NICE guidelines for caesarean sections: implications for the anaesthetist. Use of uterotonics; Uterine exteriorisation; Use of antibiotics. Intrathecal and epidural analgesia (PCA) and non-steroidal anti-inflammatory analgesics.
NICE guidelines for caesarean sections: implications for the anaesthetist. Use of uterotonics; Uterine exteriorisation; Use of antibiotics. Intrathecal and epidural analgesia (PCA) and non-steroidal anti-inflammatory analgesics.
NICE guidelines for caesarean sections: implications for the anaesthetist. Use of uterotonics; Uterine exteriorisation; Use of antibiotics. Intrathecal and epidural analgesia (PCA) and non-steroidal anti-inflammatory analgesics.
The National Institute of Clinical Excellence (NICE) guide-
lines for caesarean sections: implications for the anaesthetist M. Y. K Wee, H. Brown, F. Reynolds Department of Anaesthesia, Poole Hospital, Dorset, Department of Obstetrics and Gynaecology, Princess Anne Hospital, Southampton, Department of Anaesthesia, St. Thomass Hospital, London, UK INTRODUCTION The bodies involved; Background; Aims of the guidelines; Evidence and grading of recommendations SUMMARY OF RECOMMENDATIONS AFFECTING ANAESTHETIC PRACTICE Provision of information and consent Classification of urgency of caesarean section Planned caesarean section Factors in intrapartum care affecting likelihood of caesarean section Factors with no influence on caesarean section rates: Epidural analgesia; Eating in labour Procedural aspects of caesarean section: Decision-to-delivery interval for emergency caesarean section; Pre- operative testing and preparation for caesarean section; Urinary catheterisation at caesarean section Aspects of anaesthesia for caesarean section: Antacids and antiemetics; General versus regional anaesthesia for caesarean section; Converting epidural analgesia to anaesthesia for caesarean section; Place of induc- tion and monitoring during caesarean section; Procedures to avoid hypotension; Failed intubation Surgical techniques for caesarean section of relevance to the anaesthetist: Use of uterotonics; Uterine exteriorisation; Use of antibiotics; Thromboprophylaxis for caesarean section Care of the baby born by caesarean section Care of the woman after caesarean section: High dependency and intensive care admission; Routine monitoring after caesarean section Pain management after caesarean section: Intrathecal and epidural analgesia; Patient controlled analgesia (PCA) and non-steroidal anti-inflammatory analgesics; Other local anaesthetic techniques Post partum care: Early eating and drinking after caesarean section; Urinary catheter removal after caesarean section; Length of hospital stay CONCLUSION Keywords: NICE guidelines; Caesarean section; Anaesthesia INTRODUCTION The National Institute for Clinical Excellence (NICE) is part of the National Health Service (NHS) in the UK. It was established in 1999 as an independent organisation to promote clinical excellence by provid- ing guidance on treatments and care based on the best available evidence and effective use of resources. NICE has under its wing the Confidential Enquiries into Maternal and Child Health (CEMACH). In April 2004, NICE published caesarean section guidelines; International Journal of Obstetric Anesthesia (2005) 14, 147158 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijoa.2004.09.008 Accepted September 2004 M.Y.K. Wee, Consultant Obstetric Anaesthetist, Department of Anaesthesia, Poole Hospital NHS Trust, Longfleet Road, Poole, Dorset BH 15 2JB, UK, H. Brown, Senior Specialist Registrar in Obstetrics and Gynaecology, Princess Anne Hospital, Coxford Road, Southampton SO16 5YA, F. Reynolds, Emeritus Professor of Obstetric Anaesthesia, St. Thomass Hospital, Lambeth Palace Road, London SE1 7EH, UK. Correspondence to: M.Y.K Wee, Consultant Obstetric Anaesthetist, Department of Anaesthesia, Poole Hospital NHS Trust, Longfleet Road, Poole, Dorset BH 15 2JB, UK, Tel.: +44 120 244 2443; fax: +44 120 244 2672; E-mail: m.wee@virgin.net. 147 the aim of this review is to highlight aspects of these guidelines that may have implications for anaes- thetists. Several versions of the guidelines are available and can be downloaded from the web: i. the full document www.nice.org.uk/pdf/CG013fullguideline.pdf ii. evidence tables www.nice.org.uk/pdf/CG013evidencetables.pdf iii. an algorithm www.nice.org.uk/pdf/CG013algorithm.pdf iv. recommendations for the NHS www.nice.org.uk/pdf/CG013NICEguideline.pdf v. the quick reference guide www.nice.org.uk/pdf/CG013quickrefguide.pdf vi. information for the public www.nice.org.uk/pdf/CG013publicinfoenglish.pdf (very large print) The bodies involved The National Collaborating Centre for Womens and Childrens Health (NCC-WCH) was commissioned by NICE to produce the guidelines. NICE and 60 registered stakeholders including the Royal College of Anaesthe- tists (RCA) and Obstetric Anaesthetists Association (OAA) were involved in their development. An indepen- dent Guideline Review Panel and Patient Involvement Unit then reviewed the draft guidelines. The NCC-WCH established the Guideline Develop- ment Group (GDG) comprising a general practitioner who chaired the group, two obstetricians, two midwives, a neonatologist, an anaesthetist and two consumers. Other members of the GDG included the director of the NCC-WCH, chair of CEMACH, informatics special- ist, health economist and several research fellows. The anaesthetic representative was selected from nomina- tions submitted by the RCA and the OAA and consulted widely during development of the guidelines on issues of anaesthetic interest from obstetric anaesthetist experts within the UK. Background The National Sentinel Caesarean Section Audit (NSCSA) reported that in England and Wales, caesarean section rates increased from 9% of deliveries in 1980 to 21% in 2001, with similar increases in many developed countries. 1 The average age of women giving birth has increased and caesarean section rates increase with maternal age. The caesarean section rate for women in their first pregnancy is now 24% and for women who have had a previous caesarean section, it is markedly in- creased (67%). The caesarean section rate also varied in the UK according to ethnicity, with higher rates reported in black African and Caribbean ethnic groups. The five major indications for caesarean section in the UK are fetal compromise (22%), failure to progress in labour (20%), repeat caesarean section (14%), breech presentation (11%) and maternal request (7%). 1 The first indication is influenced by the use of continuous elec- tronic fetal monitoring, which may be associated with increased caesarean section rate unless it is used in con- junction with fetal blood sampling to assess fetal acid- base balance before a decision is made for caesarean section. Aims of the guidelines The guidelines aim to provide evidence-based informa- tion in the following areas: Risks and benefits of caesarean section Certain specific indications for caesarean section Effective management strategies to avoid caesarean section Anaesthetic and surgical aspects of care Interventions to reduce morbidity from caesarean sec- tion and Aspects of organisation and environment that affect caesarean section rates. This does not cover all the clinical decisions and care pathways that may lead to caesarean section. For exam- ple, it omits advice on the risks and benefits of caesarean section in specific conditions such as preeclampsia or gestational diabetes or in rare diseases. As well as clinical effectiveness, the guidelines were concerned with cost-effectiveness of caesarean section compared to vaginal birth. Evidence and grading of recommendations Evidence from studies that were least subject to bias and published systematic reviews or meta-analyses were used where available (Table 1). Data are presented as absolute risks, relative risks or odds ratios where rele- vant. Where data are statistically significant they are also presented as numbers needed to treat for beneficial outcomes or numbers needed to harm for adverse effects as relevant. Recommendations are graded according to the strength of the evidence that supports them (Table 2). SUMMARY OF RECOMMENDATIONS AFFECTING ANAESTHETIC PRACTICE Bullet-points below quote from, summarise or para- phrase recommendations from the guidelines; the letter following denotes their grading (Table 2). 148 International Journal of Obstetric Anesthesia Provision of information and consent Pregnant women should be given evidence-based information and support to enable them to make informed decisions about childbirth. [C] Information about caesarean section should be given during the antenatal period because about 1 in 5 preg- nant women will have a caesarean section. [GPP] The information should be in a form that is accessi- ble taking into account cultural needs of ethnic minority communities and those with disabilities. [GPP] In 1993, the Expert Maternity Group from the Department of Health released the report Changing Childbirth, 2 which made explicit the right of women to be involved in decisions regarding all aspects of their care during pregnancy and childbirth. In order to discuss decisions with caregivers, women require evidence-based information. Randomised trials (RCTs) on antenatal education suggest that the provision of information is often seen as inadequate by women. 3 The use of evidence-based information leaflets has been shown to improve maternal satisfaction. 4 As about one in five women in the UK are delivered by caesarean section (the majority unplanned), 1 all of them need information on both vaginal and caesarean delivery. The Obstetric Anaesthetists Association has produced evidence-based leaflets and a related video on anaesthesia for caesarean section that can be used to inform women. 