What would you do?

Michelle calls you from home 5 days after having an emergency caesarean section and reports that her wound is slightly red at the edges.

a) Tell her not to worry as she has just had major abdominal surgery and it is normal.

b) Ask if she is feeling well, does she have a temperature and are there any other signs and symptoms of an infection, and if not tell her not to worry.

c) Ask how she is feeling, and then go and see her and inspect the wound as well as completing a comprehensive top to toe, BP, pulse and tempurature.

d) Tell her to go to the hospital immediately.

What advice would you give Michelle about self care after her caesarean section?

a) Signs and symptoms of an infection and actions to take, pain relief, hygiene, self care, and who to contact if concerned.

b) Signs and symptoms of an infection, wound care, hygiene, diet, self care, pain relief, mobilisation and who to contact if concerned.

c) None, it's the doctors responsibility.

D) Go straight to the hospital if you are concerned.
The What, The How and The Why - Caesarean Section
(VBAC, 2010)
(Ceasarean section and MS, 2011)
  
  

Caesarean section is a common operative procedure, with the proportion of women giving birth by caesarean section increasing over time in all developed countries over the past several decades (Grivell & Dodd, 2011).

The most current NZ statistics show that 1:4 women deliver by caesarean section (up 21.3% since 2001) (MOHNZ,2010)


 

Normal

Emergency

Elective

Total

ADHB

4111

1197

1275

2472

CMDHD

5723

926

536

1464

Waitemata

4215

1009

741

1750
Indications for caesarean section:
  • Prior caesarean section
  • Dystocia or cephalo pelvic disproportion
  • Breech presentation
  • ‘Non reassuring’ fetal heart rate tracing  (Tracy, 2008)

Main Causative Organisms:

  • Staphylococcus aureus (30%)
  • Coagulase – negative staphylococci (13.7%)
  • Enterococcus spp (11.2%)                     (Hildron et al., 2008)

Contributing factors for SSIs following caesarean birth:

Pre – existing maternal conditions

Events during labour or birth

Procedure/provider related conditions and events

Extremes of maternal age

Preterm labour and birth

Pre-operative shaving

Elevated body mass index

Prolonged rupture of membranes

Pre-operative skin preparation techniques

Smoking

Prolonged labour

General anaesthesia

Primiparity

Intrapartum fever/pyrexia

Hypothermia

Low socio-economic status

Multiple vaginal examinations

Poor aseptic technique

Poor maternal hygiene

Post-term pregnancy

Inadequate sterilisation of instruments

Poor nutrition

Thick meconium staining

Delayed or omitted prophylactic antibiotics

Poor oxygenation

Internal fetal scalp electrode

Suboptimal haemostasis

Poor tissue perfusion

Uterine monitoring with an interuterine pressure catheter

Practitioner skill

Multiple comorbidities

Operative vaginal birth

Practitioner experience

Diabetes

Foley catheter

Length of procedure

Hypertension

Caesarean birth

Operative trauma

Immune compromise

Manual removal of placenta

Contamination of wound or surgical site

Splenectomy

Retained products of conception

Residual dead space following wound closure

Severe anaemia

Uterine perforation

 

Infection: bacterial vaginosis, chlamydia, gonorrhoea, trichomonis

 

 

(Maharaj, 2007; Schneid-Kofman, Sheiner, Levy, & Holcberg, 2005; Ward, Charlett, Fagan, & Crawshaw, 2008)

ADHB Clinical Guidlines For Caeserean Section (CS) Pre, Peri and Post Op Care: http://nationalwomenshealth.adhb.govt.nz/Portals/0/Documents/Policies/Caesarean%20Section_.pdf

Recommended Principles for Post-Operative LSCS Wound Care in the Community:

