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Performing caesareansection

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Performing caesarean section NICEPathways

Caesarean section pathwayCopyright NICE 2013. Pathway last updated: 10 June 2013

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1 Woman having a caesarean section

No additional information

2 Documenting the urgency of caesarean section

Document the urgency of caesarean section using the following standardised scheme in order

to aid clear communication between healthcare professionals about the urgency of a caesarean

section:

1) immediate threat to the life of the woman or fetus

2) maternal or fetal compromise which is not immediately life-threatening

3) no maternal or fetal compromise but needs early delivery

4) delivery timed to suit woman or staff.

3 Timing of planned caesarean section

The risk of respiratory morbidity is increased in babies born by caesarean section before labour,

but this risk decreases significantly after 39 weeks. Therefore do not routinely carry out planned

caesarean section before 39 weeks.

Quality standards

The following quality statement is relevant to this part of the pathway.

Caesarean section quality standard

5. Timing of planned caesarean section

4 Unplanned caesarean section

Perform category 1 caesarean section and category 2 caesarean section as quickly as possible

after making the decision, particularly for category 1.



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Perform category 2 caesarean section in most situations within 75 minutes of making the

decision.

Take into account the condition of the woman and the unborn baby when making decisions

about rapid delivery. Remember that rapid delivery may be harmful in certain circumstances.

Use the following decision-to-delivery intervals to measure the overall performance of an

obstetric unit:

30 minutes for category 1 caesarean section

both 30 and 75 minutes for category 2 caesarean section.

Use these as audit standards only and not to judge multidisciplinary team performance for any

individual caesarean section.

Implementation tools

The following implementation tools are relevant to this part of the pathway.

Caesarean section: electronic audit tool

Caesarean section: baseline assessment

Caesarean section: clinical case scenarios

Caesarean section: costing template

Caesarean section: costing report

Caesarean section: podcast

Caesarean section: slide set

5 Preoperative assessment

Information

Accommodate women's preferences for the birth where possible, such as music playing in

theatre, lowering the screen to see the baby born, or silence so that the mother's voice is the

first the baby hears.



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Give women information on different types of post-caesarean section analgesia so that

analgesia best suited to their needs can be offered (see pain management during and after

surgery in this pathway).

Inform women that the risk of fetal lacerations is about 2%.

Preparation for caesarean section

Offer a haemoglobin assessment before caesarean section to identify women who have

anaemia. Although blood loss of more than 1000 ml is infrequent after caesarean section (it

occurs in 48% of caesarean sections) it is a potentially serious complication.

Women having caesarean section for antepartum haemorrhage, abruption, uterine rupture and

placenta praevia are at increased risk of blood loss of more than 1000 ml. Carry out thecaesarean section at a maternity unit with on-site blood transfusion services.

Do not routinely offer the following tests before caesarean section to women who are healthy

and who have otherwise uncomplicated pregnancies:

grouping and saving of serum

cross-matching of blood

a clotting screen

preoperative ultrasound for localisation of the placenta, because this does not improve

caesarean section morbidity outcomes (such as blood loss of more than 1000 ml, injury of

the infant, and injury to the cord or to other adjacent structures).

Insert an indwelling urinary catheter to prevent over-distension of the bladder in women having

caesarean section with regional anaesthesia because the anaesthetic block interferes with

normal bladder function.

Prophylaxis

Offer prophylactic antibiotics before skin incision. Inform women that this reduces the risk of

maternal infection more than prophylactic antibiotics given after skin incision, and that no effect

on the baby has been demonstrated.

Offer prophylactic antibiotics to reduce the risk of postoperative infections. Choose antibiotics

effective against endometritis, urinary tract and wound infections, which occur in about 8% of

women who have had a caesarean section.



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Do not use co-amoxiclav before skin incision.

Offer thromboprophylaxis to women having a caesarean section because they are at increased

risk of venous thromboembolism. Take into account the risk of thromboembolic disease and

follow existing guidelines when choosing the method of prophylaxis (for example, graduated

stockings, hydration, early mobilisation, low molecular weight heparin). NICE has produced a

pathway on venous thromboembolism.



Caesarean section: timing of antibiotic administration clinical audit tool








6 Anaesthetic care

To reduce the risk of aspiration pneumonitis offer women antacids and drugs (such as H2receptor antagonists or proton pump inhibitors) to reduce gastric volumes and acidity before

caesarean section.

Offer women antiemetics (either pharmacological or acupressure) to reduce nausea and

vomiting during caesarean section.



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Offer women regional anaesthesia because it is safer and results in less maternal and neonatal

morbidity than general anaesthesia. This includes women who have a diagnosis of placenta

praevia.

Care for women who are having induction of regional anaesthesia in theatre because this does

not increase women's anxiety.

Offer women who are having a caesarean section under regional anaesthesia intravenous

ephedrine or phenylephrine, and volume pre-loading with crystalloid or colloid to reduce the risk

of hypotension occurring during caesarean section.

Include preoxygenation, cricoid pressure and rapid sequence induction to reduce the risk of

aspiration in general anaesthesia for unplanned caesarean section.