5,6 Provision of information is a prerequisite to consent and should cover the patients condition, possible inves- tigations and treatment options, their risks and benefits and the risk of refusing treatment. 710 Ideally, in the case of caesarean section, such estimates should be derived from intention to treat analysis of RCTs and systematic reviews comparing planned caesarean section with planned vaginal birth. 1113 Anaesthetists should give full information including the material risks of anaesthesia for caesarean section. 1415 Consent for caesarean section should be requested after providing the pregnant woman with evi- dence-based information and in a manner that respects the womans dignity, privacy, views and culture whilst taking into consideration the clinical situation. [C] A competent pregnant woman is entitled to refuse treatment even when the treatment would clearly benefit her or her babys health. Refusal of treatment needs to be one of the womans options. [D] Classification of urgency of caesarean section Caesarean section has traditionally been classified as elective and emergency. The emergency category, however, does not differentiate between true emergen- cies where the life of the woman or fetus is threatened, and situations in which there is no imminent threat to life. A four-point classification has been piloted, used in a national survey and shown to predict baby out- come. 1,16 Its adoption is recommended to aid clear com- munication between healthcare professionals about the urgency of caesarean section. Category 1: immediate threat to the life of the woman or fetus. This includes caesarean section for acute severe fetal bradycardia, cord prolapse, uterine rupture, fetal blood pH less than 7.2. Table 1. Levels of evidence Level Evidence 1a Systematic review or meta-analyses of randomised controlled trials 1b At least one randomised controlled trial 2a At least one well-designed controlled study without randomisation 2b At least one well-designed quasi-experimental study, such as a cohort study 3 Well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, case controlled studies and case series 4 Expert committee reports, or opinions and/or clinical experience of respected authorities From www.nice.org.uk/pdf/CG013fullguideline.pdf. Table 2. Grading of recommendations Grade Strength of evidence A Based on level 1 evidence B Based on level 2 evidence or extrapolated from level 1 evidence C Based on level 3 evidence or extrapolated from level 1 or 2 evidence D Based on level 4 evidence or extrapolated from level 1, 2 or 3 evidence GPP Group practice point based on the view of the guideline development group NICE TA Recommendation taken from NICE Technology Appraisal From www.nice.org.uk/pdf/CG013fullguideline.pdf. The National Institute of Clinical Excellence (NICE) guidelines for caesarean sections 149 Category 2: maternal or fetal compromise that is not immediately life-threatening. There is a degree of urgency to deliver the baby in order to prevent further deterioration of either the mothers or the babys con- dition. Examples include antepartum haemorrhage and failure to progress in labour with maternal or fetal compromise. Category 3: no maternal or fetal compromise but needs early delivery. Examples include a situation in which caesarean section is planned but the woman is admit- ted in early labour or with ruptured membranes. Category 4: delivery timed to suit woman or staff. This includes all planned elective caesarean sections. Planned caesarean section The guidelines recommend that planned caesarean sec- tion should be offered: with breech presentation at term if external cephalic version has been unsuccessful or is contraindicated [A] to HIV-positive women at term [A]. to women with grade 3 or 4 placenta praevia [D] The evidence for other indications is less sound, for example it is uncertain whether caesarean section confers any additional benefit in twin pregnancies at term where the first twin is cephalic, preterm babies or small for gestational age babies. Maternal request is not on its own considered an indication for caesarean section. Whether an indi- vidual clinician has the right to decline a request for a caesarean section is of concern to anaesthe- tists. Individual women may request caesarean sec- tion because of fear of pain in childbirth. The guideline recommends counselling for this, but the logical inference that a discussion with an anaesthe- tist about epidural analgesia could form part of this counselling is overlooked. Factors in intrapartum care affecting likelihood of caesarean section The indications for emergency caesarean section should surely feature prominently in the guidelines, as one of the aims is to provide effective management strategies to avoid caesarean section, and