Emergency Caesarean sections guideline (GL832) protocols and... · This document is valid only on the date last printed Page 5 of 9 Emergency caesarean sections (GL832) November 2018

Author: Guy Jackson, Patrick Bose Date: November 2018

Job Title: Consultant anaesthetist, Consultant obstetrician Review Date: September 2019

Policy Lead: Group Director Urgent Care Version: V4.2 November 2018 V4.0 ratified 1/9/17

Location: Policy hub/ Clinical/ Maternity/ Intrapartum/ GL832

This document is valid only on the date last printed Page 1 of 9

Emergency Caesarean sections guideline

(GL832)

Approval and Authorisation

Approved by Job Title or Chair of Committee Date

Maternity & Children’s Services

Clinical Governance Committee

Chair, Maternity Clinical

Governance Committee

1st September

2017

Change History

Version Date Author Reason

3.0 Oct 2014 P Street, Consultant Obstetrician Reviewed

3.1 July 2015 A Mansfield, Mat Info Officer VTE risk assessment & Emergency CS roles & responsibilities updated (pg. 10-12)

3.2 Aug 2015 G Jackson, Consultant

Anaesthetist

Addition of appendix B categorising degree of urgency for CS

4.0 July 2017 P Bose (Consultant Obstetrician),

G Jackson (Consultant

Anaesthetist)

Reviewed – changes made throughout to make more concise and reflect current practice

4.1 Nov 2017 A Mansfield (Mat Info Officer) Appendix C updated

4.2 Nov 2018 A Mansfield (Mat Info Officer) Appendix C updated






Emergency caesarean sections (GL832) November 2018

Overview: An emergency caesarean section (category 1-3) is usually performed in labour

(but may be required antenatally) if complications develop in pregnancy or labour that

increase the risk to the mother’s or babies health or life.

Preparation for Caesarean Section1, 2:

COMMENCE EMERGENCY OBSTETRIC CARE PATHWAY

Establish Intravenous access if time

Ensure appropriate blood samples taken: FBC, clotting (if needed), group & save

samples for all (2 samples needed – one historical and one within last 72 hours) or

cross-match (if suspected haemorrhage or difficult operation anticipated.

Ranitidine 150mgs orally

Obtain consent and provide mother with maternity information leaflet on Unplanned

(emergency) Caesarean Section

Contact:

o Anaesthetist, obstetrician, theatre team, delivery suite co-ordinator

o If category 1 Call 2222 stating Category 1 CS

o See appendix A ‘Emergency caesarean section staff responsibilities’ (2015)

o Clearly state urgency to ALL members of the team

o See appendix B Classification of urgency

Women whose situation is classified as category 2 or 3 will require regular review

whilst awaiting transfer to theatre as the situation is dynamic and may deteriorate. If

for any reason there is a delay this must be clearly documented in the mother’s

electronic records.

In the event of unavailability of a theatre or to achieve delivery within the timeframe set the

Second Emergency Theatre flowchart (EMA084) should be followed

Undertake WHO (World Health Organisation) checklist before commencing surgery

Prophylactic antibiotics

Women having a CS should have prophylactic antibiotics to reduce the risk of

postoperative infections which occurs in about 8% of women who have had a CS1.

See also ‘Antibiotic & prophylaxis guideline for Obstetrics (GL787).







Paired Cord Samples

ALL cases of emergency caesarean section will have paired cord samples taken to allow

review of fetal wellbeing and guide ongoing care of the baby1. See guideline FBS/paired

cord sampling (GL839).

DOCUMENTATION

Make comprehensive notes of the delivery in the electronic maternity health record (K2)

including any problems or concerns as soon as practical.

The minimum data required are:

Indication for caesarean section (there may be more than one)

Surgical incision and ease of access (or not) to peritoneal cavity

Lie of fetus

Condition of the liquor (meconium, odour etc)

Engagement or not of the presenting part

Condition of neonate at delivery

Whether paired cord samples were obtained or not

Delivery of the placenta and membranes

Checking of uterine anatomy, fallopian tubes and ovaries. Recording of any

deviation from normality

Estimated blood loss

Thoughts for mode of delivery in subsequent pregnancy

Any additional instructions for post operative care, particularly if the procedure has

been in any way complicated.

