The decision for caesarean should be made following discussion with the woman.

The decision should be agreed by a consultant (unless vaginal birth is contraindicated, and caesarean section is the only option for delivery).

Offer all pregnant women evidence-based information and support to enable them to make informed decision about the risks and benefits of the Caesarean Section.

Ensure the women’s preferences and concerns are central to the decision-making process.

Planned caesarean section should be planned between 39 - 40 weeks gestation to decrease the risk of neonatal respiratory morbidity and neonatal admission. If a caesarean section is planned below 39 weeks, document the reason why.

If a caesarean section is planned for less than 37 weeks, women should be offered steroids. Risks and benefits of the steroids at different gestational age should be discussed with the woman.

For women undergoing planned caesarean birth between 37+0 and 38+6 weeks an informed discussion should take place with the woman about the potential risks and benefits of a course of antenatal corticosteroids. Although antenatal corticosteroids may reduce admission to the neonatal unit for respiratory morbidity, it is uncertain if there is any reduction in respiratory distress syndrome, transient tachypnoea of the newborn or neonatal unit admission overall, and antenatal corticosteroids may result in harm to the neonate which includes hypoglycaemia and potential developmental delay.

Dose: 12mg betamethasone repeated 24 h later; only repeat earlier (at 12 hours) if birth likely <24 hours of first dose or 6 mg dexamethasone 12 hours apart for a total dosed of 24mg.

Maternal request caesarean section

• When a woman requests a CS with no contraindication to vaginal delivery explore, discuss and record the specific reasons for the request.

• Woman requesting a CS birth without medical or obstetric indication should be referred to the Birth choices ANC clinic following their 20-week anomaly scan, for counselling regarding indication, risks and benefits of LSCS versus SVD.

• If a woman requests a CS because she has anxiety about childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support.

• If a woman wants to proceed with CS after discussion, offer support (including perinatal mental health) offer a planned CS after 39+ 0 weeks at a time to suit service provision.

• Document an agreed plan for if she attends in labour. Explain to the woman that, if labouring, a vaginal delivery may be inevitable especially if she is rapidly progressing or presents in advanced labour. Explain we may not be able to facilitate CS immediately due to emergency priorities and she may become fully dilated whilst awaiting an available theatre and appropriate staff.

Complete CS pathway proforma on EPIC as below:

Caesarean Birth vs Vaginal Birth – Risks (NICE 2021)

This information comes from studies comparing the outcomes in women who choose a caesarean birth vs woman who choose a vaginal birth. This information is included to help you make your decision. Please note that the majority of these risks are rare outcomes.

Prior to elective caesarean section:

• The procedure must be ordered in EPIC through - Prep for procedure.

• The indication for the Caesarean section should be written in the comments box.

• Electronic consent must be obtained at the booking of the procedure.

• Women should be directed to watch the Frimley Health maternity online video on caesarean section and given the elective caesarean leaflet.

• Ensure that all high-risk patients for anaesthesia have been seen at the anaesthetic high risk ANC prior to listing them for CS.

All women having an elective LSCS will see an anaesthetist at the preoperative visit to discuss the anaesthetic. If the woman has expressed a preference for other than a spinal anaesthetic, she should be referred to the obstetric anaesthetic clinic earlier in pregnancy to explore the options.

• The placental site should be known, particularly in the presence of a previous scar

  • this may require an ultrasound scan prior to surgery by a fetal medicine specialist to assess for placenta accreta.

• An antacid

  – omeprazole 40 mg bd x 1 day must be prescribed by the anaesthetic / obstetric team and patients advised on how to take this prior to surgery.

• Shaving BY THE PATIENT should be avoided on the day of or the days leading up to surgery (we will shave on the day in theatre if needed).

• For patients booked for malpresentation, discuss options for delivery while booking LSCS. On the day of surgery, perform a presentation scan and re-discuss options for mode of delivery if cephalic.

• If multiple pregnancy, scan fetal hearts instead of auscultation to identify different fetal heart beats.

