Intrapartum and Postpartum Care of Cesarean Birth Families ch 11

Question 1

Cesarean birth

Answer 1

Cesarean birth, also referred to as cesarean section, C-section (C/S), or surgical birth, is an operative procedure in which the fetus is delivered through an incision in the abdominal wall and the uterus.

Question 2

Cesarean Delivery on Maternal Request (CDMR)

Answer 2

• There is insufficient evidence to fully evaluate the benefits and risks of CDMR as compared to planned vaginal delivery; more research is needed.
• CDMR is not recommended for women desiring several children, as the risks of placenta previa, placenta accreta, and gravid hysterectomy rise with each cesarean delivery.
• CDMR should not be performed prior to 39 weeks’ gestation because of the significant danger of neonatal complications that include respiratory distress, hypothermia, hypoglycemia, and NICU admission.
• CDMR should not be motivated by the unavailability of effective labor pain management.

Question 3

Indications for Cesarean Birth

Answer 3

1. Labor arrest: 34%
2. Nonreassuring fetal tracing: 23%
3. Malpresentation: 17%
4. Multiple gestation: 7%
5. Maternal-fetal: 5%
6. Macrosomia: 4%
7. Other obstetric indications: 4%
8. Preeclampsia: 3%
9. Maternal request: 3%
   The major maternal medical indications for a cesarean birth are:

● Previous cesarean birth.

● Placental abnormalities.

● Mechanical impediment of the progress of labor or arrest of active labor.

● Cephalopelvic disproportion, which occurs when ineffective uterine contractions lead to prolonged first stage of labor or when the size, shape, or position of the fetal head prevents it from passing through the maternal pelvis or when the maternal bony pelvis is not large enough or appropriately shaped to allow for fetal descent.

● Previous uterine surgery (i.e., surgeries that involve an incision through the myometrium of the uterus).

● Preexisting or pregnancy-related maternal health factors such as:

● Cardiac diseases.

● Severe hypertension, preeclampsia.

● Severe diabetes mellitus.

● Obesity.

The major fetal medical indications for a cesarean birth are:

● Malpresentation or malposition of fetus such as:

● Breech presentation.

● Transverse lie.

● Persistent occiput posterior position.

● Fetal hand preceding the fetal head.

● Asynclitism—oblique malpresentation of the fetal head.

● Category II or III fetal heart rate (FHR) pattern

● Multiple gestation

Question 4

Obesity and Cesarean Births

Answer 4

“Obese pregnant women are at increased risk for cesarean delivery, failed trial labor, endometritis, wound rupture or dehiscence, and venous thrombosis” (ACOG, 2015).

Obesity also increases a woman’s risk of complications related to anesthesia. These include:

• Difficulty in placement of spinal or epidural anesthesia related to loss of landmarks due to increased body size.
• Impaired respirations for 2 hours following placement of spinal anesthesia.
• Difficulty in placement of endotracheal tube due to increased tissue and edema.

Recommendations include:

• Administration of broad-spectrum antimicrobial prophylaxis to decrease risk of infection.
• Use of pneumatic compression devices and low-molecular-weight heparin to decrease risk of venous thrombosis.

Question 5

Preventing the First Cesarean Birth

Answer 5

One in three infants born in the United States is delivered by cesarean birth. The leading driver of both the rise and variation is first-birth cesarean deliveries performed during labor. With the large increase in primary cesarean deliveries, repeat cesarean delivery has emerged as the largest single indication.
Reserving labor induction primarily for medical indication is key to reduce cesarean delivery rates. If an induction is done for nonmedical indications, the gestational age should be at least 39 weeks or more and the cervix should be favorable, especially in the nulliparous woman.
The diagnosis of failed induction should only be made after an adequate attempt. Adequate time for normal latent and active phases of the first stage and for the second stage should be allowed as long as the maternal and fetal conditions permit. The adequate time for each of these stages appears to be longer than traditionally estimated by the well-known Friedman curve. Operative vaginal delivery with forceps or vacuum extractor are acceptable when indicated and can safely prevent cesarean delivery in appropriate situations

Question 6

Interventions and Strategies for Preventing Primary Cesarean Births

Answer 6

1. Implement the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine’s definition and management of labor dystocia.
2. Develop standardized fetal heart rate interpretation and management.
3. Use cervical ripening agents when labor is induced in women with an unfavorable cervix.
4. When inducing labor, allow longer duration of latent phase (up to 24 hours) and administer oxytocin for at least 12 to 18 hours after membrane rupture before performing cesarean section for failed induction.
5. Use nonmedical interventions such as continuous labor support by nurse or doula.
6. External cephalic version for breech presentation.
7. No elective inductions until 39 weeks.
8. Trial labor for women with twin gestations when first twin is in a vertex presentation.