Care of mother in first 24 hours1:

Following surgery the woman should remain either in recovery or on the

Delivery Suite for a minimum of two hours

Follow post anaesthetic care guideline for recovery on Delivery Suite (GL767)

Analgesia - Follow Puerperal Analgesia guideline GL768

Oral intake

Women who are recovering well after CS and who do not have complications can eat and

drink when they feel hungry or thirsty.

http://www.royalberkshire.nhs.uk/Downloads/GPs/GP%20protocols%20and%20guidelines/Maternity%20Guidelines%20and%20Policies/Anaesthetics%20relating%20to%20Obstetrics/Puerperal_analgesia_V5.0_GL768.pdf







Diabetic mothers should be managed as per guideline Diabetes in pregnancy (GL983),

Appendix 2 (pg. 9).

If the mother is unable to tolerate food or drink and when there are absent bowel sounds

there may be a paralytic ileus which should be managed according the paralytic ileus

guideline. See guideline ‘Bowel complications after CS including Paralytic Ileus (GL796)’

Removal of the urinary bladder catheter

Once a woman is mobile after a regional anaesthetic

Not sooner than 12 hours after the last epidural ‘top up’ dose or spinal

See guidelines for ‘Bladder care post-partum including women with epidural analgesia

(GL792)’.

Thromboprophylaxis

A VTE risk assessment should be performed on all cases of emergency caesarean

section

Follow “postnatal prophylaxis against thromboembolism guidance (GL891)”

See Appendix C - VTE risk assessment and management

On admission to the post-natal ward a repeat VTE assessment is done

Postoperative ongoing care

Should include:

MOWS should be performed and recorded 4 hourly for first 24 hours then twice

daily up to 48 hours

The woman should be advised to wear loose, comfortable clothes and cotton

underwear

All dressings to be left on for five days unless obvious leaking or signs of infection

of the wound, such as increasing pain/redness /discharge, separation or

dehiscence

Most wounds are closed using monocryl. If used, non-absorbable sutures (such as

prolene) are usually removed in community on day 5 unless otherwise stated

ALL caesarean sections must be reviewed within 48 hours by the obstetric SHO







If no problems identified the woman should be formally transferred to Midwife Care

after 48 hours

Prescriptions for low molecular weight heparin (LMWH, such as Clexane) have to

be obtained from the RBFT pharmacy

If any postoperative complications/concerns are identified the duty consultant

obstetrician should be informed.

There is no evidence that ‘routine’ chest physiotherapy improves respiratory outcome for

most women. However, an obstetric physiotherapist is available for women who need to

be seen and out of hours, the on-call physiotherapist can be requested to see the patient.

Discuss implications for future deliveries

After the operation there should be a discussion with the patient regarding the reasons for

the caesarean and implications for the child or future pregnancies1, 3. This discussion

should be documented in the woman’s health care record covering the following:

The events surrounding the birth

Recommendations for future pregnancy – i.e. elective CS or VBAC confirmed early

in pregnancy

Likely success at future VBAC

Information copied to GP

Women who have had a previous CS should be booked under consultant care in their next

pregnancy. The mother should be given the completed caesarean section letter of why

the caesarean was performed for their information and a copy sent to the GP.

References

1. National Institute for Clinical Excellence (2011). Caesarean Section CG132.

London.

2. Royal College of Obstetricians and Gynaecologists (2001). The National Sentinel

Caesarean Section Audit Report. London.

3. NHS Institute for Innovation and Improvement. (2007). Focus on: Caesarean

section. London.






Emergency caesarean sections (GL832) September 2017

Appendix A – Emergency C-section roles & responsibilities







Appendix B – Categorising the degree of urgency for CS







Appendix C – VTE Risk Assessment form






Emergency caesarean sections (GL832) September 2017

Documents

Emergency Caesarean sections guideline (GL832) protocols and... · This document is valid only on the date last printed Page 5 of 9 Emergency caesarean sections (GL832) November 2018