Obstetric interventions in theatre

This guidance on obstetric delivery in theatre is available as a PDF for printing. 

Labour Ward

Registrar

• Confirm the decision with the consultant (except for obvious Type I emergency when consultant should be informed as soon as safely appropriate)
• Courtesy call to theatre to let them now that the call will be going out (Bleep 1977)
• Courtesy call to anaesthetist to explain the background (Bleep 3933). The expectation is that, except in exceptional circumstances, the patient will be seen in theatre
• Phone 2222: (anaesthetist, theatre, obstetric SHO, paediatrician, SCBU, general services)
  • red cesarean section
  • orange cesarean section
  • trial of forceps in theatre
• Consent

Midwife

• Ensure bed ready for transfer
• Ensures that G+S taken (needle only, not venflon)
• Dad to get changed – transfer to theatre should net be delayed by dad not being changed
• Jewellery and gown
• Bring checklist to theatre

Transfer to theatre

Midwife

• Sodium Citrate (pre-spinal)
• Checklist jointly with theatre nurse (yellow shaded areas only)
• Catheter (post-spinal)
• Check FH

Theatre Nurse

• Prepare theatre, including spinal pack
• Checklist jointly with theatre nurse (yellow shaded areas only)
• Patient safety check

Anaesthetist

• IV access
• Epidural top-up (ideally rapid acting agent), Spinal or GA as judged following discussion with obstetrician in theatre.

Registrar

• Discuss urgency with anaesthetist and offer help with IV access
• Discuss clinical details with paeds
• Scrub

Transfer to theatre table

All obstetric patients will be transported via their beds or wheelchair or walking directly into the obstetric theatre where transfer will occur on to the tabletop, which is already docked on the table base.

Birthing partner

This person is admitted to theatre to assist in the psychological support of the patient and attendance in theatre will therefore only be permitted for regional techniques.  In the event of general anaesthesia being induced, the birthing partner will be asked to return to the Labour Suite.

The birthing partner should change into a blue suit in the Labour suite.  

Role of the midwife

The midwife shall accompany the mother in transport to theatres and whilst a regional or general anaesthetic is being initiated.

In the circumstances of a red section, fetal heart monitoring before the beginning of the operation is usually not appropriate and may delay the operation.  Fetal heart monitoring for non-red sections may be considered.

Role of neo-natal nurse

The neo-natal nurse should introduce herself to he parents and identify any specific requests they might have. It is her responsibility to check the resuscitaire before and after the procedure and to ensure that the paediatrician is present if appropriate.

Anaesthesia

Regional blocks will be performed in Main Theatre with appropriate monitoring.

The minimum number of staff should be present in theatre at this stage and noise levels should be kept as low as possible.

Birthing partners can be present at the discretion of the anaesthetist and other attending staff.

Caesarean section

The caesarean section will proceed once appropriate anaesthesia/analgesia has been induced. 

Numbers in theatre should be restricted to those needed to be there, and should not exceed 10 apart from exceptional circumstances.  (Anaesthetists 1-2, surgeons 1-2, theatre staff 2-3, neo-natal resuscitation 1-2, midwife/birthing partner 1-2, students 1-2)

Theatre temperature

Theatre temperature will be maintained at a level equivalent to that in a birthing room or SCBU (T = 25°C measured).  This assumes that radiant warmers are available on the resuscitation trolley.

Role of the midwife

If there is any significant delay in establishing regional anaesthesia in urgent or crash caesarean sections the CTG should be applied.

The midwife's role peri-operatively is to support the mother and birthing partner and to assist where necessary in neo-natal transport and resuscitation.

Following delivery of the baby it may be permissible for the midwife to return to other duties.

The baby

Unless there are medical reasons for the baby to be transported immediately to SCBU, the baby will be presented to the mother and/or birthing partner to hold until completion of the surgical procedure. This should only be foreshortened when there are concerns for the baby's temperature control or other medical conditions.

A cot should always be present in theatre. It is the responsibility of the labour ward midwife to replace it.

Recovery

Upon completion of the surgical procedure, the mother and child will be returned to their normal bed and nursed in Recovery for an appropriate period until cardio-respiratory and analgesic parameters are deemed satisfactory.

The baby

If the mother is unable to attend appropriately to the baby for example because of problems in recovery from anaesthesia, then the mother's midwife should promptly return the baby to the labour suite or post-operative environment and await mother's return from Recovery. Ideally the baby should be with the mother in her bed and handling should be restricted to mother, birthing partner, and midwife.

Warding

The mother will be returned either to Ward 17 or the Labour Suite for close observation.  It should be remembered that the mother has received a major surgical operation and should be nursed in an environment which has appropriate oxygenation, monitoring, and nursing observation available. The quality of this environment will determine the nature of the post-operative analgesic technique used.

Patients for elective caesarean section should be fasted for 6 hours pre-operatively, should be given Ranitidine 150 mg orally at 22.00 and repeated 2 hours before theatre (ie 8.00am). Sodium citrate is only to be given in theatre at the anaesthetists discretion. 

All patients going for emergency caesarean section will have prophylactic antacid in the form of ranitidine 150 mg orally prior to theatre and 30ml molar sodium citrate at the start of the procedure.

A patient information leaflet for elective caesarean section is available for printing.

All patients should receive antibiotic prophylaxis with:

• cefuroxime 1.5g IV + metronidazole 500mg IV prior to the skin incision, but not more than 30 minutes before the incision
• or, if allergic to the above, co-amoxiclav 1.2g IV bolus after clamping of the cord

For anti-thrombotic prophylaxis refer to RCOG Guideline No 37a.