Version: 2 Title: Conduct of Anaesthesia for Caesarean Section Page 1 of 28 Date: 20/01/2016 Next Review Date: December 2018 Conduct of anaesthesia for caesarean section Document type: Clinical Guideline Version: 2 Author (name and designation) Dr S Kimber Craig, Consultant Anaesthetist & Clinical Lead for Obstetrics (based on previous version written by Dr L McManamon, Dr A Putland and Dr J Roberts, Consultant Anaesthetists) Author (designation): As Above Ratified by: Women’s Quality Forum Date ratified: 12/01/2016 Ratified by: Clinical Governance & Assurance Committee Date ratified: 03/02/2016 Name of responsible committee/individual: Women’s Quality Forum Name of Executive Lead: Master Document Controller: Helen Bailey, WQF Secretary Date uploaded to intranet: 03/02/2016 Key Words: Caesarean, emergency, category 1, general anaesthesia, regional anaesthesia. Review date: December 2018 Version control Version Type of Change Date Revisions from previous issues 2 Update June 2015 Updates to include new national guidance and recommendations from MBRRACAE-UK report Equality Impact Bolton NHS Foundation Trust strives to ensure equality of opportunity for all service users, local people and the workforce. As an employer and a provider of healthcare Bolton NHS FT aims to ensure that none are placed at a disadvantage as a result of its policies and procedures. This document has therefore been equality impact assessed to ensure fairness and consistency for all those covered by it regardless of their individuality. The results are shown in the Equality Impact Assessment (EIA).
Transcript
Version: 2 Title: Conduct of Anaesthesia for Caesarean Section Page 1 of 28 Date: 20/01/2016 Next Review Date: December 2018
Conduct of anaesthesia for caesarean section Document type: Clinical Guideline
Version: 2
Author (name and designation) Dr S Kimber Craig, Consultant Anaesthetist & Clinical Lead for Obstetrics (based on previous version written by Dr L McManamon, Dr A Putland and Dr J Roberts, Consultant Anaesthetists)
Name of responsible committee/individual: Women’s Quality Forum
Name of Executive Lead:
Master Document Controller: Helen Bailey, WQF Secretary
Date uploaded to intranet: 03/02/2016
Key Words: Caesarean, emergency, category 1, general anaesthesia, regional anaesthesia.
Review date: December 2018
Version control Version Type of Change Date Revisions from previous issues
2 Update June 2015 Updates to include new national guidance and recommendations from MBRRACAE-UK report
Equality Impact
Bolton NHS Foundation Trust strives to ensure equality of opportunity for all service users, local people and the workforce. As an employer and a provider of healthcare Bolton NHS FT aims to ensure that none are placed at a disadvantage as a result of its policies and procedures. This document has therefore been equality impact assessed to ensure fairness and consistency for all those covered by it regardless of their individuality. The results are shown in the Equality Impact Assessment (EIA).
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Equality Impact Assessment Tool ...................................................................................... 26 Document Development Checklist………………………………………...……………………26
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Introduction 1. Anaesthesia for caesarean delivery, whilst generally safe, poses certain risks for
the patients. It is paramount that we used evidence-based care in our management of women requiring this type of delivery. This document aims to outline the standards of care expected for women requiring this type of delivery at Bolton NHS Foundation Trust.
Purpose 2. Caesarean section is the mode of delivery in around 1:4-1:5 women in this Trust.
The following document offers guidelines for the safe conduct of general, spinal and epidural anaesthesia for caesarean section. It is relevant for all anaesthetic staff working on Central Delivery Suite and is available for obstetric and midwifery staff to support their understanding of the process of anaesthetising women for caesarean delivery. Staff that are new to the Trust should find it useful to support their move and appreciate any differences in practice compared with their previous workplace.
3. This clinical guideline outlines the preparation and processes of delivering safe
anaesthesia for caesarean delivery in this Trust in both emergency and elective situations. Important standards to be met are outlined and some areas of best practice are defined. It is a guideline and some deviation is to be expected; in circumstances where staff choose to deviate from the specified standards, the rationale for this decision should be explained.
4. This document should be used in conjunction with other relevant guidance,
including: x Caesarean Section clinical guideline (produced by the obstetric team) x Thromboprophylaxis in pregnancy x Guidelines for the use of regional analgesia in labour and identification and
management of its complications x Guideline for the postoperative recovery of obstetric patients
Terminology and Definitions
Definitions 5. The following definitions are used in this document:
x Anaesthetic assistant – a trained nurse or Operating Department Practitioner (ODP) with appropriate obstetric experience
x Decision-to-delivery interval – time between the decision to deliver the baby and the time of delivery
x K2 monitoring system – this is the integrated electronic CTG monitoring system and the woman’s birth record used on CDS
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Abbreviations 6. These abbreviations are used:
ANTT Aseptic non-touch technique
BP Blood pressure CD Caesarean delivery
CDS Central Delivery Suite CSE Combined spinal-epidural CTG Cardiotocography DAS Difficult Airway Society DDI Decision to delivery interval FBC Full blood count GA General anaesthesia HR Heart rate
MDT Multidisciplinary team OAA Obstetric Anaesthetists' Association
PDPH Post-dural puncture headache RA Regional anaesthesia
Duties and Responsibilities of Individuals and Groups 7. Anaesthetists are responsible for the safe provision of anaesthesia to women
requiring CD. They must work as part of the MDT to ensure the woman’s safety is maintained and to minimise the risks of the anaesthetic process as far as is possible. Adherence to this guideline will be audited as per the schedule in the Monitoring and review section of this document by members of the Anaesthetic Department.
