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International Journal of Obstetric Anesthesia (2005) 14, 147–158Ó 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijoa.2004.09.008 The National Institute of Clinical Excellence (NICE) guide-lines for caesarean sections: implications for the anaesthetist Department of Anaesthesia, Poole Hospital, Dorset, Department of Obstetrics and Gynaecology,Princess Anne Hospital, Southampton, Department of Anaesthesia, St. Thomas’s Hospital, London, UK INTRODUCTIONThe bodies involved; Background; Aims of the guidelines; Evidence and grading of recommendationsSUMMARY OF RECOMMENDATIONS AFFECTING ANAESTHETIC PRACTICEProvision of information and consentClassification of urgency of caesarean sectionPlanned caesarean sectionFactors in intrapartum care affecting likelihood of caesarean sectionFactors with no influence on caesarean section rates: Epidural analgesia; Eating in labourProcedural 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 sectionCare of the woman after caesarean section: High dependency and intensive care admission; Routine monitoring after 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 Keywords: NICE guidelines; Caesarean section; Anaesthesia M.Y.K. Wee, Consultant Obstetric Anaesthetist, Department ofAnaesthesia, Poole Hospital NHS Trust, Longfleet Road, Poole, Dorset The National Institute for Clinical Excellence (NICE) BH 15 2JB, UK, H. Brown, Senior Specialist Registrar in Obstetrics is part of the National Health Service (NHS) in the and Gynaecology, Princess Anne Hospital, Coxford Road, UK. It was established in 1999 as an independent Southampton SO16 5YA, F. Reynolds, Emeritus Professor ofObstetric Anaesthesia, St. Thomas’s Hospital, Lambeth Palace Road, organisation to promote clinical excellence by provid- ing guidance on treatments and care based on the Correspondence to: M.Y.K Wee, Consultant Obstetric Anaesthetist, best available evidence and effective use of resources.
Department of Anaesthesia, Poole Hospital NHS Trust, Longfleet NICE has under its wing the Confidential Enquiries Road, Poole, Dorset BH 15 2JB, UK, Tel.: +44 120 244 2443; into Maternal and Child Health (CEMACH). In April 2004, NICE published caesarean section guidelines; International Journal of Obstetric Anesthesia the aim of this review is to highlight aspects of these the UK according to ethnicity, with higher rates reported guidelines that may have implications for anaes- in black African and Caribbean ethnic groups.
The five major indications for caesarean section in Several versions of the guidelines are available and the UK are fetal compromise (22%), Ôfailure to progress’ in labour (20%), repeat caesarean section (14%), breech presentation (11%) and maternal request (7%).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 The guidelines aim to provide evidence-based informa-  Risks and benefits of caesarean section Certain specific indications for caesarean section Effective management strategies to avoid caesarean The National Collaborating Centre for Women’s and  Anaesthetic and surgical aspects of care Children’s Health (NCC-WCH) was commissioned by  Interventions to reduce morbidity from caesarean sec- NICE to produce the guidelines. NICE and 60 registered stakeholders including the Royal College of Anaesthe-  Aspects of organisation and environment that affect tists (RCA) and Obstetric Anaesthetists’ Association (OAA) were involved in their development. An indepen- This does not cover all the clinical decisions and care dent Guideline Review Panel and Patient Involvement pathways that may lead to caesarean section. For exam- Unit then reviewed the draft guidelines.
ple, it omits advice on the risks and benefits of caesarean The NCC-WCH established the Guideline Develop- section in specific conditions such as preeclampsia or ment Group (GDG) comprising a general practitioner gestational diabetes or in rare diseases.
who chaired the group, two obstetricians, two midwives, As well as clinical effectiveness, the guidelines were a neonatologist, an anaesthetist and two consumers.
