Chapter 13. Surgical care
Introduction
Midwives can be involved in the care of pregnant women undergoing surgery for a number of reasons. The most common surgical procedure is a caesarean section, but other surgery can also be necessary including cervical cerclage, perineal repair or manual removal of placenta under anaesthetic. Occasionally pregnant women need to undergo general surgery such as appendicectomy or cholecystectomy and a midwife is required to check that all is well with the pregnancy. The midwife may have a role in preparing the woman before surgery, being with her during the operation and/or caring for her as she recovers from the anaesthetic. It is therefore vital that every midwife has a full understanding of the procedures and the care needed to support women undergoing surgery.
Read the following scenario in relation to birth by caesarean section. Consider what information you need to be able to interpret the situation:
Julie opens her eyes and begins to shake a little, turning towards the sound of the baby crying. She has just been wheeled from theatre into the recovery room, with an intravenous (i.v.) infusion. Her newborn son is tucked into the cot beside the bed. ‘Is that it?’ she asks, plucking at the hospital gown. ‘What happens now?’
Questions from trigger
■ Why has Julie begun to shake after having a caesarean section?
■ Why is there an i.v. infusion?
■ Why is she wearing a hospital gown?
■ Why is she in the recovery room?
■ How would you answer her question?
■ Did she have a birth partner?
■ How does she know it is her baby?
You will discover the answers to these questions within this chapter. 
Caesarean section
Caesarean section is the surgical delivery of a fetus through a surgical incision in the abdominal wall and uterus. It is an obstetric procedure carried out by a senior obstetrician, while the woman is anaesthetized, usually with a spinal or epidural anaesthetic. General anaesthesia is avoided except in special circumstances such as severe fetal compromise or at the woman’s request. In 2004–05 less than 10% of caesareans were conducted under general anaesthetic (The Information Centre 2006). Casearean birth is a relatively common procedure in the United Kingdom: in 2004–05 11% of women had elective surgery and 12% had an emergency procedure (The Information Centre 2006). Indications for elective caesarean section include breech presentation, multiple pregnancy, placenta praevia, and the prevention of mother to child transmission of infections such as HIV (NICE 2004). Emergency caesarean section is classified by four different grades of urgency: immediate threat to the life of the woman or fetus; maternal or fetal compromise which is not immediately life-threatening; no maternal or fetal compromise but needs early delivery; and delivery timed to suit woman or staff (NICE 2004).
Surgical care
Surgical care involves much more than the provision of care during an operation. It is an holistic process which involves the preoperative period through to the postoperative period, and midwives are involved in every aspect of this care.
Preoperative care
This refers to the care given prior to the surgical procedure. It has also been described as the psychological and physical preparation and assessment of a patient before surgery (Mallet & Dougherty 2000).
Most maternity units will have standard protocols or guidelines which govern surgical care, and within this should be a care pathway for preoperative management. A component of this is the pre-op checklist which records the care given ensuring that all criteria are met for a safe, correct and woman-centred procedure.
Find out what protocols your unit has for preoperative (pre-op) care.
Find out what pre-op checklist is used in your unit.
Perioperative care
It is common for the midwife looking after the woman to provide the preoperative care and to then be present in the operating theatre to assist, receive the baby from the surgeon, and care for mother and baby during and after the operation. Therefore the midwife must understand the principles of asepsis in an operating theatre environment. The aim of the operating theatre is to provide an area free from infectious agents (Mallet & Dougherty 2000). Therefore, all personnel wear clean scrub suits, protective footwear, hats and face masks. All those directly involved in the surgery should carry out a 5-minute hand scrub with an antiseptic soap or detergent solution, and wear sterile gowns and gloves (Mallet & Dougherty 2000).
■ Preoperative fasting
Rationale To ensure there are no gastric contents which may be regurgitated and then inhaled when the woman’s airway is compromised. Women attending for elective surgery should have fasted for 6 hours prior to the procedure (Mallet & Dougherty 2000)
■ Women are given a hospital gown to wear during the procedure
Rationale This is recommended because of the likelihood of clothing coming into contact with blood and body fluids
■ Skin preparation
Rationale Because of the location of the caesarean incision at the bikini line, it is necessary to shave an area of approximately 1 to 2 inches across the top of the pubic hair. This should be a dry shave using a new disposable razor, and the woman must have given her consent beforehand. Gloves should be worn. A strip of hypoallergenic tape applied lightly can help to remove all the hair from the area afterwards.
