planned caesarean section (cs) care pathway protocols and... · - anterior placenta praevia -...

©RBFT Planned CS Care Pathway Including Enhanced Recovery (November 2018) of 24

Planned Caesarean Section (CS) Care Pathway Including Enhanced Recovery

Likes to be known as

Consultant

Planned date of CS

Named Midwife

Date of admission

Ward

Known Allergies

CODE

Midwives responsibility White Pre op clerking and clinic visits

Yellow Admission and pre op phase

TX Doctors responsibility Pink Surgery

Green Post op

PAMS responsibility

Version 7.4 November 2018 Review before: April 2020

Approval Group Date

Maternity Clinical Governance 6th April 2018 & 2nd November 2018

Change History

Version Date Author(s), Job title Reason

Version 7.2 December 2015 Consultant Obstetrician Antenatal Services Manager

Addition of PICO dressing for BMI >35

Version 7.3 February 2018 Acting Screening MW & Consultant Obstetrician

Reviewed

Version 7.4 Nov 2018 Dept. Lead Maternity Theatres

Pg 5 - Live change to replace PN VTE risk assessment Pg 9 - Personalised CS question added Pg 13 - TEDs removed from criteria Pg 14 - Codeine changed to Dihydrocodeine Pg 17, 19 & 20 - minor changes


All members of staff who are using this Pathway use black ink and fill in this section. You can then use initials when recording care

Print Name Designation Signature Initials


How to use an Integrated Care Pathway (ICP)

Firstly, if you are going to write in the ICP you need to state your Name, Job Title and give a sample signature and initials on the front of the ICP cover

If you are recording an event which is predicted by the ICP, then you just sign against that predicted intervention in the column provided.

If your intervention is not in line with the pathway, you must record this as a variance in the variance column with the action you will take to try to bring the patient back onto the pathway.

Care given by health care assistants and student nurses must be countersigned by a registered nurse.

There are many ‘NOTES’ pages for you to write free text about the care given to the patient by you. These notes should always be dated and timed.

The ICP has been colour coded to make it easier to document your aspect of care. Black background relates to Doctors, Clear background relates to nurses and grey background relates to PAMS but check the key prior to writing.

All ICPs are chronological so you should be able track the care given very easily

Abbreviations BO Bowels open NBM Nil by mouth

BP Blood pressure NOK Next of kin

FBC Full blood count N/A Not applicable

HB Haemoglobin PU’d Passed urine

I.M Intramuscular ROS Removal of sutures

IV Intravenous SB Stillborn

IVAB Intra venous anti biotic TPR Temperature, Pulse ,Respiration

LOS Length of stay TTOs Tablets to take out

U& E’s Urea and Electrolytes

Pre-operative blood tests and investigations Blood test Patient group

FBC All patients

Group & save All patients

Cross match For those women with the following;

Known major placenta praevia (2 units if additional risk factor: - Major praevia - Low haemoglobin - Anterior placenta praevia - Placenta accreta – suspected or diagnosed - Multiple fibriods - Surgical or anaesthetic decision)

Known bleeding disorder

Haemoglobin <8g/dl

Difficulty cross matching due to known antibodies


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Antenatal Clinic visit (To be commenced when decision made to book caesarean section)

This section to be filled by medical staff booking the C/section

Name................................................................... Date.................... Name of the Doctor ............................................................Grade............................. (Doctor booking the C/section)

Reason for caesarean section.........................................................Gestation .................wks

Sterilisation Y N any other procedure (specify) .........................................

Specific medical / obstetric problems

Placental site ………………………………………

Allergy (including latex) ............................................................................................................ Medications...................................................................................................................................

Anaesthetic alert? Y N If yes, Anaesthetic referral/bleep 149 Y N

Consented Y N If No, please explain reason(s)

........................................................................................................................................................

This section to be filled by Midwife/MCA in Antenatal Clinic

Information giving Initial Reason for variance and action taken

Woman booked in CS diary

Pre op assessment arranged and date given as…………………………….

Explanation of operation and post op treatment discussed with patient ‘’elective c-section booking pack’’ given including anaesthetic information are highlighted to ensure women anticipating regional anaesthetic?

CS date given as……………

Date for CS documented in hand held notes

Enhanced recovery discussed Y N

Personalised CS discussed Y N

Anticipated date of discharge (24 hours if no contraindication) discussed? Date.....................

MRSA swabs taken Y (date ...................)