concerned with cost-effectiveness of caesarean section Other members of the GDG included the director of the NCC-WCH, chair of CEMACH, informatics special-ist, health economist and several research fellows. Theanaesthetic representative was selected from nomina- tions submitted by the RCA and the OAA and consulted Evidence from studies that were least subject to bias and widely during development of the guidelines on issues published systematic reviews or meta-analyses were of anaesthetic interest from obstetric anaesthetist experts used where available (Data are presented as absolute risks, relative risks or odds ratios where rele-vant. Where data are statistically significant they arealso presented as numbers needed to treat for beneficial outcomes or numbers needed to harm for adverse effects as relevant. Recommendations are graded according to (NSCSA) reported that in England and Wales, caesarean the strength of the evidence that supports them section rates increased from 9% of deliveries in 1980 to 21% in 2001, with similar increases in many developedcountries.The average age of women giving birth has increased and caesarean section rates increase with maternal age. The caesarean section rate for women intheir first pregnancy is now 24% and for women who Bullet-points below quote from, summarise or para- have had a previous caesarean section, it is markedly in- phrase recommendations from the guidelines; the letter creased (67%). The caesarean section rate also varied in The National Institute of Clinical Excellence (NICE) guidelines for caesarean sections Systematic review or meta-analyses of randomised controlled trials At least one well-designed controlled study without randomisation At least one well-designed quasi-experimental study, such as a cohort study Well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, case controlled studies and case series Expert committee reports, or opinions and/or clinical experience of respected authorities Based on level 2 evidence or extrapolated from level 1 evidence Based on level 3 evidence or extrapolated from level 1 or 2 evidence Based on level 4 evidence or extrapolated from level 1, 2 or 3 evidence Group practice point based on the view of the guideline development group Recommendation taken from NICE Technology Appraisal of caesarean section, such estimates should be derivedfrom intention to treat analysis of RCTs and systematic  Pregnant women should be given evidence-based reviews comparing planned caesarean section with information and support to enable them to make planned vaginal birth.Anaesthetists should give full information including the material risks of anaesthesia  Information about caesarean section should be given during the antenatal period because about 1 in 5 preg-  Consent for caesarean section should be requested nant women will have a caesarean section. [GPP] after providing the pregnant woman with evi-  The information should be in a form that is accessi- dence-based information and in a manner that ble Á Á Á taking into account cultural needs of ethnic respects the woman’s dignity, privacy, views and minority communities Á Á Á and those with disabilities.
culture whilst taking into consideration the clinical In 1993, the Expert Maternity Group from the  A competent pregnant woman is entitled to refuse Department of Health released the report Changing treatment Á Á Á even when the treatment would clearly Childbwhich made explicit the right of women benefit her or her baby’s health. Refusal of treatment to be involved in decisions regarding all aspects of needs to be one of the woman’s options. [D] their care during pregnancy and childbirth. In orderto discuss decisions with caregivers, women requireevidence-based information. Randomised trials (RCTs) Classification of urgency of caesarean section on antenatal education suggest that the provision ofinformation is often seen as inadequate by women.
Caesarean section has traditionally been classified as The use of evidence-based information leaflets has elective and emergency. The Ôemergency’ category, been shown to improve maternal satisfaction.As however, does not differentiate between true emergen- about one in five women in the UK are delivered by cies where the life of the woman or fetus is threatened, caesarean section (the majority unplanned),all of and situations in which there is no imminent threat to them need information on both vaginal and caesarean life. A four-point classification has been piloted, used delivery. The Obstetric Anaesthetists’ Association has in a national survey and shown to predict baby out- produced evidence-based leaflets and a related video come.Its adoption is recommended to aid clear com- on anaesthesia for caesarean section that can be used munication between healthcare professionals about the Provision of information is a prerequisite to consent Category 1: immediate threat to the life of the woman or and should cover the patient’s condition, possible inves- fetus. This includes caesarean section for acute severe tigations and treatment options, their risks and benefits fetal bradycardia, cord prolapse, uterine rupture, fetal and the risk of refusing treIdeally, in the case International Journal of Obstetric Anesthesia Category 2: maternal or fetal compromise that is not  Consultant obstetricians should be involved in the immediately life-threatening. There is a degree of decision-makingÁ Á Á because this reduces the likeli- urgency to deliver the baby in order to prevent further deterioration of either the mother’s or the baby’s con-  Electronic fetal monitoring is associated with an dition. Examples include antepartum haemorrhage increased likelihood of caesarean section. When cae- and failure to progress in labour with maternal or sarean section is contemplated because of an abnor- mal fetal heart rate pattern Á Á Á Á Á Á fetal blood Category 3: no maternal or fetal compromise but needs sampling should be offered if possible. [B] early delivery. Examples include a situation in whichcaesarean section is planned but the woman is admit-ted in early labour or with ruptured membranes.
Factors with no influence on caesarean section Category 4: delivery timed to suit woman or staff. This includes all planned elective caesarean sections.