The skin of the abdomen and all around the incision site will be disinfected just prior to any surgery, usually with a chlorhexidine solution (Mallet &Dougherty 2000)
■ Consent gained by obstetrician
Rationale A consent form is used and placed in the woman’s notes. This process of information sharing should ensure that the woman is aware of the need for the operation and what it will involve, along with any risks and issues about recovery. This should be checked against her ID band, and double checked prior to surgery. The consent form should be the end point of the discussion which both informs her and helps to psychologically prepare her for surgery
■ Removal of jewellery
Rationale Jewellery can pose a hazard in theatre, particularly when diathermy is being used. Also, there is the possibility that valuable jewellery could be lost in theatre. Jewellery should be removed and either placed in the care of a relative or logged into a locked cupboard by the midwife. This should be recorded in the woman’s notes. If the woman wishes to keep her wedding band on, it can be taped with hypoallergenic tape
■ Removal of nail varnish
Rationale The nail beds can be observed for oxygenation during surgery, and therefore nail varnish should be removed
■ ID bands – name, date of birth, hospital identification number
Rationale The woman may be unconscious or compromised and so correct personal identification is vital
■ Record of drug allergies/sensitivities plus red ID band
Rationale Identifying any pre-existing drug allergies or sensitivities ensures the woman is not given one of these accidentally
■ Prosthesis
Rationale The presence of any prosthesis, including false teeth, caps or crowns must be noted. False or loose teeth can cause choking or becoming dislodged if the woman needs to be intubated. Prostheses can become detached or lost during surgery. Body piercings should be removed or covered with hypoallergenic tape
■ Documentation
Rationale Other preoperative documentation should be checked, such as drug charts and anaesthetic charts – ensuring they are correct, for the correct patient and up to date. It should be recorded in the notes what time the woman was admitted to theatre, who was present, and what preparations have been carried out
■ Psychological preparation
Rationale The midwife should keep the woman fully informed of all that is occurring and explain the procedures in advance where possible. It is also useful for the woman and her partner to meet the staff who will be in the operating theatre, prior to the procedure commencing.
On transfer to the operating theatre, the woman’s identity should be checked again and she (and her partner if she is having a caesarean under spinal or epidural) should be given a few minutes, if possible, to get used to the new environment. Communication is important in maintaining a good midwife–mother relationship.
The midwife also needs to ensure she is prepared for the imminent birth of the baby, with a resuscitaire checked and ready, and the requisite paperwork and other items ready to hand. The parents may want their child dressed immediately in their own clothes; if so, these can be taken into theatre in preparation for the birth.
It is important to also remember in the case of caesarean that this is a birth environment, as well as an aseptic, operating room. The woman is undergoing an invasive procedure, but it is also almost time for her baby to be born. Women’s own wishes should be respected as much as possible (NICE 2004).
The anaesthetist and ODP will help to position the mother for the anaesthetic, which in most cases will be a spinal anaesthetic. For spinal anaesthesia, the woman will need to be supported into an upright seated position, bending forward, and the midwife can assist with this, by placing a pillow on her lap to help support her abdomen, and talking to her during the procedure. If there is to be a general anaesthetic, the partner cannot usually be present in theatre.
Once the anaesthetic has taken effect, the woman will need to be catheterized because the anaesthetic block interferes with normal bladder function (NICE 2004). An indwelling Foley catheter is used with a standard drainage bag, inserted using an aseptic technique. Catheterization also ensures that the bladder will be empty during the operation and not obscuring the uterine incision site, thus reducing the risk of bladder trauma.
During the procedure, the mother will be draped so that she cannot see the operation site although some women wish to see their baby born and the possibility of having a low screen should be discussed if required. Following the birth of the baby, the cord is clamped and cut and the baby is handed to the receiving midwife. It is then transferred to the waiting resuscitaire, dried, assessed and then wrapped warmly. Providing all is well, the midwife can then take the baby to its mother and father for skin to skin contact. The midwife must then check the placenta and membranes and take cord blood in two heparinized syringes for cord gas analysis.
