Family and Women’s Services (FAWS) Health Group C1

1 MGRP\: Caesarean Section Guideline – version 9 – January 2019

Family and Women’s Services (FAWS)

Health Group

CAESAREAN SECTION GUIDELINE

Version 9

Author / Reviewer Belinda Harvey – Outpatients, community and Birthing Unit Matron – Author

Naghmeh Teymourian-Yates – Labour Ward Coordinator;

Reviewer: Dr. Mary McLachlan, Specialty Registrar

M

Date noted 14.03.19

Noted by Trust Policy Group

Issue Date 15.03.19

Review date 14.03.22

Target audience Obstetric, midwifery, nursing and anaesthetic teams for maternity

The current version of any policy, procedure, protocol or guideline is the version held on Trust Public Folders. It is the responsibility of all staff to

ensure that they are following the current version

Signed……………………………

Chair of Trust Policy Group

C1


TABLE OF CONTENTS

Section Page

1. QUICK REFERENCE GUIDE 3

2. INTRODUCTION 4

3. PURPOSE 4

4. DEFINITIONS 4

5. DUTIES 4

6. PROCESS 5-17

7. TRAINING 17

8. MONITORING COMPLIANCE WITH THIS DOCUMENT 17-19

9. REFERENCES 19

10. RELATED TRUST POLICIES 20

APPENDIX 1 ELECTIVE LSCS PRE-ADMISSION CHECK LIST (NIGHT BEFORE OPERATION, AROUND 7.30PM)

21

APPENDIX 2 ALGORITHM FOR CATEGORY 1 & 2 SECTIONS GOING T MAIN THEATRE

22

APPENDIX 1 DOCUMENT CONTROL SUMMARY 23

APPENDIX 2 DOCUMENT CHECKLIST 24-25

APPENDIX 3 EQUALITY IMPACT ASSESSMENT 26

APPENDIX 4 PRIVACY IMPACT SCREENING TOOL 27


1. QUICK REFERENCE GUIDE Lower Segment Caesarean section (LSCS) is the end point of a number of care

pathways hence it is not possible to cover all the clinical decisions and pathways

which may lead to a LSCS in one guideline. The purpose of this particular guideline

is to coordinate the organisational aspects of the LSCS.


2. INTRODUCTION

In England, caesarean section (LSCS) rates have increased from 25% of

deliveries in 2011 to 26.2% in 2013 (RCM)

3. PURPOSE Lower Segment Caesarean section (LSCS) is the end point of a number of care

pathways hence it is not possible to cover all the clinical decisions and pathways

which may lead to a LSCS in one guideline. The purpose of this particular

guideline is to coordinate the organisational aspects of the LSCS.

4. DEFINITIONS

PAHT - Princess Alexandra Hospital Trust

LSCS - Lower Segment Caesarean Section

CTG - Cardiotocograph

SOVA - Safeguarding of vulnerable adults

BMI – Body mass index

WHO - World Health Organisation

cART- Combined Antiretroviral Therapy (Previously known as HAART- highly active antiretroviral therapy)

5. DUTIES The Lead Midwife for Quality and Compliance is responsible for all guidelines to be

reviewed at appropriate time, taken to FAWS Patient Safety and Quality (PSQ) team

for ratification and sent to the Trust policy group for noting. It is then her responsibility to

disseminate to the ward managers, Supervisors of Midwives, and Team Coordinators for

dissemination to all levels of staff.

Associate Director of Nursing and Midwifery (ADoN)’s personal assistant is

responsible for ensuring all new and revised guidelines are placed on the desktop for all

staff to access.

Matrons, Ward managers and Team Coordinators are responsible for the

dissemination of new and revised guidelines to clinical staff within their area of work.


6. PROCESS

6.1 Classification of Urgency of the Caesarean Section & Indication for

the Caesarean Section

It is extremely important, for medico-legal & audit purposes, that the urgency and

indication(s) for the LSCS are fully documented in the notes or consent form by

the surgeon who has advised the woman of the risks and benefits of proceeding to

deliver her baby by LSCS.

Determine the urgency of LSCS using the following standardised scheme

(NICE CG132, August 2012) (NICE Intrapartum Care, December 2014). The

obstetrician is responsible for deciding the status of caesarean section and this

must be clearly documented in the consent form (Theatre record 1 – operation

record) and, in cases of Category 1 Emergency or Category 2 urgent, on the

“Decision to delivery time” Audit form. The urgency status, along with the time

constraints must be conveyed to both the anaesthetist and midwifery staff at the time

of the decision.

The Trust is committed to treating people with dignity and respect in accordance

with the Equality Act 2010 and Human rights Act 1998. Throughout the

production of this policy due regard has been given to the elimination of unlawful

discrimination, harassment and victimisation (as cited in the Equality Act 2010).