8. Anaesthetic assistants’ duties are to provide support and assistance to the Anaesthetist during the preparation for and conduct of anaesthesia, to provide care to the woman and to act as part of the MDT.
9. Midwives and obstetricians should ensure effective communication with the anaesthetic team regarding relevant obstetric, medical and social details of the patient. Clear definition of the indication and the timeframe for delivery is vital.
10. The Clinical Lead for Obstetric Anaesthesia (and/or other author[s]) will be responsible for ensuring any necessary updates/changes are made to this guideline in response to newly published national standards or evidence.
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Policy Implementation 11. This is an update to the first version of this document. This version will be
reviewed by the relevant staff for comment, ratified for publication by Women’s Quality Forum and made available to staff on Qpulse, the Trust intranet and in the J:/drive on the hospital network for anaesthetists. Its publication will be communicated to all obstetric anaesthetists.
12. Monitoring will be undertaken and any appropriate changes in practice will be implemented by the Clinical Lead for Obstetric Anaesthesia and/or Labour Care Forum.
Main Content
Classification of urgency of caesarean section 13. There are four broad categories of risk defined but all staff should be aware that,
within each category, the degree of risk in individual cases can vary; this should be thought of as a continuum of risk.1
14. This variance in degree of risk requires an individual, case-by-case approach in deciding the specific DDI. Once a decision to deliver has been made, therefore, delivery should be carried out with an urgency appropriate to the risk to the baby and the safety of the mother.
15. Deliveries should be classified into the following categories:
16. DDI is a target time for delivery but it is not an absolute “cut-off” time; time for
delivery should be considered on the continuum of risk.2
17. Help should be sought from the On-call Anaesthetic Consultant and/or other anaesthetists on site in order to attain the desired DDI and to ensure patient safety, if required.
Urgency Definition (Examples of cause) Category Audit
target DDI
Maternal or fetal compromise
Immediate threat to life of woman or fetus (severe fetal bradycardia, cord prolapse, uterine rupture, FBS ≤7.2)
1 ≤30 minutes
No immediate threat to life of woman or baby (APH, FTP)
2
≤75 minutes
No maternal or fetal compromise
Requires early delivery (IUGR, failed IOL)
3
At a time to suit the woman and maternity services (Breech, previous CD)
4
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18. Good communication between midwifery staff, obstetricians and anaesthetists is of paramount importance in order to meet these targets. The Midwifery Coordinator should be made aware of all emergency CDs.
Teamworking and decision making
19. It is imperative that all members of the multidisciplinary team work together to
perform a CD. No one member or professional group can undertake this operation in isolation and there are many tasks that can be performed by any individual involved in the case (e.g. the application of Flowtron® boots).
20. Clear communication amongst team members about the indication for surgery, any concerns about the delivery or mother and other pending issues on CDS will all help with achieving a safe delivery and with resource management.
21. The involvement of senior level clinicians (e.g. Consultant Anaesthetist or Obstetrician) is always advisable where there are clinical dilemmas or concerns.
High risk women
22. Women who are identified as high risk for operative delivery antenatally should be
referred by the Obstetrician or Midwife for assessment to the Anaesthetic Antenatal Clinic3. This assessment will be recorded and available on the Obstetric Database. If they are only identified or become high risk whilst in labour or as an inpatient on the ward/CDS, the Anaesthetist on duty should be informed so that she can be reviewed.
23. For complex cases, a MDT review should be arranged. A plan of care for delivery should be agreed and circulated to all relevant staff.
24. The plan of care will depend on the woman’s individual status but the need for the following can be considered:
x Longer operating time (more than one slot to be booked) x Consultant Anaesthetist and Obstetrician involvement x Intraoperative cell salvage x Specialist advice (e.g. Haematologist/Cardiologist,Neurologist input, additional
imaging advised by the Radiologist) x Perioperative hysterectomy
25. The woman should be counselled appropriately about her relevant risks.
Preoperative preparation for CD 26. In general, the management of women prior to CD is the same in all cases, but in
emergency situations there may be some differences. This section covers all the general points that need to be done for all women and explains the caveats that may apply in deliveries where the mother or baby’s lives are at risk.
27. It is important that all women be offered information that supports them in making informed choices about their anaesthetic and that they receive high quality care.
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The amount of information that can be provided has to be balanced against the urgency of the clinical situation and the need for delivery, for either the woman or baby’s sake.
