Continuity around Rosie elective sections

Patient guide and welcome information

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Contents

• Welcome
• What can we offer you and your family?
• Meet the team
• Your caesarean birth
• Who will perform my procedure?
• Who will be with me in the theatre?
• Day of surgery admission
• During the operation
• After the operation
• After-care
• Feedback
• Contacts
• References

Welcome

You have chosen to join our new pilot scheme at the Rosie Hospital, which is designed to offer continuity of care to women and families who are having elective caesarean births.

We have created this team in line with the Better Births Initiative from NHS England, which was published in November 2015.

The Better Births vision states Our vision:

• for maternity services across England is for them to become safer, more personalised, kinder, professional and more family friendly.
• Where every woman has access to information to enable her to make decisions about her care; and where she and her baby can access support that is centred around their individual needs and circumstances.
• for all staff to be supported to deliver care which is women centred, working in high performing teams, in organisations which are well led and in cultures which promote innovation, continuous learning, and break down organisational and professional boundaries.

Our goals are:

1. Personalised care
2. Continuity of carer
3. Safer care with professionals working together
4. Better postnatal and perinatal mental health
5. Positive outcomes, birth experiences and keeping mothers and babies together

What can we offer you and your family?

When women choose to join our team and be part of our pilot they will receive continuity of carer. By this we mean you will see a named midwife from 36 weeks gestation through to your postnatal stay in the Rosie Hospital. We aim to see you at least twice but up to four times at various stages:

• at a 36 week appointment to get to know you and your birth partner, discuss your birth preferences and give you all the information we can about your upcoming elective caesarean birth
• a preoperative appointment to take bloods, offer you your consent form and give you your pre-operative medication and advice
• for your caesarean birth
• during your stay on the postnatal ward to support with feeding, baby checks and discharge

If for any reason your named midwife cannot see you at any of these times, another member of our team will be there for you.

By providing continuity of care we will be able to personalise your care and meet your individual needs. We will be more aware of your medical and obstetric background, meaning we can offer better and safer care. We will also be able to support you and your birth partner emotionally, giving you as much information we can about what to expect from your caesarean birth and after care. Personalising your care helps us improve mental health outcomes. By getting to know our patients better, we can identify women and families at risk and provide support earlier where needed.

We aim to keep you and your baby together at all times and avoid admissions to our Neonatal Unit, or Neonatal Intensive Care Unit (NICU), where possible. This is supported by the ATAIN Programme 2016, to reduce harm from Avoidable Term Admissions in Neonatal units of babies born after 37 weeks gestation.

Keeping mothers and babies together improves bonding, providing positive benefits for the mother’s mental health, breastfeeding success and long-term health of mother and baby.

By being aware of your medical and obstetric history we will be better prepared to care for your baby and pre-empt possible complications, reducing the chance of unexpected NICU admissions.

The CARES team will be establishing antenatal and breastfeeding classes specifically designed to support women and families who are having a caesarean birth. Our classes will cover what to expect on the day of your caesarean, what our theatres look like, who is who in theatre, analgesia and the operation itself. We will all support your feeding choices with a tailored breastfeeding class, which will empower you to breastfeed your baby after birth in theatre or recovery, when you are still connected to drains and drips, and have minimal sensation and after this period when you are more mobile and recovering.

Following your recovery you will be transferred to our postnatal ward, Lady Mary Ward. Whilst you are here your birth partner can stay with you and a named midwife will come and see you the day after your caesarean. During this visit the midwife will perform your baby’s Newborn Infant Physical Examination check (NIPE) and, if you and your baby are fit and well, commence your discharge home.

Meet the team

Welcome to the CARES team. We are a dedicated group of midwifes offering continuity of care to women who are having elective caesarean births. The team comprises of four midwives.

Your caesarean birth

You have been recommended a caesarean section for the birth of your baby. A caesarean section is when the baby is delivered through an incision (cut) in the abdomen (tummy). A vaginal delivery is the most common way to give birth. However, a caesarean section is often advised and performed in certain situations. The relative safety of caesarean sections has seen a rise in the number of women delivering in this way; most maternity units in the UK deliver between 15 to 25% of babies by caesarean section. An elective caesarean section is usually performed in the week before the baby's due date. This ensures that the baby is sufficiently mature before delivery. The intended benefits of a caesarean section are for the safety of the mother and baby.

Who will perform my procedure?

This procedure will be performed by an obstetrician trained in the procedure.

Who will be with me in the theatre?

Your birth partner can accompany you into theatre and remain with you throughout the operation. They can take photographs of you and your baby, hold your baby if you wish and remain beside you throughout. If you require a general anaesthetic and need to go to sleep, your birth partner will be asked to leave theatre and wait for you in recovery. Your baby may go to them whilst you are still asleep if you wish.

Your named midwife will be with you throughout the operation and facilitate skin to skin contact and breastfeeding, and support holding your baby.

