Caesarean Section
Guidelines relating to the management of
Contents
Section
1.0
2.0
3.0
3.1
3.2
3.3
3.4
4.0
4.1
4.2
4.3
4.4
5.0
5.1
5.2
5.3
6.0
7.0
Heading
Background
Aims and Objectives
Management
Indications
Classification of Caesarean section
Communications
Investigations
Procedure
General instructions
Antacid regime
Antibiotic prophylaxis
4.3.1 Penicillin allergy
Uterine atony
Post delivery care
Observations
Thromboprophylaxis
Debriefing
Monitoring Compliance
References
Page
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1.0 BACKGROUND
Caesarean Section is one of the commonest obstetric interventions. Approximately 20%
of all deliveries at LTHT are Caesarean sections with 10% elective and 10% being
performed in the emergency situation.
2.0 AIMS AND OBJECTIVES
The aim of the guideline is to ensure the correct procedures are used, staffs are aware
of their individual roles and that there is a team approach to optimise the safety of the
mother and her baby.
3.0 MANAGEMENT
3.1 Indications
3.1.1
The commonest indications for elective Caesarean section are as follows. Most routine
elective Caesarean sections should be performed at 39 weeks.
 Breech presentation
 Previous Caesarean section
 Placenta praevia (often delivered at 38 weeks)
 Multiple pregnancy when twin 1 breech (delivery 37-38 weeks depending on
chorionicity)
3.1.2
The commonest indications to perform an emergency Caesarean section are as follows
(list not exhaustive):
 Fetal distress – abnormal CTG in early labour, abnormal fetal blood sample, fetal
bradycardia that does not recover, cord prolapse
 Failure to progress in first or second stage
 Failed instrumental delivery
 Malpresentation most commonly undiagnosed breech in labour
 Second twin
 Antepartum haemorrhage e.g. abruption with evidence of fetal compromise and/or
maternal compromise, placenta praevia with active bleeding
 Pre-eclampsia/eclampsia where there has been a senior decision to deliver by
emergency Caesarean section
 Planned caesarean section that presents in labour.
All Caesarean sections must be discussed with a consultant and this decision must be
documented in the notes.
3.2 Classification of Caesarean section
When an emergency Caesarean section is necessary, it is important to minimise delays
in order to optimise the outcome for both mother and baby. By adopting the
classification described by Lucas et al (1) there will be a clear understanding of the
urgency of delivery. Appropriate management should then take place in order to
minimise the interval from decision to delivery while providing a safe anaesthetic. It is
therefore vital that all members of the team, particularly the anaesthetist are informed as
early in the process as possible. This communication must state the category of the
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Caesarean section and the reason for it. The classification and examples are outlined
below.
The reason for performing the caesarean section and the category should be clearly
stated on the operation proforma and documented in the birth record by the person
making the decision. The time of decision will be when verbal consent is obtained. This
time needs to be recorded in the clinical notes.
Any reason for delay in undertaking the caesarean section should clearly be
documented in the birth record. The decision to delivery interval (DDI) from Category 1
to 4 should be viewed as a ‘continuum of urgency’ rather than discrete categories. For
example whilst the team may aim to deliver a baby in 30 minutes when there is a pH
less than 7.20, a baby with an acute bradycardia will need to be delivered in a shorter
DDI. It is also to be remembered that the category of urgency may change after the
decision is made - a category 2 may become a category 1 or vice versa.
Failure to progress in labour when there is no maternal or fetal compromise is a
Category 3 Caesarean section according to NICE. It must however be remembered that
significant delay will increase the risk of maternal and fetal morbidity for example
bleeding secondary to uterine atony, maternal pyrexia, fetal compromise, and should be
performed at the earliest opportunity for the theatre team. The woman does not need to
be fasted in this situation.
It is of vital importance that there continues to be clear communication between the
obstetric / midwifery and anaesthetic staff at all times.
