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cesarean birth: procedural aspects: NICE2021
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cesarean birth: procedural aspects: NICE2021
1.
CAESAREAN BIRTH PROCEDURAL ASPECTS NICE guideline, March 2021 Prof Aboubakr Elnashar Benha university Hospital ABOUBAKR ELNASHAR PROCEDURAL ASPECTS OF CS ▪ Timing of planned CS: Do not routinely carry out planned CS before 39 w, as this can increase the risk of respiratory morbidity in babies. ▪ Classification of urgency for CS • Category 1. Immediate threat to the life of the woman or fetus (for example, suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia). • Category 2. Maternal or fetal compromise which is not immediately life-threatening. • Category 3. No maternal or f compromise but needs early birth. • Category 4. Birth timed to suit woman or healthcare provider. ABOUBAKR ELNASHAR
2.
▪ Decision-to-birth interval for unplanned and emergency CS ▪ Category 1: when there is immediate threat to the life of the woman or fetus ▪ Category 2: when there is maternal or fetal compromise which is not immediately life-threatening. ▪ Perform category 1 CS as soon as possible, and in most situations within 30 minutes of making the decision. ▪ Perform category 2 CS as soon as possible, and 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 birth. ▪ Rapid birth can be harmful in certain circumstances. ABOUBAKR ELNASHAR ▪ Preoperative testing and preparation for caesarean birth ▪ Carry out: ▪ CBC to identify anaemia, ▪ antibody screening, and ▪ blood grouping with saving of serum. ▪ Do not routinely carry out: • cross-matching of blood • clotting screen • preoperative US for localisation of the placenta. ▪ Carry out CS for antepartum hage, abruption or pl praevia at a maternity unit with on-site blood transfusion services,{at increased risk of blood loss of more than 1,000 ml}. ▪ With regional anaesthesia an indwelling u catheter to prevent over-distension of the bladder. ABOUBAKR ELNASHAR
3.
▪ Anaesthesia for CS ▪ Provide pregnant women having a CS with information on the different types of post-CS analgesia, so that they can make an informed choice ▪ Offer women who are having CS regional anaesthesia in preference to general anaesthesia, including women who have a diagnosis of placenta praevia ▪ Carry out induction of anaesthesia, including regional anaesthesia, for CS in theatre. ▪ 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. ABOUBAKR ELNASHAR ▪ Offer women who are having CS under spinal anaesthesia a prophylactic IV infusion of phenylephrine, started immediately after the spinal injection. ▪ Adjust the rate of infusion to keep maternal BP at 90% or more of baseline value and avoid decreases to less than 80% of baseline. ▪ When using phenylephrine infusion, give IV ephedrine boluses to manage hypotension during CS, for example if the HR is low and BP is less than 90% of baseline. ▪ Use IV crystalloid co-loading in addition to vasopressors to reduce the risk of hypotension occurring during CS. ABOUBAKR ELNASHAR
4.
▪ Ensure each maternity unit has a set of procedures for failed intubation during obstetric anaesthesia ▪ Offer women antacids and drugs (such as H2-receptor antagonists or proton pump inhibitors) to reduce gastric volumes and acidity before CS. ▪ Offer women having a caesarean birth anti-emetics (either pharmacological or acupressure) to reduce nausea and vomiting during CS ▪ Include pre-oxygenation, cricoid pressure and rapid sequence induction in general anaesthesia for CS to reduce the risk of aspiration. ABOUBAKR ELNASHAR ▪ Prevention and management of hypothermia and shivering ▪ Warm IV fluids (500 ml or more) and blood products used during CS to 37 degrees Celsius using a fluid warming device. ▪ Warm all irrigation fluids used during CS to 38 to 40 degrees Celsius in a thermostatically controlled cabinet. ▪ Consider forced air warming for women who shiver, feel cold, or have a temperature of less than 36 degrees Celsius during CS. ABOUBAKR ELNASHAR
5.