Classification Definition Example Decision

delivery interval

Category 1

Immediate threat to the life of the woman or fetus

Cord prolapse

Severe antepartum haemorrhage/Placental abruption Pathological CTG/Prolonged fetal bradycardia FBS pH <7.2

Uterine rupture

Failed instrumental Eclampsia once stabilised

Within 30min

Category 2

Maternal/fetal compromise not immediately life- threatening however urgent delivery required

Suspicious CTG unable to perform fetal blood sample Failure to progress with suspicious CTG

Failure to progress in 2nd

stage

Delivery of 2nd

twin

Undiagnosed Breech in advanced labour

Within 75 minutes of decision

Category 3

No immediate maternal/fetal compromise but needs early delivery

Failure to progress with no maternal/fetal compromise Undiagnosed breech/booked elective in early labour Failed induction of labour Premature delivery for IUGR Absent end diastolic flow Pre-eclampsia after stabilisation

According to clinical need

Category 4 Delivery timed to suit woman

or staff

Women not in labour LSCS on weekday daytime N/A


6.2 Consent

The consent form must be completed and must always accompany the woman to

theatre and to the ward following the operation. Normally, written consent should

be obtained for all operations under general or regional anaesthesia. It is

acknowledged that this may not always be possible in cases of dire emergency but in

such circumstances verbal consent must be obtained and the Obstetrician must

record the decision in the woman’s health care records and the reasons for

proceeding without a written consent.

Care must be taken when obtaining valid consent from women who are in

labour, particularly if they are in pain or under the influence of narcotic analgesics. If

a competent woman declines delivery by caesarean section, even after full

consultation and explanation of the consequences to herself and for the fetus,

her wishes must be respected and documented. (See the Consent policy)

Where a woman’s capacity to consent is in doubt a mental capacity form

should be completed (x-drive; patient forms; SOVA file) or where differences of

opinion about her best interests cannot be resolved satisfactorily, the doctor should

consult experienced colleagues and, where appropriate, seek legal advice on

whether it is necessary to apply to the court for a ruling. If doctors decide to apply

to a court, they should, as soon as possible, inform the woman and her

representative of that decision and of her right to be represented at the hearing.

Lead consultant, Supervisors of midwives and the Trust’s legal team to be consulted

as part of this process.

Women who cannot speak English must have consent obtained via a Recognised

and Independent Interpreter.

Consent to be sterilized should not normally be obtained while a woman is in

labour. An exception to this may be made if the woman has been fully informed

during the antenatal period and had an opportunity to ask questions of a senior

doctor and already provisionally agreed.

6.3 Anaesthetics

The majority of LSCS should be performed with a regional block. Acid prophylaxis

and an antiemetic should be offered prior to general or regional anaesthesia.

There should be urgent access to at least two units of uncross- matched O

negative blood in the blood bank fridge. A trolley for difficult intubation with a

variety of laryngoscopes, tracheal tubes, laryngeal masks and other aids for

airway management must be available in theatre, which should include the

ability to provide a surgical airway for a ‘cannot


intubate/cannot ventilate’ scenario. The operating table for LSCS should have a

lateral tilt of 15 degree.

A duty anaesthetist should be available for immediate response 24-hours a day

supported by a Consultant Anesthetist. The names & contact details of the duty &

Consultant Anaesthetist responsible for the Delivery Suite must be displayed in the

labour ward office at all times. Provision should be made for those who cover the

Delivery Suite on-call, but do not have regular sessions there, to spend time in the

Delivery Suite in a supernumerary capacity with one of the regular obstetric

anaesthetic consultants. If the anesthetist is a trainee, they should have at least

one year’s experience and a second anesthetist should be available if needed. The

person assisting the anaesthetist (Operational Department Practitioner/Nurse)

during the anaesthesia should have no other duties at that time. Separate staffing

and resources should be allocated to elective Caesarean section lists to prevent

delays due to emergency procedures and provision of regional analgesia in

labour.

The duty anaesthetist for the Delivery Suite should not be solely responsible for

the Intensive Care Unit (ICU) and should not carry the ‘crash bleep’ since that

anaesthetist could be urgently required in two places simultaneously. If the duty

anaesthetist covers general theatres or ICU, there must be another anaesthetist to

take over immediately should they be needed on the Delivery Suite. The lead

Obstetric anaesthetist should audit and monitor such arrangements.

6.4 Thromboembolic disease Prophylaxis

All women undergoing a LSCS should be measured for anti-embolic stockings prior

to surgery and these should be applied before going to theatre, calf stimulation

boots (eg Flotron) need to be applied just before the operation. The women will

be prescribed clexane after delivery for 7 days to 6 weeks depending on their risk

factors. In women who have had an epidural the clexane should not be given

within 4 hours of the insertion or removal of the epidural catheter (6 hours if the

epidural procedure was traumatic). Women who have had a general anesthetic

should receive clexane as soon as possible after delivery, provided that there is

no postpartum haemorrhage. In cases of post-partum hemorrhage, the timing of

the first postpartum clexane is determined according to individuals’ clinical

picture. The risk assessment tool for thromboprophylaxis (see separate guideline)

should be consulted to determine if the woman is high risk for developing

thromboembolic disease.


.5 High Risk Obstetric cases and women at risk of major haemorrhage

Advance notice of planned caesarean sections in high risk women/babies must

be given to the obstetric anaesthetic service/neonatal team as appropriate. In

the following situations, all LSCS’s should be performed by an experienced

obstetrician and any anaesthetic should be given by an experienced

anaesthetist. The Obstetric Consultant should be present in the theatre or readily

available, in the following situations;

Placenta praevia, especially with previous caesarean section

Morbidly adherent placenta

Myomectomy scars

Uterine fibroids

Placental abruption

Previous third stage complications

Multiple caesarean sections

BMI > 35

Full dilatation

Gestation less than 32 weeks .6 Do not routinely offer planned CS to women with:

An uncomplicated twin pregnancy at 37-38 weeks where first twin is

cephalic

Preterm birth

A small for gestational age baby

HIV receiving cART with a viral load < 50 HIV RNA copies/mL at 36 weeks

HIV on effective cART , irrespective of HCV viral load.

