Author: J Siddall, H Inkster Date: June 2018
Job Title: Consultant Obstetrician, Practice Educator Review Date: June 2020
Policy Lead: Group Director Urgent Care Version: 5.0 ratified 1/6/18
Location: Policy hub/ Clinical/ Maternity/ Postnatal/ GL796
Only valid on date last printed Page 1 of 11
Bowel complications after caesarean section guideline (inc.
Paralytic Ileus) – GL796
Approval
Approval Group Job Title, Chair of Committee Date
Maternity & Children’s Services Clinical Governance Committee
Chair, Maternity Clinical Governance Committee
1st June 2018
Change History
Version Date Author, job title Reason
4.0 June 2016 S Bailey (Marsh Ward Mngr)
H Inkster (Practice Educator)
Reviewed and amended to be consistent with Trust policy for NGT (CG202)
4.1 Sept 2017 H Inkster (Practice Educator)
M Redfearn (Acting Marsh Ward Manager)
Reviewed & amended against Trust policy for NGT (CG202) which itself has been updated in response to CAS Alert NHS/PSA/RE/2016/006 - Nasogastric tube misplacement: continuing risk of death and severe harm.
4.2 Dec 2017 H Inkster (Practice Educator) Pg 3 to 6 - Clarification of use of Ryles tube in Maternity
5.0 April 2018 Jane Siddall (Consultant Obstetrician)
H Inkster (Practice Educator)
Reviewed
Pg 2 – Overview updated, diameter of the caecum changed from 10cms to 9cms
Pg 3 - Ryles tube added and IV fluid balance & monitoring clarified
To be read in conjunction with
CG202 Trust policy for correct use of Nasogastric Feeding Tubes in Adults
Author: J Siddall, H Inkster Date: June 2018
Job Title: Consultant Obstetrician, Practice Educator Review Date: June 2020
Policy Lead: Group Director Urgent Care Version: 5.0 ratified 1/6/18
Location: Policy hub/ Clinical/ Maternity/ Postnatal/ GL796
Only valid on date last printed Page 2 of 11
Maternity Guidelines – Bowel complications after CS inc. Paralytic ileus (GL796) June 2018
CONTENTS
Overview ..................................................................................................................................... 2
Definitions ................................................................................................................................... 2
Diagnosis .................................................................................................................................... 2
Management ............................................................................................................................... 3
References .................................................................................................................................. 3
Appendix 1 – Management flowchart ........................................................................................... 4
Appendix 2 – Nasogastric / Ryles tube record of initial placement ............................................... 5
Appendix 4 – Competency assessment form ............................................................................... 7
Overview
Women who are recovering well after uncomplicated caesarean section should be
encouraged to eat and drink when they feel hungry or thirsty. The majority of women
regain bowel function passing flatus within 24h and stool within 72h of surgery. Delay in
bowel return of bowel function owing to paralytic ileus (loss of peristalsis) is a complication
of (excessive) handling of the intestines during abdomino-pelvic surgery and can lead to
significant maternal morbidity, through the development of Ogilvie’s syndrome, and
(rarely) mortality. Prolonged or difficult surgery, ketoacidosis and acute kidney injury are
all triggers for this condition.
Definitions
Paralytic Ileus
Bowel inactivity leading to symptoms of intestinal obstruction.
Acute Colonic Pseudo-Obstruction (ACPO; Ogilvie’s Syndrome)
A clinical and radiological picture of acute obstruction of the colon in the absence of
mechanical obstruction, leading to massive colonic dilatation. ACPO can lead to significant
maternal morbidity (hypovolaemia, electrolyte imbalance, caecal ischaemia, caecal
perforation) and mortality. If the diameter of the caecum is > = 9cms then there is a
significant risk of bowel perforation and urgent referral for decompression is
necessary (the diameter is normally up to 7.5cm)
Diagnosis
Patients may complain of abdominal pain, bloating, nausea, vomiting and failure to pass
wind or stool. On examination assess for signs of clinical dehydration, distension, pain on
palpation, resonance to percussion and absence of bowel sounds.
Author: J Siddall, H Inkster Date: June 2018
Job Title: Consultant Obstetrician, Practice Educator Review Date: June 2020
Policy Lead: Group Director Urgent Care Version: 5.0 ratified 1/6/18
Location: Policy hub/ Clinical/ Maternity/ Postnatal/ GL796
Only valid on date last printed Page 3 of 11
Maternity Guidelines – Bowel complications after CS inc. Paralytic ileus (GL796) June 2018
Abdominal x-ray is required to confirm colonic dilatation (large bowel >6cm, caecum
>9cm). Perforation presents with severe abdominal pain, a rigid abdomen and signs of
sepsis from faecal peritonitis.
Management
Request prompt obstetric review if paralytic ileus is suspected.
In Maternity we use Ryles Tubes for non-functioning bowel i.e. paralytic ileus and only used for aspiration of gastric juices used for short term use only NEVER for feeding.
If Ryles or NG tubes are to be placed this should be in accordance with trust guidelines
(see Trust policy for Nasogastric tube placement in Adults ver 10 CG202) by appropriately
trained staff. Clinical Skills (bleep 160) or Outreach Team (bleep 250) may be available to
help with NG tube placement.