Timings Table
Category
Definition
Interpretation
Examples
(1)
Emergency
Immediate
threat to life of
mother, fetus’
or both
Deliver in shortest
possible time (may be
under GA)
Cord prolapse
Major antepartum haemorrhage
Ruptured uterus
Prolonged bradycardia
Second twin
FBS Ph < 7.2 or STAN event
when delivery is indicated
Failure to progress with fetal or
maternal compromise
Antepartum haemorrhage with
fetal and /or maternal
compromise
DDI 30 minutes
(2) Urgent
Threat to life of
mother or fetus
but not
immediate
(3)a Semiurgent
No threat to life
of mother or
fetus but early
delivery
required
No threat to life
of mother or
fetus but early
delivery
required
No concerns
over time of
delivery
(3)b
Scheduled
(4) Elective
Call for senior
anaesthetist help early,
if difficulties
encountered with
regional anaesthesia
DDI 45 minutes
Generally woman in
labour
DDI 90 minutes
Consider when entire
team available and /or
when fasted
DDI 6 hours
Delivery timed to suit
woman and clinicians
Failure to progress with no fetal
or maternal compromise
Planned C/S with SROM
Failed IOL
Fetal problems e.g. IUGR
Maternal problems e.g. PET
Breech presentation
Previous C/S x2
All Category 1 Caesarean sections are subject to continuous audit and an audit form
must be completed at the time of inputting delivery information onto MATSYS.
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3.3 Communication & Documentation
There must be a clear discussion with the woman and her partner regarding the
indications for intervention. The reason for performing Category 1 or 2 Caesarean
section must be documented in the birth records by the person making the decision.
Options, if appropriate must be clearly documented in the notes. If there are language
barriers, efforts must be made by the midwife to involve an interpreter for the consent
process .
The consent should be written, apart from situations where there is maternal
compromise or fetal indications such as a pre-terminal bradycardia, where delivery must
be as swift as possible. In such cases verbal consent must be obtained. It must be
documented clearly in the clinical notes the reasons for it not being appropriate to gain
written consent.
Written consent for emergency Caesarean section must include the relevant indications.
The risks of the procedure are as for elective procedures, namely, haemorrhage
(sometimes requiring a blood transfusion), thrombo-embolic diseases, infection, and
damage to bowel or bladder and also include the risk of fetal laceration. Where the
indication for Caesarean section is placenta praevia or abruption, consideration must be
given to include hysterectomy in the consent process.
The decision to perform a Caesarean section will usually be taken by an Obstetrician of
ST3 or above. The decision MUST be discussed with a senior obstetrician including the
Consultant (i.e. Consultant + / - ST5 or above). This discussion must be documented in
hand held records and/or the birth record. For emergency caesarean sections, In the
event that delay would be life threatening to mother or baby, it is acceptable for the
delivery suite coordinator to inform the Consultant of the need to perform an Emergency
Caesarean Section.
There must be clear communication between midwifery and medical staff - obstetric and
anaesthetic, together with the theatre team. It is vital that the urgency and the category
of the Caesarean section are clearly discussed between obstetric and anaesthetic team.
The team performing the Caesarean section should work effectively. See Appendix 1 for
cascade of information and the roles that should be taken by the team members.
Consideration must be given to the potential difficulty of surgery and consideration for
the presence of a senior obstetrician (ST5 or above) to be present although this should
not delay the start of a category 1 section. Obstetric Consultants MUST be present
when the indication is placenta praevia or for LSCS for second twin. Other examples
when it may be appropriate to involve a senior obstetrician are preterm deliveries (under
32 weeks), known previous difficulty at surgery, previous abdominal surgery with known
adhesions, and significant risk of bleeding associated with abruption.
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3.4 Investigations and planning
3.4.1 Elective Caesarean section
The indication and timing of delivery must be documented in the hand held maternity
records. It is important to consider factors that may influence timing and the day of
surgery. For example it is imperative that both a consultant anaesthetist and consultant
obstetrician be available for a placenta praevia and this may therefore influence the day
of surgery. If there are considered to be significant surgical difficulties then it may be
appropriate to ensure a general surgeon is available. This should be the decision of the
obstetric consultant in charge and discussed with the consultant obstetrician whose hot
week it is.
Any significant anaesthetic issues should also be raised with the anaesthetic team.
Some women will have already been seen in the anaesthetic clinic.
Pre-assessment Visit
Woman should have a pre-assessment visit at 36 weeks or as soon as possible if the
Caesarean section is booked after 36 weeks.
All women must have MRSA screening prior to elective CS. This should be arranged in
the antenatal clinic. Please refer to separate MRSA guideline and policy for those who
screen positive. However, decolonisation will be required for a minimum of 5 days to
finish on the day prior to surgery. Prophylactic antibiotics prescribed should be those
with MRSA activity (see section 4.3).
The woman should be offered a patient information leaflet on Caesarean section and on
Consent. Informed consent should be obtained and the woman offered a copy of the
consent form.
The obstetrician should prescribe the prophylactic antibiotics (see section 4.3)
A group and save is not necessary for all women having an elective Caesarean section.