N

If latex allergy, Alert sticker Y N


Pre-operative assessment at Antenatal Clinic Date:

Planned date for caesarean section

Blood results from 34/40 check Date taken

Hb WBC Platelets

If Hb < 10.5, any treatment? Y N , Feso4 Ferrinject Blood transfusion If Platelets <100 – Anaesthetic review Y N MRSA (+) Y N If Yes, treatment given Y N

Pathology card request given for FBC Group and save Cross match (see cross

match protocol) Date bloods to be taken……………………..(to be taken within 72 hours of operation)

Maternal observations (noted from last appointment if no medical concerns) BP

Pulse

Temp Weight BMI Urinalysis Glucose Protein

TEDs Size………….

If weight greater than 130kg, theatres informed Bariatric equip arranged N/A

Current medication

Initials Reason for variance and action taken

If latex allergy, Alert sticker

Y N


Pre-operative assessment (continued) Date:

Pre-Assessment Clinic Initials Reason for variance and action taken.

Has patient read and understood anaesthetic

leaflet? Y N

Any concerns regarding spinal anaesthesia?

Y Bleep anaesthetist (149)

N

Has patient read and understood C/section

leaflet? Y N

Has patient sign consent form?

Y N

Any concerns regarding consent form?

Y Bleep Obstetrics SHO

N

Anaesthetist alert Y N Inform anaesthetist – Bleep 149 if notes with alert sticker have not been reviewed prior to clinic or any concerns from past medical history at booking or from anaesthetic questions –see below.

Information regarding Skin to skin contact Specify areas of body piercing

Information regarding baby feeding and hand expression

Consent gained for newborn Vitamin K Oral IM Documented in baby notes

Neonatal BCG discussed

Blood results within normal range Y N

Has the woman any body piercing Y N If yes, is she willing to have it removed prior to C section? Y N

Consent taken and checked with patient and form in notes Y N



Anaesthetic history – patient to be asked by midwife

Yes – give details No Initials

Have you ever had a problem with a general anaesthetic?

Has anyone in your family had a problem with a general anaesthetic? E.g. Malignant hyperthermia, suxamethonium (scoline) apnoea, severe allergic reaction to anaesthetics?

Have you had an epidural or spinal before? If yes:

Were there any problems such as difficulty or failure to achieve adequate pain relief, complications after delivery or conversion to a general anaesthetic?

Have you ever had a significant back problem, such as spina bifida, kyphoscoliosis or spinal surgery?

Do you have a problem with your jaw? (Can you open your mouth wide enough to eat an apple?)

Information giving Initials Reason for variance and action taken

Patient informed to arrive on DAU

morning of caesarean at 7:30am

Bed booked on Iffley if women to be admitted night

before operation

Notes sent to Iffley if women to be admitted the night

before surgery

Explanation given re no food after 02.30 and clear fluids only until 06.30 on the morning of operation (bring a bottle of Sports drink – non fizzy)

Informed of need for a bath/shower prior to admission

Informed that shave preparation will be carried out in theatre

Advised to remove all valuables, makeup and nail varnish prior to procedure

Given information on videoing or taking pictures in theatre

Discussed the care of valuables whilst in hospital

Partner given information and is aware of their role during the procedure Informed only one person to accompany on the day

Anticipated discharge date discussed (24 hours unless contraindication) Yes No

Advise woman to buy simple analgesia for use on discharge home

Informed to bring hand held notes

Administration

Antenatal details on computer

Patient notes has more than 1 sheet of labels



Antibiotic prophylaxis at caesarean section See Obstetric antibiotic guidelines (GL787) Based on booking weight: 1st choice: BMI < 35 IV co-amoxiclav 1.2g single dose BMI ≥35 (IV co-amoxiclav 1.2g + IV amoxicillin 1g) single dose If true penicillin allergy: IV gentamicin 5 mg/kg STAT (*Use booking weight for BMI <50. If BMI ≥ 50, use corrected dosing weight to calculate gentamicin dose) + IV clindamycin 1.2 g single dose If ‘Known MRSA’ or ‘High risk for MRSA’: IV teicoplanin 10 mg/kg single dose + IV gentamicin 5 mg/kg STAT (*Use booking weight for BMI < 50. If BMI ≥ 50, use corrected dosing weight to calculate gentamicin and teicoplanin dose)

