The role of the assisted birth practitioner in theatre

It is anticipated that there will be occasions where the assisted birth practitioner midwife (ABP) midwife in consultation with the obstetric consultant transfers a patient to theatre.

This SOP has been developed to provide guidance on roles and responsibilities in this eventuality.

The role of the ABP midwife is covered in the ABP guideline.

The obstetric consultant is the senior clinician and has ultimate responsibility for the care of the patient.

Attention should be given to Midwives Rules and Standards (NMC 2018):

"3. Except in an emergency situation, you must not provide any care, or undertake any treatment, that you have not been trained to give".

"4 In an emergency, or where a deviation from the norm, which is outside your current scope of practice, becomes apparent in a woman or baby during childbirth you must call such health or social care professionals as may reasonably be expected to have the necessary skills and experience to assist you in the provision of care".

• The decision to transfer to theatre will be made by the obstetric consultant after discussion with the ABP midwife and may be initiated by the ABP midwife prior to the arrival of the consultant. Theatres will be informed by using the bleep system 2222.
• The obstetric consultant is responsible for obtaining verbal or written consent for the procedure prior to commencement.
• If the ABP midwife is asked by the consultant obstetrician to assist in theatre she must be satisfied that any delegated tasks are within the ABP scope of practice and competence. If she is any doubt she must make it known and decline to undertake the task.
• The Hospital at Night FY1 or 2 should be called when surgical assistance for operative procedures is required.

The ABP midwife may recognise the need for transfer to theatre including, but not exclusively, the following circumstances:

• regional anaesthesia for instrumental delivery (forceps / ventouse delivery)
• regional anaesthesia for perineal repair

The ABP midwife may recognise the need for transfer to theatre in an emergency situation, for example:

• pathological CTG
• APH / PPH
• breech presentation
• cord prolapse
• MROP
• uterine inversion

In some circumstances the ABP midwife may be asked by the obstetric consultant to assist in theatre, for example:

• act as assistant during repair of complex perineal tears by holding the instrument

1. Demonstration of surgical scrub to be provided by Association of Theatre Nurses qualified practitioner to ABP midwife – see section on scrubbing up.
2. Qualified Practitioner to carry out 2 Direct Observations of Surgical Scrub with ABP midwife, to be countersigned by Supervisor of Midwives and retained in ABP log.
3. ABP midwife will use reflective practice to reflect on experiences and seek feedback from obstetric consultant.

Clinical wound infection occurs in 1-5% in patients undergoing surgery on clean areas such as muscle, bone or soft tissue.

10-20% of wound infections occur in patients undergoing surgery on hollow viscera, especially the colon and rectum as they contain large amounts of bacteria.

Hands are recognised as the main vectors of hospital acquired infections and evidence suggests that the act of hand decontamination significantly reduces the risk of cross infection.

The most important procedure of preventing infection in the operating theatre is surgical hand disinfection prior to surgery.

Proper skin cleansing and disinfection is enhanced by knowledge of the physiology of the skin, different types of bacteria carried on the skin and the specific action of detergents and antiseptic agents used for skin cleansing.

Micro-organisms are found in all levels of the skin and comprise the established resident and transient flora.

The principles and objectives of skin cleansing are:

• to remove dirt and transient microbes
• to reduce the resident microbial count as much as possible
• to prevent the rapid rebound growth of microbes

Antimicrobial agents used for surgical scrubbing should be:

• broad spectrum
• fast acting
• emollient
• non-drying

They should also, if possible accumulate in the skin with frequent and repeated use to provide a persistent effect.

The two most popular antimicrobial agents used for surgical scrubbing are povidone-iodine and 4% chlorhexidine gluconate.

The use of alcohol-based antiseptics is also a popular choice for surgical hand disinfection.

Alcohol based antiseptics are:

• very effective after cleansing with soap and water
• usually less expensive than alternatives
• at least as effective as an aqueous solution
• less irritant to the skin
• more effective therefore reducing the length of scrubbing times

Guidelines

• The cap must cover the hair completely and the mask adjusted until comfortable.
• The nails should be short and cuts and lesions should be covered with an adhesive waterproof dressing.
• When scrubbing up for the first time of the day a 5 min scrub should be done.
• This should involve a 1 min wash of hands and forearms followed by a 30 second scrub of nails on each hand.
• Nails should be scrubbed in a downward motion only. No other area on the hands should be scrubbed with the nailbrush.
• At all times hands should be held uppermost to allow water to drain off at the elbows.
• A 3 min wash of the hands and forearms should be done.
• To ensure all areas of the hands are washed Ayliffe’s hand washing technique should be use - see here for details.
• If scrubbing for consecutive cases the hands and forearm should be rubbed with 2 applications of 70% isopropyl alcohol and should be allowed to dry before donning the gown and gloves in the usual manner.
• If the hands become contaminated between cases then a 3 min scrub without the use of a brush should be done.

During the procedure

• If its necessary for scrub personnel to change positions at the table then a pre-determined technique should be employed that will avoid contamination, for example pass front to front.
• Movement between theatres in a sterile gown is to be avoided.
• Gowns and gloves should be discarded in theatre.
• The surgeon’s assistant removes the drapes at the end of the procedure before de-glove and gowning.

Nursing and Midwifery Council (2018) Midwives rules and standards; protecting the public through professional standards www.nmc.org.uk

Ayliffe (1978) Seven step hand washing technique recommended in the Hand Decontamination Guideline (2003) Infection Control Nurses Association