Question 7

CLASSIFICATION OF CESAREAN BIRTHS

Answer 7

Cesarean births are classified as either scheduled (planned) or unscheduled (unplanned). Unscheduled cesarean births include emergent, urgent, and nonurgent cesarean births.

Question 8

Scheduled cesarean births

Answer 8

● Scheduled cesarean births occur before the onset of labor.
Common reasons for a scheduled cesarean birth are:

● Previous cesarean birth.

● Maternal or fetal health conditions that place the woman or fetus at risk during labor and/or vaginal birth.

● Malpresentation, such as breech presentation, diagnosed before labor.

● CDMR.

Question 9

● Emergent cesarean birth

Answer 9

Emergent cesarean birth indicates an immediate need to deliver the fetus (e.g., prolapse of umbilical cord or rupture of uterus).

Question 10

Urgent cesarean birth

Answer 10

Urgent cesarean birth indicates a need for rapid delivery of the fetus, such as with malpresentation diagnosed after onset of labor or placenta previa with mild bleeding and fetal heart rate with Category I FHR.

Question 11

● Nonurgent cesarean birth

Answer 11

Nonurgent cesarean birth indicates a need for cesarean birth related to complications such as failure to progress (cervix does not fully dilate) and failure to descend (fetus does not descend through the pelvis) with Category I FHR.

Question 12

RISKS RELATED TO CESAREAN BIRTH

Answer 12

Women who experience cesarean births are at higher risk for postpartum infection, hemorrhage, thromboembolic disease, and maternal death. Maternal death is most often related to intrapartum or postpartum hemorrhage. Neonates are at higher risk for fetal injury during surgery, low Apgar scores, and respiratory distress.

Question 13

Risks Related to Repeat Cesarean Birth

Answer 13

The most significant long-term complication of repeat surgical birth is placenta accreta. The spectrum of placenta accreta includes:

● Accreta: The placenta does not penetrate the entire thickness of the uterine muscle.

● Increta: The placenta extends farther into the myometrium.

● Percreta: The placenta extends fully through the uterine wall and may attach to other internal organs, such as the intestine or bladder.

In all forms of placenta accreta, the placenta does not separate from the uterine wall after delivery, potentially leading to excessive hemorrhage, disseminated intravascular coagulopathy, organ failure, and, in severe cases, death. Typically, a hysterectomy is needed to control a massive hemorrhage.

Question 14

Trial of Labor After Cesarean Section

Answer 14

Women who had a previous cesarean section and want more than two children are encouraged to attempt a vaginal birth after cesarean section (VBAC). Although this comes with risks of its own, it avoids the risks of abdominal surgery, future abnormal placental implantation, and infection. The labor process in this situation is called a trial of labor after cesarean section.

Question 15

PERIOPERATIVE CARE

Answer 15

Perioperative perinatal nursing incorporates the skills of the specialties of obstetrics, surgery, and postanesthesia care to provide safe and comprehensive care to women who have had cesarean births. In most hospitals, cesarean births are performed in an operating room in the obstetrics department and labor and delivery nurses care for the family throughout the perioperative experience. Preoperative care may vary based on the urgency of the cesarean birth.

Question 16

Scheduled Cesarean Birth

Answer 16

Couples are admitted to the labor and birthing unit the day of surgery (Fig. 11–1). Diagnostic laboratory work, such as complete blood count (CBC), platelet count, urinalysis, blood type, and cross match, may be completed a few days before admission.

Question 17

Evidence-Based Practice Guidelines

Answer 17

AWHONN’s perioperative care of the pregnant woman. This guideline describes evidence-based practice to ensure the following:

1. Patient safety measures for perioperative care of the pregnant woman
2. Family-centered education and care practices
3. Assessment and interventions appropriate during preoperative, intraoperative, and postoperative periods for women undergoing cesarean birth

Question 18

Medical Management -scheduled c-section

Answer 18

● Preoperatively, the surgeon will explain the reason for the cesarean birth and what it involves prior to hospital admission and obtain surgical consent.

● The surgery is scheduled.

● Presurgical diagnostic laboratory tests, such as CBC, blood type, and Rh, are ordered.

● If the woman’s medical record is not available to the hospital electronically, a paper copy of her prenatal record and provider orders are faxed to the birthing unit to be placed in her hospital chart.

● Education is provided about which current medications the woman should take or eliminate on the day of surgery.

● To prevent postoperative infection, many providers recommend that the woman take at least one preoperative shower at home, using an antiseptic agent on the night prior to the scheduled procedure.

Question 19

Anesthesia Management-Scheduled c-section

Answer 19

● The anesthesia provider (anesthesiologist or certified registered nurse anesthetist) meets with the couple during the admission process and before the woman is transferred to the operating room.

● The anesthesia provider reviews the prenatal record.

● The anesthesia provider completes an anesthesia history and physical, discusses anesthesia options with the couple, and answers their questions regarding anesthesia and the procedure.