Anesthetic assessment and information for the woman
28. All women should be seen and assessed before surgery. Special emphasis
should be placed on:
x Indications for CD and obstetric history x Patient medical & anaesthetic history x Drug history including allergies x Airway assessment x Full blood count result x Position of placenta on ultrasound scan
29. In emergency situations, an AMPLE (allergies, medications, past medical history, last eaten, events leading to) history can be taken.
30. Women have the choice of either RA or GA for CD. RA has a better safety profile than GA in the pregnant population (due to concerns about the airway and the risk of desaturation in parturients)4 and tends to result in better pain relief and less blood loss.5 This, and the risks of the procedure, should be discussed with the woman.
31. Written information for women can be offered and provided where time allows. This can be found at www.labourpains.com.6
32. The plan for post-operative analgesia should be discussed with the woman (where urgency allows).
Emergency drug and equipment preparation
33. Emergency drugs should be available on CDS at all times in the Emergency Drug
Tray or drawn up at the start of each elective list. The following drugs should be prepared using an ANTT, labelled with the date and time of preparation and initialed by the doctor preparing them:
x Thiopentone 500mg in 20ml (pre-filled syringe) x Suxemethonium 100mg in 2ml x Ephedrine 30mg in 10ml x Phenylephrine 10mg in 100ml (30ml taken into 50ml syringe) x Atropine 1mg (or ensure a minijet is available)
34. No other drugs should be prepared or placed in the emergency drug tray. Do not place thiopentone ampoules in the same tray as antibiotic ampoules.
35. Emergency drugs should be handed over at shift changes or re-drawn after use for a patient.
36. The theatre and equipment must be prepared and checked as per AAGBI standards.7
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Perioperative oral intake and reducing gastric aspiration 37. For elective cases:
x Women should be encouraged to drink clear fluids until 07:00 on the morning of the operation – depending on the list order, the woman can drink water until 2 hours before the predicted time of surgery
x Women should be encouraged to eat up to 6 hours before surgery (practically, this means they should be advised to eat before they go to bed on the night before surgery)
38. For emergency cases:
x For category 3 CD, the oral intake should be as for elective cases, unless there is a clinical reason to deliver the woman sooner. Intravenous fluids should be commenced if the woman’s surgery is delayed due to workload on CDS.
x If the woman is at high risk during labour for needing an operative delivery, oral intake whilst laboring should be limited to clear fluids (water or still isotonic drinks)8. This includes: o Women with BMI >40 (or >35 with comorbidities) – 2-fold risk of CD
compared with women with normal BMI9 o Women having >1 baby o Women who, at last VE or team review, are felt to have made poor
progress in labour and who will be for CD at the next assessment if no further progress has been made
o Women with ongoing antepartum haemorrhage
x High risk women, and those who have received opiates, should also receive regular ranitidine (75mg 6 hourly) in labour.
Preoperative medication
39. To reduce the risk of aspiration pneumonitis, women should receive antacid
prophylaxis:
x Give ranitidine 50mg IM if not given orally (75-150mg) within the last 6 hours x 30ml 0.3 molar sodium citrate should be given to the woman having a general
anaesthetic on arrival in theatre
An antiemetic should be offered to all women undergoing CD. 40. Any woman at increased risk of moderate blood loss (i.e. expected to lose >500ml)
should be given tranexamic acid.10 Examples of where this would be needed include abnormal placental insertion cases or when women have had ≥2 previous CDs. Give 1g intravenously as a bolus prior to knife-to-skin. Another 1 gram can be given as an infusion over 8 hours should bleeding persist.
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VTE prophylaxis
41. Prophylaxis is indicated in all patients undergoing CD and they should all have
Flowtrons® applied in theatre (unless contraindicated).
42. Caution is required where a woman is on antenatal VTE prophylaxis therapy; ensure the time of the last dose given is known before proeceeding with RA. Timing of RA in relation to anticoagulants should be consistent with the AAGBI guidance (Appendix 1).11
Investigations
43. All women should have:
x Check haemoglobin level and ensure platelet count and white cell count – if otherwise low risk this can be from the last 3 months
x Group and save serum (taken within the preceding 72 hours)
Emergency and urgent (category 1-3) CD management 44. The Obstetrician should inform the Anaesthetist of the category of the CD, the
indication and the target time for delivery. The Anaesthetist will decide the appropriate method of anaesthesia.
45. Transfer to theatre should be expedited as soon as is safely possible.
46. The woman should be re-attached to the CTG monitor in theatre by the Midwife or Obstetrician if it was in use in the delivery room.