the majority of caesar- ean sections are unplanned. Yet this topic is addressed only under the heading Factors reducing the likelihood of (caesarean section). The recommendations related to care in labour are: A partogram with a 4-h action line should be used to monitor progress in women in spontaneous labour with anuncomplicated singletonpregnancyat term, because it reduces the likelihood of caesarean section. [A] Consultant obstetricians should be involved in the decision-making because this reduces the likeli- hood of caesarean section. [C] Electronic fetal monitoring is associated with an increased likelihood of caesarean section. When cae- sarean section is contemplated because of an abnor- mal fetal heart rate pattern fetal blood sampling should be offered if possible. [B] Factors with no influence on caesarean section rates Epidural analgesia A woman who mistakenly believes that epidural anal- gesia increases the likelihood of caesarean section will be prejudiced against it. Fortunately there is ample evidence of the highest level (1a: RCTs and meta-analyses 17,18 ) that epidural analgesia during labour does not influence the likelihood of caesarean section. Aspects of care in labour with no influence on the likelihood of caesarean section include walking, non-supine position during the second stage, immer- sion in water, epidural analgesia and raspberry leaf tea. [A] Eating in labour Eating in labour is an issue much debated between healthcare professionals, some midwives believing it will reduce the need for intervention. The debate is rel- evant to obstetric anaesthesia. One RCT comparing a group given a light diet in labour with a starved group given water only (the guidelines erroneously state that the starved group were given water, tea, coffee or co- coa), showed that while maternal ketosis was improved, gastric volume and vomiting were both increased by eat- ing. 19 Another RCT substituted an isotonic sport drink for solids and showed that it reduced ketosis without increasing gastric volume. 20 Neither study was powered to examine obstetric outcome, which is the subject of an on-going study. The recommendation in the guidelines states: Women should be informed that eating a low residue diet during labour results in larger gastric volumes, but the effect on the risk of aspiration if anaesthesia is required is uncertain having isotonic drinks during labour prevents ketosis without a concomitant increase in gastric volume. [A] This surely misses the point; we know larger gastric volumes are associated with increased likelihood of vomiting, but not whether calorie intake affects the pro- gress of labour. 150 International Journal of Obstetric Anesthesia Procedural aspects of caesarean section Decision-to-delivery interval for emergency caesarean section Earlier guidelines on electronic fetal heart monitoring recommended that where acute fetal compromise was suspected, delivery should occur as soon as possible, ideally within 30 min, taking into account fetal and maternal factors. 21 Research to underpin this 30-min rule is limited. 2225 Poor outcome among babies deliv- ered rapidly prompted the misapprehension that rapid delivery may itself be causative, overlooking the fact that the most compromised babies are commonly deliv- ered with the least delay. 25,26 However, general anaes- thesia to allow rapid delivery has been a cause of maternal mortality. 27 The association between decision-to-delivery interval and neonatal and maternal outcomes was examined using data from NSCSA. 1 Babies who were delivered with short (<30 min) or long (>75 min) decision-to-de- livery intervals were more likely to require special care. These findings are consistent with previous studies. 2224 A delay of more than 75 min, particularly of course in the presence of fetal or maternal compromise, is associ- ated with poorer outcomes. 28 The guidelines suggest that although 30 min is an arbitrary limit, it remains important that the obstetric team can respond safely within this time to Category 1 caesarean section. The 75-min decision-to-delivery time should be added as a clinically important stan- dard. [C] Pre-operative testing and preparation for caesarean section Women who are anaemic are less able to tolerate blood loss. 27 Recommendations for antenatal screening in- clude measuring haemoglobin at booking and at 28 weeks. 29 It has been estimated that, of all women giving birth, 1.3% have blood loss >1000 mL while 0.7% have blood loss >1500 mL. 30 Haemorrhage remains an important cause of maternal mortality. 