Question 20

Nursing Actions- scheduled c-section

Answer 20

● Complete the appropriate admission assessments (including baseline vital signs) and required preoperative forms.

● Obtain laboratory testing per orders, such as CBC, platelets, and type and screen. A delay in lab results can result in a delay in surgery.

● Obtain a baseline fetal heart rate monitor strip of at least 20 minutes before and after administration of regional anesthesia, if possible.

● Review the prenatal chart for factors that place the woman at risk during or after cesarean birth and ensure that physician and anesthesia provider are aware of risk factors such as low platelet count.

● Verify that the woman has been NPO for 6 to 8 hours before surgery, or per hospital protocol.

● Ensure that all required documents, such as prenatal record, current laboratory reports, and consent forms, are in the woman’s chart.

● Assess the woman’s knowledge and educational needs and provide preoperative teaching that includes what she and her partner can expect before, during, and after the cesarean birth.

● Identify and respect the cultural values, choices, and preferences of the woman and her family and individualize care to meet the needs of the woman and her family.

● Start an IV line and administer an IV fluid preload as per orders.

● Insert a Foley catheter as per order. Insertion is preferably done in the operating room after placement of the spinal or epidural and before the prep.

● Trim the lower abdominal and upper pubic regions with clippers prior to entering operating room (OR).

● Administer preoperative medications per orders. This might include sodium citrate to neutralize stomach acids. Famotidine or metoclopramide may be used to reduce the incidence of nausea or vomiting.

● Prepare the partner or the support person who plans to be present for the birth for the experience by providing appropriate surgical attire to wear in the operating room.

● Instruct the partner or the support person as to where he or she will sit and what he or she can anticipate regarding sights, sounds, and smells typical of an operating room.

● Provide emotional support for the couple as they wait to be transferred to the operating room.

● Complete the surgery checklist, which includes removal of jewelry, eyeglasses/contact lenses, and dentures. Eyeglasses can be given to the support person to bring into the operating room so the woman can use them to see her newborn baby.

Question 21

Antibiotic and Venous Thromboembolic Prophylaxis

Answer 21

• Administration of narrow-spectrum prophylactic antibiotics should occur within 60 minutes prior to the skin incision (AWHONN, 2011). Antibiotics of choice include cefazolin, or for women with penicillin and cephalosporin allergy, clindamycin with gentamicin may be given.
• Perform an assessment for risk of venous thromboembolism (VTE) and classify the woman based on VTE classification guidelines. Preoperative anticoagulant therapy may be necessary for women classified as moderate or high-risk or with a history of recurrent thrombosis. • Apply sequential compression devices prior to surgery.

Question 22

IV Fluid Preload Before Anesthesia

Answer 22

An IV fluid preload of 500 to 1,000 mL is given before administration of spinal or epidural anesthesia to increase fluid volume and decrease risk of hypotension related to effects of anesthetic agent.
The use of prewarmed IV fluids in women having a cesarean birth results in an increased maternal core temperature, improved neonatal umbilical arterial pH, and improved Apgar scores

Question 23

Unscheduled Cesarean Birth

Answer 23

Unscheduled cesarean births usually have an urgent or emergent cause, such as fetal intolerance of labor or placental problem.
Due to the urgency of the cesarean birth, there may not be time to fully explain the reasons for the procedure. Therefore, the woman and her partner or support person need an opportunity during the immediate postpartum period to review the events leading up to the cesarean birth.

Question 24

Medical Management

Answer 24

● Determine the need for a cesarean birth.

● Explain the reason for the cesarean birth.

● Explain the surgical procedure and obtain consent.

Question 25

Anesthesia Management

Answer 25

● The anesthesia provider completes an anesthesia history and physical and discusses anesthesia options with the woman.

● This may not occur until the woman is transferred to the operating room based on the amount of time between the decision for need of cesarean birth and transfer to the operating room.

● The anesthesia provider determines the need for a platelet count.

● The anesthesia provider explains the procedure and addresses the woman’s and support person’s questions and concerns.

Question 26

Nursing Actions-Unscheduled c-section

Answer 26

● Notify the anesthesia, labor and delivery team, and neonatal personnel of the impending cesarean birth.

● Initiate continuous electronic FHR monitoring.

● Expected findings: Category II or Category III FHR pattern when the cesarean section is related to fetal intolerance of labor.

● Administer oxygen when indicated (i.e., signs of fetal intolerance of labor).

● Assess the woman’s vital signs.

● Expected findings:

● The woman’s blood pressure is slightly elevated related to anxiety level.

● There is a potential increase in temperature and pulse rate due to infection and/or dehydration related to prolonged labor and rupture of membranes.

● Start an IV and administer IV fluid preload as per orders.

● Ensure labs are completed as ordered; CBC, platelets, and type and screen or type and cross match.