• The fetal heart should be auscultated/ scanned after the insertion of the regional anaesthetic. This may be done for at least 10 seconds so that a clear rate may be heard. This should also be documented in the medical record.

• Apply a left lateral tilt of up to 15 degrees or appropriate uterine displacement once the woman is in a supine position on the operating table to reduce maternal hypotension.

• Vaginal cleansing and catheterisation to take place after the insertion of the regional anaesthetic, or prior to administration of a general anaesthetic.

• WHO checklist prior to surgery.

A decision for an emergency CS should always be discussed with the consultant on call, unless the delay in doing so would be life threatening to the woman or baby. Once a decision has been made to perform an emergency caesarean section, it is crucial that the urgency for the CS is documented and communicated to all team members. Classifying the urgency for delivery does not dictate the anaesthetic choice but clear communication between the obstetrician and anaesthetist as to the safest option is essential. The obstetrician making the decision should clearly document the following in the maternity notes:

• time the decision was made

• indication for delivery

• classification of urgency of the delivery

Classification of emergency caesarean section

Use the following decision-to-delivery intervals to measure the overall performance of the obstetric unit:

• 30 minutes for category 1 CS

• 75 minutes for category 2 CS.

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

See flowcharts in appendices 1, 2 and 3 for individual team members’ responsibilities.

For the procedures listed below, the Consultant Obstetrician MUST attend in person:

• Caesarean birth for major placenta praevia / abnormally invasive placenta

• Caesarean birth for women with a BMI >50

• Caesarean birth < 28 wks gestation

Situations in which the consultant must ATTEND unless the most senior doctor present has documented evidence as being signed off as competent. In these situations, the senior doctor and the consultant should decide in advance if the consultant should be INFORMED prior to the senior doctor undertaking the procedure.

• Caesarean birth at full dilatation

• Caesarean birth for women with a BMI >40

• Caesarean birth for transverse lie

• Caesarean birth at <32 weeks gestation

• Multiple Pregnancy

• Known large fibroids

• Transverse lie

• Two and more previous caesarean sections and known to have significant adhesions

• Fetal anomaly expected to cause difficult delivery

• Intrauterine fetal death

• Suspected/actual uterine rupture

• Previous laparotomy with high likelihood of adhesions

The above lists are not exhaustive and therefore it is recommended that prior to any shift, there should be a discussion between the consultant and the on-call team regarding any scenarios where the consultant would wish to be informed, even if their attendance may not be immediately required. These scenarios may vary according to the level of experience of the most senior doctor present.

Offer all women prophylactic antibiotics at CS. Ideally these should be administered prior to skin incision (where practicable).

For recommended prophylaxis please refer to the “Adult Antimicrobial Guide” on the intranet.

In general, the principle pertaining to surgery outlined below should be adhered to; however, deviation from this can be made at the surgeon’s discretion if clinically indicated, provided a clear reason is provided in the medical record.

Abdominal wall incision

CS should be performed using a transverse abdominal incision because this is associated with less postoperative pain and an improved cosmetic effect compared with a midline incision. The transverse incision of choice should be the Joel Cohen incision (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).

Opening the uterus

This is usually performed by making a transverse incision on the lower uterine segment. Do not use separate surgical knives to incise the skin and deeper tissues as it does not decrease wound infection.

Extension of the uterine incision

When there is a well-formed lower uterine segment, blunt rather than sharp extension of the uterine incision should be used because it reduces blood loss, incidence of postpartum haemorrhage and the need for transfusion at CS.

Fetal laceration

Women should be informed that fetal laceration may occur at up to 2% of deliveries.

Use of forceps

Routine use of Wrigley’s forceps to deliver the fetal head should be avoided. The effect on neonatal morbidity of the routine use of forceps at caesarean birth remains uncertain.

Delayed cord clamping

Allow delayed cord clamping at all deliveries for a minimum of 1 minute if the baby’s heart rate is greater than 100 beats per minute and when below 100 BPM if processes are in place to accommodate immediate neonatal resuscitation at the operating table.

