EMEREGENCY CESAREAN SECTION
Detailed Process Outline with Suggestions for Hospital Guidelines
Definitions:
Stat Cesarean Delivery: A cesarean delivery performed due to impending fetal or maternal death, where every
effort is made to minimize the time from decision to delivery of the baby.
Urgent Cesarean Delivery: A timely cesarean delivery performed due to deteriorating maternal or fetal
condition, but where there is no imminent risk of fetal/maternal compromise. This category includes
indications for which there is wide variation in timeliness of response. Safety, including that of patient and
providers must always be considered. This includes labor arrest disorders, non-reassuring fetal heart rate
tracings etc.
Unscheduled Non-Urgent Cesarean Delivery: Cesarean delivery performed where there is no evidence of
deteriorating maternal or fetal condition. This includes cesarean deliveries performed due to malpresentations
in early labor, refused trial of labor.
Scheduled Cesarean Delivery: Self explanatory.
Personnel: This protocol uses three nurses to get the pregnant woman delivered and to stabilize the situation.
This is just one suggestion of how to perform the critical tasks, and other excellent models exist. For hospitals
using this paradigm, we anticipate that roles may be reassigned once the situation is stabilized. The primary
labor nurse takes the patient to the OR, stays at the head of the bed to help anesthesia and then becomes the
baby's nurse if needed.
1. The first responder in the room helps the primary nurse transport the patient, becomes the "bottom"
nurse and then becomes the circulator.
2. The scrub nurse is the scrub nurse.
Event/Action/Role
Patient with potential
need for stat cesarean
section
Consent for possible
cesarean section
Details
Possible Indicators:
 Abnormal FHRT
 VBAC
 Twins
 Heavy Bleeding
 Malpresentation in early labor
 Abnormal labor progress
Verbal consent at minimum
Ask about planned tubal ligation
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Ideas for discussion
 What is your culture?
 Could a nurse initiate the c/s?
 Who starts calling personnel in and
notifying teams.
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Typically it is the MD who obtains
consent.
Notify Teams of
Potential for Cesarean
Section.
Prepare for possibility
of stat c/s
Patient Delivers
Personnel to notify:
 Operative Assistant
 Charge Nurse
 Nursing Supervisor
 Anesthesia
 OR team
 Pediatrician
 Any other group/person who is part
of your stat c/s protocol
o ED MD
o Respiratory
o Lab
o X-ray
Who does notification?
 RN to RN
 MD to MD
What is the information communicated?
 Indication
 How STAT
 Gestational Age
 Major Medical/Pregnancy problems
 Meds in labor
 Allergies
Partial OR set up: trays in room,
including stat tray, but not opened
Anesthesia machine set up with drugs
out, record started.
Radiant warmer set up in OR for
possible resuscitation, but left off.
Roles assigned: who will scrub,
circulate, move patient
Patient room streamlined for rapid
transport: Cords untangled
Take everyone off alert
Who do you take off alert on off hours?
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Do you call at home at night? This
should be a multidisciplinary
discussion. Set a time before which
calls are expected.
Always call if personnel in house and
awake, regardless of time.
If no calls at night, consider a policy
that everyone is home after 11 pm,
unless they notify the unit.
All of the personnel on your notify list
should be involved in drills.
Have posters in bright colors regarding
who to notify.
Spell out who will notify each group.
Have it on the poster.
Grease Board in OR with critical
details.
Standard information sheet at desk
with details written on it.
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May put all equipment including
gloves on a table or infant warmer etc
right outside of room.
 Create a list of what needs to be done
in OR.
 May choose to open the trays, but
technically someone is supposed to be
in the OR with an open tray at all
times.
Could starting an anesthesia record on a
patient count as a consultation?
Should happen with every shift turn over
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No call backs after 10 pm
Ask each person at home what they
want?