Initial management is conservative and should focus on:
Analgesia (avoid opiate analgesics)
Antiemetic’s
NBM to rest bowel
IV fluids and fluid balance monitoring
Recommended fluid “one salty two sweet”
1L x N Saline +20mmol KCL 8 hrly
1L Dextrose + 20mmol KCL 8 hrly
1L Dextrose + 20mmols KCL 8 hrly
As maintenance only need to consider losses/insensible losses, thus up to 4L per day
Ensure adequate VTE prophylaxis
Investigations should include:
U&E to assess for electrolyte imbalance
Abdominal +/- erect chest XR if perforation suspected
NB: All referrals to surgeons must be made at consultant to consultant level to ensure that senior review takes place
References
1. Acute colonic pseudo-obstruction after caesarean section The Obstetrician and Gynaecologist 2006 (8); 207-213
Author: J Siddall, H Inkster Date: June 2018
Job Title: Consultant Obstetrician, Practice Educator Review Date: June 2020
Policy Lead: Group Director Urgent Care Version: 5.0 ratified 1/6/18
Location: Policy hub/ Clinical/ Maternity/ Postnatal/ GL796
Only valid on date last printed Page 4 of 11
Maternity Guidelines – Bowel complications after CS inc. Paralytic ileus (GL796) June 2018
History:
Abdominal pain
Distension
Nausea +/- vomiting
No flatus
Examination:
Tachycardia
Low grade pyrexia
Distension
Tenderness
Bowel sounds can be normal, tinkling or absent
Stable, < 24h Post-operative?
SHO review, inform registrar
Conservative management
Check U&E
4 hourly observations
Analgesia (NSAIDs preferred)
Antiemetic’s
Keep NBM, IV fluids
DAILY REVIEW by medical team
Deterioration
Increasing pain
Worsening distension
Clinical dehydration
RIF tenderness
Improvement
Treat as normal
Oral fluids
Light diet
Unstable, deteriorated or ≥24 - 48h Post-operative?
Keep NBM
IV fluids (replacement and maintenance)
Catheterisation and fluid balance charts
Repeat U&E
AXR (+ erect CXR if perforation)
Ryles tube insertion
Continue non-opioid analgesia and antiemetic’s
For obstetric registrar / consultant daily review
URGENT SURGICAL REVIEW referral to be consultant obstetrician to consultant surgeon directly
(Bleep SHO 701, SpR 702)
Small bowel dilatation only Manage conservatively - Ryles tube - Daily U&E - IV fluids - Avoid opiates, calcium channel blockade and anti-cholinergics
Large bowel dilatation NGT IV fluids Consider: - IV neostigmine - Endoscopic decompression - Surgical management
Suspected perforation
Senior surgical involvement
Emergency laparotomy +/- stoma formation
Appendix 1 – Management flowchart
Author: J Siddall, H Inkster Date: June 2018
Job Title: Consultant Obstetrician, Practice Educator Review Date: June 2020
Policy Lead: Group Director Urgent Care Version: 5.0 ratified 1/6/18
Location: Policy hub/ Clinical/ Maternity/ Postnatal/ GL796
Page 5 of 11
Maternity Guidelines – Bowel complications after CS inc. Paralytic ileus (GL796) December 2017
Appendix 2 – Nasogastric / Ryles tube record of initial placement
Author: J Siddall, H Inkster Date: June 2018
Job Title: Consultant Obstetrician, Practice Educator Review Date: June 2020
Policy Lead: Group Director Urgent Care Version: 5.0 ratified 1/6/18
Location: Policy hub/ Clinical/ Maternity/ Postnatal/ GL796
Page 6 of 11
Maternity Guidelines – Bowel complications after CS inc. Paralytic ileus (GL796) June 2018
Appendix 3 – Nasogastric / Ryles tube on-going record of daily care
Author: J Siddall, H Inkster Date: June 2018
Job Title: Consultant Obstetrician, Practice Educator Review Date: June 2020
Policy Lead: Group Director Urgent Care Version: 5.0 ratified 1/6/18
Location: Policy hub/ Clinical/ Maternity/ Postnatal/ GL796
Page 7 of 11
Maternity Guidelines – Bowel complications after CS inc. Paralytic ileus (GL796) June 2018
Appendix 4 – Competency assessment form
Author: J Siddall, H Inkster Date: June 2018
Job Title: Consultant Obstetrician, Practice Educator Review Date: June 2020
Policy Lead: Group Director Urgent Care Version: 5.0 ratified 1/6/18
Location: Policy hub/ Clinical/ Maternity/ Postnatal/ GL796
Page 8 of 11
Maternity Guidelines – Bowel complications after CS inc. Paralytic ileus (GL796) June 2018
Author: J Siddall, H Inkster Date: June 2018
Job Title: Consultant Obstetrician, Practice Educator Review Date: June 2020
Policy Lead: Group Director Urgent Care Version: 5.0 ratified 1/6/18
Location: Policy hub/ Clinical/ Maternity/ Postnatal/ GL796
Page 9 of 11
Maternity Guidelines – Bowel complications after CS inc. Paralytic ileus (GL796) June 2018
Author: J Siddall, H Inkster Date: June 2018
Job Title: Consultant Obstetrician, Practice Educator Review Date: June 2020
Policy Lead: Group Director Urgent Care Version: 5.0 ratified 1/6/18
Location: Policy hub/ Clinical/ Maternity/ Postnatal/ GL796
Page 10 of 11
Maternity Guidelines – Bowel complications after CS inc. Paralytic ileus (GL796) June 2018
Appendix 5 – Notes for assessors
Author: J Siddall, H Inkster Date: June 2018
Job Title: Consultant Obstetrician, Practice Educator Review Date: June 2020
Policy Lead: Group Director Urgent Care Version: 5.0 ratified 1/6/18
Location: Policy hub/ Clinical/ Maternity/ Postnatal/ GL796
Page 11 of 11
Maternity Guidelines – Bowel complications after CS inc. Paralytic ileus (GL796) June 2018