Uterotonics

NICE caesarean section guideline recommends oxytocin 5 iu by slow intravenous injection for prophylaxis of PPH in the context of caesarean delivery. In elective Caesarean section, either 5 units Oxytocin or Carbetocin 100 micrograms should be administered by slow intravenous injection over 1 minute after delivery of the baby’s shoulders. Oxytocin infusion should not be given within 4 hours of Carbetocin administration. A Cochrane review has found no statistically significant differences between carbetocin and oxytocin in terms of risk of PPH but in a statistically significant reduction in the need for further uterotonics compared with oxytocin.

Contra-indications for Carbetocin

1. Pre-eclampsia / eclampsia

2. Epilepsy

Cautions for Carbetocin

1. Severe cardiovascular disease: it depends on which condition, not just the severity

2. Asthma

3. Hyponatraemia

For women at increased risk of haemorrhage, it is possible that a combination of preventative measures might be superior to oxytocin alone to prevent PPH. Clinicians should consider the use of IV tranexamic acid (0.5 to 1g), in addition to oxytocin, at CS to reduce blood loss in women at increased risk of PPH.

If the uterus continues to be atonic and/or post-partum haemorrhage continues, further uterotonic agents may be used as per the postpartum haemorrhage guideline.

Check the drug chart prior to prescribing further uterotonics.

Method of placental removal

At CS, the placenta should be removed using controlled cord traction and not manual removal as this reduces the risk of endometritis. It is essential that a digital examination of the uterine cavity is performed to check that the cavity is empty following the removal of the placenta.

Exteriorisation of the uterus

Intra-peritoneal repair of the uterus at CS should be undertaken. Exteriorisation of the uterus is not routinely recommended because it is associated with more pain and does not improve operative outcomes such as haemorrhage and infection.

Closure of the uterus

Use single layer or double layer uterine closure in caesarean birth, depending on the clinical circumstances. Note that single layer closure does not increase the risk of postoperative bleeding or uterine rupture in a subsequent pregnancy. NICE 2021

Closure of the peritoneum

The visceral and parietal peritoneum should not be sutured at CS as this increases operating time and the need for postoperative analgesia.

Routine use of a peritoneal drain should be avoided.

Closure of the abdominal wall

In the rare circumstances that a midline abdominal incision is used at CS, mass closure with slowly absorbable continuous sutures should be used because this results in fewer incisional hernias and less dehiscence than layered closure.

Closure of subcutaneous tissue

Routine closure of the subcutaneous tissue space should not be used, unless the woman has more than 2cm subcutaneous fat, because it does not reduce the incidence of wound infection.

Closure of the skin

The method of closure and type of suture material can be left to the discretion of the individual taking into account the tissue type and body habitus of the patient.

Wound dressing

Apply a negative pressure dressing if the woman’s BMI is >/=40, BMI >/=35 with diabetes, or abdominal adipose tissue, autoimmune disease, immunosuppression, history of wound infection/healing problems.

Bladder injury

Should a bladder injury occur continue with delivery of the baby and suturing of the uterus, Consultant urogynaecologist to be called as a first point of contact, and if not available a senior urologist should be called to attend to supervise or perform the repair and arrange appropriate follow up. An indwelling Foley catheter will usually be left in situ for 7-10 days on free drainage.

Impacted fetal head

When caesarean section is performed at full dilatation it may be difficult to deliver the head from the pelvis. It is good practice to perform a vaginal examination in the operating theatre prior to surgery. Confirmation of fetal position and station can inform the method of delivery.

Resident Consultant to be present in theatre for full dilatation LSCS and communicate the problem to the multidisciplinary team.

First try lowering the operating table and/or standing on a step to gain extra height. The right or left hand can be used with a straight arm to reach beneath the fetal head to flex it and bring it up out of the pelvis. The Trendelenburg position may also be helpful.

Terbutaline 250 mcg s/c to be considered to relax the uterus.

An experienced assistant may be able to flex and disimpact the head from below, should use whole hand, not just tips of fingers. There is a risk of causing skull fractures.

An alternative is to deliver the baby by breech extraction, and this may require an extension of the uterine incision (J or T shape).