There are certain groups in which a group and save should be obtained in the week
prior to the planned surgery i.e. those with an increased risk of blood loss. These will
include previous postpartum haemorrhage, previous blood transfusion (may have
irregular antibodies), multiple pregnancy, polyhydramnios and high BMI >40, previous
difficult surgery. Blood will need to be available for the day of surgery in cases of
placenta praevia (6 units should be cross matched). Consideration should also be given
to arranging cell saver with the anaesthetic department with cases of placenta praevia
and those women who would refuse blood products.
Women having a planned Caesarean section prior to 38+6 weeks should be offered a
course of antenatal corticosteroids to reduce the chances of respiratory morbidity in the
neonate (see preterm birth guidelines for more details)
Admission
The majority of women will be admitted on the day of surgery to the postnatal ward.
Diabetics and a small number of other women e.g. maternal infection, will need
admission the night before so that treatment or additional observations can be
performed. They should be admitted to the antenatal ward. All women should have a full
set of observations documented on a MOEWs chart prior to surgery.
3.4.2 Emergency Caesarean section
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The obstetrician is responsible for prescribing the prophylactic antibiotics (see section
4.3).
All women should have a full blood count and Group and Save sent to the appropriate
laboratory. Other cases with an increased risk of bleeding will require cross matched
blood be requested – for example placenta praevia, abruption and known maternal
coagulopathy. Consideration must be given for other blood products where there has
been a significant haemorrhage antepartum or risk of coagulopathy. Please refer to
guidance on patients who decline blood products if indicated.
Swabs should be taken for MRSA screening (refer to separate MRSA guideline and
policy for those who screen positive). Ideally this would be done prior to surgery but in
an emergency situation it can be done prior to transfer to the recovery area.
If delivery does not occur for more than 45 minutes in a woman in labour, the CTG
should be categorised in order to detect any emerging fetal compromise. If the category
has changed, the obstetric team should be informed and review requested.
4.0 PROCEDURE
4.1 General Instructions
 An operative proforma should be completed including clear documentation of the
indication, category and time of decision and delivery
 Care should be given especially for the level of the uterine incision when being
performed at full dilatation
 Paired cord blood samples should be taken in all emergency cases
 Consideration should be given to leaving a pelvic drain in situ where there has been
difficulty achieving haemostasis or in the presence of thrombocytopenia or maternal
conditions such as HELLP.
4.2 Antacid regime
Those women requiring a Caesarean section, who are not fasted, should be considered
for antacid prophylaxis which can be administered in the anaesthetic room. This applies
even in women delivered by regional anaesthesia.
For high risk labour where there is a high likelihood of Caesarean section, lanzoprazole
30mg orally should be given prophylactically.
4.3 Antibiotic prophylaxis
It is the responsibility of the obstetrician to ensure that the correct antibiotics are
prescribed and given.
All women undergoing caesarean section, whether elective or as an emergency, should
be given a single dose of antibiotics (see table below) prior to the start of sugery
administered by the anaesthetist. There is good evidence to show that this reduces
maternal morbidity, in particular the risk of endometritis is reduced by 66-75%2 and thus
the use of antibiotic prophylaxis is compulsory.
4.3.1 Penicillin allergy
Before administering antibiotics, a history of any allergy, but particularly with respect to
penicillin should be checked. Some women will report nausea and vomiting or general
reaction to antibiotics. A true allergy would be confirmed by skin rashes, breathing
difficulty, urticaria, facial swelling, etc.
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Cefuroxime is contraindicated only where there is a serious penicillin allergy i.e.
anaphylaxis, breathing difficulty, facial swelling, urticarial rash or other major skin
reaction.
Procedure
Standard
prophylaxis
Caesarean
section (all
categories)
Co-amoxiclav
1.2g single dose
IV
MRSA Risk
Penicillin Allergy
Co-amoxiclav
IV 1.2g &
Teicoplanin
400mg IV
Clindamycin
600mg IV over 30
minutes plus
gentamicin
2mg/kgIV both
single dose
IV
 If antibiotics have been given in labour for maternal pyrexia, they should be
continued until there has been no pyrexia for 24 hours.
