Chapter 6. Postoperative care following caesarean
Introduction
The caesarean birth rate in the United Kingdom is currently 23.5% (The Information Centre 2007) – more than a fifth of all births. The challenge for midwives caring for a woman following caesarean section is to acknowledge that she has undergone not only the birth of her baby but also major surgery, both of which are significant life events. Supportive care that enables the woman to recover from her surgery while mothering her new baby requires the midwife to judge astutely when to stand back and observe and when to step in and offer assistance. Such care must be adapted to meet the needs of individual women, each having their own hopes and fears of both parenthood and recovery from surgery. This chapter describes both hospital and community postnatal care following caesarean birth, and outlines care additional to that described in Chapter 5, ‘Hospital postnatal care’.
Immediate postnatal care
Prophylactic antibiotics
Before the woman leaves theatre she will have received a prophylactic dose of antibiotics. As the Confidential Enquiry into Maternal and Child Health (CEMACH) report Saving Mothers’ Lives (Lewis 2007) states, puerperal infection is the second highest cause of maternal death, and the risk is increased following emergency caesarean section. Hofmeyr & Smaill (2002) undertook a systematic review to assess the effectiveness of antibiotic therapy in reducing the incidence of infection following caesarean delivery due to a reduction of endometritis by between two-thirds and three-quarters; they concluded that all women undergoing caesarean section should receive antibiotic therapy.
Hopkins and Smaill (1999) explored which drug regime is most appropriate: they found that ampicillin and cephalosporins had similar efficacy, and that one dose in theatre was probably sufficient. They recommended that further research be undertaken in order to clarify whether it should be given before or after the cord is clamped.
Postoperative recovery
When the woman comes out of theatre there is a period of close observation or ‘recovery’ during which regular observations of respiration, heart rate and blood pressure are made. Initially these are recorded every 5 minutes, but as the woman’s condition resumes normal parameters they will become less frequent (every 15 minutes, then half-hourly). In addition to the above observations, the woman’s temperature and level of pain are noted. Her wound will be observed for bleeding and her pad examined for assessment of lochia. An intravenous infusion will be in progress and her urinary catheter observed for the expected diuresis following childbirth. All observations should be meticulously documented and any deviation from normal reported to a senior midwife.
The woman should have one-to-one care until she can maintain her own airway, can communicate and is cardio-respiratorily stable (Association of Anaesthetists 2002, NICE 2004). Following transfer to the ward area (often labour ward initially) her observations should be recorded every half hour for 2 hours then hourly if satisfactory. It is particularly important to monitor the woman’s respiration rate if opioids have been administered (NICE 2004).
General anaesthesia
If the woman was asleep for the birth of her baby, she will require close observation as she recovers from the anaesthetic. It is important to be aware that she will be able to hear what is going on around her before she is able to talk to you. It is important, therefore, that messages about the wellbeing of the baby are conveyed to her before she opens her eyes. If her birthing partner is with her, then he should be encouraged to tell her the news about the baby. She will recognize his/her voice and this will be reassuring for her.
Following general anaesthetic the woman may be drowsy but her level of consciousness should gradually improve. She may feel nauseous, in which case the anaesthetist should be informed and anti-emetics prescribed and administered. Her level of pain should be continually assessed, and supplementary analgesia given as necessary. She should not leave the recovery area until she can maintain her own airway, is fully conscious and has nausea and pain under control (Association of Anaesthetists 2002).
Epidural/spinal anaesthesia
Following surgery under regional anaesthetic, the woman should feel comfortable and alert. She may be very tired, however, if the birth was preceded by a long labour, and may wish to rest rather than plunge into her mothering role. Until the effect of the anaesthetic wears off she will have reduced sensation in the lower half of her body and will thus not automatically be able to adjust her posture to alleviate the discomfort of pressure from the hard recovery trolley. She should therefore be assisted to change position regularly and her pressure points should be observed for evidence of redness (reactive hyperaemia).
Analgesia
Assessing pain levels is an integral part of postoperative care. The woman should be encouraged to inform a midwife as soon as any pain begins to return. This should be clearly distinguished from ‘let us know if you need any tablets’, because once this situation has been reached the woman will have expended unnecessary energy on coping with pain rather than enjoying her baby. Effective analgesia is also important to aid a safe postoperative recovery. When a woman is in pain she is less likely to be fully mobile. She may curl up around her scar and not feel comfortable enough to undertake leg and deep breathing exercises. She will be reluctant to walk to the toilet and her general level of mobility will be reduced, increasing her risk of venous thrombosis. When a woman is experiencing wound pain she may lack confidence to handle her baby and find breastfeeding too much to contemplate.
A non-steroidal anti-inflammatory drug (NSAID) given rectally in theatre has been shown to be an effective means of reducing the use of opioids postoperatively (Lim et al 2001). Subsequent pain managed with a combination of oral NSAIDs and paracetamol, rather than just oral paracetamol, has been shown to reduce the use of morphine administered via patient-controlled analgesia in the first 24 hours after caesarean (Munishankar et al 2008).
Read the recommendations in the NICE guidelines (2004) regarding analgesia following caesarean delivery.
List the contraindications for non-steroidal anti-inflammatory drugs (NSAIDs).
Continuing care
Support to mother
If the woman had a general anaesthetic, she should be reunited with her baby and partner as soon as possible. If she had a regional anaesthetic, they should not have been separated, unless the baby required resuscitation. She will need assistance to undertake her role as mother, and every effort should be made to help her achieve this in accordance with her wishes. For example, before the baby was born she may have had ideas about what she wanted the baby to be dressed in to meet its first visitors. Where appropriate, the woman should continue to make the decisions she would have made if the baby had been born vaginally. She should know how to summon help and be encouraged to do so.