  • The theatre dressing can be removed after 24hours – aids healing and reduces chance of infection (Review current hospital guidelines as may differ due to current research or use of dressings).
  • Information shared about the signs and symptoms of an infection
  • Women should be advised to monitor temperature/ be aware.
  • The woman should shower daily, the wound being carefully dried gently and loose cotton clothing being worn
  • The wound should be assessed then, and on every postoperative day after that whilst in hospital and every postnatal visit until care is discharged/transferred.
  •   Suture/clip/staple removal is planned – (see below)
  •  If the wound is exuding excess fluid or can catch on clothing, a dressing should be re applied, otherwise may be left uncovered.
  • If a wound requires redressing it should be with a suitable non-adherent dressing that retains moisturee.
  • If a wound requires cleansing and re dressing it should be with a clean (aseptic) technique, using body temperature (warmed slightly) normal saline or tap water, using either sterile gauze or foam swabs, and a suitable dressing (see hospital guidelines).
  •  If a wound appears infected without the presence of pyrexia a wound swab may be taken and antibiotics (Augmentin if not contra indicated prescribe, 500mg, 8 hourly. Take with food. Do not treat >14 days -) (UBMMedica,2014) . Assessment may be made in conjunction with obstetrician (Consultation) (MOHNZ, 2012).
  • A wound that is hot, tender and inflamed and is accompanied by pyrexia is highly suggestive of an infection (Transfer) (MOHNZ,2012).
  • Haematoma and abscesses can also form underneath the wound, and women may identify increased pain around the wound where these are present (Transfer) (MOHNZ, 2012).
  • Healthcare professionals caring for women who have had a CS should be aware that heavy and/or irregular vaginal bleeding should consider that this is more likely to be due to endometritis than retained products of conception (Transfer) (MOHNZ, 2012).

(Fraser & Cooper, 2008;Johnson & Taylor, 2005; NICE, 2008)

Removal of Sutures or Staples

The decision to remove sutures is taken according to the assessment of healing of the wound. Sutures are removed when the wound has healed, i.e skin edges in close apposition without signs of infection; this is often 5-10 days after surgery. Sutures that are retained too long can delay wound healing.



Use aseptic technique!!!!!!




Sutures – (Figure A)

  • Lift and hold the external part of the suture with forceps using non-dominant hand.
  • Cut beneath the knot as near to the skin as possible using scissors or stitch cutter in the dominant hand.
  • Remove the suture by pulling it gently through the skin.

(5 months after un planned c section, 2007)
(Removal of sutures and staples, 2005)

This principle applies whether the sutures are interrupted, continuous or subcuticular.

  •   A continuous suture requires the midwife to lift, cut and pull through repeatedly, until the end of the suture is removed.
  • Subcuticular suturing that is held in place with a bead should have the bead removed at the distal end of the wound so that on removal the suture is pulled from the end nearest the midwife.
  • The removal should be smooth; the woman may experience the pulling sensation rather than discomfort.               (Johnson & Taylor, 2005)
(VBAC, 2010)

Staples – (Figure B)

  • Hold the staple remover as if a pair of scissors.
  • Insert lower blade directly under staple
  • Squeeze the handles together; the staple will be lifted from the skin as it concertinas.
  • Lift clear                                                                              (Johnson & Taylor, 2006)

Be AWARE!!!!!!!

Women who have had a CS are at an increased risk of thromboembolic disease (both deep vein thrombosis and pulmonary embolism), pay particular attention to women with chest symptoms (such as cough or shortness of breath) or leg symptoms (such as painful swollen calf) (Transfer) (Ministry of Health, 2012)                                                            

(Fraser & Cooper, 2008;Johnson & Taylor, 2005; NICE, 2008)

 Pain Relief is Important!!!!!!!

  • Women should have analgesic medication prescribed, prior to discharge (day 4-5 post op) as pain can interefere in bonding and breastfeeding.
  • Diclofenac 75mgs B.D for 5 days or ibuprofen 200mg - 400mg, 6 hourly. Max 1600mg in 24 hours. take with food.
  • Paracetamol 1g 4-6 hourly, 10 days. Max 4g in 24 hours                                               

(UBMMedica, 2012; CMDHB, 2008)

 Ongoing consideration.................

  • Avoid lifting anything heavier that your baby until free of discomfort and able to move freely and with ease
  • Effective contraception for at least 1 year
  • Attendance for assessment (usually with obstetrician) at the end of puerprium)
    (Johnson & Taylor, 2005)
  • The pattern of recovery after abdominal surgery can be hightl variable and dependant on may factors. Research has demonstarted limited evidence and due to this there are no universal guidlines to advise when driving may recommence. The ability to break and perform unexpected manoeuvres is essentil to safe driving, and this ability may be comprimised by wound pain and or reduced freedom of movement. A seat belt must be worn at all times and avoiding driving whilst on sedating medications is important. It is a recommomendadtion that patients direct their enquiries to their insurance company regarding any policy reqiurements relating to driving after abdominal surgery (RANZCOG, 2012).