4.4 Uterine atony
A number of women requiring Caesarean section are at increased risk of uterine atony
and postpartum haemorrhage. These include:
 Multiple pregnancy
 Prolonged labour on oxytocin infusion
 Large baby
 Following failed trial of instrumental delivery
 Antepartum haemorrhage
 Placenta praevia
Consideration should therefore be given to prevention by commencing an oxytocin
infusion in addition to the routine oxytocin bolus in the third stage of labour. The infusion
will normally be requested by the Obstetrician. The regime is 40 units oxytocin diluted
in 500mls 0.9% sodium chloride infused over 4 hours. Should the uterus fail to
respond to first line uterotonics, consideration should be given to the use of
ergometrine, misoprostol (800 micrograms given rectally) or haemabate (250
micrograms given as an intramuscular or intramyometrial injection) as described in the
guidelines on postpartum haemorrhage.
5.0 CARE OF MOTHER IN FIRST 24 HOURS POST PARTUM
Following delivery the surgeon should clearly document a post-operative care plan in
the birth record which as a minimum should include:
-
how long the syntocinon infusion is required (if applicable)
When to remove the drain (if applicable)
When to remove the urinary catheter
Timing of suture removal (if applicable)
Thromboprophylaxis assessment
Analgesics prescribed
Need for postnatal follow up
5.1 Observations
Depending on the indication for Caesarean section the woman will be transferred to
either the recovery or high dependency area or back to her delivery room. She should
not be left unattended during the immediate recovery period especially if they have had
a general anaesthetic (see recovery guidelines). Women recovering from a GA should
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have their oxygen saturations monitored and receive supplemental oxygen until they go
to the ward and /or no longer using a PCAS.
The following observations should be performed when the woman arrives in the
recovery/HDU area and every 15 minutes thereafter: MOEWS (Modified Obstetric Early Warning Scoring) score. The midwife in
charge needs to be informed of the MOEWS or if there are any concerns about the
woman. The duty anaesthetist and obstetric registrar should be informed if MOEWS
score shows one RED or Two YELLOW or if there are any concerns about the woman
(see MOEWs information file for more detail)
 If oxygen saturations less than 95% the patient must receive oxygen 4 litres per
minute via face mask. All patients who have had general anaesthesia will have oxygen
automatically
 Ensure patient is alert and rousable
In addition the following should be noted for women in recovery: Assess pain , nausea and treat as per instructions
 Checking of wound site, drain, lochia
 Check catheter drainage and urine output every hour
 Monitor oral intake with a fluid balance chart
 Check rate of infusion of intravenous fluids and cannula site
 Check medication and administer if required
 Apply TED stockings
 If blood products are to be given check and administer in line with blood
product protocol
 Pressure areas should be noted and treated appropriately.
In general, if observations are stable for 2 hours then transfer to the postnatal ward will
take place.
Following transfer to the postnatal ward the minimum observations would be: 1 hourly for 2 hours then
 2 hourly for 2 hours then
 4 hourly for 24 hours then
 Twice daily until discharge unless deviations from normal identified in which
case medical review should be sought and a plan of care documented
All observations should be documented on the MOEWs chart
Any deviations from normal must be reported to the Obstetric and /or Anaesthetic staff
5.2 Thromboprophylaxis
A thromboprophylaxis risk assessment should be carried out for all Caesarean sections
and tinzaparin prescribed as necessary. For full details see Thromboprophylaxis in
Pregnancy and the Puerperium.
5.3 Debriefing & Advice regarding future pregnancies
It is good practice for the surgeon involved in delivery to see the woman post delivery to
offer a chance to discuss intrapartum care. It is good practice to involve the consultant
who was either responsible for antenatal care or who was involved intrapartum. Advice
should be given before discharge about the implications for future pregnancies,
particularly the mode of delivery (there are few absolute indications for a repeat
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Caesarean section in a future pregnancy) and a patient information leaflet should be
given. Details of these discussions should be documented in the birth record.
It is also a good opportunity to offer advice in future pregnancies where interventions
may be appropriate to reduce risk of recurrence of a particular problem. Whilst the
majority of women will be seen for their postnatal check in the community, it may be
appropriate to offer certain groups of women the opportunity of a consultant postnatal
appointment. This should be discussed with the appropriate consultant and an
appointment made with the consultant by the ward staff:
 Poor neonatal outcome or stillbirth
 Severely growth restricted baby or pre-eclampsia less than 34 weeks, consider
screening for inherited thrombophilia
 Advice regarding prophylactic aspirin where indication for delivery has been
severe pre-eclampsia
 Screening in a future pregnancy where there has been a preterm delivery (< 34
weeks gestation) – consider cervical screening, screening for infection, elective
cervical stitch
Staff debriefing may be appropriate especially where there has been a difficult delivery
or unexpected complications.
