1. Booking an elective caesarean Section
The woman will be seen at the Obstetric ANC and a plan for delivery made. All CS should be discussed with the Obstetric Consultant. Consent for CS should be taken and filed in the case notes. Consent should be taken by Obstetric Consultant or Obstetric Trainee. The Doctor authorizing the CS should ring delivery suite to book the CS – giving all relevant details (Indication, gestation, level of surgeon required, BMI, risk of bleeding, priority to go first, any anaesthetic or neonatal risks)
At the time of booking a preoperative appointment should be given to the woman.
All CS should be booked for >= 39 weeks unless there is an obstetric reason to be done earlier. If < 39 weeks steroids should be administered to decrease neonatal respiratory morbidity. The woman should be warned that occasionally her date for CS may require to be changed.
Details of the CS and pre-operative visit should be written on the CS information leaflet and this given to the woman.
2. Preoperative assessment
Midwifery assessment should take place and the preoperative check list completed. If the maternal weight was not checked at 36 weeks then the woman should be weighed.
A FBC is performed if this was not taken at 36 weeks or if the result was abnormal. If blood will require to be crossmatched then this should be highlighted (GGC guideline Blood ordering schedule 2015) in the CS booklet.
The woman should be given oral ranitidine 150mg to be taken the night before and the morning of surgery. She should be given written information re admission and fasting times
The woman should attend the ERAS talk – given by midwifery, anaesthetic and physiotherapy staff.
3. Admission for elective Caesarean Section
At PRM women are admitted to Ward 71 at 0730 on the day of their CS.
At QEUH they are admitted to ward 48 and to labour ward in RAH.
They are reviewed by the midwife – a full set of observations documented on the MOEWS chart and the fetal heart auscultated. Their most recent FBC should be reviewed. A group and save is performed on all women – those meeting the criteria are crossmatched (See- Blood Ordering Schedule – Obstetrics). If there are any antibodies on a previous G&S then this requires discussion with blood bank as to whether blood should be crossmatched prior to operation.
The Obstetrician planning to perform the CS should see the woman, confirm she still wishes to proceed, is appropriately consented and review the notes for any other additional surgical risk factors. They should then document this interaction in the notes.
All CS for breech should have an ultrasound performed to confirm the presentation.
The anaesthetic team for that day should also review each woman and document their findings.
4. Elective Caesarean Section in Labour Ward
The team should all meet in theatre prior to the arrival of the first patient to introduce themselves and go through the list – identifying any surgical or anaesthetic risks, deciding whether neonates require to be present at delivery or whether cord bloods are required, deciding whether cell salvage would be useful and whether the surgeon wishes diathermy. The order of the list is then confirmed and the anaesthetist lets the pre-operative ward know who can have a drink and when. Women expected to wait longer than 2 hours for their operation should be considered for clear oral fluids. For longer lists, the anaesthetist may decide to allow a light breakfast for the last patient on the list.
The theatre midwife should check the woman’s details on her arrival in labour ward. She should explore the woman’s wishes re skin to skin, delayed cord clamping and seeing the baby being born.
In theatre the WHO checklist is completed. This includes identity of patient (name and CHI), allergies, consent, placental site, whether neonates or cord bloods are required. In PRM this is split into a sign in prior to anaesthesia and a time-out prior to skin incision. The entire team should be present and involved in the time out.
Once the patient is anaesthetised a urinary catheter is placed.
All women should receive antibiotic prophylaxis. One dose of co-amoxiclav 1.2gm( + amoxicillin 1 gm for women >80kg) or clindamycin 600 mg IV and Gentamicin IV (penicillin allergy) should be given prior to skin incision (900mg clindamycin if woman >80kg and 1200mg of clindamycin if woman >120kg). A repeat dose of prophylactic antibiotics should be given during surgery if blood loss is more than 1.5 liters with Gentamicin being re-dosed at half prophylaxis dose (penicillin allergy).
There is no difference in maternal morbidity with different techniques of caesarean section including blunt vs sharp entry, single vs double layer closure of uterus, exteriorisation of uterus for closure vs intrabdominal repair, closure vs non closure of parietal and pelvic peritoneum. (CORONIS trial 2016)
Delayed cord clamping of 1 minute should be performed if there are no concerns regarding the baby or maternal bleeding. Syntocinon administration should not be delayed until after cord clamping. (Delayed cord clamping in the term neonate GGC guideline)
5 units of syntocinon IV bolus should be given slowly after delivery of baby + 15 units of syntocinon in 500 ml crystalloid infusion over at least 30 minutes. Additional doses may be required for postpartum haemorrhage, antepartum haemorrhage, atonic uterus, placenta praevia, prolonged labour and multiple pregnancy. Consider using other uterotonics according to clinical condition.
Cord pH blood sampling should be performed if there is any concern regarding neonatal wellbeing. Perform both arterial and venous sampling.
At the end of the operation the sign-out section of the WHO checklist is performed – this includes confirmation of the swab and instrument check , the estimated/measured blood loss, confirmation if any extra antibiotics were given, analgesia and thromboprophylaxis prescribed, whether there were any specimens and instructions for recovery (re syntocinon, oral fluids and tea and toast). The entire theatre team should be present and involved.
5. Post operative care:
Prior to leaving theatre skin to skin is resumed or initiated.
Women should be observed on a two to one basis (1:1 if GA) by a properly trained staff, observations (blood pressure, pulse, pain and sedation) should be done after every 5 minutes for 15 minutes then every 15 minutes for an hour and then hourly for four hours provided all observations are stable.
Any concerns should be directed to the obstetric or anaesthetic staff. Patients should not be discharged from recovery with any abnormal observations without prior medical review.