WK6: Caesarean birth, VBAC and multiple pregnancies Flashcards
(40 cards)
Define Caesarean section
the surgical procedure where the fetus, placenta and membranes are delivered via an incision made through the abdominal wall and uterus.
What are the two types of CS?
LUSCS and Classical CS
Describe the difference between a LUSCS and a classical incision.
LUSCS: lower uterine segment caesarean section (bikini line incision)
- used after 28 weeks
- LUS has less muscles and is thinner= Therefore causes less risk of uterine rupture in subsequent pregnancies and heals faster
Classical (vertical) incision
- Only to be done if there is no lower uterine section formed yet
- More risk of uterine rupture
- More healing is needed and increased risk of uterine rupture in future pregnancies
What are common indicators for an emergency CS?
- Previous caesarean section
- Failure to progress in labour
- Presumed fetal compromise (abnormal FHR)
- Breech position
- Ante Partum Haemorrhage (APH)
- Cord prolapse
- Fetal compromise
- Uterine rupture
- CPD diagnosed in labour
- Severe pre-eclampsia / Eclampsia
What are common indications for an elective/planned CS?
- Twin pregnancy + twin pregnancy when presenting twin is not cephalic
- Placenta previs
- Active primary genital herpes simplex viris (HSV)
- HIV= C/S is recommended when not receiving any antiretroviral therapy or are receiving anti-retroviral therapy (ART) and have a viral load of 400 copies per ml or more. + CS is considered because of the mother to child transmission
- Breech presentation
- Maternal request
- Previous C/S
- CPD cephalo-pelvic disproportion
- Placenta praevia
- Multiple pregnancy
- Active primary genital simplex virus (third trimester)
- HIV (specific circumstances)
- Breech presentation
- Maternal request (following counselling)
- Moderate/severe pre-eclampsia
- Underlying medical condition
- Fetal abnormality
What are the 4 categories of CS?
Category 1: Immediate threat to the life of the woman or fetus (DDI within 30 minutes)
- Stop everything and rush to CS
- Usually a GA unless already has good epidural
- Life saving
- Hopefully less than 15mins
Code green or pink
Category 2: Maternal or fetal compromise which is not immediately life-threatening (DDI usually 45 – 90 minutes)
- Failure to progress or obstructed labour= causing fetal compromise
- No benefit in continuing labour
Category 3: No maternal or fetal compromise but needs early delivery (DDI usually within 3 - 4 hours)
- E.g. attempted to indice 4-5 times tried both gel and prostin and cervix has never become favourable
- Sint not causing labour
Category 4: Elective. Delivery timed to suit woman or healthcare team.
- Planned date and time
What is the difference between emergency and elective CS?
An elective is decided before the labour begins.
An emergency is decided once labour has commenced. It does not always mean a mad rush!
What are the types of analgesia use for CS?
- spinal
- epidural
- general
What are the benefits of an epidural/spinal compared to a general anesthetic?
Regional anaesthetic
- Allows the woman to experience the first minutes after the baby’s birth
- partner/support person may be present
- Less adverse effects for mother and baby
- If woman had epidural that was working well and sitting she would get a bolus to make it a very well block of pain.
-skin on skin
- staying present to prevent PND
- birth trauma
- avoid the risks and recovery of GA
GA
- Used rarely if rapid anaesthesia is required e.g. fetal distress/compromise
- faster to use than siting a new epidural
Downside
- GA impacts babys
- partner is not in room
- no immediate skin on skin
Define and describe an epidural
= is a form of regional anaesthesia in which a local anaesthetic drug is injected into the epidural space to provide pain relief in labour.
Epidural space (extradural space)= a thin layer of fat and connective tissue containing nerve roots, blood vessels and lymphatics which lie outside the dura. It contains the spinal nerves as they pass through from the spinal cord out through the intervertebral foramina.
Main effect is on nerves leaving the spinal cord (rather than the spinal cord itself) as it delivers the local anaesthetic outside the dura.
Define and describe a spinal anesthetic
= local anaesthetic is injected into the intrathecal space directly into the CSF in the spinal cord.
- Either a combined epidural/spinal anaesthetic or a spinal anaesthetic for a caesarean section.
- A combined epidural/spinal allows lower doses and concentrations of lower spinal and epidural anaesthesia
- Goes deeper than epidural
What are some complications of regional anesthetic?
- Iaccidental V injection = injection into a vein causing cardiac hypotoxicity and profound hypotension
- Headache=
- caused from unintentional dural puncture
- Puncture of the dura by needle= leaks CSF- reducing intracranial pressure causing;
- Headache (especally in an upright position)
- Vasodilation when blood vessels try to compensate for fluid loss, stimulating pain receptors, causing headaches - High spinal = in anesthetic goes above the breast line the muscles of the lungs are depressed in function so breathing becomes difficult
- Dyspnoea
- Hypotension- with nausea and vomiting
- Backache: tenderness at the site is anticipated for 5-7 days. Review by anesthetist if it lasts longer
- More serious conditions such as prolapsed disc, subdural abscess, and epidural abscess as associated with epidural but are not common and are difficult to recognise.
- Epidural haematoma
- May form if the needle insertion causes bleeding and bruising.
- This can compress vital structures such as the spinal cord. - Estimated at 5/million insertions
- Infection (a late signs)
How can a midwife prepare a woman for a CS?