27 Although caesarean section in labour is associated with greater blood loss than vaginal or planned caesarean delivery, 30 there may be little differ- ence in blood loss between planned caesarean section and planned vaginal birth, 31,32 while factors such as placental abruption or antepartumhaemorrhage contribute. Women who have caesarean section for antepartum haemorrhage, placenta praevia or uterine rupture account for 21% of cases of blood loss >1000 mL in the UK. 1 Women should be offered a haemoglobin assessment before caesarean section to identify those who have anaemia. [C] Women having caesarean section for antepartum haemorrhage, placenta abruption, uterine rupture and placenta praevia are at increased risk of blood loss >1000 mL and should be delivered at a maternity unit with on-site blood transfusion services. [C] Grouping and saving of serum, cross-matching and a clotting screen are unnecessary before caesarean sec- tion in uncomplicated pregnancy. [C] Urinary catheterisation at caesarean section A survey of UK obstetricians reported that for caesarean section under regional anaesthesia the majority (82%) use an indwelling urinary catheter for both the procedure and postoperatively, with a minority using the catheter for the procedure only or an in-out catheter. 33 Women having caesarean section with regional anaesthesia require an indwelling urinary catheter to prevent over-distension of the bladder because the anaesthetic block interferes with normal bladder function. [GPP] Aspects of anaesthesia for caesarean section The options for anaesthesia and analgesia should be dis- cussed with the woman before her caesarean section using obstetric anaesthesia and analgesia information media. 5,6 Antacids and antiemetics Aspiration pneumonitis is now a rare event associated with general anaesthesia for caesarean section. In the UK 99% of units routinely use drugs to reduce the gastric volume and acidity for elective caesarean sec- tion and 98% for emergency caesarean section; 1 99% use H 2 receptor blockers (ranitidine, cimetidine), 2% proton pump inhibitors (omeprazole) and 99% non- particulate antacid (sodium citrate). RCTs have shown that sodium citrate reduces acidity without affecting gastric volume, 34 that ranitidine combined with sodium citrate reduces gastric volume and increases pH, 35 that omeprazole also reduces the risk of aspiration 36 and that omeprazole results in higher mean pH than ranitidine, although ranitidine with sodium citrate is cheaper. 3739 Nausea and vomiting may be provoked by hypoten- sion during regional anaesthesia for caesarean section. Treatment of the cause will alleviate the symptom. Var- ious RCTs and a meta-analysis showed reduced nausea and vomiting with metoclopramide, propofol, droperidol and ondansetron in women having caesarean section un- der spinal anaesthesia. 4045 One RCT found that acu- pressure and metoclopramide were equally effective in this context. 46 Ondansetron appears to be more effective than metoclopramide but the latter is cheaper, while The National Institute of Clinical Excellence (NICE) guidelines for caesarean sections 151 ondansetron is not advised for use during pregnancy and breastfeeding. To reduce the risk of aspiration pneumonitis, women should be offered drugs to reduce gastric volume and acidity before caesarean section. [B] To reduce the incidence of nausea and vomiting, women having caesarean section should be offered antiemetics (either pharmacological or acupressure). [A] General versus regional anaesthesia for caesarean section Regional anaesthesia is reportedly used in 77% of emergency and 91% of elective caesarean sections. 1 In category 1 caesarean sections, general anaesthesia was used in 41%, regional anaesthesia in 54% and general anaesthesia following failure of regional anaesthesia in 3%. A UK survey of anaesthetic tech- niques for caesarean section reported an overall fail- ure rate for epidural anaesthesia of 7.1%, for combined spinal epidural 2% and for single-shot spinal anaesthetic 1.9%. Failure of regional anaesthe- sia accounted for 10% of general anaesthetics for cae- sarean section. 47 The guidelines cite three RCTs comparing the effect of general versus regional anaesthesia for elective caesar- ean section on maternal and neonatal morbidity. 4850 At least three more were published in 2003. The document asserts that no difference in neonatal outcomes was detected between general and regional anaesthesia groups, and overlooks the adverse effect that spinal as opposed to general or epidural anaesthesia may have on fetal acid-base balance. General anaesthesia has commonly been found to re- sult in increased blood loss. 51 The same applies to cae- sarean section for placenta praevia. 5254 The authors cite one RCT comparing general with regional anaesthesia for severe preeclampsia, which found little difference in maternal and/or fetal complications. 