47. Intrauterine fetal resuscitation is advocated where there is fetal distress:
x Stop oxytocin if appropriate x Position in the left lateral position x Give high flow oxygen via a face mask if oxygen saturations are <96% x Give intravenous fluids x Tocolysis - give terbutaline 250 micrograms subcutaneously x Other specific measures (e.g. postural measures taken with cases of cord
prolapse)
Specific category 1 CD management (see also Appendix 2)
48. The "Category 1 C section" bleep should be activated by the Obstetrician or Midwifery Coordinator or by another person on their instruction – this will alert the Anaesthetist, Theatre Team and ODP:
x Call switchboard on 2222 x State: “Category 1 C section” x Give the location of the woman (e.g. “Delivery Room 2”)
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49. Do not allow unnecessary delay in transfer to theatre – the woman should receive an explanation of what is happening, surgical consent should be obtained by the Obstetrician and she should be assessed by the Anaesthetist prior to transfer to theatre (unless the Anaesthetist states differently).12
50. “Grab bags” containing a consent form, cannula & blood taking equipment (with the relevant forms) and the abbreviated "Cat 1 CS" checklist (Appendix 3) are available in the Clean Utility room. The checklist should be used prior to departure from the delivery room to ensure safe transfer to theatre.
51. The Midwife should remain with the woman until her transfer into theatre; she should hand the patient over to the theatre staff (using SBAR) at the door of theatre before going to get changed into theatre scrubs if she is not already in them.
General intraoperative management of all CDs
Woman’s preferences
52. Accommodate women’s preferences for the birth (such as music playing in theatre
or viewing delivery by dropping the screen) where possible.
53. Be supportive, where clinically feasible, of a mother’s desire to have skin-to-skin contact with her baby.
WHO Safer Surgery Checklist
54. A Sign in, Time out and Sign Out is mandatory and must be done for every patient.
Antibiotic prophylaxis 55. Prophylactic antibiotics should be given before the skin incision:
1. Intravenous co-amoxiclav 1.2g (Recommended by British Society for Antimicrobial Chemotherapy (BSAC) and approved by the Trust Microbiologist13)
2. Intravenous Clindamycin 600 mg in case of allergy to penicillin
General measures 56. The following must be placed prior to surgery, either after the spinal has been
done or whilst the patient is being preoxygenated during a GA:
x Urinary catheter x Flowtron boots (unless contraindicated) x Pressure-relieving gel pads for the legs x Strap to prevent the legs from moving during surgery
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Preparation for Induction of anaesthesia
57. An Anaesthetic Assistant must be present for induction and the entirety of the
case.
58. Gain/confirm IV access (ideally at least 16G) and commence IV fluids (caution in pre-eclamptic women on the protocol).
59. Monitor the women as per AAGBI standards.14 Ensure at least one BP measurement has been taken prior to induction of anaesthesia (whether RA or GA).
60. When supine the woman must be tilted 15o to the left until the baby is delivered.
Post-delivery drugs 61. Give oxytocin 5 units slowly after clamping of the cord (after the last cord is
clamped in a multiple delivery). If an oxytocin infusion is required, infuse 30 international units oxytocin in 500ml 0.9% saline, run at 150ml/hr (or 30 international units in 50ml 0.9% saline at 15ml/hr in fluid restricted women).
62. Give the following drugs during/at the end of surgery (providing there are no contraindications):
x Paracetamol 1g iv (substitute 1g rectal paracetamol for the iv dose in fluid restricted women)
x 100mg rectal diclofenac
Regional anaesthesia for CD
Spinal anaesthesia 63. Pre-loading with fluid is not necessary in the cardiovascularly stable woman.15
64. The woman’s skin should be prepared using 0.5% chlorhexidine spray. This must be allowed to dry to be effective. (Wiping the skin after the first spray and then re-spraying may augment the bacterial decontamination.) Chloraprep® wands should not be used as they contain 2% chlorhexidine which has the potential to be toxic to neural tissue.16
65. Using a strict sterile technique (i.e. hat, gown, gloves, mask, drapes), an intrathecal injection using a 24G-27G pencil point needle should be done. Give 300mcg diamorphine with an appropriate dose of Heavy Marcain. The dose of local anaesthetic should take into account:
x Extreme prematurity or very small for gestational age babies (increase dose) x Predicted very large babies or the presence of polyhydramnios (decrease
dose) x The presence of an epidural that has been running for a long time or has
required multiple top-up boluses (be prepared for exaggerated cephalad spread)
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x Very tall or short women (may need an increased or decre ased dose or (reverse) Trendelenburg positioning to establish block height)
66. A CSE technique is an appropriate alternative to spinal anaesthesia, particularly where surgery may be prolonged or there is need to maintain strict cardiovascular stability.
67. Increase the frequency of BP recordings to every 2 minutes once the spinal is sited. Maintain this rate until the baby is delivered AND the woman’s BP is stable.
68. Intravenous fluid and drugs should be used to maintain normotension (see section on Prevention and management of hypotension).
69. It is not necessary to administer supplemental oxygen to all women; maintain oxygen saturations >94%.17
Conversion of a labour epidural to anaesthesia for CD
70. If the woman has a well-functioning epidural (confirmed by the Anaesthetist) and there is time, it can be converted to use for anaesthesia. The block achieved with the low dose mix for analgesia may appear to be high enough, but it will not be “dense” enough for CD.
