Having read this chapter, the reader should be able to:
A surgical procedure is that in which there is excision of tissue, penetration of the skin or closure of a previous wound. It takes place in an operating theatre (a ‘sterile’ environment) (WHO 2009). Midwives care for and support women and their families who deliver by caesarean section (CS), but women may also undergo procedures such as manual removal of placenta, perineal repair, abscess drainage, and cervical suture removal. In 2013, Birth Choice UK reported that CS births accounted for 25% of deliveries in England, of which 10% were planned CSs and 15% emergencies (BirthChoiceUK 2013). The US has an even higher rate, the Centers for Disease Control and Prevention (CDC 2013) recorded a CS rate of 32.7% in 2013. The midwife has a significant role in caring safely for the woman before, during and after surgery.
This chapter considers care prior to elective and emergency surgery, intraoperative care and postoperative recovery care. It focuses largely upon CS, but the principles may be applied to other types of surgery.
Care in theatre is specialized care, requiring cooperative teamwork between all the professional groups involved (Yentis & Clyburn 2014). The midwife may take on a number of different roles (e.g. pre- or postoperative care, theatre scrub nurse or runner, recovery care) for which competency should be assessed and maintained.
Reducing CS rates
No surgery is without risks. The postnatal complications of pain and immobility can affect the woman’s early parenting skills and attachment with her baby (NCT 2011). Thromboembolism, infection and haemorrhage all feature as significant causes of maternal death (for which the risks are increased after CS) (Knight et al 2014). A uterine scar can affect future pregnancies (increased risks of uterine rupture and placenta praevia), and the baby, too, can experience adverse effects, e.g. lacerations, poor respiratory response and less effective temperature control (NICE 2011). These issues are just a snapshot; delivery by CS should have the decision made with a consultant obstetrician and a clear clinical reason documented (NICE 2011). Reducing the CS rate reduces the overall risks for the woman and her baby, as well as the financial and other demands on the service.
NICE (2011) recommend several factors that can reduce the incidence of CS:
• less use of electronic fetal heart rate monitoring. Suspected abnormal fetal heart rate patterns should instigate fetal blood sampling (where possible and appropriate) to confirm whether early delivery is required or not
• Other measures such as an increase in homebirth, use of birthing centres, supporting women who choose vaginal birth after caesarean (VBAC), and the use of external cephalic version for breech presentations can also reduce the incidence of CS.
In the UK, CS is categorized in one of four ways:
For the purposes of audit, a category 1 CS should take place within 30 minutes of the decision, category 2, 75 minutes (NICE 2011).
Indications for planned CS (NICE 2011)
There are other reasons why CS is considered, these include previous pelvic floor or anal sphincter damage, previous shoulder dystocia, and previous CS with a classical scar. Wherever possible, planned CS is undertaken after 39 weeks’ gestation. The list above, and the reasons often cited for category 1 and 2 CS (pre-eclampsia, fetal compromise antepartum haemorrhage, failure to progress, previous CS etc.), would suggest that there are often risk factors present before surgery takes place. Good preparation for surgery, whether rushed or completed at leisure, aims primarily to facilitate uneventful surgery and smooth postoperative recovery.
Preparation for surgery
For planned surgery the woman should be given the opportunity to discuss the practicalities, i.e. preparations beforehand, what to bring, when to come, what will happen at each different stage of the process, and have the opportunity to have her questions answered. Given that approximately one in four babies are delivered by CS, antenatal education should help all prospective parents to understand delivery in this way, whether planned or unexpected.
Consultation with obstetrician and anaesthetist
Each woman should be seen by a consultant obstetrician (see above). It is in conjunction with the woman and after detailed discussion of the risks and benefits of CS that the decision is made. The woman is asked to sign a consent form (verbal consent may be acceptable in some circumstances); this may be relatively stress free for planned surgery, but may be very difficult if surgery is being contemplated hurriedly. The midwife should work to support the woman in making her decision, whatever that may be (Charles 2013). The woman should also see an anaesthetist prior to surgery. The woman’s health, reason for surgery and suitability for chosen anaesthetic are all assessed (ASA 2007, AAGBI & OAA 2005). NICE (2011) recommend offering all women regional anaesthesia (spinal or epidural), the risks being less than with a general anaesthetic.
A full blood count will confirm the haemoglobin level. Other haematology screening (group and saving of serum, cross-matching, and clotting screening) and ultrasonic location of the placenta are not routinely required (NICE 2011) for healthy women with uncomplicated pregnancies. If heavy blood loss is anticipated, e.g. placenta praevia, cross-matching would take place prior to surgery. This and other high-risk CS must take place in a location where blood transfusion services are readily available. Other investigations may be ordered as indicated (e.g. chest X-ray). The midwife will undertake an antenatal assessment and baseline vital sign observations. These are charted on a Modified Early Obstetric Warning Score (MEOWS) chart in preparation for postoperative assessment and comparison. Allergies (e.g. to latex, antibiotics, etc.) should be carefully documented and the whole team made fully aware.
Care of the gastrointestinal tract
Fasting prior to surgery is indicated so that the risk of aspiration is reduced; however, it is advisable to continue to take prescribed medication with clear fluid unless contraindicated (Crenshaw & Winslow 2006). It takes approximately 6–8 hours for the stomach to be empty from food, and 2–3 hours for fluids (ASA 2007, Scott et al 1999). However, pregnancy, labour, some drugs (e.g. pethidine) and anxiety can all delay gastric emptying; nevertheless, starvation for periods of longer than 6 hours is unnecessary and distressing for the woman. Antacid therapy or H2 antagonists are given so that the gastric acid will be less acidic and reduced in volume, respectively. NICE (2011) recommend that all women should be offered this therapy. Often the woman takes these medications orally the evening before and the morning of surgery. An anti-emetic may also be included to reduce nausea. An intravenous (I.V.) infusion will be sited prior to the surgery, particularly if preloading is required for regional anaesthesia to reduce the risk of hypotension (ASA 2007). Good hydration also reduces the risks of thromboembolism.
Premedication are drugs administered prior to surgery in preparation for, or as part of, the anaesthetic. They may be prescribed in any form according to need – relaxant, antiemetic, analgesic, etc. The most likely premedication in the maternity setting are the antacid/H2 antagonists and/or anti-emetics described above. Other drugs would be administered with caution, anticipating their transfer across the placenta. It becomes important, therefore, that a premedication is given at the prescribed time, and that the anaesthetist is informed if for some reason the surgery is then delayed.
In an attempt to reduce postoperative wound infections, preoperative skin preparation is indicated. This is discussed in Chapter 52 but remains a largely inconclusive science. The woman, as a minimal requirement, should take a shower. She will wear a gown, without any underwear, particularly noting that bras may reduce chest expansion and have metal components that may interact with other theatre equipment. She is asked not to use deodorant or talcum powder, both of which may be flammable. All make-up is removed, so that the actual colour of her nail beds and mucous membranes may be seen in order to recognize any cyanosis.
Hair removal from the wound site remains controversial; it is considered that if the hair is interfering with the wound or adhesive dressing then it should be removed. Shaving causes microabrasions on the skin that microorganisms can then colonize; shaving should be avoided (Jose & Dignon 2013). Better methods for hair removal are disposable head electric clippers or depilatory creams. NICE (2013) recommend that if hair does need removing, electric clippers with a single-use head should be used on the day of surgery by healthcare personnel. Women should be made aware that they themselves should not undertake any pubic hair removal.