Hepatitis B

Hepatitis C

Recurrent genital herpes at term

BMI>50

.7 Offer planned CS to women with:

A singleton breech presentation at term for whom external cephalic

version is contraindicated, declined or unsuccessful

A twin pregnancy where first twin is not cephalic

A placenta that partially or completely covers internal cervical os

HIV receiving cART with a viral load 50–399 HIV RNA copies/mL at 36 weeks, ; Planned CS should be considered, taking into account the actual viral load, the trajectory of the viral load, length of time on treatment, adherence issues, obstetric factors and the woman’s views.


HIV who are not receiving any antiretroviral therapy

HIV on cARTWhere the viral load is ≥ 400 HIV RNA copies/mL at 36 wee

Primary genital herpes simplex virus (HSV) occurring in third trimester of pregnancy


6.8 Timing of planned LSCS:

Do not routinely carry out elective LSCS before 39 weeks of gestation.

Elective lower segment caesarean section should normally be performed

at or after 39+0 weeks of gestation to reduce respiratory morbidity.

Corticosteroids should be given to reduce the risk of respiratory morbidity in

all babies delivered by elective caesarean section prior to 38+6 weeks of

gestation.

6.9 Maternal requests for caesarean delivery Around 6-8% of pregnant women do express a preference of a caesarean over

vaginal birth.

When a woman requests a caesarean birth, the reasons for the request should be

explored and discussed and carefully documented. If a woman requests a LSCS

in the absence of an indication, discuss the overall risks and benefits of LSCS and

vaginal birth and document the discussion.

Women who request caesarean birth as a result of a previous negative birth

experience or anxiety or fear of childbirth, should be offered support and an

appointment with the Birth Reflections Midwife

If after discussion and offer of support, a vaginal delivery is still not an acceptable

option, offer a planned LSCS. An obstetrician can decline a woman’s request for a

LSCS. In this instance, they should refer the woman to an obstetrician who will carry

out LSCS.

6.10 Use of Prophylactic Antibiotics during Caesarean Section

Offer women prophylactic antibiotics at LSCS, such as a single dose of first

generation cephalosporin, to reduce the risk of postoperative infections (such

as endometritis, urinary tract and wound infection),

The rate of wound infection is in the region of 97 per 1000 and 68 per 1000 for

emergency and elective caesarean sections, respectively; for endometritis the rates

are 184 per 1000 versus 39 per 1000 (2014 Cochrane review).

A single dose of antibiotic is sufficient unless there is established ascending

infection.

Suggested regimes: -


Augmentin 1.2 Grams Intravenously stat:

Do not use when giving antibiotics before skin incision.

Or (2) Cefuroxime 1.5 Grams Intravenously stat

6.11 Skin to Skin Contact

All mothers should be encouraged to hold their babies in skin to skin contact and

for as long as the mother wishes in an unhurried environment as soon as possible

after delivery regardless of their intention to feed or the type of delivery.

Ideally at least 1 hour or until the first breast feed and bottle feed. (UNICEF

Maternity Standards 2013) Following a LSCS this may take place in theatre whilst

the operation is in progress, if this is safe for the baby and comfortable for the

mother. All post LSCS babies should be placed skin to skin against their mother

in the recovery room to ensure thermoregulation and regulation of heartbeat and

respirations, enhance bonding and promote breastfeeding unless the mother

specifically declines.

6.12 Emergency / Urgent Caesarean Sections

Any non-elective LSCS must be discussed with a consultant at the time the

decision is being made, unless doing so would be life threatening to the

woman or the fetus in which case the surgeon must ask a colleague or a

Midwife to inform the Consultant as soon as possible.

Prior to emergency/urgent LSCS for fetal compromise, efforts to obtain a fetal blood

sample should be made at cervical dilatations of 4cm or more, unless the degree

of compromise is such that immediate delivery is necessary. (see Fetal Monitoring

and Fetal Blood Sampling guideline 2016)

Paired cord blood samples should be taken after all caesarean sections with

suspected fetal compromise, as well as in cases where the baby shows any actual

signs of compromise at birth.

Continuous cardiotocograph (CTG) monitoring of the fetal heart will be necessary

during spinal/epidural administration if there are any concerns relating to the CTG.

This may involve the application of a fetal scalp electrode, if necessary. The fetal

heart must be auscultated just before the operation is started. Rarely the fetal

heartbeat may need to be confirmed with the portable ultrasound scanner to confirm

the fetus is alive. If a fetal scalp electrode is in situ, this must be removed before the

operation starts.

All swabs must be weighed and estimated blood loss calculated.


NB The World Health Organisation (WHO) surgical safety checklist must be

completed at the beginning and the end of the procedure and filed in the

woman’s health care records.