● Complete and witness surgical and anesthesia consent forms.

● Insert a Foley catheter as ordered. Insertion may be done in the operating room after placement of the spinal or epidural anesthesia and before prep, unless the FHR indicates immediate delivery. In that situation, the catheter may be inserted in the woman’s room before transfer to the operating room.

● If hair needs to be removed because it interferes with surgical site, hair clippers are used on the pubic region so that no hair is visible when the woman’s legs are together. This should be done in the labor room and not in the operating room.

● Ensure that all required documents are in the woman’s chart.

● Complete the surgical checklist.

● Facilitate the transition to unscheduled surgical birth in a timely manner. Guidelines in all hospitals that provide OB care should have the capability of responding to obstetrical emergencies within 30 minutes. Hence the 30-minute “decision to incision rule.”

● Assess the couple’s emotional response to the need for a cesarean birth.

● Expected findings

● Couples and family may experience high levels of anxiety based on fear of injury to the woman and/or unborn child.

● Couples are not emotionally or mentally prepared for cesarean birth.

● Couples and family have a knowledge deficit regarding cesarean birth and anesthesia options.

● Couples and family ask questions regarding cesarean birth and anesthesia options.

● Help ensure the woman and her support person(s) receive information appropriate to the circumstances. Reinforce reason for cesarean section and address questions.

● Provide emotional support during transitional process from labor to preparation for surgery.

● Facilitate couple’s communication with entire health care team to decrease fear, anxiety, and distress.

● Facilitate presence of woman’s support person during preoperative preparation and surgical procedure because emotional support decreases anxiety.

● Review with the couple what to expect during and after the cesarean birth. Explain that the woman may feel pressure or pulling as her baby is being born.

● Prepare the partner or support person who plans to attend the birth as to what to anticipate in the operating room and provide him or her with proper surgical garb to wear in the operating room.

Question 27

INTRAOPERATIVE CARE

Answer 27

The complete intraoperative team includes a surgeon, an anesthesia provider, a surgical first assist, a circulating nurse, and neonatal staff. The circulating nurse is responsible for patient safety. This generally includes responsibility for positioning the woman safely, assuring all time-outs and consents are completed appropriately, confirming the presence of newborn care providers at the birth, maintaining a correct count of surgical sponges, and labeling surgical specimens correctly and confirming their disposition to pathology or medical waste. The woman and her family will be anxious about the cesarean birth, whether it is a scheduled or unscheduled procedure. It is often the woman’s first surgical experience, which can increase the anxiety level for both the woman and her partner. To help decrease anxiety, it is best if the nurse who admitted the woman for a scheduled cesarean section or the nurse who cared for the couple during labor continues to care for them during the surgery as the circulating nurse.

Question 28

Complications

Answer 28

● Hemorrhage: Increased morbidity and mortality rates are associated with intraoperative and postpartum hemorrhage, which can result in hypovolemic shock, disseminated intravascular coagulation, renal and/or hepatic failure, and possibly the need for emergency hysterectomy.

● Bladder, ureter, and bowel trauma.

● Maternal respiratory depression related to anesthesia.

● Maternal hypotension related to anesthesia, which increases the risk for fetal acidemia.

● Inadvertent injection of the anesthetic agent into the maternal bloodstream; the woman may experience ringing in her ears, metallic taste in her mouth, and hypotension that can lead to unconsciousness and cardiac arrest.

Question 29

Anesthesia Management

Answer 29

● Determine the method of anesthesia based on the following factors:

● Which one is the safest and most comfortable for the woman

● Which has the least effect on the fetus/neonate

● Which provides the optimal conditions for the surgery

Question 30

● Spinal anesthesia

Answer 30

Spinal anesthesia is the preferred method for scheduled cesarean sections or for laboring women who do not have an epidural in place (Fig. 11–2). Spinal anesthesia, which is faster than an epidural to place, provides a full sensory and motor block.

Question 31

● Epidural anesthesia

Answer 31

● Epidural anesthesia is used for laboring women who have an epidural in place for labor pain management and who then require a cesarean birth (see Fig. 11–2). Women with epidurals may feel tugging and pulling during the procedure because epidurals are not as dense and do not provide full sensory and motor block.

Question 32

General anesthesia,

Answer 32

● General anesthesia, which is rarely used and carries increased risks, is indicated in the following situations:

● Rapid delivery is imperative

● Severe hemorrhage

● Seizures

● Failed spinal

Question 33

● Contraindications for epidural or spinal anesthesia

Answer 33

● Low platelet count is the most common contraindication, especially with women who have preeclampsia and/or HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome.

● Infection or dermatological issues of concern at the proposed site of needle insertion

● Uncorrected maternal hypovolemia

● The woman’s refusal or inability to cooperate with the procedure

● Spine abnormalities, injuries, and/or surgeries

● Sepsis

Question 34

● Administration of anesthesia

Answer 34

● Administration of anesthesia

● Bupivacaine is the preferred anesthetic agent for spinal and epidural blocks.

