Oxford Handbook of Midwifery (87 page)

• At this visit the obstetrician verifies the rationale for the operation,
  clearly documents this in the woman’s hospital notes, and obtains
  

  written informed consent from the woman. Document the information given to the woman.
  

• Assess baseline observations of blood pressure, pulse, temperature and urinalysis. Review fetal well-being, this may include an ultrasound scan.
  
• The anaesthetist reviews the general health of the woman. The type of anaesthetic is discussed and confirmed with the woman—usually spinal/regional anaesthesia. If a spinal anaesthetic is accepted, the partner may accompany the woman in theatre to provide support. General anaesthetic may occasionally be requested by the woman or be necessary if the regional anaesthesia proves inadequate.
  
• Obtain FBC and G&S and send for testing. However, NICE guidelines suggest that G&S is not necessary for a healthy woman with an uncomplicated pregnancy.
  ¹
  
• During the caesarean section antibiotics should be given to the woman, therefore carefully document any allergy.
  
• Low-molecular-weight heparin (enoxaparin) will be prescribed prophylactically to help prevent deep vein thrombosis.
  
• Ranitidine 150mg is prescribed 8h. Usually two doses prior to caesarean section. This minimizes the amount of gastric acid produced. Ensure that the woman understands the need to take no food/drinks for at least 6h before the caesarean section.
  
• Explain the procedure, the immediate postoperative care, and the probable length of hospital stay. It should be recognized that while some women will feel content to experience caesarean section, others may miss the sense of achievement a normal delivery can afford. Be sensitive to this, listen, and answer questions.
  
• Give the woman and her partner an appropriate time at which to attend the ward prior to the caesarean section.
  
• If the woman has a BMI >35 theatre staff should be made aware.
  

  On the day of the caesarean section
  

• Ideally, the woman and her partner should be welcomed by a midwife who is known to them. Throughout the procedure, the midwife should keep the couple informed of events affecting care.
  
• The midwife should prepare the woman for theatre. The woman may wish to have a bath. A shave of the skin area affected by the caesarean section scar might be considered necessary. Provide a clean theatre robe, cap, and anti-embolic stockings. Place an identity label on the woman’s wrist and remove all jewellery or cover it with adhesive strapping. Reassess maternal observations and listen to the fetal heart.
  

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  • Give sodium citrate, 30mL orally, prior to transfer. This neutralizes the gastric acid.
    
  • Prepare documentation according to local protocol.
    
  • Escort the woman and her partner to theatre where the theatre staff, obstetrician, and anaesthetist should welcome them.
    
  • The anaesthetist sites an IV infusion and spinal anaesthetic. When
    the woman is positioned for the operation, the theatre table is
    

    tilted, or a wedge placed to facilitate a slight left lateral position, to
    

    prevent supine hypotension.
    

  • When the woman is comfortable and the spinal anaesthetic is effective, insert an indwelling urinary catheter, since the bladder must be empty prior to the caesarean section. This will remain in place for 24h.
    
  • Seat the partner so that support may be given to the woman during surgery. Sensitively describe and explain the proceedings while preparing baby resuscitation equipment and warm towels.
    
  • Note the time of the start of the operation. The surgeon divides the skin, fat, rectus sheath, abdominal muscle, abdominal and pelvic peritoneum, and uterine muscle. Once the uterus is opened, the amniotic fluid is aspirated and the baby is quickly delivered. Occasionally it is necessary to use forceps to deliver the head. The operator places the baby on a sterile towel. Dry him or her well, note the time of delivery, assess the Apgar scores, wrap the baby and, if in good condition, give to the parents to cuddle. If there is concern about the baby, call the paediatrician.
    
  • IV oxytocin is given to the woman to facilitate the delivery of placenta and membranes. Prophylactic antibiotics (e.g. 1.2g co-amoxiclav) are given IV.
    
  • The surgeon then repairs the wound using dissolvable sutures or clips to the skin.
    
  • Diclofenac 100mg per rectum may be given for effective analgesia when the spinal anaesthetic wears off.
    
  • If the woman’s blood group is Rh-negative, take samples from the cord and from the woman 1h following delivery, as usual.
    

    Immediately post delivery
    

    • The midwife accompanies the family to a recovery area. One-to-one care is maintained.
      
    • Assess maternal blood pressure, pressure, respirations, colour, and oxygen saturation (using pulse oximetry) every 15min until stable. Take her temperature 2h. MEWS may be used.
      
    • Every 30min, assess:
      
      • Is there any oozing from the wound?
        
      • Is the uterus well contracted?
        
      • Is the vaginal loss of blood excessive?
        
