1116 l DECEMBER JOGC DÉCEMBRE 2015 COMMENTARY Key Words: Caesarean section, emergency Caesarean section, neonatal complications, checklists Competing Interests: None declared Received on May 25, 2015 Accepted on May 28, 2015 Preparedness for Emergency “Crash” Caesarean Section Thomas F. Baskett, MB, FRCSC Department of Obstetrics and Gynaecology, Dalhousie University, Halifax NS J Obstet Gynaecol Can 2015;37(12):1116–1117 T here are a number of obstetric complications in which a very rapid or “crash” Caesarean section (CS) is necessary to save the fetus from death or disability. These situations are relatively rare but can include uterine rupture (usually after a previous CS), cord prolapse, sustained bradycardia, and antepartum hemorrhage. In some of these instances resuscitation manoeuvres may give temporary respite from the “fetal distress” and allow a more orderly progression to CS. In others, most often uterine rupture or sustained bradycardia, the need to deliver the fetus from inexorable hypoxia is urgent and compelling. For example, with uterine rupture during labour after previous CS the fetus needs to be delivered within 20 minutes to avoid severe neonatal asphyxia, 1,2 and even this will not protect against neonatal acidosis in all cases. 3 Through my experience working on the labour wards of both large and small hospitals, from hospital peer review surveys, and from litigation case reviews, I have found that many hospitals do not have an agreed and detailed plan for the rarely needed crash CS. None of the relevant national guidelines go into detail on this point, but simply state “Suspected uterine rupture requires urgent attention and expedited laparotomy to attempt to decrease maternal and perinatal morbidity and mortality.” 4 The following list of practical factors need to be agreed upon in advance by all responsible parties: administration, anaesthesia, midwifery, nursing, obstetrics, and neonatology. 5 The time to debate, clarify, and formulate these points (below) into an accepted policy is in committee and not at 3:00 a.m. in the middle of an emergency. • Limit the preoperative checklist. All of the relevant points are usually known from the antenatal or admission records. The dogged and time-consuming adherence to a preoperative multiple question checklist is one of the most frustrating and unnecessary delays for the accoucheur. The Society of Obstetricians and Gynaecologists of Canada’s obstetrical surgical safety checklist has 38 items to check off. It does, however, contain the statement that for cases of urgent CS the obstetrician should just say, “Doing a crash Caesarean section. Does anyone have any concerns prior to proceeding?” 6 • Verbal consent only. Provide a clear, sympathetic, and decisive explanation of the need for immediate CS. This is supported by both the American College of Obstetricians and Gynecologists 7 and the Royal College of Obstetricians and Gynaecologists. 8 • Anticipate the need for general anaesthesia: give oral antacid, e.g., sodium citrate 30 mL. • At the time of the decisive pelvic examination (when the decision to move to emergency CS is taken) the obstetrician or midwife/nurse should quickly, and without full aseptic rituals, insert a Foley catheter into the bladder. • At the time of the decisive pelvic examination the obstetrician or midwife/nurse should apply a fetal scalp electrode if one is not in place. This allows an accurate recording of the fetal heart rate (FHR) in the operating room (OR), as opposed to the often ineffective, incomplete, and inconclusive attempts with a Doptone. Sometimes the FHR will recover sufficiently to allow a slower and safer approach to the CS or, alternatively, confirm the need for extreme urgency.
Preparedness for Emergency “Crash” Caesarean Section
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Preparedness for Emergency "Crash" Caesarean SectionCOMMENTARY
Competing Interests: None declared .