● Preservative-free morphine or fentanyl is administered intrathecally to provide postoperative analgesia.

● Epidural or spinal anesthesia may be administered with the woman sitting on the operating room table or lying on her side. When the woman is lying down, position her with a hip tilt to maintain uterine displacement before, during, and after administration of anesthesia. This will decrease the risk of aortocaval compression related to compression on the aorta and inferior vena cava by the gravid uterus.

● Monitor vital signs and oxygen saturation.

● Expected findings:

● Vital signs and oxygen saturation within normal limits with potential mild increase in blood pressure due to anxiety.
● Hypotension following administration of the anesthetic agent

● Monitor level of anesthesia, effectiveness of anesthesia, and complications.

● Gastric aspiration: Aspiration of gastric contents can lead to pneumonitis. This is a potential complication of general anesthesia. Additional conditions that may increase the risk of aspiration include:

● Morbid obesity.

● Diabetes.

● Difficult airway (Apfelbaum et al., 2013).

● Monitor blood loss, accomplished when the circulating nurse weighs lap sponges for a quantified blood loss (QBL) and reports findings to the surgical team. A QBL of up to 1,000 mL is expected in a cesarean birth.

● Administer antibiotics when indicated, generally within 1 hour of the incision time.

● Administer oxytocin after the delivery of the placenta to minimize bleeding.

Question 35

Medical Management

Types of incisions

Answer 35

● Two primary operative techniques are used for cesarean births. Most often, a Pfannenstiel incision, or “bikini cut,” is the skin incision. This is a transverse skin incision made at the level of the pubic hairline (Fig. 11–3A). Typically, a lower uterine segment incision is performed on the uterus (Fig. 11–3C). The second operative technique, the classical cesarean delivery, is a vertical abdominal wall skin incision and vertical incision in the body of the uterus (Fig. 11–3 B and D). This technique is rare and is used in emergent cesarean births when immediate delivery is critical.

● The neonate is delivered through the uterine and abdominal incisions (Fig. 11–4). Following the delivery of the neonate, the placenta is manually removed. The uterus may be lifted out of the abdominal cavity or left in place while the uterine incision is repaired. The abdominal tissues and incision are repaired.

Question 36

Nursing Actions

Answer 36

● Conduct a pre-procedure informational process according to facility policy. Include assessments, comments, and lab work.
● Position woman with a hip tilt to maintain uterine displacement before, during, and after administration of anesthesia to decrease the risk of aortocaval compression related to compression on the aorta and inferior vena cava due to weight of the gravid uterus.

● Continue external FHR monitoring until abdominal preparation is initiated. Remove the fetal scalp electrode (FSE) after abdominal surgical preparation is done and before delivery. FSE should not be removed until MD orders it.

● Conduct a time-out before administering anesthesia and before initial incision for validating correct patient, site, and procedure.

● Assist the woman into the proper position for epidural or spinal anesthesia.

● Reposition the woman after epidural or spinal anesthesia into a supine position with a left lateral tilt to decrease the pressure from the uterus on the inferior vena cava and maintain placental perfusion.

● Assess FHR after anesthesia placement.

● Apply the grounding device to the woman’s thigh.

● Insert Foley.

● Perform abdominal skin prep using sterile technique.

● Secure the woman to the operating room table with a strap over her upper legs.

● Perform the duties of the circulating nurse, including instrument count, needle count, and sponge count.

● Check equipment used for the newborn to ensure it is in working order and all supplies are readily available for care of the neonate.

● Assess the couple’s response to the cesarean birth.

● Expected findings:

● Anxiety levels increase related to operating room environment and impending surgery.

● Couples may have concerns related to potential injury to the woman from anesthesia and/or surgery.

● The woman may feel abdominal pressure as the neonate is being delivered.
● Position the partner or support person on a stool next to the woman’s head. Instruct the partner or support person to remain seated on the stool. This may prevent falling if the person feels faint.

● Instruct the partner or support person as to what he or she can and cannot touch.

● Provide emotional support to the woman and her partner or support person.

● Facilitate care for the neonate. Neonatal care is usually performed by the neonatal personnel (neonatal nurse, nurse practitioner, and/or neonatologist) who are present for the birth.

● At least one person skilled in neonatal resuscitation should be available whose only responsibility is to receive and care for the baby.

● Expected finding: The neonate’s 1- and 5-minute Apgar scores are 7 or above unless there is fetal intolerance of labor before the birth.

● Record the time of delivery of the neonate and delivery of the placenta.

● Whenever possible, the newborn should remain in the operative suite with the mother.

● Complete identification bands and place on the neonate and parents before the neonate leaves the operating room.

