what is happening
Attempts to keep her calm
5!plains possible 85T
&eevaluate in %& -as patient's status changed"
/radycardia often resolves with
transport, recheck $-&
ervi! may move to complete
dilation
/leeding may be less
+resenting part may be so low in
vagina that c/s is no longer safest
way to deliver baby <i.e. breech at
introitus=
Should take D ( minute
&e9uires a monitor in the %&.
o 1ho will move it if it is not
already there.
$irst
&esponder//ottom
4urse
-elps move patient to %&"
Takes foot of bed
-elps detach monitor leads or ,.'s if
needed
0ay help raise bed up
1orks on 6ower half of body in %&
Assess $-& with monitor or
3oppler
,nserts $oley
+laces -ip wedge
+laces leg strap
+erforms Skin+rep
-elps gown +roviders if above tasks
are done
Sets u! suction
onsider rapid preps that are single
application ie"
-ibicleanse prep
,odoband drape <no prep necessary=
/ovey is optional
/ecomes irculator once case is started. This is only a suggestion" At some
institutions, the primary nurse becomes
the circulator and a second nurse might
help with infant resuscitation
Scrub 4urse Euick one minute scrub
8owns and gloves 9uickly
F
+uts out provider gowns and gloves,
anticipate they will gown and glove
themselves
0ake sure providers have practiced
gowning and gloving themselves.
%pen stat pack
3o not count if this is truly stat
6ights/suction
ritical instruments to have on field
Suction
/ladder bar
Bocher's !*
3isposable scalpel taped to package
Tissue forceps
0ayo's
6arge &ichardson retractor
Sponge's
Belly's for cord
/andage Scissors
,f no scrub, have instruments laying on
the patient's knees or on table very
near. There is also a role pack that
has all the instruments laid out very
neatly.
>se disposable scalpels for stat
cesarean sections. 3o not try to load
them.
,f the scrub is not familiar with the
names of the instruments, a stat pack
that is rolled up is critical. Then
providers can #ust grab their own.
Always protect everyone from scalpel...
never hurry to cut corners hereG
+rovider 3oes not transport patient, ,t only takes * personnel to do a transport
efficiently. -owever, provider should ask
if e!tra help is needed before leaving the
room.
>pdates anesthesia and pediatrics as
they report to %&
8owns and gloves themselves +ractice with vaginal deliveries.
8ives scrub personnel tips if he/she is
unfamiliar with tray
,f truly stat"
>se vertical skin incision and
scalpel for all layers
3on't make bladder flap
3o low transverse on uterus if
possible <it is 9uicker=
3o both sides of the case, never
puts down the instruments
%nce the baby is out, consider changing
gloves.
$irst Assistant ould be 40 or &4. +rimary purpose
is to hold retractors.
Anesthesia &eport directly to %&, not patientHs
room
I
8et critical information from %/
+rovider, with additional information
from 6abor 4urse
,ndication for c/s
-ow stat is it
8estational age
0a#or medical and %/ problems
<-T4, Asthma=
0edications during labor
Allergies
This could be put on a grease board in the
%&. The board could have permanent
letters that say"
Status
,ndication
8A
0a# 0ed/%/ -!
0eds in 6abor
Allergies
The board could be updated by the
recorder.
0ake sure there is someone helping
you, especially if ricoid pressure
needed
ould have respiratory therapy be
part of stat team
/aby &esuscitation ,solette should be set up already if there
was warning.
6aryngeal mask is e!pensive, but gets
around problem of intubation.
Additional help may be found from
o 53 03
o &espiratory Therapist
o 4,> team if you have one
The 6abor 4urse, who was the
patient's primary nurse moves to this
from the head of the bed.
+ediatrician takes charge when
he/she arrives.
0ake sure a transport team was called if
it is preterm and you lack the resources.
,deas for Additional
+ersonnel
Adult respiratory therapist
Anesthesia
+ediatric Assistant
53 3oc
ould start conscious sedation
ould help get monitor leads on
ould help resuscitate newborn if
+ediatric provider not there
+ediatric respiratory therapist for
resuscitation
+ediatric nurse
4urse manager of hospital on call
+astoral are for family
+olice/Security for difficult family
J
&ecorder &ecords critical times on cesarean
section outcomes tool"
3ecision to do c/s
+atient in %&
All teams assembled
+atient ready for c/s
,ncision
3elivery of baby
This person may be a tech or someone
with limited training in %/.
This person could also be responsible for
writing information on the grease board.
$amily +erson 3irects family out of room ould be a chaplain, Tech, &eceptionist,
house keeper or security.
Should be specific about information they
can give to family
onsider including in drills
onsider having tools for them to use
readily available if they have limited %/
background
omforts family
6ets them know when baby is
born/things are ok
K