Umbilical vessel pH measurement

Umbilical vessel pH levels should be taken after all category 1-3 CS and category 4 CS if there is suspected fetal compromise or a breech presentation. This allows review of fetal wellbeing and guides ongoing care of the baby. These paired cord gas samples should be taken as soon as reasonably possible after delivery of the placenta.

Thermal care for babies born by CS

Babies born by CS are more likely to have a lower temperature, and thermal care should be in accordance with good practice for thermal care of the newborn baby. Offer early skin to skin contact.

Give according to the Trust guideline Thromboprophylaxis and treatment of venous thromboembolism in pregnancy and puerperium. When indicated, the thromboprophylactic dose of LMWH should be given 4 hours after spinal anaesthetic or removal of epidural catheter and when there is no immediate risk of postpartum haemorrhage.

All women are transferred back to labour ward or recovery for the immediate recovery period after CS until stable enough for transfer to the postnatal ward.

During the recovery period from anaesthesia, regular observations should be performed including:

• BP and Pulse

• Temperature

• Respiratory rate

• Oxygen saturation

• Level of sedation

• Lochia or blood loss

• Abdominal incision site

• Uterine size and tone

• Fluid balance

• Adequacy of analgesia

The epidural catheter should be removed from the patient before transfer to postnatal ward.

Observations should be taken and recorded on MEOWS chart:

• On admission to the postnatal ward

• Every 30 mins for 2 hrs

• Every 60 minutes for the following 2 hours (until 4 hrs following PN ward admission)

• Every 4 hrs thereafter.

During the recovery period, provided the mother is conscious and stable encourage early skin-to-skin contact between the woman and her baby and offer support to initiate breastfeeding.

See Anaesthesia for caesarean section for guidance on post-operative analgesia.

Eating and drinking after CS

Women who are recovering well after CS and who do not have complications can eat and drink when they feel hungry or thirsty. For patients who have had a complicated surgical procedure, medical personnel should establish the return of bowel sounds before offering food to the patient.

Urinary catheter removal after CS

See Intrapartum and Postpartum Bladder Care. Note that after emergency CS, the urinary catheter should stay in for 12 hours post-operatively, unless stated otherwise.

Contraception

Contraception to be discussed in the postnatal ward rounds and about pregnancy intervals post CS and allowing for 18 months - 2 years recovery.

Debriefing the patient

Prior to discharge from hospital the woman should be given the opportunity to discuss with healthcare professionals the events surrounding the delivery and the reasons for the CS. They should also be provided with information about birth options for any future pregnancies. Women will be reviewed by an anesthetist the day after their regional anesthetic.

Postnatal wound care

Remove honeycomb dressing after 5 days, negative pressure dressing after 28 days.

Follow surgeon’s instructions for the removal of non-absorbable suture material.

Background

The core ethos of enhanced recovery is to speed up a patient’s recovery after surgery and improve patient outcomes, with associated benefits for staff and healthcare systems. The aim of enhanced recovery is to optimise multiple aspects of patient care to improve recovery and so facilitate earlier discharge.

Inclusion criteria

All elective caesarean sections unless excluded by the surgeon.

Some women who have a category 3 CS may be suitable for the enhanced recovery programme and this should be considered on an individual basis.

Antenatal

Elective Caesarean section agreed:

• Obstetrician to discuss early normalisation and expectation regarding discharge.

Preoperative appointment: midwife/ anaesthetist

Discuss pain relief, the possibility of nausea and vomiting, catheter removal and mobilisation.

Reaffirm expectation regarding normality and discharge.

On the day of surgery

Midwife to discuss expectations around normalisation (i.e., feeding, catheter removal) / mobilisation / discharge.

Theatre team to inform the ward of delays to the list to allow hydration (IV/Oral) if CS is delayed.

Anaesthetist

Regional anaesthesia with intrathecal opioids.

Consider TAP (transverse abdominis plane) block after a GA.

Small amount of intravenous fluids at CS.

An under patient heating blanket should be used.

Anti-emetics to be administered routinely.

IV down before transfer to recovery.

Obstetrician

SHO to complete discharge letter in theatre.