● Ensure that new parents have an opportunity to see and hold their newborn. In many birthing units, the neonate, if stable, remains in the operating room and skin-to-skin contact is initiated. The neonate is then transferred to the labor and delivery recovery room with the woman and her partner or support person.

● Transfer unstable neonate to the nursery and encourage the partner or support person to accompany the newborn to the nursery. Neonatal personnel are responsible for transferring unstable neonates.

● Address parents’ questions regarding the health of their newborn.

● Complete intraoperative documentation.

Question 37

Evidence-Based Practice: Skin-to-Skin Contact During Cesarean Birth

Answer 37

Nursing implication: Early and continuous contact with the newborn facilitates parent-infant bonding and attachment. Skin-to-skin contact in the operating room significantly decreases the percentage of newborns who are separated from their parents due to transfers to the NICU for observation.

Question 38

Universal Protocol for Preventing Wrong Patient, Wrong Site, Wrong Person Surgery

Answer 38

Joint Commission Standard PC 13.20 EP 9 states that “the site, procedure, and patient are accurately identified and clearly communicated using active communication techniques, during a final verification process such as time-out before the start of any surgical or invasive procedure” (Joint Commission, 2003).

The operating room circulating nurse assists in actively verifying that this is the correct patient and procedure when time-out is called immediately before the epidural or spinal procedure begins and immediately before the surgical incision is made to verify that it is the correct site, procedure, and patient.

Question 39

POSTOPERATIVE CARE

Answer 39

The recovery time following a cesarean birth is longer compared to vaginal delivery due to the tissue trauma related to surgical intervention. The usual hospital stay is 3 days, with full recovery from surgery taking 6 weeks or longer. The maternal morbidity rate is increased twofold with cesarean delivery compared with vaginal delivery (Cunningham et al., 2014). Principal sources of complications are infection, hemorrhage, and thromboembolism. There is a twofold increase in rehospitalization.

Question 40

Complications

Answer 40

Women who enter pregnancy in a healthy state and have experienced a healthy pregnancy are at low risk for complications. In contrast, women who experience a prolonged labor, multiple interventions such as internal monitoring, or prolonged rupture of membranes are at higher risk for postoperative complications. These include the following:

● Hemorrhage: Postpartum hemorrhage is most often identified in the intraoperative period or within the first few hours post-op.

● Anemia related to blood loss

● Deep vein thrombosis

● Pulmonary embolism

● Paralytic ileus

● Hematuria related to bladder trauma

● Infections of the bladder, endometrium, and incision

● Severe headache related to method of anesthesia

Question 41

Postoperative Complications

Answer 41

A multidisciplinary team approach is needed to provide care to women experiencing postoperative complications. Nurses have a key role in recognizing deteriorating conditions in the postoperative period. The most common preventable errors related to cesarean births are failure to recognize and act upon changes in vital signs and failure to act on postpartum hemorrhage.

• Pulmonary embolism presents as an acute event. Signs and symptoms are dyspnea, tachypnea, chest tightness, shortness of breath, hypotension, and decreasing oxygen saturation levels.
• Increased morbidity and mortality rates are associated with postpartum hemorrhage due to hypovolemic shock, disseminated intravascular coagulation, renal and/or hepatic failure, and the possible need for emergency hysterectomy.
• Surgical site infection rate is estimated to be 3% to 15%. Signs include serous or purulent drainage, erythema, fever, pain, and wound dehiscence.
• Endometritis is usually diagnosed within the first few days after delivery. Fever is the most common sign. Other signs include chills, uterine tenderness, and foul-smelling lochia.

Question 42

Immediate Postoperative Care

Answer 42

The woman and her newborn are transferred from the operating room to the labor and delivery postanesthesia care unit (PACU) or to her labor room following the cesarean birth. Immediate assessment and monitoring of maternal and newborn status is influenced by the type of anesthesia and preoperative or intraoperative complications. It focuses on maternal and fetal oxygenation, ventilation, circulation level of consciousness, and body temperature. The purpose of PACU care is to stabilize vital signs, bleeding, pain, itching, and nausea and to monitor anesthesia level. One RN should be assigned solely to the care of the mother and one nurse assigned to her newborn until the critical elements are completed, such as report, assessments, and stable vital signs. Equipment comparable to that in the main PACU should be available for the care of post-op OB patients.

● Blood loss and uterine tone are monitored closely in the PACU. Hospital policy may be to weigh on a scale pads and chux for more accurate measurement of QBL (1gram = 1 mL).

● Input and output (I&O) is monitored.

● Active warming measures are used to prevent hypothermia.

● Facility-based scoring system is used to determine the appropriate timing for discharge from the recovery room.

Question 43

Medical Management

First 24 Hours After Birth

Answer 43

● Assess for involutional changes and signs of potential complications.

● Assess pulmonary function: assess for atelectasis and pneumonia.

