Professional Documents
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Caesarean Section1846
Caesarean Section1846
Contents
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1.0 BACKGROUND
The aim of the guideline is to ensure the correct procedures are used, staffs are aware
of their individual roles and that there is a team approach to optimise the safety of the
mother and her baby.
3.0 MANAGEMENT
3.1 Indications
3.1.1
The commonest indications for elective Caesarean section are as follows. Most routine
elective Caesarean sections should be performed at 39 weeks.
Breech presentation
Previous Caesarean section
Placenta praevia (often delivered at 38 weeks)
Multiple pregnancy when twin 1 breech (delivery 37-38 weeks depending on
chorionicity)
3.1.2
The commonest indications to perform an emergency Caesarean section are as follows
(list not exhaustive):
Fetal distress – abnormal CTG in early labour, abnormal fetal blood sample, fetal
bradycardia that does not recover, cord prolapse
Failure to progress in first or second stage
Failed instrumental delivery
Malpresentation most commonly undiagnosed breech in labour
Second twin
Antepartum haemorrhage e.g. abruption with evidence of fetal compromise and/or
maternal compromise, placenta praevia with active bleeding
Pre-eclampsia/eclampsia where there has been a senior decision to deliver by
emergency Caesarean section
Planned caesarean section that presents in labour.
All Caesarean sections must be discussed with a consultant and this decision must be
documented in the notes.
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therefore vital that all members of the team, particularly the anaesthetist are informed as
early in the process as possible. This communication must state the category of the
Caesarean section and the reason for it. The classification and examples are outlined
below.
The reason for performing the caesarean section and the category should be clearly
stated on the operation proforma and documented in the birth record by the person
making the decision. The time of decision will be when verbal consent is obtained. This
time needs to be recorded in the clinical notes.
Any reason for delay in undertaking the caesarean section should clearly be
documented in the birth record. The decision to delivery interval (DDI) from Category 1
to 4 should be viewed as a ‘continuum of urgency’ rather than discrete categories. For
example whilst the team may aim to deliver a baby in 30 minutes when there is a pH
less than 7.20, a baby with an acute bradycardia will need to be delivered in a shorter
DDI. It is also to be remembered that the category of urgency may change after the
decision is made - a category 2 may become a category 1 or vice versa.
Timings Table
DDI 45 minutes
(3)a Semi- No threat to life Generally woman in Failure to progress with no fetal
urgent of mother or labour or maternal compromise
fetus but early DDI 90 minutes
delivery
required
(3)b No threat to life Consider when entire Planned C/S with SROM
Scheduled of mother or team available and /or Failed IOL
fetus but early when fasted Fetal problems e.g. IUGR
delivery Maternal problems e.g. PET
required DDI 6 hours
(4) Elective No concerns Delivery timed to suit Breech presentation
over time of woman and clinicians Previous C/S x2
delivery
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All Category 1 Caesarean sections are subject to continuous audit and an audit form
must be completed at the time of inputting delivery information onto MATSYS.
The consent should be written, apart from situations where there is maternal
compromise or fetal indications such as a pre-terminal bradycardia, where delivery must
be as swift as possible. In such cases verbal consent must be obtained. It must be
documented clearly in the clinical notes the reasons for it not being appropriate to gain
written consent.
Written consent for emergency Caesarean section must include the relevant indications.
The risks of the procedure are as for elective procedures, namely, haemorrhage
(sometimes requiring a blood transfusion), thrombo-embolic diseases, infection, and
damage to bowel or bladder and also include the risk of fetal laceration. Where the
indication for Caesarean section is placenta praevia or abruption, consideration must be
given to include hysterectomy in the consent process.
There must be clear communication between midwifery and medical staff - obstetric and
anaesthetic, together with the theatre team. It is vital that the urgency and the category
of the Caesarean section are clearly discussed between obstetric and anaesthetic team.
The team performing the Caesarean section should work effectively. See Appendix 1 for
cascade of information and the roles that should be taken by the team members.
Consideration must be given to the potential difficulty of surgery and consideration for
the presence of a senior obstetrician (ST5 or above) to be present although this should
not delay the start of a category 1 section. Obstetric Consultants MUST be present
when the indication is placenta praevia or for LSCS for second twin. Other examples
when it may be appropriate to involve a senior obstetrician are preterm deliveries (under
32 weeks), known previous difficulty at surgery, previous abdominal surgery with known
adhesions, and significant risk of bleeding associated with abruption.
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3.4 Investigations and planning
Any significant anaesthetic issues should also be raised with the anaesthetic team.
Some women will have already been seen in the anaesthetic clinic.
Pre-assessment Visit
Woman should have a pre-assessment visit at 36 weeks or as soon as possible if the
Caesarean section is booked after 36 weeks.
All women must have MRSA screening prior to elective CS. This should be arranged in
the antenatal clinic. Please refer to separate MRSA guideline and policy for those who
screen positive. However, decolonisation will be required for a minimum of 5 days to
finish on the day prior to surgery. Prophylactic antibiotics prescribed should be those
with MRSA activity (see section 4.3).
The woman should be offered a patient information leaflet on Caesarean section and on
Consent. Informed consent should be obtained and the woman offered a copy of the
consent form.
The obstetrician should prescribe the prophylactic antibiotics (see section 4.3)
A group and save is not necessary for all women having an elective Caesarean section.
There are certain groups in which a group and save should be obtained in the week
prior to the planned surgery i.e. those with an increased risk of blood loss. These will
include previous postpartum haemorrhage, previous blood transfusion (may have
irregular antibodies), multiple pregnancy, polyhydramnios and high BMI >40, previous
difficult surgery. Blood will need to be available for the day of surgery in cases of
placenta praevia (6 units should be cross matched). Consideration should also be given
to arranging cell saver with the anaesthetic department with cases of placenta praevia
and those women who would refuse blood products.
