Author(s) Dr Matthew Toal Dr Neelima Dixit Dr Deepa Janga Dr Amit Shah Dr Anil Gudi Dr Maryam Parisaei Version 1.1

Version Date November 2010

Implementation/approval Date November 2010

Review Date November 2012

Review Body Department of Obstetrics and Gynaecology and Department of Midwifery, Homerton University Hospital Policy Reference Number

Caesarean Section

Summary - A caesarean section (CS) may be planned in advance (elective CS) or it may be done at short notice (emergency CS) if complications develop during pregnancy or labour. Pregnant women should be given evidence-based information on CS, as 1 in 5 will have one. This should include indications, what the procedure involves, the risks and benefits and implications for future pregnancies. Maternal request alone is not an indication for CS and specific reasons for the request should be explored, discussed and documented. Planned CS should be performed after 39 weeks (deduced risk of respiratory morbidity).

The following interventions should be used to decrease morbidity from CS:  Regional anaesthesia  Antibiotic prophylaxis  Thromboprophylaxis  Antacids  Anti-emetics Reducing the likelihood of CS:  Women who have uncomplicated singleton breech pregnancy at 36 weeks should be offered external cephalic version (except for women in labour, women with a uterine scar or abnormality, fetal compromise, ruptured membranes, vaginal bleeding or medical conditions).  Women should be informed that continuous support during labour from birth partners with or without prior training reduces the likelihood of CS  Women with uncomplicated pregnancies should be offered induction of labour beyond 41 weeks, because this reduces the risk of perinatal mortality and the likelihood of CS.  A partogram with a 4-hour action line should be used to monitor progress of women in spontaneous labour with an uncomplicated pregnancy at term.  Consultant obstetricians should be involved in the decision making for CS because it reduces the likelihood of CS, unless it is life threatening to do so.  Support of women who choose vaginal birth after CS reduces the likelihood of CS.

Scope- This policy applies to all employees of the Trust in primary, community and secondary healthcare who are involved in the care of women during pregnancy, birth and in the postnatal period. It may also apply to public health, trust managers, pregnant women, their families, birth supporters and other carers.

Roles and Responsibilities - All staff working in the department of obstetrics and midwifery at Homerton University Hospital are expected to have read this guideline prior to working on the Delivery Suite. The guideline is to be reviewed and updated 2 yearly. The implications of the guideline are to be reviewed annually and continually.

Policy Reference:

This policy should be read in conjunction with the Recognition and care of the critically ill Woman which is on the trust intranet.

Caesarean section (CS)

The classification of urgency should be documented using the following standardised scheme:

 Grade 1 (emergency) - immediate threat to the life of the woman/baby (within 30 minutes)  Grade 2 (urgent) - maternal/fetal compromise not immediately life-threatening (within 60 minutes)  Grade 3 (scheduled) - early delivery required but no current compromise  Grade 4 (elective) - delivery timed to suit woman or staff Emergency (Grade 1) and Urgent (Grade 2) CS

Pre-operative procedure:  The decision for CS must be made by the registrar and agreed by the on call consultant. The time of decision and the involvement of all relevant staff should be documented in the notes/EPR.  The grade of CS MUST be clearly conveyed to the theatre team, including healthcare assistant, operating department practitioner, neonatologist and anaesthetist and documented in the notes.  If there is a delay in performing the CS the reason should be clearly documented in the notes, consultant should be informed and an incident form should be completed.  All patients should have blood for FBC and group and save sent prior to CS. Cross match should be considered in advance if there are any risk factors for PPH.  Women should be offered regional anesthesia to reduce maternal and neonatal morbidity.  The consent form should be completed prior to theatre except in extreme emergencies. Please see appendix 1 for risks of CS.  The patient should be transferred to theatre in the left lateral position and a CTG monitor should be available for continuous monitoring until knife to skin.  The woman should be offered 30ml sodium citrate orally to reduce the risk of aspiration pneumonitis.