● Assess for ileus, cholecystitis, persistent nausea and vomiting, and intestinal obstruction.

● Medical orders are usually standardized. These orders include:

● IV therapy.

● Medications such as analgesics and stool softeners.

● Antibiotic therapy for the woman at risk for infection related to prolonged rupture of membranes, prolonged labor, or elevated temperature during labor.

● Progression of diet.

● Removal of the Foley catheter, generally at 12 hours postsurgery.

● Activity level.

● Immediate care of the newborn is the same for vaginal delivery . (ch 8, 15)

Question 44

Anesthesia Management-First 24 Hours After Birth

Answer 44

● When intrathecal morphine is used for postoperative pain management, the anesthesia provider manages the woman’s pain for the first 24 hours and administers medications to counteract side effects of intrathecal opioids.

Question 45

Preservative-Free Morphine

Answer 45

● Indication: Severe pain

● Action: Alters perception of and response to painful stimuli and produces generalized CNS depression

● Common side effects: Respiratory depression, itching, hypotension, nausea and vomiting, and urinary retention

● Route and dose: Administered intrathecally by anesthesiologist or CRNA; 5–10 mg

Question 46

Maternal Respiratory Depression Related to Intrathecal Morphine

Answer 46

Severe respiratory depression (3% occurrence) is a life-threatening adverse reaction to intrathecal morphine.

• Naloxone and resuscitative equipment must be available whenever intrathecal morphine is administered and during the 24 hours postoperative after injection.
• Respiratory rate and level of sedation are monitored for the first 24 hours postoperative after administration. Normal respiratory rate is 12 to 18 breaths per minute.
• An initial dose of 0.4 to 2 mg of naloxone is administered intravenously for severe respiratory depression. Dose can be repeated every 2 to 3 minutes for a total of 10 mg.
• Respiratory resuscitation is initiated immediately and continued until normal respiratory function returns.

Question 47

Nursing Actions-First 24 Hours After Birth

Answer 47

After a cesarean birth, most women recover in the labor and birthing recovery unit instead of the postanesthesia unit of the main OR. Nursing actions are similar to those when caring for a woman who had a vaginal birth, with emphasis on the following:

● Review prenatal, labor, and intrapartal records for risk factors.

● Monitor vital signs as per protocol.

● Monitor respiratory rate, heart rate, blood pressure, pain, pulse oximetry, and level of sedation every hour for the first 24 hours after administration of intrathecal morphine.

● Monitor for hemorrhage (increased bleeding, increased pulse, decreased blood pressure).

● Assess the fundus and lochia per protocol.

● Assess abdominal dressing for signs of bleeding.

● Assess woman’s level of pain and use pharmacological and nonpharmacological interventions for pain management. Evaluate effectiveness of pain management interventions.

● Monitor for side effects of intrathecal morphine and provide appropriate interventions. The primary side effects and interventions are:

● Pruritus: Administer medication as ordered, such as naloxone or diphenhydramine.

● Nausea/vomiting: Administer medication as ordered, such as naloxone or metoclopramide.

● Urinary retention: Occurs after removal of catheter: Administer naloxone or catheterize as ordered.

● Respiratory depression: Administer oxygen as needed and/or naloxone as ordered.

● Monitor the level of sensation.

● Monitor for seizures, spinal headache, and neurological deficits (e.g., prolonged decreased sensation in legs).

● Auscultate lungs, encourage coughing and deep breathing, and assist woman in using incentive spirometry.

● Monitor intake and urinary output (per Foley catheter and for the first 24 hours following catheter removal).

● Advance diet as tolerated.

● Regulate IV fluids as ordered.

● Oxytocin is added to IV fluids initially, to reduce the risk of postpartum hemorrhage related to uterine atony.

● Facilitate skin-to-skin contact with parents and infant.

● Assist the woman into a comfortable position for infant feeding.

● Assist with infant care and provide teaching as indicated.

● Provide emotional support by actively listening to the couple recall their birth experience and addressing their questions and concerns.

Question 48

Sudden Unexpected Newborn Collapse (SUNC)

Answer 48

SUNC is a rare event when a healthy-appearing, full-term infant suddenly experiences respiratory and cardiac arrest. Infants are at greatest risk during the first few hours of life. To decrease risk of SUNC during skin-to-skin contact, the nurse should place the infant on the mother’s chest; confirm that the mother is in a semi-Fowler’s position or higher and that the baby is not prone. The newborn’s face should be turned to the side. Newborn prone position on the mother’s chest, especially if the mother is on her back, can contribute to SUNC.

Question 49

Expected Assessment Findings

Answer 49

● Vital signs are within normal limits.

● Lochia is moderate to scant.

● The fundus is firm and midline and generally 1 to 2 cm above the umbilicus initially, moving down throughout the woman’s hospital stay.

● The abdominal dressing is dry.