6.13 Decision-to-delivery interval for emergency & urgent caesarean sections

Guidelines on electronic fetal monitoring recommend that where acute fetal compromise is suspected or confirmed, delivery should occur as soon as possible, ideally within 30 minutes, taking into account fetal heart rate and maternal factors. However, rapid delivery may be dangerous in itself for the fetus. Delays in delivery of more than 75 minutes are associated with poorer outcomes.

In cases of emergency section, there should be no delay in transferring the woman to theatre. The pre-operative preparation may be carried out in theatre.

The Obstetrician who has advised the woman of the risks and benefits of proceeding to deliver her baby by LSCS must document

The reason for the caesarean section

Time of decision

Classification

Any reasons for delay in undertaking the Caesarean Section.

All should be recorded in the maternity notes or on the consent form and the audit form.

6.14 Emergency/Urgent Caesarean Sections in Main Theatre

Occasionally it is necessary for women to be transferred to main theatre for an

emergency/urgent LSCS if the maternity theatre is in use at the time of decision. See

flowchart appendix 3

Action Rationale

If the maternity theatre is in use. Explain the situation on labour ward to the operating obstetrician and ask the surgeon how long it will be before they finish the on-going procedure. Bleep 255 (Bleep 628 if no response) for main theatre availability.

To establish if the situation can be delayed so the maternity theatre can be utilised for the emergency.

Ensure there will be an anaesthetist and operation department practitioner (ODP) available in main theatre for the LSCS. The main theatre will organise this (bleep 255 or 628).

Essential for the procedure to continue.

Arrange for an assistant for the obstetrician who has made the decision for the emergency LSCS. Look on the on-call rota to see who is free to help. After 2000hrs and at

Essential for the procedure


weekends other arrangements will have to be made, i.e. call in the on call consultant.

Explain to the woman and her birth partner the need for the emergency procedure and the need for her transfer to main theatre.

Ensure effective communication and co- operation.

Ensure the obstetrician who has advised the woman of the risks and benefits, of proceeding to deliver her baby by LSCS, completes the consent form with the woman.

To comply with trust guidelines

Call the porters on bleep 299 request assistance in transferring equipment and woman to theatre advising them which theatre to go to. Daily check with Switch board to ensure Lifts are working See Appendix 1

To ensure minimal delay in the procedure.

Contact the paediatrician and explain to him/her that there will be an emergency LSCS in main theatre advising him/her of the theatre number.

To prevent confusion and delay in emergency treatment.

Ask Samson ward staff to transfer a suitable bed to main recovery for the woman after the operation.

For transfer back to the maternity department

Main theatre recovery staff will recover the woman and transfer back down to maternity either to delivery suite recovery area or to Samson ward depending on the woman’s condition.

To allow the woman to recover from the operation sufficiently to facilitate safe transfer.

Measure and document woman’s temperature every 30 minutes, maintain ambient temperature at 21.0c or above whilst woman exposed. Warm Intravenous fluids and blood products to 37.oc

To prevent perioperative hypothermia and slow recovery of the post-operative mother

The baby should be labelled as soon as possible and transferred to the recovery room with the woman’s birthing partner in accordance with Trust guidelines

To ensure security and initiate the first baby check.

Complete relevant paperwork and complete register, indicating that the LSCS was performed in main theatre. Ensure the obstetrician who has advised the woman of the risks and benefits of proceeding to deliver her baby by LSCS completes the audit tool.

In accordance with the NMC guidelines.

For audit purposes

Ask porters to transfer labour ward equipment back to the department. Check all equipment has been returned and in working order.

To prevent loss of equipment.

Cord blood gases must be taken by the surgeon. Take samples and give these to a member of staff from theatre who will analyse them using their blood gas analyser.

To ascertain baby’s condition


6.15 Elective/Scheduled LSCS in main theatre

There are lists for planned LSCS in main theatre.

LSCS should be spread evenly over the week.

The Friday morning list should only be booked when other lists are full.

Maximum three on the main theatre lists.

Elective (category 4) LSCS should not routinely be carried out before

39 weeks, if done so before 39 weeks steroids to be given as per

protocol.

Action Rationale

The risks and benefits of LSCS will be discussed with the woman and consent will be taken prior to booking an elective or planned LSCS An independent Interpreter must be present when gaining consent from a woman does not speak English

To ensure informed choice and time to consider the information given.

Elective LSCS will be discussed with the woman following consultation with the consultant and the Elective LSCS booking form is completed with her EDD and accompanying information. Including a request for an interpreter should the woman not speak English. Information regarding going to Same day admissions to be given to the woman.

To ensure that there is information for the Consultant and the midwifery manager to plan the date of the operation

The ANC co-ordinator will advise the woman to make an appointment for MRSA screening and collect ranitidine as prescribed (in Maternal and Fetal Assessment Unit). The women will be advised of the same day admissions area and the need to attend at 07.30 on the day of their surgery. An information leaflet will be given.

To ensure appropriate venue & to screen for MRSA and collect ranitidine and information regarding it use. To ensure that women attend for their surgery in the correct venue and prevent delay in surgery.

Each week the Lead consultant and Maternity manager scrutinise the Elective Caesarean Section forms to allocate the women their Caesarean Section date.

To ensure the C/S theatre list is accommodated appropriately

The Maternity Manager contacts the woman to give her the date for the operation and the check list on the reverse of the form is completed.