Midwife

Facilitate skin to skin contact in theatre because early skin-to-skin contact improves breastfeeding success.

In recovery

Baby to be fed in recovery. Encourage the woman to drink in recovery.

Patient on the ward

Encourage to eat and drink normally.

Regular analgesia and patient allocated oral opioids (oramorph regime)

Offer regular analgesia as described in Anaesthesia for Caesarean Section.

Review after approximately 4- 6 hours to assess spinal has worn off (can be done sooner at patient request)

Remove catheter 6 hours after surgery if the spinal has worn off enough for the woman to get up and walk to the toilet.

Patient out of bed and in a chair with baby.

Day 1

Early midwifery and obstetric reviews

NIPE (newborn infant physical examination) and hearing examination to be completed

Ensure any TTOs which may be needed are available.

Subsequent time in hospital

The time of discharge is aimed at 24-36 hours after the operation. This is suitable if there are no medical or midwifery concerns and the patient has support at home. The woman should be given information about the Maternity triage and asked to attend in 24 hours if there are any concerns.

If there are communication issues (e.g., English as a second language, learning difficulties, blindness/partial sightedness, deafness) staff will take appropriate measures to ensure the patient (and her partner, if appropriate) understand the actions and rationale behind them.

The latest ratified version of this guidance will be posted on the Trust's guidelines platform for all members of staff to view. A notice will be placed on the intranet and the ‘In Touch’ newsletter informing Maternity staff of version changes. New members of Maternity staff will be signposted to how to find and access this guidance at Induction.

Audit will be as per the maternity annual audit plan

Auditable standards for enhanced recovery

Met criteria for inclusion in the enhanced recovery programme.

Urinary catheter removed six hours after delivery.

Auditable standards

• Classification and timings of caesarean sections are as described within this guidance

• The reason for performing an emergency caesarean section is recorded in the maternity notes by the person making the decision, and a consultant is included in the decision making process

• Any reasons for delay in undertaking the CS are documented

• All women undergoing CS are given antibiotics and thromboprophylaxis (anti embolism stockings +/- low molecular weight heparin)

• All women undergoing emergency caesarean section will be monitored in the appropriate location at the specified intervals.

• The implications for future deliveries will be discussed with all women undergoing caesarean section prior to discharge and the discussion documented in the maternity notes

This will be achieved through:

• Continuous audit of all caesarean sections presented at monthly academic half days.

• Daily reviews of all emergency caesarean sections performed in the last 24 hours.

• Monthly report and discussions of issues affecting caesarean section rates at labour ward forum and action plans developed as necessary.

• Quarterly report to the obstetric clinical governance group to monitor implementation and completion of action plans.

National Institute for Health and Care Excellence [NICE] (2021) Caesarean birth. NG192. Available at: https://www.nice.org.uk/guidance/ng192 (Accessed: 18 September 2023). National Institute for Health and Care

Royal College of Obstetricians and Gynaecologists [RCOG] (2022) Antenatal corticosteroids to reduce neonatal morbidity and mortality. Green-top Guideline No.74.

Stutchfield, P. et al. (2005) ' Antenatal betamethasone and incidence of neonatal respiratory distress after elective caesarean section: pragmatic randomised trial', The British Medical Journal, 331(662).

Vousden, N. et al. (2014) Caesarean section at full dilatation: incidence, impact and current management, The Obstetrician & Gynaecologist, 16(3), pp. 199-205. Available at: https://doi.org/10.1111/tog.12112 (Accessed: 19 September 2021).