Other drugs at caesarean section

Diclofenac suppository +/- 100mgs PR at end of procedure

Paracetamol suppository 1g

Post op prescription Morphine 10-15mg 3-4 hourly for the 1st 24 hours Ibuprofen 400mg Four times a day (not for mod-severe asthmatics &

pre eclampsia) First dose should not be given prior to 12 hours post procedure

Dihydrocodeine phosphate & Paracetamol

60mg 1g

Six hourly as required in combination

Senna 1-2 tablets At night

For patient who CANNOT have NSAIDs

Tramadol 100mg 6 hourly orally

Medication Initial Reasons for variance and action

Outpatient prescription for Ranitidine 150mg (evening and morning before surgery) Dihydrocodeine phosphate 30-60mgs QDS for 7 days. Senna 1-2 tablets daily

Advice

Advice sought from surgeon Y N Not required

Name: Result

Advice sought from anaesthetist Y N Not required

Name: Result


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Day of operation - Pre-operative check list Date:

Maternal Observations

Blood results

BP Blood group =

Pulse Hb WBC Platelets

Temp

Resp MRSA Swab Result

Fetal Observations Blood sugar

FH Time Blood sugar Action

Time of last fluid (Clear energy drink) intake

......................

Additional information

Initial Reason for variance and action taken

Patient admitted on computer

Theatre prepared for latex allergy Y N/A

Partner to be present in theatre Y N


Pre-operative check list Date:

Nil by mouth Food . . . . . . hours Fluid . . . . . . . . . hours

Ward Specify Details

Patient has taken x 2 doses of Ranitidine Y / N

If blood X matched, available in Labour ward Y / N

Patient has bathed / showered today Y / N

Wearing gown (opening at back) Y / N

Consent form present and correct with second signature from midwife / Dr

Y / N

Name band and red allergy band insitu Y / N

Drug Chart & relevant medication present Y / N

Prosthesis removed if necessary Y / N

Dentures / cap / crowns / tongue piercing (specify)

Y / N

Jewellery & body piercing removed / taped Y / N

Nail varnish / makeup removed Y / N

Contact lenses removed if applicable Y / N

Hearing aid (left / right / insitu?) Y / N

Baby consent given for IM Vit K

Oral Vit K Y / N

Mother & baby clothes, sanitary towels etc Y / N

Prepared for theatre by :................................ Date

Has the patient any pressure damage Y N At risk of pressure damage Y N If yes to any of the following a Waterlow assessment needs to be completed and attached to the document


Theatre (To be completed by theatre team)

Date:

Time into theatre:………………hrs Time out of theatre……………. THEATRE (No:.................) Initial Reason for variance and action taken

Resuscitaire checked

Neonatologist present if required

Additional equipment Cell salvage Ultrasound scanner CTG machine Other ……………………….

WHO checklist

IV sited ………………………time……………..

VIP chart commenced

Spinal procedure commenced at…………..hrs

Urinary catheter inserted Size 12 (10mls water)

SPACE FOR CATHETER STICKER

Presentation/ Lie confirmed (please circle) Cephalic, Breech, Transverse

Fetal heart beat auscultated Y N

Patient position Supine with wedge Right arm Left arm By side By side Extended on board Extended on board Flexion onto chest Flexion onto chest

Pressure areas protected

Head Elbows Sacrum Leg rest

Flowtron leggings used Y N

Diathermy plate applied Thigh right left

Skin preparation used

Swab and suture count for operative procedure

Abdo Large Small Other Sutures Needles Blades

Swab and instrument count correct post procedure

Sutures; insoluble

Nylon Prolene & beads Clips Silk Other..................... Soluble

Monocryl Vicryl other............

Interrupted Continuous

Date to be removed……………

Drain insitu Y N Date to be removed……………


Operation performed Elective LSCS

Other procedure performed

Dressings applied;

Mepilex Steristrips Pressure dressing If Booking BMI>35 for PICO Dressing Other (please specify)……………………………………………………….

Diathermy plate site clear

Date:

Third stage details Method of delivery Placenta check

Spontaneous Complete Incomplete

Cord traction Sent to pathology Y N

Manual removal Membranes Complete Incomplete

Blood loss…………….mls 3 cord vessels present Y N ………………..

Obstetrician informed if placenta or membranes appear incomplete Y N

Medication Carbetocin

Oxytocin

Ergometrine

PR Diclofenac

Other procedures: …………………………………………………………………………………….

Blood taken Maternal Y N Reason Kleihauer

Cord Y N Electrophoresis

PH cord Other

Infant details Infant Birth date /

Time Weight Sex Maturity Alive / SB Apgar score

@ 1 min……… @ 5mins………

Initial

ID bands x2 to baby

Baby transferred to Ward NNICU Reason………………………………………….