Education should be offered antenatally:
- What to bring
- Where to attend and what time
- Fasting (at least 12 hours) to prevent gastric acid reflux
- The process of pre-op/OT and post-op
- To alleviate stress
Pre-caesarean review info/education:
- Checked into hospital by midwife early
- Pre-anaesthetic review
- Check month and neck for ease of intubation if GA is necessary
- Assess womens back for RA
- Answer womens questions
Obstetric Registrar/HMO check=
- Consent
- confirms surgery,
- discusses what the procedure involves & associated risks/benefits
- Hysterectomy is bleeding and mothers life is at risk
- Pathology
- Usually done the night before
- FBE (to see platelet count, heamoglobin to compare changes before and after to sus how she is coping with the blood loss)
- Group & hold (incase blood productions are neccessary)
- U&E
what is the midwives role in preparing for CS?
- Check women in and ensure she is the right person in the right room
- support the woman’s choice
- Make it a lovely experience
- complete vital signs
- abdominal palpation (confirm fetal presentation)
- If for breech CS we do US also to confirm it!!
- FHR
- review antenatal history
Get to know her
- What is her experience
- What are the childs name???
- Develop a relationship
Explain the pre op considerations that must be taken by a midwife.
- Vital signs & urinalysis
- Review History – past history & health/issues during pregnancy
- Current Medications
- Abdominal palpation - FHR (US if breech)
- Review US – placenta
- Review pathology – pre-op and during pregnancy
- Allergies
What are some important pre op preps for the mother?
- Aminister pre-op antacid= To avoid aspiration of the gastric contents (Mendelson’s Syndrome)
- Complete documentation
- Admission documentation
- Theatre checklist= ID bands, allergies noted, fasting, consent, pathology, nail polish, prosthetics, gown, underwear removed (we need to have access to vagina to inster IDC and monitor bleeding), jewellery removed/taped e.t.c
- Measure for ante-embolic stockings (prevent DVT which is a risk factor of both pregnancy and surgery)
- Anaesthetic doc – baseline vital signs documented
- Special considerations – language, support people, cultural traditions
- Birth plan
- E.g. lotus birth, delayed cord clamping, immediate skin on skin, immediate brast feeding
What are some important practice points of consent prior to CS?
- Obtained prior to any surgical procedure
- Must be “informed”
- Responsibility of the medical practitioner (surgeon, anaesthetist)
Includes
- Description
- purpose
- possible benefits & risks
- Alternatives
- right to refuse treatment or chnge their mind - Special considerations – age, language or is interpretation needed?, emotional/mental state, emergency (these things may be inhibitors of informed consent)
What is the role of the midwife in theatre?
- Prepare resuscitare
- Ensure you have the correct paper work
- Reintroduce yourself as mask can make you look different
- Tell comen about reusuitare and say thats where baby will go first the to skin on skin
- Assist with positioning of the woman (curls over)
- Awareness of asepsis environment (maintain sterile field)
- Ensure partner is supported
- May assist with IDC insertion
- Review blood group and arrange cord bloods if RH neg
- Check resuscitaire
- Prepare to receive baby
- Warm sterile towel
- Document birth,
- Time of first incision (skin)
- Time of first incision (uterus and membranes)
- Time of birth of baby
- Time of borth of placenta
- Do mornal baby checks
- APGARS
- Resuscitate baby
- Promote skin to skin
- Baby has missed opportunity to contact microbiome of the mothers vagina
- Issues of immune and gut health
- Enourage mum to give lost of face kisses
- Skin to skin with father is another good option to give baby exposure of diverse biome
- Check placenta
- Can check when you get back up to the warm
What are some important post-operative assessments?
- Vital signs, conscious state, colour (more than vaginal, look at policy commonly 15 minutley)
- Spinal – Colour, warmth, movement & sensation, is she getting movement back?
- IV fluids (Oxytocin infusion must be run through pump), observe site
- Wound
- assess dressing C&D
- ? Presence of drains (not usually unless complex)
- IDC – draining, colour (expect diuresis within a few hours= lots of urine as all the blood inside of here is being filtered out, lack of progesterone means body will reduce blood), heamaturia can indicate bladder injury
- Lochia (PV or vaginal bleeding) – expect rubra, slight to moderate
- +/- fundus assessment according to local clinical practice guideline (do it while she still has pain relief on board, still do it even though there is an incision)
- Pain: provide analgesia as soon as possible
assess pain and arrange analgesia as indicated – - Assess nausea & vomiting – usually may commence fluids asap Promote skin to skin and BF
What are some important nursing management for a midwife post CS?
- pain management
- fluid balance
- lochia assessment
- wound care
- obs
Define the two types of PPH
Primary PPH= >500ml EBL at the time of surgery and up to 24hrs post (some hospital have different for normal vaginal and CS)
- usually caused by atony= uterus not contracting
Secondary PPH= >500ml >24hrs and up to 6 weeks post partum
- usually due to retained placenta or infection
What are some common complications post CS?
- uterine infection
- PPH
- UTI
- Thromboemolic disorders
- Paralytic ileus
- Bladder injury
- Chest infection
Define VBAC
Vaginal birth after ceaseran section= when a women expereinces a trial of labour following a pevious cesarean secition and outcome is vaginal birth.
- Huge amount of research suggests VAC is clinically safe for majority of women with a single previous lower segment caesarean delivery.
What are some contraindications of a VBAC?
Women how have
- previous uterine rupture
- Previous classical CS scar (due to high risk of uterine rupture)
- other absolute contraindications to vaginal birth that apply irrespective of the presence or absence of a scar. E.g. placenta previa