55 The recommendations state: Women should be offered regional anaesthesia because it is safer and results in less maternal and neonatal morbidity than general anaesthesia. This includes women who have a diagnosis of placenta praevia. [A] This may be misleading in relation to spinal anaesthe- sia and newborn acid-base balance. Converting epidural analgesia to anaesthesia for caesarean section Conversion of an analgesic epidural to one suitable for anaesthesia in the shortest time possible is desirable in category 1 and 2 caesarean sections because this avoids general anaesthesia. One RCT comparing 0.5% bupiva- caine alone, 2% lidocaine plus epinephrine and a mix- ture of the two found no difference between the groups in time to adequate block. 56 Another found that the addition of bicarbonate accelerated the onset of 2% lidocaine plus epinephrine and fentanyl. 57 Place of induction and monitoring during caesarean section One non-obstetric RCT comparing induction in the oper- ating theatre with that in an anaesthetic room showed no difference in patient anxiety between the two groups. 58 A survey of 115 women having elective caesarean sec- tion under regional anaesthesia reported that stress was related to anxiety about pain and the baby rather than to the environment. 59 The controversy relating to top- ping up other than in the environs of the operating the- atre was not addressed. The recommendations state: For caesarean section under regional block continu- ous pulse oximetry, non-invasive blood pressure capable of one-minute cycles and electrocardiogra- phy are recommended; for general anaesthesia there should be full monitoring as recommended in the national guidelines. 60,61 The fetal heart rate should be recorded during the initiation of regional block and until the abdominal skin preparation is begun in emergency caesarean section. Regional anaesthesia for caesarean section should be induced in theatre because this does not increase patient anxiety [B] They do not mention that the important fact that this allows continuous monitoring throughout induction and maintenance of anaesthesia. Procedures to avoid hypotension Lateral tilt of the operating table is standard practice in the UK for the prevention of hypotension caused by aortocaval compression. 47 A systematic review of three early studies, and one more recent one found no differences in Apgar scores or umbilical artery pH with lateral tilt, 62,63 which is odd because early studies certainly detected a benefit. Another RCT comparing lateral with no tilt at emergency caesarean section found no differences in maternal or neonatal outcomes. 64 Two RCTs comparing the effect of the full lateral position (described incorrectly as laternal tilt) versus 15 wedge found no difference in inci- dence of hypotension between the methods. 64,65 A sys- tematic review that included 20 RCTs reported that the following interventions reduce the incidence of hypotension under spinal anaesthesia for caesarean section: pre-load with crystalloid 20 mL/kg versus control, pre-emptive colloid versus crystalloid, ephe- 152 International Journal of Obstetric Anesthesia drine versus control and lower limb compression ver- sus control. 66 No differences in maternal or neonatal side effects were reported. The use of crystalloid has been shown by systematic review to be inconsistent in its ability to prevent maternal hypotension [see Conclusion]. The guidelines recommend the use of phenyl- ephrine and ephedrine indiscriminately as being equally effective as vasopressors, but fail to mention that mothers given phenylephrine may have fewer episodes of nausea and vomiting and that their babies are less likely to be acidotic. 6769 The recommenda- tions state: The operating table for caesarean section should have a lateral tilt of 15 because this reduces maternal hypotension. [A] Intravenous ephedrine or phenylephrine should be used in the management of hypotension during cae- sarean section. [A] Failed intubation The document points out that failed intubation has a re- ported incidence of 1/249 70 and is still an occasional cause of maternal death. 27 The place of the laryngeal mask and the importance of a failed intubation drill are mentioned. 7176 General anaesthesia for caesarean section should include preoxygenation, cricoid pressure and rapid sequence induction to reduce the risk of aspiration [GPP] Each maternity unit should have a drill for failed intu- bation [D] Surgical techniques for caesarean section of relevance to the anaesthetist Use of uterotonics The authors remind us that the licensed dose of oxytocin for caesarean section is 5 units by slow intravenous injection; problems associated with the use of larger bo- lus doses given rapidly are highlighted. 27,77 One RCT comparing different oxytocin infusion concentrations (20 versus 160 units/L) showed no difference in the inci- dence of hypotension but the lower-concentration group were more likely to need additional utertonics. 78 Evi- dence is divided about whether prostaglandins are as effective as oxytocin. 