Received on May 25, 2015
Accepted on May 28, 2015
Preparedness for Emergency “Crash” Caesarean Section Thomas F. Baskett, MB, FRCSC Department of Obstetrics and Gynaecology, Dalhousie University, Halifax NS
J Obstet Gynaecol Can 2015;37(12):1116–1117
There are a number of obstetric complications in which a very rapid or “crash” Caesarean section (CS) is
necessary to save the fetus from death or disability. These situations are relatively rare but can include uterine rupture (usually after a previous CS), cord prolapse, sustained bradycardia, and antepartum hemorrhage. In some of these instances resuscitation manoeuvres may give temporary respite from the “fetal distress” and allow a more orderly progression to CS. In others, most often uterine rupture or sustained bradycardia, the need to deliver the fetus from inexorable hypoxia is urgent and compelling. For example, with uterine rupture during labour after previous CS the fetus needs to be delivered within 20 minutes to avoid severe neonatal asphyxia,1,2 and even this will not protect against neonatal acidosis in all cases.3
Through my experience working on the labour wards of both large and small hospitals, from hospital peer review surveys, and from litigation case reviews, I have found that many hospitals do not have an agreed and detailed plan for the rarely needed crash CS. None of the relevant national guidelines go into detail on this point, but simply state “Suspected uterine rupture requires urgent attention and expedited laparotomy to attempt to decrease maternal and perinatal morbidity and mortality.”4 The following list of practical factors need to be agreed upon in advance by all responsible parties: administration, anaesthesia, midwifery, nursing, obstetrics, and neonatology.5 The time to debate, clarify, and formulate these points (below) into an accepted policy is in committee and not at 3:00 a.m. in the middle of an emergency.
• Limit the preoperative checklist. All of the relevant points are usually known from the antenatal or admission records. The dogged and time-consuming adherence to a preoperative multiple question checklist is one of the most frustrating and unnecessary delays for the accoucheur. The Society of Obstetricians and Gynaecologists of Canada’s obstetrical surgical safety checklist has 38 items to check off. It does, however, contain the statement that for cases of urgent CS the obstetrician should just say, “Doing a crash Caesarean section. Does anyone have any concerns prior to proceeding?”6
• Verbal consent only. Provide a clear, sympathetic, and decisive explanation of the need for immediate CS. This is supported by both the American College of Obstetricians and Gynecologists7 and the Royal College of Obstetricians and Gynaecologists.8
• Anticipate the need for general anaesthesia: give oral antacid, e.g., sodium citrate 30 mL.
• At the time of the decisive pelvic examination (when the decision to move to emergency CS is taken) the obstetrician or midwife/nurse should quickly, and without full aseptic rituals, insert a Foley catheter into the bladder.
• At the time of the decisive pelvic examination the obstetrician or midwife/nurse should apply a fetal scalp electrode if one is not in place. This allows an accurate recording of the fetal heart rate (FHR) in the operating room (OR), as opposed to the often ineffective, incomplete, and inconclusive attempts with a Doptone. Sometimes the FHR will recover sufficiently to allow a slower and safer approach to the CS or, alternatively, confirm the need for extreme urgency.
DECEMBER JOGC DÉCEMBRE 2015 l 1117
Preparedness for Emergency “Crash” Caesarean Section
• The above equipment (sodium citrate, Foley catheter, and scalp electrode) should be immediately available in each labour and delivery room, rather than in a central location.
• The bed or trolley should be swiftly transferred to the OR, including commandeering the elevator if necessary.
• The FHR monitor should be quickly transferred to the OR and re-established there.
• Accept an “all hands on deck” approach, so that all personnel (medical, nursing, midwifery, clerical) assist in the transfer of the patient and equipment to the OR.
• OR clothing: in an emergency, personnel need not change to full OR scrubs. Put on a gown, hair cap, foot covers, and mask—roll up your sleeves and scrub/ glove.
• Limit or omit scrub time. • Scrub nurse: if full OR nursing personnel are not
available, any nurse or midwife on labour and delivery should be able to do the initial set-up and scrub for CS.
• Skin preparation: accept a “splash and dash” approach for antiseptic skin preparation.
• A “starter pack” for emergency CS includes enough to get the baby delivered. Such a pack can be designed locally, but might include a scalpel, curved Mayo scissors, tooth-dissecting forceps, retractor, 2 artery forceps, 2 Kelly clamps for the cord, 4 laparotomy sponges, and bulb suction for the neonate. This also makes the task of the scrub nurse easier and quicker.
• No preoperative instrument count is necessary: a postoperative X-ray is acceptable under these circumstances.
• A clear system of responsibility is needed to alert the additional personnel required for anaesthesia and neonatal resuscitation.
Unless streamlined as above, each of these factors can add one to several minutes of time that cumulatively may lead to the difference between an intact neonate or a permanently disabled infant. A clear policy including the above factors, with which all labour ward personnel must be familiar, should help inculcate an appropriate, efficient, and undisputed response on the rare occasions that a crash Caesarean section is necessary.