A woman who mistakenly believes that epidural anal- gesia increases the likelihood of caesarean section will The guidelines recommend that planned caesarean sec- be prejudiced against it. Fortunately there is ample  with breech presentation at term if external cephalic meta-analyses ) that epidural analgesia during version has been unsuccessful or is contraindicated labour does not influence the likelihood of caesarean  to HIV-positive women at term [A].
 Aspects of care in labour with no influence on the  to women with grade 3 or 4 placenta praevia [D] likelihood of caesarean section include walking,  The evidence for other indications is less sound, for non-supine position during the second stage, immer- example it is uncertain whether caesarean section sion in water, epidural analgesia and raspberry leaf confers any additional benefit in twin pregnancies at term where the first twin is cephalic, pretermbabies or small for gestational age babies.
 Maternal request is not on its own considered an indication for caesarean section. Whether an indi- Eating in labour is an issue much debated between vidual clinician has the right to decline a request healthcare professionals, some midwives believing it for a caesarean section is of concern to anaesthe- will reduce the need for intervention. The debate is rel- tists. Individual women may request caesarean sec- evant to obstetric anaesthesia. One RCT comparing a tion because of fear of pain in childbirth. The group given a light diet in labour with a starved group guideline recommends counselling for this, but the given water only (the guidelines erroneously state that logical inference that a discussion with an anaesthe- the starved group were given water, tea, coffee or co- tist about epidural analgesia could form part of this coa), showed that while maternal ketosis was improved, gastric volume and vomiting were both increased by eat-ing.Another RCT substituted an isotonic sport drinkfor solids and showed that it reduced ketosis without Factors in intrapartum care affecting likelihood of increasing gastric Neither study was powered to examine obstetric outcome, which is the subject of an The indications for emergency caesarean section should on-going study. The recommendation in the guidelines surely feature prominently in the guidelines, as one of the aims is to provide effective management strategies  Women should be informed that eating a low residue to avoid caesarean section, and the majority of caesar- diet during labourÁ Á Á results in larger gastric volumes, ean sections are unplanned. Yet this topic is addressed but the effect on the risk of aspiration if anaesthesia is only under the heading Factors reducing the likelihood required is uncertainÁ Á Á having isotonic drinks during of (caesarean section). The recommendations related labour prevents ketosis without a concomitant  A partogram with a 4-h action line should be used to This surely misses the point; we know larger gastric monitor progress in women in spontaneous labour with volumes are associated with increased likelihood of an uncomplicated singleton pregnancy at term, because vomiting, but not whether calorie intake affects the pro- it reduces the likelihood of caesarean section. [A] The National Institute of Clinical Excellence (NICE) guidelines for caesarean sections  Women having caesarean section for antepartum haemorrhage, placenta abruption, uterine rupture Decision-to-delivery interval for emergency caesarean and placenta praevia are at increased risk of blood loss >1000 mL and should be delivered at a maternity Earlier guidelines on electronic fetal heart monitoring unit with on-site blood transfusion services. [C] recommended that where acute fetal compromise was  Grouping and saving of serum, cross-matching and a suspected, delivery should occur as soon as possible, clotting screen are unnecessary before caesarean sec- ideally within 30 min, taking into account fetal and maternal factorResearch to underpin this 30-minrule is limited.Poor outcome among babies deliv- Urinary catheterisation at caesarean section ered rapidly prompted the misapprehension that rapiddelivery may itself be causative, overlooking the fact A survey of UK obstetricians reported that for caesarean that the most compromised babies are commonly deliv- section under regional anaesthesia the majority (82%) ered with the least delay.However, general anaes- use an indwelling urinary catheter for both the procedure thesia to allow rapid delivery has been a cause of and postoperatively, with a minority using the catheter for the procedure only or an in-out cathet The association between decision-to-delivery interval  Women having caesarean section with regional and neonatal and maternal outcomes was examined anaesthesia require an indwelling urinary catheter to using data from NSCSA.Babies who were delivered prevent over-distension of the bladder because the with short (<30 min) or long (>75 min) decision-to-de- anaesthetic block interferes with normal bladder livery intervals were more likely to require special care.
These findings are consistent with previous studies.A delay of more than 75 min, particularly of course in Aspects of anaesthesia for caesarean section the presence of fetal or maternal compromise, is associ-ated with poorer outcomes.