Intra-operative procedure:  All women should have 5 IU syntocinon intravenously and then an Infusion of IV 40 IU syntocinon should be given to prevent PPH.  Paired cord gas samples should be taken.  Prophylactic antibiotic cover should be offered for all women undergoing CS: . IV co-amoxiclav 1.2g stat dose after cord clamping, or . IV clindamycin 900mg stat in cases of true penicillin allergy  Enoxaparin (Clexane) 40mg sc daily should commence 6 hours after the CS unless contraindicated (see thromboprophylaxis guideline for further recommendations especially in obese women).  If women are not able to receive enoxaparin for example in cases of massive obstetric haemorrhage, the use of flowtrons should be considered.

Post-operative procedure:  The operating note should include the grade of urgency, indication and times of the decision for CS and knife-to-skin time and any reason for delay. Women should be monitored one-to-one post-operatively in the recovery area.  Early skin to skin contact between woman and baby should be encouraged and facilitated and additional support offered to help start breast feeding as soon as possible after birth. Mother and baby/babies should not be separated unless clinically necessary.  Early mobilisation and good hydration must be encouraged. Graduated stockings and enoxaparin should be used for all patients unless contraindicated.  Once on postnatal ward, the post caesarean section observations must be continued which are: Every 15 minutes for 1 hour, every 30 minutes for the next two hours and every hour for the next 9 hours thereafter observations of temperature, pulse and blood pressure, respiration rate should then twice daily until discharge.  All women following CS should be given an opportunity to be debriefed about the indication for their CS, any complications, their post-operative care and implications for future pregnancies by a doctor.  Women should be reviewed by a doctor again before discharge or earlier if any complications arise to debrief.  The discharge summary should be fully completed on EPR prior to discharge and the patient should be issued with the additional discharge summary letter (Appendix 2).  Women who have had an emergency CS especially those which were grade 1 and under general anaesthetic or complicated by blood loss of more than 2000mls, should be offered a postnatal follow up appointment in ANC.

Planned CS - Scheduled (Grade 3) and Elective (Grade 4)

Pre-operative procedure

Some routine indications for elective CS:  Pregnant women with a singleton breech presentation at term: when external cephalic version is contraindicated or has been unsuccessful, should be offered CS.  Uncomplicated twin pregnancy if the first twin is presenting as a breech  Some cases of preterm labour (not routinely)  Major placenta praevia.  HIV-positive women who are pregnant may be offered a planned CS because it reduces the risk of mother-to-child transmission of HIV compared with vaginal delivery.  Women with primary genital herpes simplex virus (HSV) infection occurring in the third trimester of pregnancy should be offered planned CS because it decreases the risk of neonatal HSV infection.

It is recommended that planned CS should be carried out at 38+ to 39 weeks due to the risk of respiratory morbidity if before. All women must be prepared for elective CS in advance in the antenatal clinic. This should include:  A completed consent form, and in cases of complex caesarean sections this should be done by a registrar/consultant.  FBC to identify any anaemia or thrombocytopenia (4-8% risk of post partum haemorrhage (PPH) of >1000ml at CS)  Group and save or a cross match if major blood loss is anticipated  MRSA swabs taken prior to admission  Premedication of ranitidine and metoclopramide tablets  The CS should be booked on EPR and on the delivery suite diary. Risks of CS

The woman and partner should be made aware of potential risks of CS. It is recommended that clinicians make every effort to separate serious from frequently occurring risks (appendix 1). Women who are obese, who have had previous surgery or pre-existing medical conditions must understand that the quoted risks for both serious and frequent complications will be increased. All surgery carries risks of wound infection and thromboembolism.

 Delivery suite staff should check all bloods and MRSA screening have been undertaken and results are available.  Pre operation checklist should be completed.  Identity label should be put on the woman and red allergy label if appropriate.  The woman should be prepared for theatre by shaving if necessary and the woman should wear a theatre gown and hat  Consent should be checked and confirmed again by the operating team.  At start of each operating list the modified maternity World Health Organisation Surgical Checklist should be performed and documented.