71. The anaesthetic dose (“top-up”) can be administered in the delivery room providing the following are adhered to:
x The Anaesthetist remains with the woman at all times after the top-up is commenced
x Vasopressors/ionotropic drugs are immediately available x The woman and baby are monitored up to immediately prior to transfer to
theatre and that the monitoring is reapplied immediately on arrival in theatre
72. The epidural catheter should be aspirated to help detect intravascular and intrathecal placement. (Subdural migration will have a negative aspiration test.) Prior to administering any epidural top-up doses for surgery, a test dose of LA should be given (as used for establishing epidural analgesia) to reduce the risk of causing a high or total spinal block.
73. Give 0.5% levobupivacaine (maximum safe dose 2mg/kg) or 0.75% ropivacaine (maximum safe dose 3mg/kg) via the catheter. Giving the dose in 5-10ml aliquots will help prevent profound hypotension or high blocks. A volume of 15-20ml is usually required (occasionally more for levobupivacaine). A slight head down position and further 5ml bolus may be required to anaesthetise the higher thoracic dermatomes.
74. Opioids (fentanyl 100mcg or diamorphine 2.5-5mg) will improve the quality of analgesia.
75. Confirm block height and quality (including motor block of legs) prior to surgery (see Confirming block height section). Further doses of local anaesthesia can be given during surgery to augment or improve the anaesthetic blockade.
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76. Hypotension is less profound following epidural top-up compared to intrathecal anaesthesia but may still occur (see Prevention and management of hypotension section).
77. Diamorphine 2.5-5mg can be given (if not already) for post-operative analgesia. The epidural catheter should then be removed at the end of the operation, provided there is no contraindication. This should be documented on the epidural chart.
78. A PCA is not usually required if epidural diamorphine has been given.
Confirming block height 79. Bilateral loss of sensation to cold from T4, and light touch from T6, down to the
sacral roots is required for CD. Motor blockade of the legs should also be assessed.
80. Record the block height and method of assessment on the anaesthetic chart. Record the time of this assessment.
81. Record any comments the patient makes about block assessment.
Prevention and Management of Hypotension following RA 82. Hypotension following spinal anaesthetic for CD is common; it may result in
compromised placental blood flow. The woman may become symptomatic (nausea, vomiting, lightheadedness) prior to a reduced BP being measured.18
83. The aim is to maintain systolic blood pressure at pre-spinal levels19. Hypotension should be prevented by:
x Avoiding aortocaval compression x Infusion of intravenous fluids x Drugs to maintain or increase the BP - phenyleprine or ephedrine can be used
84. See Appendix 4 for the phenylephrine preparation and infusion regime.
Pain during CD
85. Pain during CD is a serious complication of RA and must be treated. If the woman
complains of pain:
x Stop the surgery – if it is safe to do so x Establish the nature of the discomfort – whether this is a painful sensation or
the usual awareness of pressure or tugging x If she confirms pain, she must be offered a GA x If she declines GA, treat her pain
86. Options for analgesia include:
x Inhaled nitrous oxide x Rapid onset systemic opioids, such as alfentanil (which can be given
intravenously in 100-250 microgram boluses), until the pain is adequately managed – inform the Midwife or Neonatologist if this is done pre-delivery
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x Alternative analgesics, such as ketamine (given in boluses of 10-20mg to achieve analgesia)
x LA infiltration of the skin at the site of incision (if this is the cause for discomfort)
87. All discussions with the patient and every intervention must be recorded on the anaesthetic chart (with timings). Document whether each intervention was effective and what further steps were taken to stop the pain if it was not effective. If possible, document the cause of pain (e.g. cleaning of the paracolic gutters). Provide explanations to the woman at the time and debrief her postoperatively.
General anaesthesia for CD 88. There is a higher incidence of airway complications during GA in pregnancy
compared with the general adult population and the women are also prone to rapid desaturation. Morbidly obese women are particularly at risk of complications.20
89. Before undertaking any GA for CD, consider with the team what actions would be taken were the intubation to be difficult or to fail entirely (as per the OAA/DAS guidelines).21 Consider whether it would be appropriate to wake the woman up or proceed with surgery with an alternative airway (e.g. LMA).
90. Administer sodium citrate (as per paragraph 39).
91. Ensure optimum positioning for intubation. In the obese, use the “ramped” position; the Oxford Head Elevating Laryngoscopy Pillow (HELP) is kept in the Theatre Store Room.
92. Pre-oxygenate the woman with a tight fitting facemask 100% O2. During preoxygenation, the following can be done:
x The general measures listed in paragraph 56 x A WHO Time Out x Skin preparation by the Surgeon
93. Use a rapid sequence induction technique; ensure adequate dosing of induction and muscle relaxants for the pregnant woman.