Feeding the baby
Women who wish to breastfeed should be helped to do so as soon as practicable after the baby’s birth. This may mean asking the mother if she wishes to feed her baby while she is in the recovery area. This can be achieved in a lying position and will require the constant presence of a knowledgeable carer. The mother will still have an intravenous infusion in her arm at this point and will need help dealing with her theatre gown and holding her baby. The opportunity to feed the baby while she is most alert should not be missed (irrespective of method of feeding) and will give her confidence to enjoy future feeds. However, if the mother is unable to feed during this time, she should be reassured that breastfeeding will still be established.
As already mentioned, it is essential that the woman is pain free so that she can focus her attention on enjoying the feed. NSAIDs are not contraindicated during breastfeeding and during the time when opioids are more likely to be used by the mother, lactation is not established. Thus, it has been suggested that there is little evidence to support the restricted use of opioids at this time (Hestenes et al 2008).
Mobility and prophylaxis against thromboembolism
Depending on when the baby was born and on her general condition, the woman should be encouraged to get out of bed within a few hours. When sitting in a chair, the legs should be positioned on a stool to avoid additional strain on the abdominal muscles. When walking, care should be taken to ensure that the back is straight and that the woman is looking ahead, not down.
Venous thrombosis and thromboembolism (VTE) remain the highest cause of direct maternal death (Lewis 2007). The audit reported 15 postnatal direct deaths attributed to VTE, 7 of which were after caesarean section. Although abdominal surgery presents its own risk, it is the accumulation and coincidence of other risk factors that necessitate caution when caring for women who have caesarean deliveries. For example, the woman may have had a long labour and enforced immobility due to epidural analgesia prior to the birth. In the early postnatal period, she will be less mobile than a woman who has had a vaginal birth. Other factors, such as obesity, infection, multiparity and age over 35 years, also increase the risk of VTE.
Each woman should be assessed for her individual risk of VTE and offered prophylactic treatment accordingly. The Royal College of Obstetricians and Gynaecologists (RCOG 1995) recommends that women who have had elective surgery and are otherwise well with no other risk factors (i.e. low risk) should be encouraged to mobilize early and ensure adequate hydration. Women who have had emergency caesarean or who have another risk factor, such as obesity, are deemed ‘moderate risk’ and should be offered one form of prophylaxis. Women who have three or more risk factors or who have had a complicated caesarean experience are ‘high risk’ and should receive both heparin prophylaxis and possibly leg stockings.
A systematic review (Gates et al 2002) concluded that there was insufficient evidence regarding the best method of thromboprophylaxis after birth. Using decision analysis, Quinones and colleagues (2005) concluded that pneumatic compression stocking reduced the risk of VTE without increasing the risk associated with heparin prophylaxis and was the most appropriate method to use.
Fluid balance and dietary intake
The woman can drink sips of water within an hour of her baby’s birth and eat as soon as she feels hungry, provided there are no complications (NICE 2004). In a systematic review comparing early oral fluids versus delayed fluids (Mangesi & Hofmeyr 2002) the authors concluded that caesarean may not disrupt bowel function and there is no evidence to recommend withholding food or drink after caesarean. The woman’s intravenous infusion can be discontinued the day after the birth provided that her urinary output has been adequate and oral fluids have been well tolerated. The urinary catheter can also be removed the next day or as soon as the woman is mobile, at least 12 hours after her last epidural top-up (NICE 2004).
Personal hygiene
When the woman has had a chance to spend some time with her new family she may appreciate help with a refreshing wash before she is inundated with visitors. A change of clothes, face wash, brush of teeth and perineal toilet will suffice initially. On the next and subsequent days it will be easier for the woman to shower rather than bathe following surgery, as she will find it difficult to get in and out of the bath. Assistance should always be offered as she may also find it difficult to stand, walk and carry her wash things while holding her abdominal wound.
Wound care
The dressing should be removed from the wound the day after the birth and inspected to ensure that it is dry and the skin edges are in close proximity. The woman should be encouraged to look at it, as her expectations may be much worse than reality. She should be reassured that the skin will usually be healed within the week, although it will take longer for the underlying tissues to recover.
It is probably appropriate at this point to ask the woman what she understands about the process involved in order to deliver her baby abdominally. An explanation can help her understand the sensations she experienced during the birth and help dispel misconceptions.
Length of hospital stay
Length of stay following caesarean section has been reported to be between two and four days, irrespective of whether surgical birth was planned (The Information Centre 2007). However, the caesarean section clinical guideline (NICE 2004) states that women who are apyrexial, are recovering and have not had any complications can be offered early discharge (after 24 hours).
Ideally, a woman should be able to decide when she feels ready to go home. This will depend on her confidence regarding the care of her baby in conjunction with her physical capacity to undertake this role. The latter will be mediated by the support she has at home. Going home on day two is probably less feasible for a woman who has had a long labour, a general anaesthetic and a toddler to contend with than for a primigravida following elective surgery under spinal anaesthetic. However, individual women will have their own hopes, concerns and support systems. Some women enjoy being in hospital, feel reassured by the 24-hour availability of support and make lifelong friends during their stay. Other women yearn for the comfort and privacy of their own home and aim to return as soon as physically possible.
Special care babies
For some mothers, recovery from surgery is compounded by the need to visit a sick or premature baby in a special care environment. The woman had probably not anticipated needing an emergency caesarean and it may have been undertaken with little time to adjust to the idea. If the baby then required specialist care, she may be left feeling shocked and bewildered.
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