Tan, P. C., Norazilah, M. J. and Omar, S. Z. (2012) Hospital discharge on the first compared with the second day after a planned cesarean delivery: a randomized controlled trial, Obstetrics & Gynecology, 120(6), pp. 1273-1282. Available at: https://doi.org/10.1097/aog.0b013e3182723a95

Dickinson, J. E. (1999) 'Caesarean section', in James, D. K. et al. High risk pregnancy: Management options. London: Saunders, W. B. pp. 1217-1229. Harper, C. M. and Alexander, R. (2006) Hypothermia and spinal anaesthesia, Anaesthesia, 61(6), p.612. Available at: https://doi.org/10.1111/j.1365-2044.2006.04668.x

Hui, C. K. et al. (2006) A randomised double-blind controlled study evaluating the hypothermic effect of 150μg morphine during spinal anaesthesia for Caesarean section, Anaesthesia, 61(1), pp. 29-31. Available at: https://doi.org/10.1111/j.1365-2044.2005.04466.x

Hutton, E. K and Hassan, E. S. (2007) Late vs early clamping of the umbilical cord in full-term neonates: systematic review and meta-analysis of controlled trials, JAMA: The Journal of the American Medical Association, 297(11), pp. 1241-1252. Available at: https://doi.org/10.1001/jama.297.11.1241

Lucas, D. N. and Gough, K. L. (2013) Enhanced recovery in obstetrics - - a new frontier? International Journal of Obstetric Anesthesia, 22(2), pp. 92-95. Available at: https://doi.org/10.1016/j.ijoa.2013.02.001 (Accessed: 19 September 2023).

McDonald, S. J. et al. (2013) Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes, Cochrane Database of Systematic Reviews, 7, CD004074. Available at: https://doi.org/10.1002/14651858.cd004074.pub3 (Accessed: 19 September 2023).

MacKenzie, I. Z. and Cooke, I. (2001) Prospective 12 month study of 30 minute decision to delivery intervals for “emergency” caesarean section, The British Medical Journal, 322(7298), pp. 1334-1335. Available at: https://doi.org/10.1136%2Fbmj.322.7298.1334 (Accessed: 19 September 2023).

Moore, E. R. et al. (2012) Early skin-to-skin contact for mothers and their healthy newborn infants, Cochrane Database of Systematic Reviews, 5, CD003519. Available at: https://doi.org/10.1002/14651858.CD003519.pub3

Niranjan, N., Bolton, T. and Berry, C. (2010) Enhanced recovery after surgery - current trends in perioperative care, Update in Anaesthesia, 26(1), pp. 18-23. Available at: https://e-safe-anaesthesia.org/e_library/05/Enhanced_recovery-after-surgery_Update_2010.pdf

National Health Service [NHS]. Commissioning for Quality and Innovation. Available at: https://www.england.nhs.uk/nhs-standard-contract/cquin/

Thomas, J., Paranjothy, S. and James, D. (2004) National cross sectional survey to determine whether the decision to delivery interval is critical in emergency caesarean section, The British Medical Journal, 328(7441), p. 665> Available at: https://doi.org/10.1136/bmj.38031.775845.7C

Prior, E. et al. (2012) Breastfeeding after cesarean delivery: a systematic review and meta-analysis of world literature, The American Journal of Clinical Nutrition, 95(5), pp. 1113-1135. Accessible at: https://doi.org/10.3945/ajcn.111.030254

Royal College of Obstetricians and Gynaecologists [RCOG] (2015) Reducing the Risk of Thrombosis and Embolism during Pregnancy and the Puerperium. Green-top Guideline No. 37a. Available at: https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/reducing-the-risk-of-thrombosis-and-embolism-during-pregnancy-and-the-puerperium-green-top-guideline-no-37a/

Royal College of Obstetricians and Gynaecologists [RCOG] (2016) Prevention and Management of Postpartum Haemorrhage. Green-top Guideline No.52. Available at: https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/prevention-and-management-of-postpartum-haemorrhage-green-top-guideline-no-52/

Varadhan, K. K. et al. (2010). The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials, Clinical Nutrition, 29(4), pp. 431-340. Available at: https://doi.org/10.1016/j.clnu.2010.01.004

Vickers, R. and Das, B. Enhanced recovery in obstetrics, International Journal of Obstetric Anesthesia, 22(4), p.349. Available at: https://doi.org/10.1016/j.ijoa.2013.05.011

Wee, M., Brown, H. and Reynolds, F. (2005) The National Institute of Clinical Excellence (NICE) guidelines for caesarean sections: implications for the anaesthetist, International Journal of Obstetric Anesthesia, 14(2), pp. 147-158. Available at: https://doi.org/10.1016/j.ijoa.2004.09.008