To ensure that the woman has a date for her operation.

NB if a woman gives birth before the elective list or an addition to the list is made, the theatre staff must be informed the night before or at 0730 hrs of the morning for LSCS on bleep 628.

To ensure the list remains correct and preventing any confusion or delay.


6.16 Procedure There are usually three woman allocated to the elective caesarean section list in main theatre.

The night before surgery

The midwife will:

Check consent signed

Check bloods and MRSA status and print out the report, so they are

available in the morning for review.

Women are advised of Same Day Admissions area to attend at 7.30am

Women, whose babies are presenting in the breech position, will have been

informed that they need to attend the labour ward at 07.00hrs, for ultra-sound

scan to check fetal position. If the baby is cephalic the midwife and the

obstetrician on the antenatal ward will explain the options with the

woman and complete a new plan for her. If the baby is breech she should

be directed to the Same Day Admissions Unit. (Appendix 1)

Equipment –

The theatre trolley containing all the equipment for the re-stocking of the

resuscitaire in main theatre is located in the linen cupboard on the labour

ward. (Use the printed out sheet to make sure you have all the required

equipment such as a sonicaid, vitamin K, thermometer, pillows and pumps

etc.).

The woman’s notes are situated in the Antenatal ward office.

TED stockings are kept in the clean utility room on the labour ward.

Syntocinon pumps are kept on the corridor of the labour ward, one

pump per woman needed.

There will be two midwives allocated to the elective LSCS list.

1. The notes of the women for LSCS will be collected from the designated shelf

in the labour ward office and taken to theatre by one of the midwives;

she will meet and greet the women and their partners and start prepping

the women for their caesarean sections,

All the women are prepped for theatre at this time as the order of the list is

not usually determined until after the team briefing in theatre is complete.


2. If a woman is for an Elective LSCS from the Antenatal ward, she

should be prepped by the night staff. The midwife must accompany her to

theatre and take her directly to the holding bay, not same day admissions,

as she is already an inpatient.

3. The midwives must check name bands with the women they are caring for

and complete operation check list in consent form to ensure correct identity;

there must be 2 name bands per woman.

4. The second midwife will take the theatre trolley to main theatre (she will

need to check on the theatre list which theatre has been allocated) and

check, and sign the resuscitaire is ready for use.

5. Second midwife will then join the first midwife in same day admissions, to

prepare the second and third woman for LSCS. Each woman is

informed that they will need to be catheterised to reduce bladder trauma

during the LSCS procedure and for the need to have her pubic hair clipped

around the incision site to reduce the infection risk these procedures will be

done in the theatre.

6. The midwives must auscultate the fetal heart on admission to the theatre of

the women they are caring for. In the case of multiple births, 2 midwives

should auscultate the fetal hearts simultaneously.

7. The first woman is taken to the holding bay, the midwife then goes to

changing room near theatre 8 (code 1524) to change to theatre greens.

8. The midwife returns to theatre, and prepares to receive the baby in the

theatre. The baby check, labelling and weighing of baby is performed in the

anaesthetic room. The placenta is checked in the dirty utility room and

placed in a yellow placenta bag and bin provided, at the end of the LSCS list

this will be brought back to labour ward for disposal.

9. The resuscitaire must be checked and made ready for next baby.

10. Transfer the woman to recovery area to help with breast feeding etc, the

recovery observations are completed by the recovery nurse.

11. The second woman and her partner are escorted by the second midwife to

the holding bay after being called through by the theatre staff.

12. Once the first woman has been recovered in main theatre recovery area

she is escorted back to the postnatal ward by the midwife caring


for her in the recovery. She will be handed over to the postnatal ward

midwife using the CHAPS tool.

13. The recovery midwife returns to the Same Day Admissions, to be with the

third woman.

14. Once the women are recovered in main theatre recovery the two midwives

return to the post-natal ward with their respective women, and handover

the care of the women and their babies using the CHAPS tool, to the staff on

the post-natal ward

15. The full placenta bin and the theatre trolley area taken to recovery.

16. One of the midwives will return to theatre to check the resuscitaire and

return the trolley to labour ward and the placenta bin to the sluice in

Labour ward for disposal. The trolley should be restocked and ready for use.

6.17 Skin to Skin Contact

All mothers should be encouraged to hold their babies in skin to skin contact and

for as long as the mother wishes in an unhurried environment as soon as possible

after delivery regardless of their intention to feed or the type of delivery.

Ideally at least 1 hour or until the first breast feed and bottle feed. (UNICEF

Maternity Standards 2013) Following a LSCS this may take place in theatre whilst

the operation is in progress, if this is safe for the baby and comfortable for the

mother. All post LSCS babies should be placed skin to skin against their mother

in the recovery room to ensure thermoregulation and regulation of heartbeat and

respirations, enhance bonding and promote breastfeeding unless the mother

specifically declines.

6.18 Documentation

The two midwives are responsible for their own record keeping, the maternal health

care records, the computer and register to be completed on Labour ward.

NB The bleep holder needs to be informed once the theatre list is completed so

that the midwives can be redeployed if necessary.

6.19 Management of Inadvertent perioperative hypothermia

Prevention of inadvertent perioperative hypothermia requires the use of

simple measures to keeping women comfortably warm.