94. Confirm tube placement prior to surgery commencing. 95. If it is not possible to intubate the woman, follow the OAA/DAS Management of the
difficult or failed intubation in obstetric anaesthesia algorithm (see Appendix 4)21 – this is displayed in all operating theatres. Declare the critical nature of the situation to all staff in theatre and summon help (using the 2222 emergency call system):
x Theatre Anaesthetist on bleep 7404 x ICU Anaesthetist on bleep 7403 x Consultant on call during daytime on bleep 7305 x Consultant on call overnight via switchboard
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96. Adequate depth of anaesthesia must be achieved prior to knife to skin. It is usual practice to administer nitrous oxide and oxygen in a mixture with 1 MAC of volatile agent prior to delivery.
97. Administer intravenous opioid analgesia and antiemetics during surgery, after delivery of the baby (in addition to the usual medications listed in the Post-delivery drugs section). Transversus abdominus plane blocks or infiltration of the wound with local anaesthetic can be used to augment postoperative analgesia.
98. Reverse neuromuscular blockade then extubate the woman awake either sitting upright or on her left side. Consider the use of an in/out orogastric tube to empty the stomach.
Postoperative analgesia
99. Regular analgesics should be prescribed (except where a contraindication exists):
x Paracetamol 1g PO/IV qds x Ibuprofen 400mg PO qds x Codeine Phosphate 30-60mg PO qds may be prescribed in non-breastfeeding
women only
100. As required pain relief and antiemetic should also be prescribed:
x Morphine 30mg PO (maximum 4 hourly) x Ondansetron 4-8mg iv (maximum 8 hourly)
101. Ensure any doses given in theatre are documented on the wardex and that any regular doses that would exceed the maximum daily allowance are crossed off.
102. A Morphine PCA should also be prescribed for women undergoing CD without intrathecal or epidural opioid.
Postoperative Care
103. All women should be observed and monitored in Recovery on a one-to-one basis
by an appropriately trained member of staff (as per the Recovery Guidelines for CDS Theatres). Discharge back to the ward should only take place once the discharge criteria have been met.
104. The urinary catheter can be removed once the woman has begun to mobilise.
105. Flowtrons should be used until the woman is mobile and LMWH should commence between 4-6 hours after surgery as per the Thromboprophylaxis in pregnancy guideline.
Documentation and record keeping
106. The anaesthetic record should be completed in line with the national standards.22
All relevant sections should be completed. Any deviations from this Clinical Guideline document should be recorded with the reasons for that deviance.
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107. Block height and the method of assessment must be recorded (as per the Confirming block height section).
108. Document any discomfort or pain as per the Pain during CD section. Always ocument when the woman was offered a GA and record if she declined it. If the woman was comfortable throughout surgery, record this (e.g. write ‘No complaints of pain or discomfort at any stage’).
109. Record the CD in the obstetric database.
Follow-up
110. All women should be reviewed postoperatively, usually in the following 12-24 hours.23 This should be recorded in the Obstetric Database. Arrange further follow up if required.
111. Any complications of RA, such as PDPH or neuropraxia, should be managed as per the Regional Analgesia in Labour guideline.
Monitoring and Review 112. Regular audit of CD in the CDS will be undertaken as per the RCOA’s Audit
Recipe Book.24 Adherence to this policy will also be audited at least once in every three year period. The results of the audit will be considered at the Anaesthetist Department Audit Meetings and any actions will be escalated via the Labour Care Forum, Anaesthetic Governance Group and/or Women’s Quality Forum. If deficiencies in care are identified an action plan will be agreed to improve care and the Women’s Quality Forum will be responsible for monitoring the implementation of the action plan.
113. Any adverse incidents or “near misses” should be reported using the Safeguard reporting system. Escalate any issues requiring immediate attention to the Midwifery Coordinators and/or the Consultant Anaesthetist on duty.