Decision to perform
emergency cesarean
section
Notify Unit
Can be made by RN, MD, CNM
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Typical Indications:
 Fetal distress (prolonged
bradycardia, repetitive severe
decelerations with decreased
variability),
 Cord prolapse,
 Massive hemorrhage,
 Malpresentation with rapidly
progressing labor,
 Rapidly deteriorating maternal
condition, including cardiopulmonary arrest.
 Suspected uterine rupture
 Second twin with one of the above
issues.
Be clear if it is stat or urgent
Emergency Call button in room, so don't
need to leave patient's side
Must include nursing supervisor
Do you have call backs?
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Remember this is for getting everyone
in. You can change your mind.
Create a culture that is non-punitive if
the decision is made to call off the
cesarean section.
See above definitions.
Decide what to call the emergency button,
create unit culture around it
Train using the call button; make sure
everyone knows what it means and what it
does.
Consider testing buttons quarterly.
Call Backs
 Call backs decrease response times.
 Without call backs, how do you know
everyone is on their way in?
 You could call back a beeper and put
your beeper number into the beeper
you paged. That would let the person
leading the effort know you are on
your way. You could do this from a
cell phone, or have a family member
do it for you as you are leaving home.
Every institution needs a method of
testing/simulating the notification system.
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Who places all the pages?
If you don't have a stat pager system,
you should have daily paging lists
Every institution needs a method of
testing/simulating the notification
system.
What priority do you page personnel in:
OB attending, anesthesia attending, OR
team, assistant, Pedi?
Labor nurse stays with
patient, at head and
moves patient to OR
Is chief communicator to other services
 OB Provider
 Anesthesia
 Pediatricians
 Responders
Assigns roles
May give updates to the family once the
baby is delivered.
Moves patient to OR, staying at head of
bed
 Caps all IV's
 Caps Epidural
 Takes everything off pumps
 Raises bed all the way up with side
rails up.
 Detaches monitor leads from
machine just prior to transfer
Gives patient bicitra in OR
Use a special code, so that folks know
it is a stat (ie 911)
 Consider dedicated stat pagers that
never change and that can be accessed
through a computer program.
 Switch board: They have a list of
who is on call.
 Nursing supervisor.
 Med/Surg Coordinator: list of who is
on call with pagers.
 Keep a list of all the pagers.
Must have daily paging lists.
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This should be done at least monthly.
Large systems may consider doing it
daily.
Consider Pedi prior to assistant
Consider going by distance form
hospital
ED doc, X-ray, Lab last
Consider who talks with family. This
could be the MD as the patient is being
assessed. Some one needs to give
them updates after the baby is out...
this could be a nurse.
Who assigns roles... or are they
scripted?. The labor nurse could
assign them as responders come in.
What is the quickest route to OR
Do you need to call elevators? If so
who does this?
Walk in a controlled pace. If you rush
you can break equipment and it will
take longer.
Tape to pillow in OR or to Pedi
warmer, top of anesthesia cart.
Make stocking Bicitra part of the
routine for cleaning the OR.
Reevaluate in OR
First
Responder/Bottom
Nurse
Scrub Nurse
Performs anesthesia related tasks, until
relieved by anesthesia.
 Puts oxygen on patient
 Hangs IV fluids
 Pulse oximetry
 BP Cuff
 ECG leads
 Turns on Machine, if off
Performs Cricroid pressure if needed
Comforts patient
 Indication for c/s
 We are moving very quickly
 Explains what is happening
 Attempts to keep her calm
 Explains possible GET
Has patient's status changed:
 Bradycardia often resolves with
transport, recheck FHR
 Cervix may move to complete
dilation
 Bleeding may be less
 Presenting part may be so low in
vagina that c/s is no longer safest
way to deliver baby (i.e. breech at
introitus)
Helps move patient to OR:
 Takes foot of bed
 Helps detach monitor leads or IV's if
needed
 May help raise bed up
Works on Lower half of body in OR
 Assess FHR with monitor or
Doppler
 Inserts Foley
 Places Hip wedge
 Places leg strap
 Performs SkinPrep
 Helps gown Providers if above tasks
are done
 Sets up suction
Becomes Circulator once case is started.