The options for anaesthesia and analgesia should be dis-  The guidelines suggest that although 30 min is an cussed with the woman before her caesarean section using arbitrary limit, it remains important that the obstetric obstetric anaesthesia and analgesia information media.
team can respond safely within this time to Category1 caesarean section. The 75-min decision-to-delivery time should be added as a clinically important stan-dard. [C] Aspiration pneumonitis is now a rare event associatedwith general anaesthesia for caesarean section. In theUK 99% of units routinely use drugs to reduce the Pre-operative testing and preparation for caesarean gastric volume and acidity for elective caesarean sec- tion and 98% for emergency caesarean sect99%use H2 receptor blockers (ranitidine, cimetidine), 2% Women who are anaemic are less able to tolerate blood proton pump inhibitors (omeprazole) and 99% non- Recommendations for antenatal screening in- particulate antacid (sodium citrate). RCTs have shown clude measuring haemoglobin at booking and at 28 that sodium citrate reduces acidity without affecting gastric that ranitidine combined with sodium It has been estimated that, of all women giving birth, citrate reduces gastric volume and increases that 1.3% have blood loss >1000 mL while 0.7% have blood omeprazole also reduces the risk of aspiration loss >1500 mL.Haemorrhage remains an important and that omeprazole results in higher mean pH than cause of maternal mortaAlthough caesarean section ranitidine, although ranitidine with sodium citrate is in labour is associated with greater blood loss than vaginal or planned caesarean deliverthere may be little differ- Nausea and vomiting may be provoked by hypoten- ence in blood loss between planned caesarean section and sion during regional anaesthesia for caesarean section.
planned vaginal birth,while factors such as placental Treatment of the cause will alleviate the symptom. Var- abruption or antepartum haemorrhage contribute. Women ious RCTs and a meta-analysis showed reduced nausea who have caesarean section for antepartum haemorrhage, and vomiting with metoclopramide, propofol, droperidol placenta praevia or uterine rupture account for 21% of and ondansetron in women having caesarean section un-  Women should be offered a haemoglobin assessment pressure and metoclopramide were equally effective in before caesarean section to identify those who have this context.Ondansetron appears to be more effective than metoclopramide but the latter is cheaper, while International Journal of Obstetric Anesthesia ondansetron is not advised for use during pregnancy and caine alone, 2% lidocaine plus epinephrine and a mix- ture of the two found no difference between the  To reduce the risk of aspiration pneumonitis, women groups in time to adequate block.Another found that should be offered drugs to reduce gastric volume and the addition of bicarbonate accelerated the onset of 2% lidocaine plus epinephrine and fentanyl.
 To reduce the incidence of nausea and vomiting, women having caesarean section should be offered antiemetics(either pharmacological or acupressure). [A] Place of induction and monitoring during caesareansection General versus regional anaesthesia for caesarean One non-obstetric RCT comparing induction in the oper- ating theatre with that in an anaesthetic room showed no Regional anaesthesia is reportedly used in 77% of difference in patient anxiety between the two groups emergency and 91% of elective caesarean sect A survey of 115 women having elective caesarean sec- In category 1 caesarean sections, general anaesthesia tion under regional anaesthesia reported that stress was was used in 41%, regional anaesthesia in 54% and related to anxiety about pain and the baby rather than to the environment.The controversy relating to top- anaesthesia in 3%. A UK survey of anaesthetic tech- ping up other than in the environs of the operating the- niques for caesarean section reported an overall fail- atre was not addressed. The recommendations state: For caesarean section under regional block continu- combined spinal epidural 2% and for single-shot ous pulse oximetry, non-invasive blood pressure spinal anaesthetic 1.9%. Failure of regional anaesthe- capable of one-minute cycles and electrocardiogra- sia accounted for 10% of general anaesthetics for cae- phy are recommended; for general anaesthesia there should be full monitoring as recommended in the The guidelines cite three RCTs comparing the effect national guidelinesThe fetal heart rate should of general versus regional anaesthesia for elective caesar- be recorded during the initiation of regional block ean section on maternal and neonatal morAt and until the abdominal skin preparation is begun in least three more were published in 2003. The document asserts that no difference in neonatal outcomes was  Regional anaesthesia for caesarean section should be detected between general and regional anaesthesia induced in theatre because this does not increase groups, and overlooks the adverse effect that spinal as opposed to general or epidural anaesthesia may have They do not mention that the important fact that this allows continuous monitoring throughout induction and General anaesthesia has commonly been found to re- sult in increased blood loss.The same applies to cae-sarean section for placenta praevia.The authors cite one RCT comparing general with regional anaesthesiafor severe preeclampsia, which found little difference Lateral tilt of the operating table is standard practice in maternal and/or fetal complications.