1. Background

World Health Organisation recommends vaginal cleansing with povidone-iodine immediately before Caesarean section¹. The evidence² indicates an overall reduction of post-Caesarean endometritis by 59%. The risk decreases by 65% in emergency Caesarean sections and by 14% in elective Caesarean sections. Additionally, there is a 36% decrease in post-operative fever, 38% decrease in post-operative wound infection and a 54% decrease in composite wound complications. Vaginal cleansing solutions, such as chlorhexidine and povidone‐iodine, have very few side effects in general, with low rates of noted allergies or irritation symptoms².

2. Method of vaginal cleansing

• Vaginal cleansing with chlorhexidine solution should be performed before elective and emergency caesarean sections at the time of urinary catheter insertion in theatre.

• Use a swab soaked in chlorhexidine to clean in the following order: the labia majora, labia minora and urethra. 

• Using a sponge holder and mounted swab soaked in chlorhexidine, insert once into the vagina and rotate for 30 seconds.

• Remove from the vagina and count swabs.

• Proceed with urinary catheter insertion. 

• Document on EPIC that vaginal cleansing has been performed.

3. Contraindications

• Category 1 emergency Caesarean sections due to time restriction (cord prolapse, abruption, uterine rupture)

• Patient not consenting to the procedure.

4. Auditable standards

• Verbal consent has been obtained and documented.

• Post-Caesarean infection rate (endometritis, post-op fever and wound infection).

• Allergies/adverse reactions.

5. References

6. WHO Recommendations for Prevention and Treatment of Maternal Peripartum Infections

7. Haas DM, Morgan S, Contreras K, Kimball S. Vaginal preparation with antiseptic solution before caesarean section for preventing postoperative infections. Cochrane Database of Systematic Reviews 2020, Issue 4.

CONSENT FORM 1

Patient agreement to investigation or treatment

NAME

DATE OF BIRTH

HOSPITAL NUMBER

NAME OF PROPOSED PROCEDURE OR COURSE OF TREATMENT

Caesarean section

STATEMENT OF HEALTH PROFESSIONAL

I have explained the procedure to the patient. I have explained this is for safe delivery of baby and placenta through the cut in the tummy

THE INTENDED BENEFIT

Delivery of the baby and placenta

SERIOUS OR FREQUENT OCCURING RISK

Serious risks include:

• fetal injury lacerations (2.0%)

• admission to intensive care unit (0.9%)

• emergency hysterectomy (7 to 8 in every 1000 women; uncommon)

• need for further surgery at a later date (5 in every 1000 women; uncommon)

• bladder injury (1 in every 1000 women; rare)

• ureteric injury (3 in every 1000 women; rare)

• death (approximately 1 in every 12 000 women; extremely rare).

Frequent maternal risks include:

• persistent wound and abdominal discomfort in the first few months after surgery (9 in every 100 women; common)

• increased risk of repeat caesarean section for subsequent pregnancies (1 in every 4 women; extremely common)

• readmission to hospital (5 women in every 100 women; common)

• haemorrhage (5 in every 1000 women; uncommon)

• infection 6 in every 100 women (common).

Frequent fetal risks include:

• lacerations (1 to 2 in every 100 babies; common).

Any extra procedures which may be necessary during the procedure:

• BLOOD TRANSFUSION

• OTHER PROCEDURES-

1. Repair of any injuries

2. B Lynch

3. Bakri balloon

4. Hysterectomy

I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments (including no treatment) and any particular concerns of this patient.

The following leaflet / tape has been provided (direct hyperlinks are not available at this time, in order to view or print linked leaflets, highlight link text.

This procedure will involve:

General anaesthesia

Regional anaesthesia

Local anaesthesia

Sedation

Signed by

Contact details (if the patient wishes to discuss options later)

Statement of interpreter (where appropriate)

Statement of patient

I agree

I understand

I understand

I have been told

Patient name and Signature

Witness name and Signature

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

Version History

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