51. Principles of perioperative skills
Reducing rates of caesarean section349
Preparation for surgery350
Physical preparation for elective surgery350
Role and responsibilities of the midwife355
Having read this chapter the reader should be able to:
• discuss thorough preoperative care prior to elective and emergency CS
• summarise the general principles of intraoperative care
• discuss recovery and post CS care
• summarise the midwife’s responsibilities in each role.
Caesarean section (CS) rates continue to rise within the UK with some hospitals delivering over 30% of babies by caesarean section (BirthChoiceUK 2009). Women can also attend theatre for procedures such as manual removal of placenta, perineal repair, abscess drainage and cervical suture removal. NICE (2004) lists the estimates of risks and benefits of CS, for which there are few benefits listed, and unfortunately surgery may result in fatality. 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 caesarean section, but the principles may be applied to other types of surgery.
Care in theatre is specialised care, requiring cooperative teamwork between all the professional groups involved. The midwife may take on a number of different roles (e.g. pre- or postoperative care, theatre scrub nurse or runner, recovery care).
Reducing rates of caesarean section
Reducing the risks of surgery is a significant aspect of care. If, however, the need for surgery itself can be reduced, this is highly advantageous. NICE (2004)recommend an increase in homebirth, external cephalic version for a singleton breech, continuous labour support, partogram use, availability of fetal blood sampling for suspected fetal distress, induction of labour post maturity and consultation with a consultant prior to surgery.
Preparation for surgery
Delivery by CS is very different from vaginal delivery, but is still nevertheless the precious birth of someone’s child. Some women may anticipate operative delivery to be useful in helping them to avoid the pain of labour and so psychologically prepare for surgery and the recovery afterwards. Other women may feel cheated of a labour experience and feel deeply distressed at being delivered by caesarean section, particularly if it is an emergency. Emergency surgery can also be a frightening experience in which the woman may fear for her life or that of her baby. Psychological care before, during and afterwards are all vital components of care (Wiklund et al 2008).
Physical preparation for elective surgery
Many of the physical complications that occur during or after surgery can be reduced or eradicated by careful preoperative preparation. The National Patient Safety Agency (NPSA) (2009) has adapted the World Health Organization (WHO) surgical safety checklist for use with all operative procedures across England and Wales (online copies are available from the NPSA).
Consultations with obstetrician and anaesthetist
Elective CS should be undertaken after 39 weeks gestation to reduce the baby’s risks of respiratory disorder. Each woman should be seen by an obstetrician (see above) and anaesthetist prior to surgery. Other members of the multidisciplinary team may also be included (e.g. theatre nurse, physiotherapist). The woman’s health, reason for surgery and suitability for chosen anaesthetic are all assessed (ASA (American Society of Anesthetists), 2007 and AAGBI, OAA (The Association of Anaesthetists of Great Britain and Ireland and Obstetric Anaesthetists’ Association), 2005). NICE (2004) recommend offering all women regional anaesthesia (spinal or epidural), the risks being less than with a general anaesthetic although Afolabi et al (2006) found no clear evidence to support regional over general anaesthesia and suggest the type of anaesthesia chosen will be dependent on whether the woman wishes to be asleep or awake for the procedure. Equally, all women should give both verbal and written consent; clearly this can only be after thorough discussions of the risks and benefits of the CS. Women who seek CS for social and not clinical reasons may be denied their request or referred for a second opinion.
A full blood count will confirm the haemoglobin level. Other haematology screening is not routinely required (NICE 2004) for healthy women with uncomplicated pregnancies but is considered on an individual basis. Usually blood is taken to be grouped and saved and if indicated (e.g. major placenta praevia) cross-matched prior to surgery. High risk CS (e.g. placenta praevia) must take place 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. Allergies (e.g. to latex, antibiotics, etc.) should be carefully documented. It is helpful to discuss what is likely to happen on the day of surgery, the surgery itself, postoperative care and analgesia. Ideally this will occur prior to the elective surgery date so that the woman arrives on the day with all of the preparations completed.
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 (American Society of Anesthetists), 2007 and 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 H 2 antagonists are given so that the gastric acid will be less acidic and reduced in volume, respectively – the woman should have received these to take at home the night before and/or the day of surgery. An antiemetic may also be included to reduce nausea. The ASA (2007) recommend metoclopramide due to its efficacy in reducing intrapartum nausea and vomiting. 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/H 2 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 recognise any cyanosis. Hair removal from the wound site remains controversial; shaving is technically contraindicated due to the abrasions of the skin and the likely increase of wound infection. Hair may be clipped or a depilatory cream used, but often a small number of pubic hairs are shaved immediately below the site for incision, as close to the surgery time as possible (see Chapter 52 for a fuller discussion).
Care of bladder and bowels
Constipation may be a problem postoperatively after fasting and being immobolised; it is therefore better for the bowel to be emptied preoperatively. Glycerin suppositories may be administered the evening before surgery if necessary (see Chapter 22). An indwelling catheter is used to prevent any trauma or overdistension to the bladder during surgery and is sometimes inserted prior to transfer to theatre, or at the time of surgery (see Chapter 14).
Death from pulmonary embolism (following deep vein thrombosis (DVT)) is a serious risk for childbearing women who have experienced surgery or any period of immobility. This is discussed in detail in Chapter 54, but correctly sized compression stockings should be applied prior to surgery, particularly for women with higher risk factors (e.g. obesity or varicose veins). Early mobilisation and a subcutaneous heparin regimen will be commenced postoperatively.
Identity and removal of prosthesis
All prostheses are removed prior to surgery (e.g. contact lenses, false limbs, dentures). Hearing aids may be retained depending on the surgeon/anaesthetist. Capped teeth are noted if general anaesthesia is to be administered due to the risk of being dislodged and inhaled. Metallic jewellery is removed, but wedding rings can be taped securely in place. Identity bands are worn; some hospitals require two identity bands for surgical cases: one on the wrist, one on the ankle. It is important to use allergy alert bands should an allergy be present.
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