in the UK for the prevention of hypotension caused by aortocaval compresA systematic review of  Women Á Á Á should be offered regional anaesthesia three early studies, and one more recent one found because it is safer and results in less maternal and no differences in Apgar scores or umbilical artery neonatal morbidity than general anaesthesia. This pH with lateral tilt,which is odd because early includes women who have a diagnosis of placenta studies certainly detected a benefit. Another RCT comparing lateral with no tilt at emergency caesarean This may be misleading in relation to spinal anaesthe- section found no differences in maternal or neonatal outcomes.Two RCTs comparing the effect of thefull lateral position (described incorrectly as laternal Converting epidural analgesia to anaesthesia for tilt) versus 15° wedge found no difference in inci- dence of hypotension between the methods.A sys-tematic review that included 20 RCTs reported that Conversion of an analgesic epidural to one suitable for the following interventions reduce the incidence of anaesthesia in the shortest time possible is desirable in hypotension under spinal anaesthesia for caesarean category 1 and 2 caesarean sections because this avoids section: pre-load with crystalloid 20 mL/kg versus general anaesthesia. One RCT comparing 0.5% bupiva- control, pre-emptive colloid versus crystalloid, ephe- The National Institute of Clinical Excellence (NICE) guidelines for caesarean sections drine versus control and lower limb compression ver- sus control.No differences in maternal or neonatalside effects were reported. The use of crystalloid has Only a minority of obstetricians in the UK exteriorise been shown by systematic review to be inconsistent the uterus.One RCT found that uterine exteriorisa- in its ability to prevent maternal hypotension [see tion did not increase nausea, vomiting, sensation of tugging or pain scores,although two women in The guidelines recommend the use of phenyl- the exteriorised group had their epidurals converted to general anaesthesia because of pain. This has equally effective as vasopressors, but fail to mention implications for the anaesthetist as supplementary that mothers given phenylephrine may have fewer analgesia or conversion to general anaesthesia may episodes of nausea and vomiting and that their babies be needed and there may be medico-legal implica- are less likely to be acidotic.The recommenda- tions. No surgical advantage has been found for the  The operating table for caesarean section should have  Exteriorisation of the uterus is not recommended a lateral tilt of 15° because this reduces maternal because it is associated with more pain and does not improve operative outcomes such as haemorrhage  Intravenous ephedrine or phenylephrine should be used in the management of hypotension during cae-sarean section. [A] Prophylactic antibiotics reduce the incidence of fever, endometritis, wound, urinary tract and other infection.There is no advantage in using multiple doses compared The document points out that failed intubation has a re- with a single dose.Ampicillin and first generation ported incidence of 1/249and is still an occasional cephalosporins are equally effective.
cause of maternal The place of the laryngeal  Women having caesarean section should be offered mask and the importance of a failed intubation drill prophylactic antibiotics Á Á Á to reduce the risk of post- operative infections, which occur in about 8% of  General anaesthesia for caesarean section should include preoxygenation, cricoid pressure and rapidsequence induction to reduce the risk of aspiration[GPP]  Each maternity unit should have a drill for failed intu- The reported incidence of pulmonary thromboembolismis 6 per 10 000 maternities but varies with maternal age,obesity and smoking.It is the leading direct cause of Surgical techniques for caesarean section of maternal death in the UKVarious interventions have been explored for its prevention but the trials were toosmall to evaluate outcoIncreased risk is associated with emergency versus elective caesarean section, The authors remind us that the licensed dose of oxytocin maternal age >35 years, weight >80 kg and medical for caesarean section is 5 units by slow intravenous complications. Recommended thromboprophylaxis in- injection; problems associated with the use of larger bo- cludes hydration, early mobilisation, graduated elastic lus doses given rapidly are highliOne RCT comparing different oxytocin infusion concentrations (20 versus 160 units/L) showed no difference in the inci-  Women having caesarean section should be offered dence of hypotension but the lower-concentration group thromboprophylaxis because they are at increased were more likely to need additional utertoEvi- risk of thromboembolism. The chosen method of pro- dence is divided about whether prostaglandins are as phylaxis. should take into account risk of thrombo- effective as oxytoOxytocin, however, has a  Oxytocin 5 units by slow intravenous injection should be used at caesarean section to encourage contraction Care of the baby born by caesarean section of the uterus and to decrease blood loss. [C]Perhaps ill-advisedly, there is no mention of the need The guidelines state that infants born by caesarean sec- to follow this with an oxytocin infusion.