▪ Surgical techniques for CS ▪ Methods to reduce infectious morbidity ▪ Use alcohol-based chlorhexidine skin preparation before CS to reduce the risk of wound infections. ▪ If alcohol-based chlorhexidine skin preparation is not available, alcohol-based iodine skin preparation can be used. ▪ Use aqueous iodine vaginal preparation before CS in women with ruptured membranes to reduce the risk of endometritis. ▪ If aqueous iodine vaginal preparation is not available or is contraindicated, aqueous chlorhexidine vaginal preparation can be used. ABOUBAKR ELNASHAR ▪ Methods to prevent HIV transmission in theatre ▪ Wear double gloves when performing or assisting a caesarean birth for women who have tested positive for HIV, to reduce the risk of HIV infection of staff. ▪ Follow general recommendations for safe surgical practice during caesarean birth to reduce the risk of HIV infection of staff. ABOUBAKR ELNASHAR
6.
▪ Abdominal wall incision ▪ Transverse abdominal incision: ▪ {make postoperative pain less likely & an improved cosmetic effect compared with a midline incision}. ▪ 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). ▪ This allows for shorter operating times and reduces postoperative febrile morbidity. ABOUBAKR ELNASHAR ▪ Instruments for skin incision Do not use separate surgical knives to incise the skin and the deeper tissues, as it does not decrease wound infection. ▪ Extension of the uterine incision When there is a well formed LUS, use blunt rather than sharp extension of the uterine incision to reduce blood loss, incidences of postpartum hge and the need for transfusion ▪ Fetal laceration Inform women that the risk of fetal lacerations is about 2%. ▪ Use of forceps Only use forceps if there is difficulty delivering the baby's head. The effect on neonatal morbidity of the routine use of forceps remains uncertain. ABOUBAKR ELNASHAR
7.
▪ Use of uterotonics Use oxytocin 5 IU by slow IV injection to encourage contraction of the uterus and decrease blood loss. ▪ Method of placental removal Remove the placenta using controlled cord traction and not manual removal to reduce the risk of endometritis. ▪ Exteriorisation of the uterus ▪ Perform intraperitoneal repair of the uterus for CS ▪ Routine exteriorisation of the uterus is not recommended because it is associated with more pain and does not improve operative outcomes such as hge and infection. ABOUBAKR ELNASHAR ▪ Closure of the uterus ▪ Use single layer or double layer uterine closure, depending on the clinical circumstances. ▪ Single layer closure does not increase the risk of postoperative bleeding or uterine rupture in a subsequent pregnancy. ▪ Closure of the peritoneum Do not suture the visceral or the parietal peritoneum to reduce operating time and the need for postoperative analgesia, and improve maternal satisfaction. ▪ Closure of the abdominal wall If a midline abdominal incision is used, use mass closure with slowly absorbable continuous sutures as this results in fewer incisional hernias and less dehiscence than layered closure. ABOUBAKR ELNASHAR
8.
▪ Closure of SC tissue Do not routinely close SC tissue space unless the woman has more than 2 cm SC fat, as it does not reduce the incidence of wound infection. ▪ Use of superficial wound drains Do not routinely use superficial wound drains as they do not decrease the incidence of wound infection or wound haematoma. ▪ Closure of the skin Consider using sutures rather than staples to reduce the risk of superficial wound dehiscence. ▪ Umbilical artery pH measurement Perform paired umbilical artery and vein measurements of cord blood gases after CS for suspected fetal compromise, to allow for assessment of fetal wellbeing and guide ongoing care of the baby. ABOUBAKR ELNASHAR ▪ Timing of antibiotic administration Offer women prophylactic antibiotics before skin incision, choosing antibiotics that are effective against endometritis, UTI and wound infections. ▪ Inform women that: endometritis, UTI and wound infections occur in about 8% of women who have had CS using prophylactic antibiotics before skin incision reduces the risk of maternal infection more than prophylactic antibiotics given after skin incision, and that there is no known effect on the baby ▪ Do not use co-amoxiclav when giving prophylactic antibiotics before skin incision ABOUBAKR ELNASHAR
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▪ Thromboprophylaxis ▪ Offer thromboprophylaxis ▪ Take into account the risk of thromboembolic disease when choosing the method of prophylaxis ▪ graduated stockings, ▪ hydration, ▪ early mobilisation, ▪ low molecular weight heparin ▪ Women's preferences during caesarean birth Accommodate a woman's preferences whenever 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. ABOUBAKR ELNASHAR
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