[CG] Caesarean section

Warning

exp date isn't null, but text field is

Objectives

Caesarean Section (CS)– Clinical Guideline

This guideline provides information about procedural aspects of CS including preoperative and postoperative care – both for elective and emergency CS.

Please report any inaccuracies or issues with this guideline using our online form

Elective Caesarean Section

1. Booking an elective caesarean Section

The woman will be seen at the Obstetric ANC and a plan for delivery made. All CS should be discussed with the Obstetric Consultant. Consent for CS should be taken and filed in the case notes. Consent should be taken by Obstetric Consultant or Obstetric Trainee.  The Doctor authorizing the CS should ring delivery suite to book the CS – giving all relevant details (Indication, gestation, level of surgeon required, BMI, risk of bleeding, priority to go first, any anaesthetic or neonatal risks)

At the time of booking a preoperative appointment should be given to the woman.

All CS should be booked for >= 39 weeks unless there is an obstetric reason to be done earlier. If < 39 weeks steroids should be administered to decrease neonatal respiratory morbidity. The woman should be warned that occasionally her date for CS may require to be changed.

Details of the CS and pre-operative visit should be written on the CS information leaflet and this given to the woman.

 

2.   Preoperative assessment

Midwifery assessment should take place and the preoperative check list completed. If the maternal weight was not checked at 36 weeks then the woman should be weighed.

A FBC is performed if this was not taken at 36 weeks or if the result was abnormal. If blood will require to be crossmatched then this should be highlighted (GGC guideline Blood ordering schedule 2015) in the CS booklet.

The woman should be given oral ranitidine 150mg to be taken the night before and the morning of surgery. She should be given written information re admission and fasting times

The woman should attend the ERAS talk – given by midwifery, anaesthetic and physiotherapy staff.

 

3.   Admission for elective Caesarean Section

At PRM women are admitted to Ward 71 at 0730 on the day of their CS.
At QEUH they are admitted to ward 48 and to labour ward in RAH.

They are reviewed by the midwife – a full set of observations documented on the MOEWS chart and the fetal heart auscultated. Their most recent FBC should be reviewed. A group and save is performed on all women – those meeting the criteria are crossmatched (See- Blood Ordering Schedule – Obstetrics). If there are any antibodies on a previous G&S then this requires discussion with blood bank as to whether blood should be crossmatched prior to operation.

The Obstetrician planning to perform the CS should see the woman, confirm she still wishes to proceed, is appropriately consented and review the notes for any other additional surgical risk factors. They should then document this interaction in the notes.

All CS for breech should have an ultrasound performed to confirm the presentation.

The anaesthetic team for that day should also review each woman and document their findings.

 

4.   Elective Caesarean Section in Labour Ward

The team should all meet in theatre prior to the arrival of the first patient to introduce themselves and go through the list – identifying any surgical or anaesthetic risks, deciding whether neonates require to be present at delivery or whether cord bloods are required, deciding whether cell salvage would be useful and whether the surgeon wishes diathermy. The order of the list is then confirmed and the anaesthetist lets the pre-operative ward know who can have a drink and when. Women expected to wait longer than 2 hours for their operation should be considered for clear oral fluids. For longer lists, the anaesthetist may decide to allow a light breakfast for the last patient on the list.

The theatre midwife should check the woman’s details on her arrival in labour ward. She should explore the woman’s wishes re skin to skin, delayed cord clamping and seeing the baby being born.

In theatre the WHO checklist is completed. This includes identity of patient (name and CHI), allergies, consent, placental site, whether neonates or cord bloods are required. In PRM this is split into a sign in prior to anaesthesia and a time-out prior to skin incision. The entire team should be present and involved in the time out.

Once the patient is anaesthetised a urinary catheter is placed.

All women should receive antibiotic prophylaxis. One dose of co-amoxiclav 1.2gm( + amoxicillin 1 gm for women >80kg) or clindamycin 600 mg IV  and Gentamicin IV (penicillin allergy) should be given prior to skin incision (900mg clindamycin if woman >80kg and 1200mg of clindamycin if woman >120kg). A repeat dose of prophylactic antibiotics should be given during surgery if blood loss is more than 1.5 liters with Gentamicin being re-dosed at half prophylaxis dose (penicillin allergy).

There is no difference in maternal morbidity with different techniques of caesarean section including blunt vs sharp entry, single vs double layer closure of  uterus, exteriorisation of uterus for closure vs intrabdominal repair, closure vs non closure of parietal and pelvic peritoneum. (CORONIS trial 2016)

Delayed cord clamping of 1 minute should be performed if there are no concerns regarding the baby or maternal bleeding. Syntocinon administration should not be delayed until after cord clamping. (Delayed cord clamping in the term neonate GGC guideline 3.2019)

5 units of syntocinon IV bolus should be given slowly after delivery of baby + 15 units of syntocinon in 500 ml crystalloid infusion over at least 30 minutes. Additional doses may be required for postpartum haemorrhage, antepartum haemorrhage, atonic uterus, placenta praevia, prolonged labour and multiple pregnancy. Consider using other uterotonics according to clinical condition.