tion under general anaesthesia are at an increased risk of International Journal of Obstetric Anesthesia 1-and 5-min Apgar scores <7 when compared with those guidelines state that the postoperative care of a caesar- born with regional anaesthesia, but most studies find that ean section patient should meet the same standard of only the one-minute score is affected.
care as that required for any postoperative patient.
 An appropriately trained practitioner skilled in  After caesarean section, women should be observed resuscitation of the newborn should be present at on a one-to-one basis by a properly trained member caesarean section performed under general anaes- of staff until they have regained airway control and thesia or where there is evidence of fetal compro- cardiorespiratory stability and are able to communi-  After recovery from anaesthesia, observations (respi- Care of the woman after caesarean section ratory rate, heart rate, blood pressure, pain and seda-tion) should be continued every half hour for two High dependency and intensive care admission hours and hourly thereafter provided that the observa-tions are stable or satisfactory. If these observations The incidence of severe morbidity among parturients has are not stable, more frequent observations and medi- been reported to be 12 per 1000 deliveries.A small proportion of women (0.1–0.9%) develop complicationsof pregnancy that require admission to intensive 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 intensivecare.shows the proportion of women who re- Morphine is commonly used in countries other than the quired admission to intensive care following caesarean UK,where diamorphine is available and used with section, according to the reason for caesarean section.
good effect.Both are effective but diamorphine The indications for caesarean section that were most has fewer and less severe side effBoth morphine likely to lead to admission to intensive care accounted and diamorphine may be given both epidurally and for <20% of all caesarean sections. Maternal disease intratand relative efficacy and side effects produced the largest number of women. The recommen-  Women should be offered diamorphine (0.3–0.4 mg  Health professionals caring for women after caesar- intrathecally) for intra- and postoperative analgesia ean section should be aware that, although it is rare because it reduces the need for supplemental analge- for women to need intensive care following childbirth sia after caesarean section. Epidural diamorphine this occurs more frequently after caesarean section (2.5–5.0 mg) is a suitable alternative. [A] Patient controlled analgesia (PCA) and non-steroidal Routine monitoring after caesarean section Poor postoperative care is a recurring factor in maternal In the absence of intrathecal or epidural opioid analge- deaths.The national obstetric anaesthetic service sia, opioid PCA may be used for postoperative analge-sia. There is little difference among the variousrecipes.
Admission to intensive therapy unit (ITU) according to Rectal diclofenac administered immediately after caesarean section is regularly found to reduce the need  Patient controlled analgesia using opioid analgesics  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] Data from The National Sentinel Caesarean Section Audit Report.
As an alternative to systemic analgesia, wound infiltra- The odds ratio was calculated in relation to the proportion of women tion and ilioinguinal nerve block have been found with breech presentation who were admitted to ITU, but by extrapo- equally effective in relieving pain after caesarean lation it appears that this proportion was similar to that in the caesareansection population taken as a whole, which is lucky.
The National Institute of Clinical Excellence (NICE) guidelines for caesarean sections and the use of regional anaesthesia and analgesia toimprove safety and quality of care. One might quibble Early eating and drinking after caesarean section with the view that spinal is safer than general anaes- A systematic review of six RCTs comparing early with de- thesia for the babythat ephedrine or phenylephrine layed oral fluids and food after caesarean section found may be “offered” indiscrimior that crystal- that early eating and drinking were associated with re- loid is effective to prevent maternal hypotensio duced time to return of bowel sounds and reduced hospital and with the omission of any mention of maternal stay.There was no difference between the groups with oxygen during regional anaesthesia or of oxytocin 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 Á Á Á can eat and drink when they 1. Thomas J, Paranjothy S., Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. The National Urinary catheter removal after caesarean section Sentinel Caesarean Section Audit Report. London: RCOG Press,2001.
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