Day of surgery admission

Most patients are admitted on the day of surgery. You will be informed what time you need to arrive by the midwife at the pre-operative assessment. The surgeon and anaesthetist will come and see you prior to the operation. Shortly before your operation you will change into a hospital gown and then walk up to the operating theatre with your birth partner. When you arrive in the theatre or anaesthetic room and before starting your anaesthesia, the medical team will perform a check of your name, personal details and confirm the operation you are expecting.

During the operation

Before the operation we will give you the necessary anaesthetic (see below for details). Most operations are done with a regional (spinal or epidural) anaesthetic and you are awake. Your partner can be present during the caesarean section if you are having spinal or epidural anaesthesia. If, for any reason, you need to have a general anaesthetic, your partner will be asked to leave the theatre. A screen will separate you and your partner from the surgeons. The anaesthetist will stay with you throughout to ensure you are comfortable and safe. You will have a catheter inserted into your bladder.

Once you are anaesthetised, the obstetrician will make a small horizontal incision in your skin above your pubic bone (called a bikini cut). Once the operation is underway you may feel pulling and pressure, but you should not feel pain. Women have described it like someone doing the washing-up in their stomach. The anaesthetist will assess you throughout the operation and can give you more pain relief if required. Whilst it is unusual, it is sometimes necessary to give you a general anaesthetic.

From the start it takes about 5 to 15 minutes before your baby is born, depending mainly on how much surgery you have previously had. Immediately afterwards the obstetrician will pass your baby to the midwife, who will dry and quickly examine him or her in the cot on the far side of the theatre. A paediatrician may also be present.

If your baby is very small or unwell, he/she might need to go straight to the special care baby unit. For all other babies, you or your partner can hold him/her while the placenta is being delivered and you are being sutured (stitched). Immediately after the birth, a drug called Syntocinon® (oxytocin) is put into your drip to help your uterus contract and deliver the placenta (afterbirth). An antibiotic is also routinely given to reduce the chance of wound infection.

Each layer of muscle and skin that has been cut then needs to be closed using sutures (stitches), staples or clips. This part of the operation takes about 30 minutes.

After the operation

Once your surgery is completed you will usually be transferred to the recovery ward where you will be looked after by specially trained nurses, under the direction of your anaesthetist. The nurses will monitor your heart rate, blood pressure and oxygen levels.

You may be given oxygen via a facemask, fluids via your drip and appropriate pain relief until you are comfortable enough to return to your ward. You might have drains (tubes) coming from your wound. These collect tissue fluid from the wound in a small collecting chamber. They will usually be removed after 24 hours. The anaesthetic will gradually wear off over the next few hours and you often feel tingling in your legs. Within a couple of hours you will be able to move them again. When you feel ready to stand out of bed for the first time after the operation, you should make sure that there is someone to assist you. Your catheter will be left in position for 12 to 24 hours, until you are more mobile. Most women need pain-relieving drugs for a few days after the caesarean section. It is important that you are comfortable so that you can recover quicker from the surgery. It is usual to be prescribed regular pain-relieving tablets to take three to four times a day. The midwives will be able to give you further pain relief if required.

Aftercare

We are developing an enhanced recovery programme to enable you and your newborn baby to go home quicker. We will provide you with antenatal education to help you prepare for your operation, recovery period and breastfeeding. Enhanced recovery will aim to remove drains, catheters and cannulas quicker than before, allowing you to become more mobile earlier. We aim to improve your feeling of wellbeing by encouraging you to eat and drink appropriately following your caesarean section, maintain good hydration and self-medicate your pain relief with your own drug chart.

We aim to keep you and your baby together at all times and avoid admissions to our Neonatal Unit, or NICU, where possible. To aid this, the Rosie Hospital has implemented a RAG rating guideline where all babies are colour coded as red, amber or green, depending on their health and clinical needs. To identify these babies, we use coloured hats which have been kindly knitted and donated by the local community. Most babies born by elective caesarean will have a green hat as they will need minimal additional care. However, babies who have risk factors, or who are born to high risk mothers, will need amber or red hats, to act as a visual cue to staff and highlight their individual needs.

These risks include

• diabetes
• mothers on anti-hypertensive medication
• small or growth restricted babies
• Intravenous antibiotics

Feedback

The CARES team is a pilot scheme, so you will be approached by us to provide feedback from your experience with us. We will ask you how many times you saw your named midwife and at which points throughout your care. We will also ask you questions about your experience, recovery, infant feeding and if you have any recommendations. Your feedback will enable us to continue to develop our scheme and add improvements where needed.

Contact

If you choose to have your care with us you will be referred to our team by your consultant at the Rosie Hospital. We will contact you for appointments and to offer antenatal classes. Should you wish to contact us, our email address is: rosiecocc.sssteam@addenbrookes.nhs.uk

Please note this email address is for non-urgent queries only; with any urgent queries please call our Rosie maternity assessment line.

References

Better Births, 2015

National Maternity Review report

ATAIN, 2016

NHS England Reducing admission of full term babies to neonatal units

RAG rating guideline

Patient information for caesarean section

Coates et al, 2016

Enhanced recovery pathway for elective caesarean section