7983 Oxytocin, however, has a half-life of only 410 min. Oxytocin 5 units by slow intravenous injection should be used at caesarean section to encourage contraction of the uterus and to decrease blood loss. [C] Perhaps ill-advisedly, there is no mention of the need to follow this with an oxytocin infusion. Uterine exteriorisation Only a minority of obstetricians in the UK exteriorise the uterus. 84 One RCT found that uterine exteriorisa- tion did not increase nausea, vomiting, sensation of tugging or pain scores, 85 although two women in the exteriorised group had their epidurals converted to general anaesthesia because of pain. This has implications for the anaesthetist as supplementary analgesia or conversion to general anaesthesia may be needed and there may be medico-legal implica- tions. No surgical advantage has been found for the technique. 85,86 Exteriorisation of the uterus is not recommended because it is associated with more pain and does not improve operative outcomes such as haemorrhage or infection. [A] Use of antibiotics Prophylactic antibiotics reduce the incidence of fever, endometritis, wound, urinary tract and other infection. 87 There is no advantage in using multiple doses compared with a single dose. 88 Ampicillin and first generation cephalosporins are equally effective. Women having caesarean section should be offered prophylactic antibiotics to reduce the risk of post- operative infections, which occur in about 8% of women. [A] Thromboprophylaxis for caesarean section The reported incidence of pulmonary thromboembolism is 6 per 10 000 maternities but varies with maternal age, obesity and smoking. 89 It is the leading direct cause of maternal death in the UK. 27 Various interventions have been explored for its prevention but the trials were too small to evaluate outcome. 90 Increased risk is associated with emergency versus elective caesarean section, maternal age >35 years, weight >80 kg and medical complications. Recommended thromboprophylaxis in- cludes hydration, early mobilisation, graduated elastic compression stockings and low-molecular-weight heparin. 91,92 Women having caesarean section should be offered thromboprophylaxis because they are at increased risk of thromboembolism. The chosen method of pro- phylaxis... should take into account risk of thrombo- embolic disease and should follow existing guidelines. [D] Care of the baby born by caesarean section The guidelines state that infants born by caesarean sec- tion under general anaesthesia are at an increased risk of The National Institute of Clinical Excellence (NICE) guidelines for caesarean sections 153 1-and 5-min Apgar scores <7 when compared with those born with regional anaesthesia, but most studies find that only the one-minute score is affected. 49 An appropriately trained practitioner skilled in resuscitation of the newborn should be present at caesarean section performed under general anaes- thesia or where there is evidence of fetal compro- mise. [C] Care of the woman after caesarean section High dependency and intensive care admission The incidence of severe morbidity among parturients has been reported to be 12 per 1000 deliveries. 93 A small proportion of women (0.10.9%) develop complications of pregnancy that require admission to intensive care. 94 The NSCSA reported that 10% of women who had cae- sarean section required admission to a high dependency unit; 3.5% of these women were transferred to intensive care. 1 Table 3 shows the proportion of women who re- quired admission to intensive care following caesarean section, according to the reason for caesarean section. The indications for caesarean section that were most likely to lead to admission to intensive care accounted for <20% of all caesarean sections. Maternal disease produced the largest number of women. The recommen- dation given was: Health professionals caring for women after caesar- ean section should be aware that, although it is rare for women to need intensive care following childbirth this occurs more frequently after caesarean section (about 9 per 1000). [B] Routine monitoring after caesarean section Poor postoperative care is a recurring factor in maternal deaths. 27 The national obstetric anaesthetic service guidelines state that the postoperative care of a caesar- ean section patient should meet the same standard of care as that required for any postoperative patient. 60,61,95 After caesarean section, women should be observed on a one-to-one basis by a properly trained member of staff until they have regained airway control and cardiorespiratory stability and are able to communi- cate. [D] After recovery from anaesthesia, observations (respi- ratory rate, heart rate, blood pressure, pain and seda- tion) should be continued every half hour for two hours and hourly thereafter provided that the observa- tions are stable or satisfactory. If these observations are not stable, more frequent observations and medi- cal review are recommended. [GPP] Pain management after caesarean section Intrathecal and epidural analgesia Morphine is commonly used in countries other than the UK, 9698 where diamorphine is available and used with good effect. 