Birth trauma or abnormalities

Further information Cord Blood Gases Arterial Venous

PH PH

PCo2 PCo2

PO2 PO2

HCO3 HCO3

Base Excess Base Excess

Machine no. Machine no.

Date Date

Time Time

Delivered by Status Midwife in charge (please print name)


Recovery observations Name:

Hospital No:

Date: Maternity Unit MOWS Chart

Date >

0o C Time >

220

39o C

200

38o C

180

37o C

160

36o C

140

35o C

120

Temp 100

FHR 80

x

Pulse 60

BP 40

Resp Rate

O2 L/min

O2 Saturation

Lochia

Fundus

Urine Output

Conscious Level

Signature

Score – Resp

Pulse

Systolic

Diastolic

Consciousness

Urine Output

Total MOWS

3 2 1 0 1 2 3

Resp rate < 8 8 9-18 19-25 26-30 >30

Pulse rate < 40 40-50 51-100 101-110 111-129

>129

BP Systolic

< =70 71-80 81-100 101-159 160–199 200 >200

BP Diastolic

< 95 95-109 >= 110

Urine 0ml/hr OR 0ml/24hrs

<=30ml/hr OR <=720ml/24hrs

<=45ml/hr OR <=1000ml/24hrs

>=45ml/hr OR >=1000ml/24hrs

Conscious level

Unresponsive

Responds to pain

Responds to voice Alert Irritated V6.4 Feb 17

Action to be taken

0

1

2

3

4 or more

Repeat observations when appropriate for clinical scenario – at least daily

Minimum of 4 hourly observations as there is potential for deterioration.

Inform midwife in charge, obstetric registrar. Minimum 1 hourly observations

Inform senior midwife, obstetric and anaesthetic staff. Minimum ½ hourly observations

As above but the consultant obstetrician and consultant anaesthetist should be informed. Minimum 30 minute observations. If no one is available to review the patient, inform the Outreach Team


Recovery Record Date:

Fluid balance Time Fluid intake Fluid output

IV Oral Urine Vomit Lochia


Transfer Date:

Criteria for safe transfer to ward : Initial Reason for variance and action taken

MOWs less than 1

Medication prescribed: Post -op analgesia anti-emetics

Anticoagulants LMWH FLOTRONS

None IV fluids stopped Y N Time stopped............................

Haemodynamically stable

Pain score (page 5) <5 or acceptable to patient

Wound drain in situ Y N No signs of bleeding from drain site If yes, drain remains vacuumed

'Sensation/mobility returning to lower limbs' Y N If No please refer to Anaesthetist

Nausea & vomiting under control

Baby’s labels present and correct

Computer details completed

Birth register completed

LSCS letter

Blood group Kleihauer required Y N

Handover to ward staff completed using SBAR tool (to include review of post-op instructions)

Note, if Diamorphine has been given via spinal, Ward midwife made aware that further analgesia within 24hours to be discussed with an Anaesthetist Bleep 142

Time transferred................................hrs

Recovery midwife signature

Received by midwife signature

SBAR - To be completed in postnatal record book and sign over transfer of care.


Caesarean Section – Operation Record Date …………………………………………………..

Location ……………………………………………...

Time of Decision ……………………………………………

Consultant informed …………………Initials

Time of Incision ……………………………………………

Time of Delivery ……………………………………………

Time of Conclusion ………………………………………

Indication for delivery: ……………………………………………………………

Classification of Urgency: RCOG/RCA Category: 1 2 3 4

Written consent obtained: Yes No If not, reason …………………………………………………………..

Type of Anaesthesia: Epidural Spinal CSE GA

Pre-operative discussion:

Urinary Catheter: Foley Other Findings e.g. fetal position/tubes/ovaries/adhesions Procedure:

Drain: Yes / No Removal : ……

Skin closure: Monocryl Prolene Other....…….

Pressure dressing Yes Removal Instructions……….…... PICO Dressing 7 Days

Estimated blood loss………..If EBL > 2L MOH: Controlled / Uncontrolled Call

Swabs checked Needles checked Instruments checked

Paired cord gasses taken Yes No Vaginal Toilet Post-operative instructions:

Suggestion for next confinement VBAC ELCS

Surgeon (PRINT)………………………….. Signature…………………Grade

Assistant ……………………………….. Anaesthetist……………… Scrub nurse……………

C/S letter for GP signed Y N


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planned caesarean section (cs) care pathway protocols and... · - anterior placenta praevia -...

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