Each maternity unit should have a drill for failed intubation during obstetric anaesthesia.

Use intravenous ephedrine or phenylephrine in the management of hypotension during

caesarean section.

Use a lateral tilt of 15 for the operating table, because this reduces maternal hypotension.

7 Pain management during and after surgery

Offer women diamorphine (0.30.4 mg intrathecally) for intra- and postoperative analgesia

because it reduces the need for supplemental analgesia after a caesarean section. Epidural

diamorphine (2.55 mg) is a suitable alternative.

Offer patient-controlled analgesia using opioid analgesics after caesarean section because it

improves pain relief.

Providing there is no contraindication, offer non-steroidal anti-inflammatory drugs post-

caesarean section as an adjunct to other analgesics, because they reduce the need for opioids.

Prescribe and encourage women to take regular analgesia for postoperative pain, using:

for severe pain, co-codamol with added ibuprofen

for moderate pain, co-codamol

for mild pain, paracetamol.



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8 Performing the surgery

Abdominal wall incision

Perform caesarean section using a transverse abdominal incision because this is associated

with less postoperative pain and an improved cosmetic effect compared with a midline incision.

Use the Joel Cohen incision as the transverse incision of choice (a straight skin incision, 3 cm

above the symphysis pubis; subsequent tissue layers are opened bluntly and, if necessary,

extended with scissors and not a knife), because it is associated with shorter operating times

and reduced postoperative febrile morbidity.

Do not use separate surgical knives to incise the skin and the deeper tissues because it doesnot decrease wound infection.

When there is a well formed lower uterine segment, use blunt rather than sharp extension of the

uterine incision because it reduces blood loss, incidence of postpartum haemorrhage and the

need for transfusion.

Forceps

Use forceps only if there is difficulty delivering the baby's head. The effect on neonatal morbidityof the routine use of forceps at caesarean section remains uncertain.

Uterotonics

Use oxytocin 5 IU by slow intravenous injection to encourage contraction of the uterus and to

decrease blood loss.

Placental removal

Remove the placenta using controlled cord traction and not manual removal as this reduces the

risk of endometritis.

Wound closure

Undertake intraperitoneal repair of the uterus. Do not exteriorise the uterus because it is

associated with more pain and does not improve operative outcomes such as haemorrhage and

infection.



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The effectiveness and safety of single layer closure of the uterine incision is uncertain. Except

within a research context, suture the uterine incision with two layers.

Do not suture either the visceral or the parietal peritoneum because this reduces operating time

and the need for postoperative analgesia, and improves maternal satisfaction.

In the rare circumstances that a midline abdominal incision is used, use mass closure with

slowly absorbable continuous sutures because this results in fewer incisional hernias and less

dehiscence than layered closure.

Do not use routine closure of the subcutaneous tissue space, unless the woman has more than

2 cm subcutaneous fat, because it does not reduce the incidence of wound infection.

Do not use superficial wound drains because they do not decrease the incidence of woundinfection or wound haematoma.

Obstetricians should be aware that the effects of different suture materials or methods of skin

closure are not certain.

Umbilical artery pH measurement

Perform umbilical artery pH after all caesarean sections for suspected fetal compromise, to

allow review of fetal wellbeing and guide ongoing care of the baby.

Preventing HIV transmission in theatre

Wear double gloves when performing or assisting at caesarean section on women who have

tested positive for HIV, to reduce the risk of HIV infection of healthcare professionals during

surgery.

Follow general recommendations for safe surgical practice to reduce the risk of HIV infection of

staff.

NICE has produced guidance on Intraoperative blood cell salvage in obstetrics (NICE

interventional procedure guidance 144).

..(2) http://guidance.nice.org.uk/ipg144 View IPG144 at NICE website



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9 Monitoring after surgery

After caesarean section, women should be observed on a one-to-one basis by a properly

trained member of staff until they have regained airway control and cardiorespiratory stability

and are able to communicate.

After recovery from anaesthesia, continue observations (respiratory rate, heart rate, blood

pressure, pain and sedation) every half hour for 2 hours, and hourly thereafter provided that the

observations are stable or satisfactory. If these observations are not stable, carry out more

frequent observations and medical review.

For women who have had intrathecal opioids, carry out a minimum hourly observation of

respiratory rate, sedation and pain scores for at least 12 hours for diamorphine and 24 hours formorphine.

For women who have had epidural opioids or patient-controlled analgesia with opioids, carry out

routine hourly monitoring of respiratory rate, sedation and pain scores throughout treatment and

for at least 2 hours after discontinuation of treatment.

Be aware that, although it is rare for women to need intensive care following childbirth, this

occurs more frequently after caesarean section (about 9 per 1000).

Quality standards

The following quality statement is relevant to this part of the pathway.


9. Monitoring for postoperative complications following caesarean section

10 Care after caesarean section

Care of the baby

An appropriately trained practitioner skilled in the resuscitation of the newborn should be

present at caesarean section performed under general anaesthesia or where there is evidence

of fetal compromise.



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Babies born by caesarean section are more likely to have a lower temperature. Offer thermal

care in accordance with good practice for thermal care of the newborn baby.