99103 Both are effective but diamorphine has fewer and less severe side effects. 100 Both morphine and diamorphine may be given both epidurally and intrathecally, 103,104 and relative efficacy and side effects are largely dependent on dosage. Women should be offered diamorphine (0.30.4 mg intrathecally) for intra- and postoperative analgesia because it reduces the need for supplemental analge- sia after caesarean section. Epidural diamorphine (2.55.0 mg) is a suitable alternative. [A] Patient controlled analgesia (PCA) and non-steroidal anti-inflammatory analgesics In the absence of intrathecal or epidural opioid analge- sia, opioid PCA may be used for postoperative analge- sia. There is little difference among the various recipes. 105,106 Rectal diclofenac administered immediately after caesarean section is regularly found to reduce the need for other types of analgesia. 107,108 Patient controlled analgesia using opioid analgesics should be offered [GPP] Providing there is no contraindication, non-steroidal anti-inflammatory drugs should be offered after cae- sarean section as an adjunct to other analgesics, because they reduce the need for opioids. [A] Other local anaesthetic techniques As an alternative to systemic analgesia, wound infiltra- tion and ilioinguinal nerve block have been found equally effective in relieving pain after caesarean section. 109,110 Table 3. Admission to intensive therapy unit (ITU) according to reason for caesarean section Reason for caesarean section % admitted to ITU OR (95% CI) Uterine rupture 6.4 43.3 (9.9 to 189.5) Maternal medical disease 2.7 17.8 (6.4 to 49.2) Placenta praevia, actively bleeding 2.5 16.6 (5.3 to 52.2) Pre-eclampsia/ eclampsia/HELLP 1.9 12.4 (4.3 to 35.5) Placenta praevia, not actively bleeding 1.1 7.0 (2.2 to 22.1) Placental abruption 1.1 7.2 (1.7 to 30.4) Breech 0.2 1.00 Data from The National Sentinel Caesarean Section Audit Report. 1 The odds ratio was calculated in relation to the proportion of women with breech presentation who were admitted to ITU, but by extrapo- lation it appears that this proportion was similar to that in the caesarean section population taken as a whole, which is lucky. 154 International Journal of Obstetric Anesthesia Post partum care Early eating and drinking after caesarean section Asystematic reviewof six RCTs comparing early with de- layed oral fluids and food after caesarean section found that early eating and drinking were associated with re- duced time to return of bowel sounds and reduced hospital stay. 111 There was no difference between the groups with respect to nausea and vomiting, abdominal distension, time to bowel action, paralytic ileus or need for analgesia. Women who are recovering well and who do not have complications can eat and drink when they feel hungry or thirsty. [A] Urinary catheter removal after caesarean section The best time to remove a urinary catheter and the value of routine indwelling catheterisation are currently uncer- tain. 112,113 No difference has been detected in the inci- dence of urinary retention after general and epidural anaesthesia. 114 The urinary catheter should be removed once a woman is mobile after a regional anaesthetic and not sooner than 12 h after the last epidural top-up dose. [D] Length of hospital stay Women are usually discharged after caesarean section on day three, 115 but the ideal time is under review. 116 In general, early discharge promotes maternal satisfac- tion and has little detrimental effect. 117 Early discharge has implications for the anaesthetist as some of the late complications of regional anaesthesia may not be readily detected in the community. Length of stay is likely to be longer after a caesarean section (an average of 34 days) than after vaginal birth. However, women who are recovering well, are apyrexial and do not have complications should be offered early discharge (after 24 h) from hospital and follow-up at home, because this is not associated with more infant or maternal readmissions. [A] CONCLUSION These guidelines are based on some of the evidence available at the time of writing, but there are areas where evidence is conflicting or absent; these are pre- sented as group practice points which are the subject of discussion, debate and stimulus for further research. The recommendations that we feel are of particular importance to anaesthetists are the value of evidence- based information, the adoption of the new category of urgency of caesarean section by the obstetric team and the use of regional anaesthesia and analgesia to improve safety and quality of care. 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