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

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.

Skin preparation

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.