● The catheter is draining clear/yellow urine. A small amount of blood in the urine may be present when there has been trauma to the bladder during the procedure.

● The IV site is free of signs of infiltration or inflammation.

● The pain level is below 3 on a pain scale of 0 to 10, or within the woman’s chosen number.

● The woman gradually regains full motor and sensory function as the effects of the anesthetic agent decrease.

● The woman sits at the bedside for short periods of time.

● The woman may experience itching, nausea, or decreased respirations related to side effects of morphine. Itching and nausea are the most common side effect of morphine. Itching varies from a facial rash to a full-body rash. Antihistamines are given to promote comfort.

● The woman feeds her newborn with or without assistance.

● The partner and family assist in care of the newborn.

● The couple may be tired and need time to rest.

● Women with unplanned cesarean births may experience guilt or a sense of failure or disappointment.

● Couples with unplanned cesarean births may ask questions about the cesarean birth and the events leading up to it.

● The couple will want time alone with their newborn.

● The couple will call family and friends, informing them of the birth.

Question 50

24 Hours Postoperative to Discharge-Medical Management-before discharge

Answer 50

● Assess the woman for involutional changes and signs of potential postoperative complications.

● Administer antibiotic therapy for women who experienced a prolonged labor or prolonged rupture of membranes or who are febrile.

● Remove abdominal dressing and assess for signs of dehiscence and infection (redness, tenderness, swelling). The dressing is usually removed on the first postoperative day.

● Provide discharge instructions.

Question 51

24 Hours Postoperative to Discharge-Nursing Actions-before discharge

Answer 51

Nursing actions are similar to those when caring for a woman who had a vaginal birth with addition to and/or emphasis on the following:

● Monitor vital signs as per protocol, generally every 4 hours.

● Assess breath sounds.

● Instruct the woman to deep breaths and cough every 2 hours.

● Instruct the woman on the use of an incentive spirometer if ordered.

● Assess postoperative pain and medicate as indicated.

● Use nonpharmacological pain management strategies.

● Assess the fundus and lochia per protocol. Use gentle pressure when assessing the fundus, as the woman’s abdomen will be tender.

● Monitor for signs of hemorrhage and infection.

● Assess the abdominal dressing or surgical wound for drainage and signs of infection.

● Administer antibiotics as ordered.

● Remove the Foley catheter as ordered when the woman can ambulate to the bathroom. This generally occurs 8 to 12 hours postsurgery. Ensure woman voids at least 200 to 300 mL after urinary catheter removal and inform the provider if she cannot. Avoid overdistention of the bladder to reduce risk of subinvolution and hemorrhage.

● Assist the woman with ambulation.

● Encourage oral fluid intake to assist in hydration.

● Discontinue IV fluids as ordered, generally when the woman can take adequate fluids by mouth without nausea.

● Assess bowel sounds and allow the woman to eat regular desired foods unless ordered otherwise. Patients who eat solid foods early rather than waiting for the presence of bowel sounds have shown earlier return of bowel function (Saad et al., 2016).

● Provide information on nutrition to promote tissue healing.

● Assist the woman into a comfortable position for infant feeding. Breastfeeding mothers may be more comfortable in a side-lying position or football hold, which prevents pressure on the abdomen.

● Assist the woman with infant care.

● Facilitate mother-infant attachment by bringing the infant to the woman and ensuring the woman’s comfort.

● Instruct the family that they need to assist the woman with infant care and housework, as she needs 6 weeks to recover from surgery.

● Provide opportunities for the family to ask questions about their cesarean birth experience.

● Provide teaching on infant care, postoperative care, and post-partum care.

● Remove staples before discharge per protocol. Instruct woman to make an appointment at her provider’s clinic/office for staple removal, if stapes not removed in the hospital.

Question 52

Expected Assessment Findings

Answer 52

● Vital signs and glucose levels are within normal limits. Temperature elevations may be a sign of infection.

● Lung sounds are clear bilaterally.

● The woman deep breathes and coughs every 2 hours while awake.

● Pain level is 3 or below, or reflects the woman’s chosen number on a pain scale of 0 to 10 with the use of nonpharmacological and pharmacological interventions.

● The fundus is firm and midline at one finger breadth below the umbilicus.

● Lochia is moderate to scant.

● The abdominal incision is clean, intact, approximated, and free of redness, edema, ecchymosis, and drainage.

● The woman spontaneously voids at least 200 mL within 2 to 3 hours of Foley removal.

● The woman ambulates to the bathroom and in the hallways.

● Bowel sounds are present and the woman reports passing gas.

● The woman is able to tolerate oral fluids and food.

● The woman is able to feed her newborn with or without assistance.

● The couple cares for the needs of their newborn.

● The woman may remain in the taking-in phase longer, as her focus is on pain control and integration of the birthing experience.

● Couples talk about their cesarean birth experience with staff, family, and friends.