REFERENCES
1. Leung AS, Leung EK, Paul RH. Uterine rupture after previous cesarean delivery: maternal and fetal consequences. Am J Obstet Gynecol 1993;169:945–9.
2. Holmgren C, Scott JR, Porter TF, Esplin MS, Bardsley T. Uterine rupture with attempted vaginal birth after cesarean delivery: decision-to-delivery time and neonatal outcome. Obstet Gynecol 2012;119:725–9.
3. Bujold E, Gauthier RJ. Neonatal morbidity associated with uterine rupture: what are the risk factors? Am J Obstet Gynecol 2002;186:311–6.
4. Martel M-J, MacKinnon CJ; Society of Obstetricians and Gynaecologists of Canada Cinical Practice Obstetrics Committee. Guidelines for vaginal birth after previous Caesarean birth. SOGC Clinical Practice Guideline, No.155, February 2005. J Obstet Gynaecol Can 2005;27:164–74.
5. Baskett TF. Essential management of obstetric emergencies. 5th ed. Bristol (GB): Clinical Press Ltd; 2015:229–31.
6. Singh SS, Mehra N, Hopkins L; Society of Obstetricians and Gynaecolosists of Canada Clinical Practice Gynaecology Committee. Surgical safety checklist in obstetrics and gynaecology. SOGC Clinical Practice Guideline, No. 286, January 2013. J Obstet Gynaecol Can 2013;35(Suppl): S1-S5.
7. American College of Obstetricians and Gynecologists. Vaginal birth after previous cesarean delivery. Practice Bulletin no. 115. Obstet Gynecol 2010;116:1232–40.
Competing Interests: None declared .
Received on May 25, 2015
Accepted on May 28, 2015
Preparedness for Emergency “Crash” Caesarean Section Thomas F. Baskett, MB, FRCSC Department of Obstetrics and Gynaecology, Dalhousie University, Halifax NS
J Obstet Gynaecol Can 2015;37(12):1116–1117
There are a number of obstetric complications in which a very rapid or “crash” Caesarean section (CS) is
necessary to save the fetus from death or disability. These situations are relatively rare but can include uterine rupture (usually after a previous CS), cord prolapse, sustained bradycardia, and antepartum hemorrhage. In some of these instances resuscitation manoeuvres may give temporary respite from the “fetal distress” and allow a more orderly progression to CS. In others, most often uterine rupture or sustained bradycardia, the need to deliver the fetus from inexorable hypoxia is urgent and compelling. For example, with uterine rupture during labour after previous CS the fetus needs to be delivered within 20 minutes to avoid severe neonatal asphyxia,1,2 and even this will not protect against neonatal acidosis in all cases.3
Through my experience working on the labour wards of both large and small hospitals, from hospital peer review surveys, and from litigation case reviews, I have found that many hospitals do not have an agreed and detailed plan for the rarely needed crash CS. None of the relevant national guidelines go into detail on this point, but simply state “Suspected uterine rupture requires urgent attention and expedited laparotomy to attempt to decrease maternal and perinatal morbidity and mortality.”4 The following list of practical factors need to be agreed upon in advance by all responsible parties: administration, anaesthesia, midwifery, nursing, obstetrics, and neonatology.5 The time to debate, clarify, and formulate these points (below) into an accepted policy is in committee and not at 3:00 a.m. in the middle of an emergency.
• Limit the preoperative checklist. All of the relevant points are usually known from the antenatal or admission records. The dogged and time-consuming adherence to a preoperative multiple question checklist is one of the most frustrating and unnecessary delays for the accoucheur. The Society of Obstetricians and Gynaecologists of Canada’s obstetrical surgical safety checklist has 38 items to check off. It does, however, contain the statement that for cases of urgent CS the obstetrician should just say, “Doing a crash Caesarean section. Does anyone have any concerns prior to proceeding?”6
• Verbal consent only. Provide a clear, sympathetic, and decisive explanation of the need for immediate CS. This is supported by both the American College of Obstetricians and Gynecologists7 and the Royal College of Obstetricians and Gynaecologists.8
• Anticipate the need for general anaesthesia: give oral antacid, e.g., sodium citrate 30 mL.