Women having a planned Caesarean section prior to 38+6 weeks should be offered a
course of antenatal corticosteroids to reduce the chances of respiratory morbidity in the
neonate (see preterm birth guidelines for more details)
Admission
The majority of women will be admitted on the day of surgery to the postnatal ward.
Diabetics and a small number of other women e.g. maternal infection, will need
admission the night before so that treatment or additional observations can be
performed. They should be admitted to the antenatal ward. All women should have a full
set of observations documented on a MOEWs chart prior to surgery.
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3.4.2 Emergency Caesarean section
The obstetrician is responsible for prescribing the prophylactic antibiotics (see section
4.3).
All women should have a full blood count and Group and Save sent to the appropriate
laboratory. Other cases with an increased risk of bleeding will require cross matched
blood be requested – for example placenta praevia, abruption and known maternal
coagulopathy. Consideration must be given for other blood products where there has
been a significant haemorrhage antepartum or risk of coagulopathy. Please refer to
guidance on patients who decline blood products if indicated.
Swabs should be taken for MRSA screening (refer to separate MRSA guideline and
policy for those who screen positive). Ideally this would be done prior to surgery but in
an emergency situation it can be done prior to transfer to the recovery area.
If delivery does not occur for more than 45 minutes in a woman in labour, the CTG
should be categorised in order to detect any emerging fetal compromise. If the category
has changed, the obstetric team should be informed and review requested.
4.0 PROCEDURE
For high risk labour where there is a high likelihood of Caesarean section, lanzoprazole
30mg orally should be given prophylactically.
If antibiotics have been given in labour for maternal pyrexia, they should be
continued until there has been no pyrexia for 24 hours.
5.1 Observations
Depending on the indication for Caesarean section the woman will be transferred to
either the recovery or high dependency area or back to her delivery room. She should
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not be left unattended during the immediate recovery period especially if they have had
a general anaesthetic (see recovery guidelines). Women recovering from a GA should
have their oxygen saturations monitored and receive supplemental oxygen until they go
to the ward and /or no longer using a PCAS.
The following observations should be performed when the woman arrives in the
recovery/HDU area and every 15 minutes thereafter:-
MOEWS (Modified Obstetric Early Warning Scoring) score. The midwife in
charge needs to be informed of the MOEWS or if there are any concerns about the
woman. The duty anaesthetist and obstetric registrar should be informed if MOEWS
score shows one RED or Two YELLOW or if there are any concerns about the woman
(see MOEWs information file for more detail)
If oxygen saturations less than 95% the patient must receive oxygen 4 litres per
minute via face mask. All patients who have had general anaesthesia will have oxygen
automatically
Ensure patient is alert and rousable
In general, if observations are stable for 2 hours then transfer to the postnatal ward will
take place.
Following transfer to the postnatal ward the minimum observations would be:-
1 hourly for 2 hours then
2 hourly for 2 hours then
4 hourly for 24 hours then
Twice daily until discharge unless deviations from normal identified in which
case medical review should be sought and a plan of care documented
5.2 Thromboprophylaxis
A thromboprophylaxis risk assessment should be carried out for all Caesarean sections
and tinzaparin prescribed as necessary. For full details see Thromboprophylaxis in
Pregnancy and the Puerperium.
Staff debriefing may be appropriate especially where there has been a difficult delivery
or unexpected complications.
An audit will be carried out in accordance with the Maternity Services Audit Plan.
Auditable standards include:
- Indication for CS
- Grading of urgency of CS (classification)
- Involvement of Consultant in decision making process
- Time from decision to delivery and reason for delay if any
- Whether paired cord blood samples were taken as indicated
- Use of antibiotic prophylaxis and thromboprophylaxis
- Care of mother within first 24 hours
- Documented discussion with woman re implications for future pregnancies
A continuous audit will be carried out on all category one caesarean sections whereby
the delivery is entered onto a log kept on delivery suite. Every 24 hours, the
coordinating midwife and the Consultant will review the notes and ensure that an audit
form has been completed. If there was a delay in the decision to delivery interval or
there are any adverse outcomes (e.g. low cord pH, unplanned admission to NNU etc)
then the incident should be reported via the clinical incident reporting process (DATIX)
and the case reviewed at the weekly risk management meeting. The Consultant and
Co-ordinator are responsible for any immediate actions which should be documented on
on DATIX
Audit results will be presented twice a year at the Clinical Governance and Audit
meeting and an action plan developed as necessary. A lead will be appointed to monitor
the action plan and progress and updates of the action plan will be presented quarterly
to the Women’s Services Clinical Governance and Risk Management forum. Results of
the audit will be included in the quarterly Risk Management report and any subsequent
changes will be disseminated via the Maternity Services Forum, Women’s Services
Clinical Governance and Risk Management Forum, Team Leaders Forum and
Supervisor of midwives Forum.
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7.0 REFERENCES
(1) NICE Clinical Guideline 13. Caesarean Section. April 2004. National Institute for
Clinical Excellence.
(3) Kieser KE, Baskett TF. A 10-year population-based study of uterine ruure. Obstet
Gynecol. 2002 Oct;100(4):749-53.
7.0 PROVENANCE
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Protocol relating to the management of Caesarean section
Author(s) T Glanville (Consultant Obstetrician SJUH)
Contact name T Glanville (Consultant Obstetrician SJUH)
Approval process Maternity Services Forum
for amendments
Audit and Will be carried out in accordance with Maternity Services Audit Plan
Monitoring
Broad Recommendations
All pregnant women should be offered a high standard of care based on the best available evidence
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