    • Monitor fluid balance. Continue the IV infusion (e.g. 1000mL Hartmann’s solution) as prescribed by the anaesthetist. Urine output from the catheter drainage should be at least 30mL hourly.
      
    • Ensure that the woman is comfortable and give analgesia as prescribed by the anaesthetist. Diamorphine 5mg hourly may be given via a
      

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    subcutaneous cannula (NICE guidelines suggest epidural/intrathecal diamorphine).
    ¹
    

1h and thereafter food as the woman feels hungry.
¹

with the mother and she should be given opportunity to initiate breastfeeding.

Emergency LSCS

Complications can occur in pregnancy and labour which may necessitate an emergency caesarean section.

Some indications

In pregnancy:

The urgency of the caesarean section

In cases of suspected acute fetal compromise, delivery should be achieved in 30min.
¹
A general anaesthetic may be necessary in acute emergency, or when the woman requests it.

During emergency LSCS, prioritise:

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• A cord blood sample for assessment of fetal pH post delivery (b see Cord blood samples: fetal pH at delivery, p. 437).
  
• Clear documentation of urgency, time of decision, and delivery.
  
• High-dependency support for a woman immediately following general anaesthesia.
  

  Complications of caesarean section
  

  •
  Haemorrhage that could lead to shock. This may be manifest during
  

  the surgery, immediately post delivery, or may result from a slow, initially undetected blood loss due to internal bleeding or PV trickle. Occasionally retained products may cause bleeding.
  

• There is a risk of deep vein thrombosis which can result in pulmonary embolism.
  
• Damage/bruising during the operation is possible and may include bladder and ureters. Urinary tract infection may occur or urinary tract trauma may cause a fistula and leaking urine.
  
• Trauma to the colon is possible.
  
• There is a risk of infection, endometritis, or breakdown of the wound.
  
• Complications of general anaesthesia may occur. The effects of progesterone on the gastrointestinal tract lead to delayed emptying of the stomach. During induction of general anaesthesia, silent regurgitation may occur and cause aspiration into the lungs and chemical pneumonitis. This impairs breathing and can be serious—a cause of maternal death.
  

  1
  National Institute for Health and Clinical Excellence (NICE) (2004). Caesarean section. Clinical guideline 13. London: NICE. Available at: M
  www.nice.org.uk/cg13.
  

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  Breech delivery
  

  A breech delivery will usually take place in a hospital maternity unit with experienced obstetricians and facilities for operative measures should this become necessary. It is customary for most known cases of breech to be delivered by elective LSCS.
  ¹
  ECV may be offered at 36–38 weeks,
  

  depending on parity and the position of the placenta. An undiagnosed breech in labour is usually delivered by emergency LSCS. However, it may
  

  sometimes be necessary to perform a vaginal breech birth, or the woman may choose to give birth vaginally. b See Breech presentation, p. 160.
  

  Management of labour: first stage
  

• The first stage often proceeds normally as with a cephalic presentation, particularly if the breech is engaged in the pelvis.
  
• Sometimes the breech may not be well applied to the cervix resulting in a long latent phase.
  
• Augmentation of labour is not recommended. If progress during established first stage is limited, caesarean section might be considered.
  
• Where the breech is not engaged, it is probably in a flexed position. This poses a risk of early rupture of the membranes and cord prolapse. IV access should be established and FBC and G/S taken.
  
• In either situation, perform a vaginal examination to exclude cord prolapse and assess progress.
  
• Monitor the fetal heart continuously and observe carefully maternal condition and progress in labour. Encourage maternal mobility as much as possible.
  
• Epidural anaesthesia may be recommended for pain relief but those caring for the woman should give consideration to maternal choice. The breech may tend to slip through the cervix before full dilatation. This may result in a premature urge to push, so that the larger diameter of the fetal head gets delayed because of the partially dilated cervix. This could lead to serious delay in the second stage. If epidural anaesthesia is in place, descent may occur more steadily and slowly and the woman will not use her pushing instincts prematurely. However, epidural may restrict mobility and inhibit positions for comfort and facilitation of a breech delivery.
  
• Where an epidural is not
  in situ
  , the woman may be helped with inhalational analgesia to avoid premature pushing. She may wish to adopt alternative positions.
  
• Ranitidine may be prescribed throughout labour in view of the possibility of a general anaesthetic.
  
• On vaginal examination, the breech feels soft and irregular with no palpable sutures. This may be mistaken for a face presentation. The anus or external genitalia may be felt. In a flexed breech, a foot may be felt. The fetus may well pass meconium.
  

  Mechanism of labour