Bowel complications after caesarean section guideline (inc ... protocols and... · Request prompt...

Author: J Siddall, H Inkster Date: June 2018

Job Title: Consultant Obstetrician, Practice Educator Review Date: June 2020

Policy Lead: Group Director Urgent Care Version: 5.0 ratified 1/6/18

Location: Policy hub/ Clinical/ Maternity/ Postnatal/ GL796

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Bowel complications after caesarean section guideline (inc.

Paralytic Ileus) – GL796

Approval

Approval Group Job Title, Chair of Committee Date

Maternity & Children’s Services Clinical Governance Committee

Chair, Maternity Clinical Governance Committee

1st June 2018

Change History

Version Date Author, job title Reason

4.0 June 2016 S Bailey (Marsh Ward Mngr)

H Inkster (Practice Educator)

Reviewed and amended to be consistent with Trust policy for NGT (CG202)

4.1 Sept 2017 H Inkster (Practice Educator)

M Redfearn (Acting Marsh Ward Manager)

Reviewed & amended against Trust policy for NGT (CG202) which itself has been updated in response to CAS Alert NHS/PSA/RE/2016/006 - Nasogastric tube misplacement: continuing risk of death and severe harm.

4.2 Dec 2017 H Inkster (Practice Educator) Pg 3 to 6 - Clarification of use of Ryles tube in Maternity

5.0 April 2018 Jane Siddall (Consultant Obstetrician)

H Inkster (Practice Educator)

Reviewed

Pg 2 – Overview updated, diameter of the caecum changed from 10cms to 9cms

Pg 3 - Ryles tube added and IV fluid balance & monitoring clarified

To be read in conjunction with

CG202 Trust policy for correct use of Nasogastric Feeding Tubes in Adults






Maternity Guidelines – Bowel complications after CS inc. Paralytic ileus (GL796) June 2018

CONTENTS

Overview ..................................................................................................................................... 2

Definitions ................................................................................................................................... 2

Diagnosis .................................................................................................................................... 2

Management ............................................................................................................................... 3

References .................................................................................................................................. 3

Appendix 1 – Management flowchart ........................................................................................... 4

Appendix 2 – Nasogastric / Ryles tube record of initial placement ............................................... 5

Appendix 4 – Competency assessment form ............................................................................... 7

Overview

Women who are recovering well after uncomplicated caesarean section should be

encouraged to eat and drink when they feel hungry or thirsty. The majority of women

regain bowel function passing flatus within 24h and stool within 72h of surgery. Delay in

bowel return of bowel function owing to paralytic ileus (loss of peristalsis) is a complication

of (excessive) handling of the intestines during abdomino-pelvic surgery and can lead to

significant maternal morbidity, through the development of Ogilvie’s syndrome, and

(rarely) mortality. Prolonged or difficult surgery, ketoacidosis and acute kidney injury are

all triggers for this condition.

Definitions

Paralytic Ileus

Bowel inactivity leading to symptoms of intestinal obstruction.

Acute Colonic Pseudo-Obstruction (ACPO; Ogilvie’s Syndrome)

A clinical and radiological picture of acute obstruction of the colon in the absence of

mechanical obstruction, leading to massive colonic dilatation. ACPO can lead to significant

maternal morbidity (hypovolaemia, electrolyte imbalance, caecal ischaemia, caecal

perforation) and mortality. If the diameter of the caecum is > = 9cms then there is a

significant risk of bowel perforation and urgent referral for decompression is

necessary (the diameter is normally up to 7.5cm)

Diagnosis

Patients may complain of abdominal pain, bloating, nausea, vomiting and failure to pass

wind or stool. On examination assess for signs of clinical dehydration, distension, pain on

palpation, resonance to percussion and absence of bowel sounds.







Abdominal x-ray is required to confirm colonic dilatation (large bowel >6cm, caecum

>9cm). Perforation presents with severe abdominal pain, a rigid abdomen and signs of

sepsis from faecal peritonitis.

Management

Request prompt obstetric review if paralytic ileus is suspected.

In Maternity we use Ryles Tubes for non-functioning bowel i.e. paralytic ileus and only used for aspiration of gastric juices used for short term use only NEVER for feeding.

If Ryles or NG tubes are to be placed this should be in accordance with trust guidelines

(see Trust policy for Nasogastric tube placement in Adults ver 10 CG202) by appropriately

trained staff. Clinical Skills (bleep 160) or Outreach Team (bleep 250) may be available to

help with NG tube placement.

Initial management is conservative and should focus on:

Analgesia (avoid opiate analgesics)

Antiemetic’s

NBM to rest bowel

IV fluids and fluid balance monitoring

Recommended fluid “one salty two sweet”

1L x N Saline +20mmol KCL 8 hrly

1L Dextrose + 20mmol KCL 8 hrly

1L Dextrose + 20mmols KCL 8 hrly

As maintenance only need to consider losses/insensible losses, thus up to 4L per day

Ensure adequate VTE prophylaxis

Investigations should include:

U&E to assess for electrolyte imbalance

Abdominal +/- erect chest XR if perforation suspected

NB: All referrals to surgeons must be made at consultant to consultant level to ensure that senior review takes place

References

1. Acute colonic pseudo-obstruction after caesarean section The Obstetrician and Gynaecologist 2006 (8); 207-213

http://sql0/sites/intranet/policies/Shared%20Documents/Clinical%20Documents/0%20-%20General%20(Trustwide)/Adult%20NG%20tube%20policy%20-%20V%2010%20-%20CG202.pdf







History:

Abdominal pain

Distension

Nausea +/- vomiting

No flatus

Examination:

Tachycardia

Low grade pyrexia

Distension

Tenderness

Bowel sounds can be normal, tinkling or absent

Stable, < 24h Post-operative?

SHO review, inform registrar

Conservative management

Check U&E

4 hourly observations

Analgesia (NSAIDs preferred)

Antiemetic’s

Keep NBM, IV fluids

DAILY REVIEW by medical team

Deterioration

Increasing pain

Worsening distension

Clinical dehydration

RIF tenderness

Improvement

Treat as normal

Oral fluids

Light diet

Unstable, deteriorated or ≥24 - 48h Post-operative?

Keep NBM

IV fluids (replacement and maintenance)

Catheterisation and fluid balance charts

Repeat U&E

AXR (+ erect CXR if perforation)

Ryles tube insertion

Continue non-opioid analgesia and antiemetic’s

For obstetric registrar / consultant daily review

URGENT SURGICAL REVIEW referral to be consultant obstetrician to consultant surgeon directly

(Bleep SHO 701, SpR 702)

Small bowel dilatation only Manage conservatively - Ryles tube - Daily U&E - IV fluids - Avoid opiates, calcium channel blockade and anti-cholinergics

Large bowel dilatation NGT IV fluids Consider: - IV neostigmine - Endoscopic decompression - Surgical management

Suspected perforation

Senior surgical involvement

Emergency laparotomy +/- stoma formation

Appendix 1 – Management flowchart





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Maternity Guidelines – Bowel complications after CS inc. Paralytic ileus (GL796) December 2017

Appendix 2 – Nasogastric / Ryles tube record of initial placement





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Appendix 3 – Nasogastric / Ryles tube on-going record of daily care





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Appendix 4 – Competency assessment form





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Appendix 5 – Notes for assessors





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