References 1 Royal College of Obstetricians and Gynaecologists, Royal College of Anaesthetists. Classification of Urgency of Caesarean Section – a Continuum of Risk. Good Practice No 11. RCOG, London: 2010. Available at: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/good-practice-11/ [accessed 26 Nov 2015] 2 National Institute for Health and Care Excellence (2011). CG132: Caesarean section. http://www.nice.org.uk/guidance/cg132 [accessed 26 Nov 2015] 3 Association of Anaesthetists of Great Britain and Ireland, Obstetric Anaesthetists’ Association. OAA / AAGBI Guidelines for Obstetric Anaesthetic Services 2013. AAGBI/OAA, London: 2013. Available at: http://www.aagbi.org/sites/default/files/ obstetric_anaesthetic_ services_2013.pdf [accessed 26 Nov 15]
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4 Wong CA. Report of a debate held at the Society of Obstetric Anesthesia and Perinatology, 40th Annual Meeting, Chicago, USA, May 2008: General anesthesia is unacceptable for elective cesarean section. Int J Obstet Anesth 2010;19:209–217 5 Afolabi BB, Lesi FEA. Regional versus general anaesthesia for caesarean section. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD004350. DOI: 10.1002/14651858.CD004350.pub3. 6 Obstetric Anaesthetists’ Association (2015). Your anaesthetic for Caesarean section. [online] Available at: http://www.labourpains.com/ui/content/content.aspx?ID=330 [Accessed 28 Nov. 2015] 7 Association of Anaesthetists of Great Britain and Ireland. Checking Anaesthetic Equipment 2012. Anaesthesia 2012; 67: pages 660-68. Available at: http://www.aagbi.org/sites/default/files/checking _anaesthetic_equipment_2012.pdf [Accessed 28 Nov 2015] 8 National Institute for Health and Care Excellence (2014). CG190: Intrapartum care: care of healthy women and their babies during childbirth. Available at: http://www.nice.org.uk/guidance/cg190/chapter/1-recommendations#care-in-established-labour [Accessed 28 Nov 15] 9 Denison FC, Price J, Graham C, Wild S, Liston, WA. Maternal obesity, length of gestation, risk of post-dates pregnancy and spontaneous onset of labour at term. Br J Obs Gynae 2008; 115(6):720-5. doi: 10.1111/j.1471-0528.2008.01694.x. Available at: http:// onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2008.01694.x/abstract;jsessionid=C856 BE2709F41CEC53530309EB8417B5.f01t04 [Accessed 28 Nov 15] 10 National Institute for Health and Care Excellence (2015). NG24: Blood transfusion. Available at: https://www.nice.org.uk/guidance/ng24 [Accessed 19 Jan 2016] 11 W. Harrop-Griffiths et al. Regional anaesthesia and patients with abnormalities of coagulation. Anaesthesia 2013, 68, 966–972 12 Brittain M, Campbell G, Kimber Craig, S. Designing a care pathway to improve decision to delivery interval in category 1 caesarean section. Abstracts of free papers presented at the annual meeting of the Obstetric Anaesthetists’ Association, Dublin, 22 & 23 May 2014. In: IJOA 2014; 23 (S7–S62) 13 McIlmoyle K, Young S. Antibiotic timing at caesarean section. Int J Obstet Anesth 2012; 21(3):283-284 14 Association of Anaesthetists of Great Britain and Ireland. Recommendations for standards of monitoring during anaesthesia and recovery (4th ed). AAGBI, London: 2007. Available at: http://www.aagbi.org/sites/default/files/standards ofmonitoring07.pdf [Accessed 28 Nov 15] 15 Mhyre JM. What’s new in obstetric anesthesia? Int J Obstet Anesth 2011;20(2):149-159
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16 Membership of the Working Party:, Campbell, J. P., Plaat, F., Checketts, M. R., Bogod, D., Tighe, S., Moriarty, A. and Koerner, R. (2014), Safety guideline: skin antisepsis for central neuraxial blockade. Anaesthesia 2014;69:1279–1286 17 Chatmongkolchart S, Prathep S. Supplemental oxygen for caesarean section during regional anaesthesia. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD006161. DOI: 10.1002/14651858.CD006161.pub2 18 Cyna AM, Andrew M, Emmett RS, Middleton P, Simmons SW. Techniques for preventing hypotension during spinal anaesthesia for caesarean section. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD002251. DOI: 10.1002/ 14651858.CD002251.pub2. 19 Ngan Kee WD, Khaw KS, Ng FF. Comparison of phenylephrine infusion regimens for maintaining maternal blood pressure during spinal anaesthesia for Caesarean section. Br J Anaesth 2004;92(4):469-474. doi:10.1093/bja/aeh088 20 Cooper GM, McClure JH. Anaesthesia chapter from Saving Mothers' Lives; reviewing maternal deaths to make pregnancy safer. Br J Anaesth 2008;100(1):17-22. doi: 10.1093/bja/aem344 21 Mushambi MC, Kinsella SM, Popat M, Swales H, Ramaswamy KK, Winton AL, Quinn AC. Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia 2015; 70: 1286 – 1306 22 Royal College of Anaesthetists and Association of Anaesthetists of Great Britain and Ireland. Good practice - A guide for departments of anaesthesia, critical care and pain management. 3rd ed. London: RCOA/AAGBI, 2006 23 Association of Anaesthetists of Great Britain and Ireland and Obstetric Anaesthetists’ Association. OAA/AAGBI Guidelines for Obstetric Anaesthetic Services. London: OAA/AAGBI, 2013. Available at: http://www.aagbi.org/sites/default/files/obstetric _anaesthetic_services_2013.pdf [Accessed 23 Oct 2015] 24 Royal College of Anaesthetists. Raising the Standard: a compendium of audit recipes. 3rd ed. London: RCOA, 2012. Available from: http://www.rcoa.ac.uk/system/files/CSQ-ARB-2012_0.pdf [Accessed 23 Aug 2015]
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Appendices Appendix 1 – Table of recommendation related to drugs used to modify coagulation
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Appendix 2 – Management of women requiring category 1 caesarean delivery
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Appendix 4 – Master algorithm for obstetric GA and failed intubation