• At the time of the decisive pelvic examination (when the decision to move to emergency CS is taken) the obstetrician or midwife/nurse should quickly, and without full aseptic rituals, insert a Foley catheter into the bladder.
• At the time of the decisive pelvic examination the obstetrician or midwife/nurse should apply a fetal scalp electrode if one is not in place. This allows an accurate recording of the fetal heart rate (FHR) in the operating room (OR), as opposed to the often ineffective, incomplete, and inconclusive attempts with a Doptone. Sometimes the FHR will recover sufficiently to allow a slower and safer approach to the CS or, alternatively, confirm the need for extreme urgency.
DECEMBER JOGC DÉCEMBRE 2015 l 1117
Preparedness for Emergency “Crash” Caesarean Section
• The above equipment (sodium citrate, Foley catheter, and scalp electrode) should be immediately available in each labour and delivery room, rather than in a central location.
• The bed or trolley should be swiftly transferred to the OR, including commandeering the elevator if necessary.
• The FHR monitor should be quickly transferred to the OR and re-established there.
• Accept an “all hands on deck” approach, so that all personnel (medical, nursing, midwifery, clerical) assist in the transfer of the patient and equipment to the OR.
• OR clothing: in an emergency, personnel need not change to full OR scrubs. Put on a gown, hair cap, foot covers, and mask—roll up your sleeves and scrub/ glove.
• Limit or omit scrub time. • Scrub nurse: if full OR nursing personnel are not
available, any nurse or midwife on labour and delivery should be able to do the initial set-up and scrub for CS.
• Skin preparation: accept a “splash and dash” approach for antiseptic skin preparation.
• A “starter pack” for emergency CS includes enough to get the baby delivered. Such a pack can be designed locally, but might include a scalpel, curved Mayo scissors, tooth-dissecting forceps, retractor, 2 artery forceps, 2 Kelly clamps for the cord, 4 laparotomy sponges, and bulb suction for the neonate. This also makes the task of the scrub nurse easier and quicker.
• No preoperative instrument count is necessary: a postoperative X-ray is acceptable under these circumstances.
• A clear system of responsibility is needed to alert the additional personnel required for anaesthesia and neonatal resuscitation.
Unless streamlined as above, each of these factors can add one to several minutes of time that cumulatively may lead to the difference between an intact neonate or a permanently disabled infant. A clear policy including the above factors, with which all labour ward personnel must be familiar, should help inculcate an appropriate, efficient, and undisputed response on the rare occasions that a crash Caesarean section is necessary.
REFERENCES
1. Leung AS, Leung EK, Paul RH. Uterine rupture after previous cesarean delivery: maternal and fetal consequences. Am J Obstet Gynecol 1993;169:945–9.
2. Holmgren C, Scott JR, Porter TF, Esplin MS, Bardsley T. Uterine rupture with attempted vaginal birth after cesarean delivery: decision-to-delivery time and neonatal outcome. Obstet Gynecol 2012;119:725–9.
3. Bujold E, Gauthier RJ. Neonatal morbidity associated with uterine rupture: what are the risk factors? Am J Obstet Gynecol 2002;186:311–6.
4. Martel M-J, MacKinnon CJ; Society of Obstetricians and Gynaecologists of Canada Cinical Practice Obstetrics Committee. Guidelines for vaginal birth after previous Caesarean birth. SOGC Clinical Practice Guideline, No.155, February 2005. J Obstet Gynaecol Can 2005;27:164–74.
5. Baskett TF. Essential management of obstetric emergencies. 5th ed. Bristol (GB): Clinical Press Ltd; 2015:229–31.
6. Singh SS, Mehra N, Hopkins L; Society of Obstetricians and Gynaecolosists of Canada Clinical Practice Gynaecology Committee. Surgical safety checklist in obstetrics and gynaecology. SOGC Clinical Practice Guideline, No. 286, January 2013. J Obstet Gynaecol Can 2013;35(Suppl): S1-S5.
7. American College of Obstetricians and Gynecologists. Vaginal birth after previous cesarean delivery. Practice Bulletin no. 115. Obstet Gynecol 2010;116:1232–40.
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