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• Pregnant women should be offered evidence-based information and support to enable them to make informed decisions about childbirth.
• Addressing their views and concerns should be recognised as being integral to the decision making process.
• The woman’s consent for caesarean section will be obtained after providing her with evidence based information and in a manner that respects her dignity, privacy, views and culture whilst also considering the clinical situation.
• The category and reason for performing the caesarean section will be clearly documented in the Maternity records by the person who makes the decision in order to aid clear communication between healthcare professionals.

Definition

• Lower Segment Caesarean Section (LSCS) A surgical operation which facilitates the delivery of baby/babies through a cut in the abdomen and lower segment of the uterus. (Royal College of Obstetricians and Gynaecologists (RCOG)2010).

Elective LSCS

• The risk of respiratory morbidity is increased in babies born by CS before labour, but this risk decreases significantly after 39 weeks.
• Therefore CS should not routinely be performed before 39+0 weeks of pregnancy (NICE 2011)
• A Consultant Obstetrician should always be involved in the decision regarding caesarean section, unless doing so would be life threatening to the woman or fetus.
• The safety of the mother must always be the most paramount focus and must never be overridden by an unnecessary attempt at immediate delivery without thorough assessment.
• 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. NICE 2011)
• All should have been seen by a senior clinician prior to surgery and that a plan for the Caesarean Section (CS) is clearly documented on the Maternity EPR
• This must include the indication for the CS
• Inform staff of the correct level of observation that are necessary in the postoperative period and care required in the immediate post-operative period
• Ensure that all women (post-surgery) have the implications for future pregnancies discussed with them prior to discharge and that information is documented in the Maternity EPR.

GRADE 1: CRASH

• Definition: CRASH - Immediate threat to the life of mother and / or fetus. Decision to Delivery Interval: As soon as it’s safely possible – aim for within 30 minutes.
• Transfer the woman to theatre immediately a decision has been made. Obstetric Emergency Category 1 Caesarean section, Delivery Suite
• If the Consultant Obstetrician and / or Consultant Anaesthetist are needed urgently then they should be paged / phoned.
• Indications:
  • Prolonged Fetal Bradycardia > 4minutes
  • Abnormal CTG without FBS
  • FBS – Lactate above 4.8 or PH of 7.20 or below
  • Massive Placental abruption/APH/Uterine rupture
  • Cord prolapse
  • Failed instrumental (decision time – at time of failure of instrumental)
  • Maternal cardiac arrest (Within 4 minutes to facilitate resuscitation)
  • Breech in advanced labour/rapidly progressing and decision for CS
  • This list is not exhaustive. If in doubt, involve Consultant Obstetrician immediately.

GRADE 2: URGENT

• Definition: URGENT – Maternal or fetal compromise but not immediately life threatening. Decision to Delivery Interval: As soon as it’s safely possible – aim for within 75 minutes.
• Liaise with Anaesthetist immediately and then transfer to theatre as soon as it’s safely possible. Document any reasons for delay, if unable to transfer immediately to theatre. Shift Coordinator (who may delegate other staff) to: Contact Theatre team , Obstetric Team, Anaesthetist (middle grade ) and Paediatric team – informing them of the location that the team is needed e.g. Labour ward theatre / procedure room, the category
• Indication and timing for CS.
  • Non-reassuring CTG (not abnormal)
  • Minimal to moderate Abruption/APH
  • Failure to progress
  • Undiagnosed breech in labour
  • Planned LSCS in active labour
  • Maternal exhaustion/maternal request during active labour
  • This list is not exhaustive. If in doubt, involve Consultant Obstetrician immediately.

GRADE 3: SCHEDULED

• Definition: SCHEDULED - Needs early delivery, but no immediate maternal or fetal compromise. Decision to Delivery Interval: As soon as feasible – aim for within 24 hours.
• Obstetric Consultant to specify time depending on the urgency of each individual case. Following consultation with the Obstetrician, the Shift Coordinator to contact Theatre team, Obstetric Team, Anaesthetist and Paediatric team informing them of the location that the team is needed e.g. Labour ward theatre/room the category, indication and timing for CS.
• Indications:
  • Planned LSCS admitted with pre- labour SROM and or very early labour/latent phase
  • Failed IOL
  • Preeclampsia needing CS (and requiring stabilization)
  • IUGR needing CS
  • Delayed/cancelled Elective CS due to other Obstetric emergencies (See SOP on intranet)
  • This list is not exhaustive. If in doubt, involve Consultant Obstetrician immediately. In some situations, this can be undertaken after 24hrs, depending on Consultant Obstetrician’s assessment of each individual case.

GRADE 4: PLANNED

• Definition: PLANNED - When the delivery is planned on an elective list to suit the woman and/or the service. Delivery gestation: Between 39+0 weeks to 39+6 weeks gestation unless specified. Obstetric registrars may book a CS from 39 weeks gestation. Decision to deliver before 39+0 weeks gestation must be made by a Consultant Obstetrician.
• Give steroids if < 39+0 weeks. Maximum benefit is between 24hrs and 7days of delivery.
• A CS may sometimes be booked at 41-42 weeks gestation where spontaneous labour is desired but induction is to be avoided.
• Indications:
  • Placenta praevia (around 38 weeks)
  • Failed ECV with normal CTG if patient request for LSCS
  • Breech presentation / malpresentation – decision for CS made
  • Multiple pregnancy with first twin non-cephalic (around 36wks for Monochorionic and 37wks for Dichorionic pregnancies)
  • Previous 2 or more LSCS
  • Previous Classical LSCS ( around 36 to 37weeks)
  • Previous uterine surgery i.e. Myomectomy breeching cavity
  • Maternal request after previous 1 CS/ or for other reasons
  • Maternal/fetal medical/structural conditions in which vaginal delivery is contraindicated This list is not exhaustive. If in doubt, involve Consultant Obstetrician immediately

DUTIES FOR Consultant Obstetrician: Deliveries 1-3

• Must be involved in the decision making and communication with his team as to classification and urgency of the CS and reason for Grade 1- 3 CS.
• He / she must provide support and be in attendance for junior colleagues at high risk cases

Duties for Specialty Obstetrician Deliveries 1-3

• Inform consultant on call and document the grade and reason for CS in Maternity EPR. Inform the shift coordinator immediately.
• Discuss the reasons for the CS with the woman and inform her of the potential risks and complications associated with surgery and gain her written signed consent.
• Prescribe 40mg IV omeprazole in 100ml saline for all emergency CS unless had oral in last 6 hours.
• Ensure that the Anaesthetist is aware of the level of urgency and any medical problems/comorbidities.
• Ensure that the Paediatric team are aware of the level of urgency and any neonatal alerts.
• It is the surgeon’s responsibility for taking Cord blood samples. These must be given immediately to the shift coordinator for prompt analysis.
• Review the woman in the first 24 hours post-surgery, discuss the delivery and recommendations for future pregnancies and document in Maternity EPR.

References

• NHS Guideline document