Reproduced from Mushambi MC, Kinsella SM, Popat M, Swales H, Ramaswamy KK, Winton AL, Quinn AC. Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia 2015; 70: 1286– 1306, with permission from Obstetric Anaesthetists’ Association / Difficult Airway Society
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Phenylephrine infusion for prevention and treatment of hypotension during caesarean delivery
PHENYLEPHRINE – DILUTED PREPARATION Using an ANTT: x Inject 10mg phenylephrine into 100ml 0.9% saline infusion bag
(100mcg/ml) x Label this with a signed sticker (including above details and date & time of
preparation)
SYRINGE FOR INFUSION: x Draw 30-40ml of the diluted phenylephrine preparation into a 50ml Luer-
lock syringe x Attach the syringe to an extension line and prime before attaching to an
anti-reflux Y-connector with the intravenous fluid on the other port (ensure any dead space is flushed)
x Fit the syringe into the syringe driver – choose PHENYLEPHRINE from the drug library
INFUSION PROTOCOL: x Never start the phenylephrine infusion prior to siting the spinal anaesthetic x Immediately following the spinal, commence the infusion at 30ml/hr x Measure BP every 2 minutes and HR continuously x Aim to keep SBP at baseline – alter the infusion rate up or down by 5ml/hr x Maximum infusion rate should not exceed 50ml/hr
DURING INFUSION: x Always consider the volaemic status of the woman – ensure adequate
intravenous fluid has been given and is infusing x If BP remains below baseline despite an increase in infusion rate, boluses
of 50-100mcg phenylephrine can be given x If SBP is less than 75% of baseline and not responding to the maximum
x Treat any associated bradycardia with glycopyrolate (200-600mg) – aim to keep the HR above 60bpm
AFTER DELIVERY: x Gradually reduce the infusion rate as tolerated x Aim to discontinue prior to leaving theatre x If the patient still requires the infusion in Recovery, instruct the nurse in
how to titrate its reduction (stickers are available to aid this)
Appendix 5 – Phenyephrine infusion protocol
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Equality Impact Assessment Tool
Yes/No Comments
1. Does the document/guidance affect one group less or more favourably than another on the basis of:
x Race No
x Ethnic origins (including gypsies and travellers) No
x Nationality No
x Gender (including gender reassignment) Yes This guideline is intended for use with women requiring caesarean delivery; it is therefore only relevant for female patients.
x Culture No
x Religion or belief No
x Sexual orientation No
x Age No
x Disability - learning disabilities, physical disability, sensory impairment and mental health problems
No
2. Is there any evidence that some groups are affected differently?
No
3. If you have identified potential discrimination, are there any valid exceptions, legal and/or justifiable?
N/A
4. Is the impact of the document/guidance likely to be negative?
No
5. If so, can the impact be avoided? N/A
6. What alternative is there to achieving the document/guidance without the impact?
N/A
7. Can we reduce the impact by taking different action?
N/A
If you have identified a potential discriminatory impact of this procedural document, please refer it to your divisional E and D lead together with any suggestions as to the action required to avoid/reduce this impact.
For advice in respect of answering the above questions, please contact Suzanne Hudson.
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Document Development Checklist
Type of document Clinical Guideline Lead author: Dr S Kimber Craig Is this new or does it replace an existing document? Replace an existing document What is the rationale/ Primary purpose for the document [Motivation for developing the document]?
To provide definition of the standard of care expected at Bolton Foundation Trust and to provide guidance to staff in how to manage women requiring caesarean section and how to manage the conduct of their anaesthetic.
What evidence/standard is the document based on? See extensive reference list – complies with NICE, MBRRACE and AAGBI/OAA/RCOA national standards and current literature, including Cochrane reviews.
Is this document being used anywhere else, locally or nationally?
Versions of guidance have been produced by other Trusts to cover this subject (which have been reviewed via the OAA website) but this particular document is specific to Bolton FT.
Who will use the document? Specifically, anaesthetists (but midwives and obstetricians may also use it) to guide their care of women undergoing a caesarean delivery.
Has a pilot run of the document taken place (optional)
This document is an update of a current document to take account of new guidance and current practice – no pilot required.
Has an evaluation taken place? What are the results (optional)
N/A
What is the implementation and dissemination plan? [How will this be shared?]
Document to be available on Q pulse and intranet, also on J:/drive for Anaesthetists. Anaesthetist staff will be asked to read and confirm that they have done so by the Clinical Lead.
How will the document be reviewed? [When, how and who will be responsible?]
As per the review schedule 3 yearly or sooner in the light of new national guidance, if relevant.
Are there any service implications? [How will any change to services be met? Resource implications?]
Document reflects current practice. No service implications identified.
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Keywords [Include keywords for the document controller to include to assist searching for the policy on the Intranet]
Caesarean, emergency, category 1, general anaesthesia, regional anaesthesia.
Staff/Stakeholders Consulted: Anaesthetists, obstetricians and midwives at Bolton FT
All documents with a pharmacy impact should be reviewed and signed by a nominated member of the pharmacy team to validate that consideration has been given to pharmacy impact
EIA: Completed.
Signed and dated By validator By ratifying officer