Women for elective caesarian should be informed that staying warm before

surgery will lower the risk of post-operative complications, they should bring

additional clothing, such as a dressing gown, warm clothing and slippers to wear

to theatre to keep them comfortably warm and they should tell staff if they feel

cold at any time during their hospital stay.

6.20 Post Delivery care

For details of care of the mother following delivery by LSCS see separate

Recovery Guideline. Following non-elective LSCS & prior to discharge from the

maternity unit, all women should be seen by a member of the obstetric team in

order to discuss any implications for future pregnancies. This discussion must be

documented in the woman’s notes. A letter for the woman documenting why she

had the operation and whether she can have a VBAC (Vaginal birth after

Caesarean section) when she has her next pregnancy should be completed by

the operating surgeon.

7. TRAINING

The method used to classify the urgency of caesarean section is communicated to new

doctors, midwives & recovery nurses as a part of their induction programme. New

maternity nurses spend two weeks training in main theatres during which time they

complete a “recovery competencies assessment”. ST1 and ST2 doctors training is by

supervision and completion of OSAT forms

8. MONITORING COMPLIANCE WITH THIS DOCUMENT

The table below outlines the Trust’s monitoring arrangements for this document. The

Trust reserves the right to commission additional work or change the monitoring

arrangements to meet organisational needs.

Aspect of compliance or effectiveness being monitored

Method of monitoring

Individu respons e for the monitor

Monitoring Frequency

Group or committee who receive the findings or report

Group or committee or individual responsible for completing any actions

Duties To be addressed by the monitoring activities below.

Documentation of reason for emergency or urgent caesarean section by the Obstetrician who has advised the woman of the risks and benefits of proceeding to deliver her baby by LSCS

A formic audit tool is provided for completion following all Category 1 – 3 caesarean sections. The data is collated every two months and a report produced by the obstetrician allocated. A retrospective audit of 1% of health records of

Labour Ward matron

. A continuous & on-going audit of “Decision to delivery time” for all Category 1-3 LSCS is in place. An Annual audit against the auditable

FAWS audit meeting

Labour Ward Matron, Audit leads will facilitate


women who have had an emergency or urgent caesarean section chosen at random from the previous three months deliveries will be audited against the auditable standards.

standards

Documentation in the records of the classificat time and reasons for del

A formic audit tool is provided for completion following all Category 1 – 3 caesarean sections. The data is collated every two months and a report produced by the obstetrician allocated. A retrospective audit of 1% of health records of women who have had an emergency or urgent caesarean section chosen at random from the previous three months deliveries will be audited against the auditable standards

Labour Ward matron

A continuous & on-going audit of “Decision to delivery time” for all Category 1-3 LSCS is in place. An Annual audit against the auditable standards

FAWS audit meeting

Labour Ward Matron, Audit leads will facilitat

Consultant involved in the decision making

A formic audit tool is provided for completion following all Category 1 – 3 caesarean sections. The data is collated every two months and a report produced by the obstetrician allocated. A retrospective audit of 1% of health records of women who have had an emergency or urgent caesarean section chosen at random from the previous three months deliveries will be audited against the auditable standards

Labour Ward matron

A continuous & on-going audit of “Decision to delivery time ” for all Category 1-3 LSCS is in place. An Annual audit against the auditable standards

FAWS audit meeting



Women offered prophyla antibiotics

A formic audit tool is provided for completion following all Category 1 – 3 caesarean sections. The data is collated every two months and a report produced by the obstetrician allocated. A retrospective audit of 1% of health records of women who have had an

Labour Ward matron

A continuous & on-going audit of “Decision to delivery time” for all Category 1 -3 LSCS is in place. An Annual audit against

FAWS audit meeting

Labour Ward Matron, Audit lea will facilitate


emergency or urgent caesarean section chose random from the previous three months deliveries will be audited against the auditable standards

the auditable standards

Documentation of discussion before discharge of implications for future pregnancies following delivery

A formic audit tool is provided for completion following all Category 1 – 3 caesarean sections. The data is collated every two month and a report produced by the obstetrician allocated. A retrospective audit of 1% of health records of women who have had an emergency or urgent caesarean section chosen at random from the previous three months deliveries will be audited against the auditable standards

Labour Ward matron

s

A continuous & on-going audit of “Decision to delivery time” for all Category 1-3 LSCS is in place. An Annual audit against the auditable standards

FAWS audit meeting


If there is mandatory training associated with this document state the mandatory training here

Training will be monitored in line with the Statutory and Mandatory Training Policy

Where a lack of compliance is found, the identified group, committee or individual will identify required actions, allocate responsible leads, target completion dates and ensure an assurance report is represented showing how any gaps have been addressed.

9. REFERENCES

NICE Guideline 132 (August 2012) - Caesarean Section.

NMC – Guidelines for records and record keeping. January 2019

Royal College of Obstetricians and Gynaecologists (2015) Obtaining Valid Consent Clinical Governance Advice number 6

Royal College of Obstetricians and Gynaecologists Green-top guideline No 37 a Reducing the risk of Thrombosis and embolism During Pregnancy and puerperium ( 2015)

OAA/AAGBI Guidelines for Obstetric Anaesthetic Services 2013


The National Sentinel Caesarean Section Audit. RCOG clinical Effectiveness Support Unit 2001.