6.0 MONITORING COMPLIANCE
An audit will be carried out in accordance with the Maternity Services Audit Plan.
Auditable standards include:
-
Indication for CS
Grading of urgency of CS (classification)
Involvement of Consultant in decision making process
Time from decision to delivery and reason for delay if any
Whether paired cord blood samples were taken as indicated
Use of antibiotic prophylaxis and thromboprophylaxis
Care of mother within first 24 hours
Documented discussion with woman re implications for future pregnancies
A continuous audit will be carried out on all category one caesarean sections whereby
the delivery is entered onto a log kept on delivery suite. Every 24 hours, the
coordinating midwife and the Consultant will review the notes and ensure that an audit
form has been completed. If there was a delay in the decision to delivery interval or
there are any adverse outcomes (e.g. low cord pH, unplanned admission to NNU etc)
then the incident should be reported via the clinical incident reporting process (DATIX)
and the case reviewed at the weekly risk management meeting. The Consultant and
Co-ordinator are responsible for any immediate actions which should be documented on
on DATIX
Audit results will be presented twice a year at the Clinical Governance and Audit
meeting and an action plan developed as necessary. A lead will be appointed to monitor
the action plan and progress and updates of the action plan will be presented quarterly
to the Women’s Services Clinical Governance and Risk Management forum. Results of
the audit will be included in the quarterly Risk Management report and any subsequent
changes will be disseminated via the Maternity Services Forum, Women’s Services
Clinical Governance and Risk Management Forum, Team Leaders Forum and
Supervisor of midwives Forum.
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7.0 REFERENCES
(1) NICE Clinical Guideline 13. Caesarean Section. April 2004. National Institute for
Clinical Excellence.
(2) ACOG Committee on Obstetric Practice. Obstet Gynecol. 2002 Apr;99(4):679-80.
(3) Kieser KE, Baskett TF. A 10-year population-based study of uterine ruure. Obstet
Gynecol. 2002 Oct;100(4):749-53.
7.0 PROVENANCE
7.1 Author(s): Tracey Glanville Consultant Obstetrician .
7.2 Objectives: The improve the provision of care for women undergoing emergency
Caesarean section within the Leeds Teaching Hospitals NHS Trust.
7.3 Target Patient Group: All women undergoing emergency Caesarean section
within the Leeds Teaching Hospitals NHS Trust.
7.4 Target Professional Group: All professionals undertaking maternity care at the
Leeds Teaching Hospitals NHS trust
7.5 Person responsible for review: T Glanville (Consultant Obstetrician)
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Protocol relating to the management of Caesarean section
Author(s)
T Glanville (Consultant Obstetrician SJUH)
Contact name
T Glanville (Consultant Obstetrician SJUH)
Approval process
for amendments
Maternity Services Forum
First Issue Date
August 2008
Version no:
3.2
Review Date:
August 2015
Clinical Guidelines Committee December 2009 (LHP version 1.0)
Amendments approved by MSF 27/07/2012 (version 3.2)
Ratified by
Consultation Process
Maternity Services Guideline Group / Maternity Services Forum, Maternity Services Clinical
Governance and Risk Management Forum / Obstetricians / Team Leaders / Supervisors of Midwives
Scope of guidance
Clinical condition
Patient Group
Professional
Group
Distribution List
All
All pregnant women booked to deliver within the Leeds teaching Hospitals
NHS Trust
All Health Care Professionals involved in the provision of maternity care
within the Leeds Teaching Hospitals NHS Trust
All Obstetricians within the Women and Children's Division.
Lead Clinician (Midwifery and Neonates)
Head of Midwifery
Matrons (midwifery and neonatal)
Clinical Midwifery Team Leaders (for distribution to midwives within their
areas)
Dissemination
Via Risk Management Midwife
Audit and
Monitoring
Will be carried out in accordance with Maternity Services Audit Plan
Broad Recommendations
All pregnant women should be offered a high standard of care based on the best available evidence
Equity and Diversity
Leeds Teaching Hospitals NHS Trust believes in fairness, equity and above all values diversity in all
dealings, both as providers of health services and employers of people. The Trust is committed to
eliminating discrimination on the basis of gender, age, disability, race, religion, sexuality or social class.
We aim to provide accessible services, delivered in a way that respects the needs of each individual
and does not exclude anyone. By demonstrating these beliefs the Trust aims to ensure that it develops
a healthcare workforce that is diverse, non discriminatory and appropriate to deliver modern
healthcare.
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