Quick one minute scrub
Gowns and gloves quickly
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Should take < 1 minute
Requires a monitor in the OR.
o Who will move it if it is not
already there.
Consider rapid preps that are single
application ie:
 Hibicleanse prep
 Iodoband drape (no prep necessary)
Bovey is optional
This is only a suggestion: At some
institutions, the primary nurse becomes
the circulator and a second nurse might
help with infant resuscitation
Puts out provider gowns and gloves,
anticipate they will gown and glove
themselves
Open stat pack
Do not count if this is truly stat
Lights/suction
Critical instruments to have on field
 Suction
 Bladder bar
 Kocher's x2
 Disposable scalpel taped to package
 Tissue forceps
 Mayo's
 Large Richardson retractor
 Sponge's
 Kelly's for cord
 Bandage Scissors
Provider
First Assistant
Anesthesia
Always protect everyone from scalpel...
never hurry to cut corners here!
Does not transport patient,
Make sure providers have practiced
gowning and gloving themselves.
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If no scrub, have instruments laying on
the patient's knees or on table very
near. There is also a role pack that
has all the instruments laid out very
neatly.
Use disposable scalpels for stat
cesarean sections. Do not try to load
them.
If the scrub is not familiar with the
names of the instruments, a stat pack
that is rolled up is critical. Then
providers can just grab their own.
It only takes 2 personnel to do a transport
efficiently. However, provider should ask
if extra help is needed before leaving the
room.
Updates anesthesia and pediatrics as
they report to OR
Gowns and gloves themselves
Practice with vaginal deliveries.
Gives scrub personnel tips if he/she is
unfamiliar with tray
If truly stat:
Once the baby is out, consider changing
gloves.
 Use vertical skin incision and
scalpel for all layers
 Don't make bladder flap
 Do low transverse on uterus if
possible (it is quicker)
 Do both sides of the case, never
puts down the instruments
Could be CNM or RN. Primary purpose
is to hold retractors.
Report directly to OR, not patient’s
room
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Get critical information from OB
Provider, with additional information
from Labor Nurse
 Indication for c/s
 How stat is it
 Gestational age
 Major medical and OB problems
(CHTN, Asthma)
 Medications during labor
 Allergies
Baby Resuscitation
Ideas for Additional
Personnel
Recorder
Family Person
Make sure there is someone helping
you, especially if Cricoid pressure
needed
 Could have respiratory therapy be
part of stat team
Isolette should be set up already if there
was warning.
 The Labor Nurse, who was the
patient's primary nurse moves to this
from the head of the bed.
 Pediatrician takes charge when
he/she arrives.
Make sure a transport team was called if
it is preterm and you lack the resources.
Adult respiratory therapist
 Anesthesia
 Pediatric Assistant
ED Doc
 Could start conscious sedation
 Could help get monitor leads on
 Could help resuscitate newborn if
Pediatric provider not there
Pediatric respiratory therapist for
resuscitation
Pediatric nurse
Nurse manager of hospital on call
Pastoral Care for family
Police/Security for difficult family
Records critical times on cesarean
section outcomes tool:
 Decision to do c/s
 Patient in OR
 All teams assembled
 Patient ready for c/s
 Incision
 Delivery of baby
Directs family out of room
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This could be put on a grease board in the
OR. The board could have permanent
letters that say:
 Status
 Indication
 GA
 Maj Med/OB Hx
 Meds in Labor
 Allergies
The board could be updated by the
recorder.
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Laryngeal mask is expensive, but gets
around problem of intubation.
Additional help may be found from
o ED MD
o Respiratory Therapist
o NICU team if you have one
This person may be a tech or someone
with limited training in OB.
This person could also be responsible for
writing information on the grease board.
Could be a chaplain, Tech, Receptionist,
Comforts family
Lets them know when baby is
born/things are ok
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house keeper or security.
Should be specific about information they
can give to family
Consider including in drills
Consider having tools for them to use
readily available if they have limited OB
background