Post-operative procedure:  Please refer to the post operative recovery guideline for observation procedure.  It is essential that before discharge for an elective CS the woman is seen by the obstetric team to discuss implications for future pregnancies and to debrief her regarding the operation and recovery process.  The discharge summary should be completed fully on EPR prior to discharge including any complications. Audit and monitoring Measurable Monitoring/ Frequency ofResponsibility forMonitoring reported to Policy Objective Audit monitoring performing thewhich monitoring groups/committee, inc responsibility for reviewing action plans Implementation Audit Continuously Nominated Maternity Risk of classification maternity lead Management Review and timing of all Meeting and Friday Grade 1 morning departmental caesarean meetings sections

Requirements Audit Continuously Nominated Maternity Risk to document the Maternity lead Management Review reason for Meeting and Friday performing morning departmental Grade 1 meetings caesarean section in the health records by the person who makes the decision Requirement Audit Continuously Nominated Maternity Risk to document Maternity lead Management any reasons Review Meeting and for delay in Friday morning undertaking departmental meetings the caesarean section Need to Audit Continuously Nominated Maternity Risk include a Maternity lead Management consultant Review Meeting and Obstetrician in Friday morning the decision departmental meetings making process Measurable Monitoring/ Frequency of Responsibility Monitoring reported Policy Objective Audit monitoring for performing to which the monitoring groups/committee, inc responsibility for reviewing action plans

All women to Audit Continuously Nominated Maternity Risk be offered Maternity lead Management antibiotic and Review Meeting and Thrombo Friday morning -prophylaxis departmental meetings

Care of mother Audit Continuously Nominated Maternity Risk in the 1st 24 Maternity lead Management hours following Review Meeting and delivery Friday morning departmental meetings

Requirements Audit Continuously Nominated Maternity Risk to discuss Maternity lead Management with the Review Meeting and women the Friday morning implications departmental meetings for future pregnancies before discharge

Sources of Evidence; References / Bibliography

National Institute for Clinical Excellence (NICE). (2004). Caesarean Section: Clinical Guideline CG13. April 2004. London: National Institute for Clinical Excellence. Available from www.nice.org

Royal College of Obstetricians and Gynaecologists (RCOG). (2009). Caesarean Section: Consent Advice No. 7. October 2009. London: RCOG. Available from www.rcog.org.uk/women-health/clinical-guidance/caesarean-section-consent-advice Appendix 1 - Consent Procedure for CS

The following frequency of risks may be used as guidance when taking consent for a caesarean section in absence of morbid obesity, placenta praevia, or multiple previous caesarean sections.

Name of proposed procedure or course of treatment Caesarean section. Intended benefits Safe delivery of baby. Serious and frequently occurring risks

Frequently occurring: Maternal  Persistent wound and abdominal pain (9 in 100)  Increased risk of repeat CS in subsequent pregnancies (1 in 4)  Haemorrhage (5 in 100)  Infection (6 in 100) Fetal  Laceration (1-2 in 100)

Serious risks: Maternal  Emergency hysterectomy (7-8 in 100)  Need for further surgery such as evacuation of retained products of conception (ERPC) (5 in 100)  ICU admission  Thrombo-embolic disease, (4–16 women in every 10 000)  Damage to adjacent structures:  Bladder injury (1 in 1000)  Ureteric injury (3 in 10 000)  Bowel injury  Death (1 in 12 000) Future pregnancies  Increased risk of uterine rupture during subsequent pregnancies/deliveries (2-7 in 1000)  Increased risk of ante partum stillbirth (1-4 in 1000)  Increased risk in subsequent pregnancies of placenta praevia and placenta accreta (4-8 in 1000)

Any extra procedures, which may become necessary during the procedure

 Hysterectomy– this must be discussed for all women who are undergoing a caesarean section for placenta praevia, or those who have had more than two caesarean sections  Blood transfusion– any women who chooses to decline blood transfusion must be referred to a consultant obstetrician.  Repair to damaged adjacent structures such as bladder, ureter, bowel or blood vessels Appendix 2 – Template for discharge summary for CS Patient Details:

Caesarean section: □ Emergency □ Elective

Indication: □ Previous CS □ Fetal distress in labour □ Failure to progress in labour at ___cm □ Fetal growth restriction □ Breech or Transverse lie □ Pre-eclampsia □ Unsuccessful ventouse □ Unsuccessful forceps □ Other ------

Fetal position at delivery if at fully: □ OA □OP □ OT

Intraoperative findings of note or any complications ------

Postoperative complication------

Suitable for Vaginal Birth after Caesarean (VBAC) next pregnancy

□ Yes □ No

Date and time of discussion ------

Name of Doctor ------Grade of Doctor ------Signature------