Cord pH blood sampling should be performed if there is any concern regarding neonatal wellbeing. Perform both arterial and venous sampling.

At the end of the operation the sign-out section of the WHO checklist is performed – this includes confirmation of the swab and instrument check , the estimated/measured blood loss, confirmation if any extra antibiotics were given, analgesia and thromboprophylaxis prescribed, whether there were any specimens and instructions for recovery  (re syntocinon, oral fluids and tea and toast). The entire theatre team should be present and involved.

 

5. Post operative care:

Prior to leaving theatre skin to skin is resumed or initiated.

Women should be observed on a two to one basis (1:1 if GA) by a properly trained staff, observations (blood pressure, pulse, pain and sedation) should be done after every 5 minutes for 15 minutes then every 15 minutes for an hour and then hourly for four hours provided all observations are stable.

Any concerns should be directed to the obstetric or anaesthetic staff. Patients should not be discharged from recovery with any abnormal observations without prior medical review.

Emergency Caesarean Section

1. Decision for Emergency Caesarean Section

The time of decision to proceed to CS, the indication for CS and the Category should be clearly documented in the case notes and communicated to all staff.

 

2. Classification of Urgency of CS

Category 1 - Immediate threat to the life of the woman or fetus.

Category 2 - Maternal or fetal compromise which is not immediately life-threatening.

Category 3 - No maternal or fetal compromise but needs early delivery.

Category 4 - Delivery timed to suit woman or staff with no urgency to deliver.

Documentation of decision to delivery time is essential for all CS (categories 1-3).

Thirty minutes is a gold standard for decision to delivery interval for category 1 CS and for category 2 CS woman should be delivered within 75 minutes of making a decision.

 

3. Emergency CS procedure

Written consent should ideally be obtained. For some Category 1 CS verbal consent alone is appropriate but must be documented.

Bloods should be sent for FBC and G&S – if not already done.

Consider in utero resuscitation including stopping syntocinon, left lateral position, oxygen (only for maternal indication e.g. maternal hypoxia or preoxygenation), terbutaline 0.25 mg ( 0.5 ml in 1.0 ml ampoule) subcutaneous if contracting and IV fluids (Hartmann’s 1 litre rapid infusion unless fluid restricted e.g. preeclampsia). (Intrauterine fetal resuscitation GGC Guideline 3.2018). This should not delay transfer to theatre.

The decision regarding method of anaesthesia should be made by the anaesthetist after discussion with the obstetrician.

Once in theatre the urgency of the CS may require to be reclassified. Level 2 caesarean sections have an increased morbidity in part because deterioration may occur during the “wait for surgery”. Continued monitoring and re-evaluation of risk is an essential requirement.

The woman should not be left alone once the decision for a category 1 or 2 CS has been made.

If there is the potential for rapid labour progress a repeat vaginal examination should be performed in theatre prior to commencing the CS.

A neonatologist or ANNP should be asked to attend after giving information re indication and category for CS, gestation and any fetal concerns, using an SBAR format.

A surgical pause / WHO checklist should be performed prior to any CS.

The relevant antibiotics should be administered prior to the skin incision and the routine oxytocics after delivery of the baby.

Paired cord samples should be taken if there has been any suspected or proven fetal distress or if there is any concerns regarding the baby at birth.

The formal debrief should be completed prior to the woman leaving theatre, skin to skin initiated and then the woman transferred to recovery.

The surgeon should clearly document in the notes whether VBAC would be an option in a future pregnancy.

Care on the postnatal wards

Removal of the catheter should be carried out at 6-8 hours following elective CS and 12 hours after emergency CS. (Catheters should be removed 12 hours after CS). The timing of removal catheter should be documented together with the timing of the next void. ( Postpartum bladder care GGC guideline 12.2018)

Prior to discharge home the IDL should be completed and any thromboprophylaxis and analgesia prescribed.

Indication for CS, the procedure and implications for future pregnancies should be discussed post-operatively prior to discharge home.

References

National Institute for Health and Clinical Excellence. Caesarean section NICE guideline CG 132.
Caesarean section surgical techniques (CORONIS) Lancet 382:9888 ; 234-248 2013

Last reviewed: 01 October 2019

Next review: 01 July 2022

Author(s): Dr A Nausheen, ST7; Dr J Roberts, Consultant; Dr F Mackenzie, Consultant

Co-Author(s): Updated by Dr Joy Simpson, October 2019

Approved By: Obstetric Governance Group