Unicef Maternity Standards 2013 http://www.babyfriendly.org.uk/page.

Antenatal corticosteroids to reduce neonatal morbidity RCOG Green- top guidelines No 7 (October 2010) British HIV Association Guidelines for the management of HIV infection in pregnant women 2018 PAH Antibiotic Surgical Prophylaxis Guideline, May 2017 Scottish Intercollegiate Guidelines Network 104 • Antibiotic prophylaxis in surgery, April 2014

10. RELATED TRUST POLICIES

Family and Women’s Services Health Group - Recovery

Guidelines

Family and Women’s Services Health Group Obstetric

thromboprophylaxis and the Investigation and Management of

women in whom venous thromboembolism is suspected guidelines

PAH Continuous LSCS Audit of Decision to Delivery Time audit tool.

Family and Women’s Services Health Group – Enhanced

Recovery Guidelines and Standard Operating Procedure

Family and Women’s Services Health Group – Bladder Guideline

Trust policy – Adult Urinary Catheterisation

Consent Policy

http://www.babyfriendly.org.uk/page


APPENDIX 1

Elective LSCS pre-admission check list (night before operation, around 7.30pm)

Notes available and admission pack completed

Print identification wristbands

Consent form signed

Blood results available and printed

If blood results not available, bloods taken before allowing the woman

to go home

Prophylactic antibiotic dose for theatre has been prescribed

Ranitidine 150mg x 2 prescribed on the drug chart and then given to the woman to take at home at 2200 hrs & 0600 hrs with a sip of water

Woman aware she needs to be nil by mouth from midnight

Inform the woman that she need not shave herself that this procedure

will be performed just prior to her operation

Ask the woman to have a bath or shower and remove nail vanish and

make-up prior to admission

Inform the woman that our default method of care is to offer skin to skin contact as soon as she is able to following delivery for approximately one hour and then the baby is usually ready to feed.

Warm dressing gown, slippers and shoes to ensure the woman is warm in transit to the main theatre for elective caesarean section

Ask the woman if she wishes her baby to have Vitamin K and preferred

route of administration.

Inform the woman the time she needs to go to the Same day admissions Unit at 0730 hrs the following day and advise her that she needs to bring her hand held notes with her.

If the baby is in the breech position to attend labour ward at 0700hours of the day of the Caesarean section to confirm presentation of breech prior to going to the Same day admissions

Reconfirm consent for the procedure giving the woman the opportunity to ask any questions or voice any concerns prior to going home. Access to a doctor trained in the booked procedure must be made available if requested.

Check whether she is on the enhanced recovery pathway and complete


documents as required

Appendix 2

ALGORITHM FOR CATEGORY 1 & 2 SECTIONS GOING TO MAIN THEATRE ACTION

Bleep 255 emergency theatre - if no response bleep 628 (Practitioner in charge of theatre) to ascertain availability of a theatre and its location. Theatres inform clinical specialist if staff are required to scrub and run.

Call theatre porters Bleep 255 on initial call

THEATRE NOT IMMEDIATELY AVAILABLE

628 will secure next available theatre and inform clinical specialist

THEATRE AVAILABLE CLINICAL SPECIALIST:

In hours -Bleep 017 (on-call anaesthetist for labour ward) Inform them of the situation and the plan to go to main theatre for section, if they are busy, Bleep 002(emergency anaesthetist). Also bleep Paeds on 018 (SHO) or 013 (REG).

Out of hours – Call the On call Consultant Anaesthetist (At home and may need travel time) Via Switch board to attend.

Main theatre staff will prepare theatre for section: resuscitaire and cot are kept in theatre. This equipment is in use on a Monday, Wednesday, Thursday and Friday morning. (If

Alexandra Day Unit is to be used, all equipment and sets will need to be supplied).

LIFTS BROKEN – go in service lift with PORTERS

Call 2222 and request for Porters to take you via the service lift (Behind the canteen) A porter is required to help push the bed, GAIN ACCESS to the lift and keep thoroughfare in Penn Ward clear. Contact security to ensure the main doors are unlocked.

Midwife, surgeon and partner to escort patient to theatre. Birthing partner will remain in the theatre to support the woman or be shown to quiet room in theatres if a

general anaesthetic is required.

Patient recovered in main theatre with midwife until fit to return to labour ward

N.B. It remains the responsibility of the midwives to check and restock the resuscitaire

MTW:\ caesarean section guideline- v8-July 2016

Page 22 of 28


Page 23 of 28

APPENDIX 3 – VERSION CONTROL SUMMARY

Document Title: Caesarean Section Guideline

Version Number

Purpose / Changes

Author

Date Changed

8

Due for review in line with the NICE intrapartum guidelines – Dec 2014

Belinda Harvey – Outpatients, community and Birthing Unit Matron – Author

Naghmeh Teymourian- Yates – Labour Ward Coordinator - Reviewer

25.07.16


Page 24 of 28

APPENDIX 4 - CHECKLIST FOR PROCEDURAL DOCUMENTS

To be completed by the author and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval / ratification.

Document Title and Version No.

Caesarean Section Guideline V9

Yes/No/

Unsure Comments

1. Title

Is the title clear and unambiguous? Yes

Is it clear whether the document is a guideline, policy, protocol or standard?