Encourage and facilitate early skin-to-skin contact between the woman and her baby because it

improves maternal perceptions of the infant, mothering skills, maternal behaviour, and

breastfeeding outcomes, and reduces infant crying.

NICE has produced a pathway on postnatal care.

Care of the woman

Offer women additional support to help them to start breastfeeding as soon as possible after the

birth of their baby. This is because women who have had a caesarean section are less likely to

start breastfeeding in the first few hours after the birth, but, when breastfeeding is established,they are as likely to continue as women who have a vaginal birth.

Allow women who are recovering well after caesarean section and who do not have

complications to eat and drink when they feel hungry or thirsty.

Remove the urinary bladder catheter once a woman is mobile after a regional anaesthetic and

not sooner than 12 hours after the last epidural 'top up' dose.

Do not offer routine respiratory physiotherapy to women after a caesarean section undergeneral anaesthesia, because it does not improve respiratory outcomes such as coughing,

phlegm, body temperature, chest palpation and auscultatory changes.

In addition to general postnatal care, provide women with:

specific care related to recovery after caesarean section

care related to management of other complications during pregnancy or childbirth.

Include the following wound care1

:

removing the dressing 24 hours after the caesarean section

specific monitoring for fever

assessing the wound for signs of infection (such as increasing pain, redness or discharge),

separation or dehiscence

encouraging the woman to wear loose, comfortable clothes and cotton underwear

gently cleaning and drying the wound daily

if needed, planning the removal of sutures or clips.



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1 For more recent recommendations on wound care see the prevention and control of healthcare-associated

infections pathway.


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For women who have urinary symptoms, consider the possible diagnosis of:

urinary tract infection

stress incontinence (occurs in about 4% of women after caesarean section)

urinary tract injury (occurs in about 1 per 1000 caesarean sections).

For women who have heavy and/or irregular vaginal bleeding, consider that this is more likely to

be due to endometritis than retained products of conception.

Pay particular attention to women who have chest symptoms (such as cough or shortness of

breath) or leg symptoms (such as painful swollen calf) because women who have had a

caesarean section are at increased risk of thromboembolic disease (both deep vein thrombosis

and pulmonary embolism).

Inform women that after a caesarean section they are not at increased risk of difficulties with

breastfeeding, depression, post-traumatic stress symptoms, dyspareunia and faecal

incontinence.

While women are in hospital after having a caesarean section, give them the opportunity to

discuss with healthcare professionals the reasons for the caesarean section and provide both

verbal and printed information about birth options for any future pregnancies. If the woman

prefers, provide this at a later date.

NICE has written information for the public explaining the guidance on caesarean section.

Length of hospital stay is likely to be longer after a caesarean section (an average of 34 days)

than after a vaginal birth (average 12 days). Offer women who are recovering well, are

apyrexial and do not have complications, early discharge (after 24 hours) from hospital and

follow-up at home, because this is not associated with more infant or maternal readmissions.

Women who have had a caesarean section should resume activities such as driving a vehicle,

carrying heavy items, formal exercise and sexual intercourse once they have fully recovered

from the caesarean section (including any physical restrictions or distracting effect due to pain).

NICE has produced a pathway on postnatal care.

Quality standards

The following quality statements are relevant to this part of the pathway.



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8. Post caesarean section discussion

9. Monitoring for postoperative complications following caesarean section












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Glossary

Source guidance

Caesarean section. NICE clinical guideline 132 (2011)

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS

Constitution for England all NICE guidance is written to reflect these. Treatment and care

should take into account individual needs and preferences. People should have the opportunity

to make informed decisions about their care and treatment, in partnership with their healthcareprofessionals. If someone does not have the capacity to make decisions, healthcare

professionals should follow the Department of Health's advice on consent, the code of practice

that accompanies the Mental Capacity Act and the supplementary code of practice on

deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on

consent from the Welsh Government.

If the person is under 16, healthcare professionals should follow the guidelines in Seeking

consent: working with children. If a young person is moving between paediatric and adult

services their care should be planned and managed according to the best practice guidance

described in the Department of Health's Transition: getting it right for young people.

Your responsibility

The guidance in this pathway represents the view of NICE, which was arrived at after careful

consideration of the evidence available. Those working in the NHS, local authorities, the wider

public, voluntary and community sectors and the private sector should take it into account when

carrying out their professional, managerial or voluntary duties. Implementation of this guidance

is the responsibility of local commissioners and/or providers. Commissioners and providers are

reminded that it is their responsibility to implement the guidance, in their local context, in light of

their duties to avoid unlawful discrimination and to have regard to promoting equality of

opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent

with compliance with those duties.



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Copyright

Copyright National Institute for Health and Care Excellence 2013. All rights reserved. NICE

copyright material can be downloaded for private research and study, and may be reproduced

for educational and not-for-profit purposes. No reproduction by or for commercial organisations,

or for commercial purposes, is allowed without the written permission of NICE.

Contact NICE

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[email protected]

0845 003 7781


Caesarean section pathwayCopyright NICE 2013 Pathway last updated: 10 June 2013

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