Yes

2. Rationale

Are reasons for development of the document stated?

Yes

3. Development Process

Is the method described in brief? Yes

Are individuals involved in the development identified?

Yes

Do you feel a reasonable attempt has been made to ensure relevant expertise has been used?

Yes

Is there evidence of consultation with stakeholders and users?

Yes

4. Content

Is the objective of the document clear? Yes

Is the target population clear and unambiguous?

Yes

Are the intended outcomes described? Yes

Are the statements clear and unambiguous?

Yes

5. Evidence Base

Is the type of evidence to support the document identified explicitly?

Yes

Are key references cited? Yes

Are the references cited in full? Yes

Are local/organisational supporting documents referenced?

Yes

6. Approval

Does the document identify which committee/group will approve it?

Yes


Page 25 of 28

Yes/No/

Unsure Comments

If appropriate, have the joint Human Resources/staff side committee (or equivalent) approved the document?

Yes

7. Dissemination and Implementation

Is there an outline/plan to identify how this will be done?

Yes

Does the plan include the necessary training/support to ensure compliance?

Yes

8. Document Control

Does the document identify where it will be held?

Yes

Have archiving arrangements for superseded documents been addressed?

Yes

9. Process for Monitoring Compliance

Are there measurable standards or KPIs to support monitoring compliance of the document?

Yes

Is there a plan to review or audit compliance with the document?

Yes

10. Review Date

Is the review date identified? Yes

Is the frequency of review identified? If so, is it acceptable?

Yes

11. Overall Responsibility for the Document

Is it clear who will be responsible for coordinating the dissemination, implementation and review of the documentation?

Yes

Completed by

Name Marianne Green Date 25.07.16

Job Title Lead Midwife for Quality and Compliance

Acknowledgement: Cambridgeshire and Peterborough Mental Health Partnership NHS Trust


Page 26 of 28

APPENDIX 5 – EQUALITY IMPACT ASSESSMENT

The organisation aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. The Equality Impact Assessment Tool is designed to help you consider the needs and assess the impact of your policy.

Name of Document: Caesarean Section Guideline

Completed by: Marianne Green

Job Title: Lead Midwife for Quality and Compliance

Date: 25.07.16

Yes/No

1. Does the document/guidance affect one group less or more favourably than another on the basis of:

Race No

Ethnic origins (including gypsies and travellers) No

Nationality No

Gender (including gender reassignment) No

Culture No

Religion or belief No

Sexual orientation No

Age No

Disability - learning disabilities, physical disability, sensory impairment and mental health problems

No

2. Is there any evidence that some groups are affected differently? No

3. If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable?

N/A

4. Is the impact of the document/guidance likely to be negative? N/A

5. If so, can the impact be avoided? N/A

6. What alternative is there to achieving the document/guidance without the impact?

N/A

7. Can we reduce the impact by taking different action? N/A

If you have identified a potential discriminatory impact of this procedural document or the answer to any of the above is Yes, please refer it to the Head of Patient Experience, Tel 01279 444455 – Extn 2358 [email protected] , together with any suggestions as to the action required to avoid/reduce this impact. In this case, ratification of a procedural document will not take place until approved by the Head of Patient Experience.

Date of approval by Head of Patient Experience:

Evidence of approval must be available if requested

mailto:[email protected]

APPENDIX 6 - PRIVACY IMPACT ASSESSMENT SCREENING

Privacy impact assessments (PIAs) are a tool which can help organisations identify the most effective way to comply with their data protection obligations and meet individual’s expectations of privacy. The first step in the PIA process is identifying the need for an assessment.

The following screening questions will help decide whether a PIA is necessary. Answering ‘yes’ to any of these questions is an indication that a PIA would be a useful exercise and requires senior management support, at this stage the Information Governance Manager must be involved.

Name of Document: Caesarean section guideline

Completed by: Marianne Green

Job title Lead Midwife for Quality and Compliance Date 25.07.16

Yes or No

1. Will the process described in the document involve the collection of new information about individuals? This is information in excess of what is required to carry out the process described within the document.

No

2. Will the process described in the document compel individuals to provide information about themselves? This is information in excess of what is required to carry out the process described within the document.

No

3. Will information about individuals be disclosed to organisations or people who have not previously had routine access to the information?

No

4. Are you using information about individuals for a purpose it is not currently used for, or in a way it is not currently used?

No

5. Does the process involve the use of new technology which might be perceived as being privacy intrusive? For example, the use of biometrics.

No

6. Will the process result in decisions being made or action taken against individuals in ways which can have a significant impact on them?

No

7. Is the information about individuals of a kind particularly likely to raise privacy concerns or expectations? For examples, health records, criminal records or other information that people would consider to be particularly private.

No

8. Will the process require you to contact individuals in ways which they may find intrusive?

No

If the answer to any of these questions is ‘Yes’ please contact the Information Governance

Manager, Tel: 01279 444455 - Extn: 1272 / Mobile: 07908 632215 [email protected] /

[email protected]. In this case, ratification of a procedural document will not take place

until approved by the Information Governance Manager.

IG Manager approval Name:

Date of approval



Documents

Family and Women’s Services (FAWS) Health Group C1