Cesarean Birth

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Marianne Belleza, R.N. July 27, 2016

There are pregnant women who have complications in their pregnancy and are not allowed
to give birth vaginally. Cesarean birth becomes the birth method of choice, which is entirely
different from vaginal birth, so from assessment until discharge, healthcare professionals
holistically adjust the care plan to accommodate the woman anticipating cesarean birth.

Preoperative Assessment
A nursing assessment of a pregnant woman about to undergo cesarean birth is also
important to obtain health history that would become essential later on.

Assess the woman about past surgeries, secondary illnesses, allergies to foods or
drugs, reaction to anesthesia, and medications that could increase any surgical risk.
The woman should be in the best possible physical and psychological state before
undergoing any surgery.
An obese woman with poor nutritional status is at risk for a slow wound healing.
Tissue that contains extra fatty cells would be difficult to suture and the incision will
heal much slower and predispose the woman to infection and dehiscence.
An obese woman would also have difficulty in initiating ambulation and turning after
surgery as it will increase the risk for pneumonia or thrombophlebitis.
A woman with protein or vitamin deficiency is also at risk for poorer healing because
these are needed for new cell formation at the incision site.
Age can also affect surgical risk because it can cause decreased circulatory and renal
function.
A woman who has secondary illness is also at greater surgical risk depending on the
extent of the disease because the secondary illness may affect the woman’s ability to
adapt to the demands of the surgery.
The general medication history of the woman must also be assessed because there are
drugs that could increase the surgical risk by interfering with the effects of anesthesia.
A woman with lower than normal blood volume might feel the effects of surgery more
than a woman with normal blood volume.
An example of this is a woman who began labor and was told later on that she should
undergo cesarean birth instead because she may not have had anything to eat or drink
for almost 24 hours.
To prevent fluid and electrolyte imbalance, intravenous fluid replacement is initiated
preoperatively and postoperatively.
There are women who are very worried about the procedure, so they need a very
detailed explanation of the procedure before they can enter surgery without intense
fear.
A woman who is frightened is at greater risk for cardiac arrest during anesthesia
administration.
Acknowledge that the woman’s fear of surgery is normal so that she can view her
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 feelings as expected which could increase her self-esteem.
The newborn is also at greater risk than those newborn born through vaginal delivery.
Infants born through cesarean delivery develop a degree of respiratory difficulty
because when a fetus is pushed through the birth canal, pressure on the chest helps to
rid the newborn lungs of fluid.

Preoperative Diagnostic Procedures

Before undergoing surgery, the woman must subject herself to the diagnostic procedures as
recommended by her physician.

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Diagnostic procedures that a woman must undergo before surgery include circulatory
and renal function assessments and fetal heart rate.
For the circulatory system, diagnostic procedures include complete blood count, and
PT and PTT.
For the renal function, assessment of urine is necessary.
Other diagnostic procedures include vital sign determination, serum electrolyte and
pH, blood typing and cross matching, and ultrasound to determine the fetal
presentation and maturity.
When a woman experiences prolonged labor, she may have an elevated leukocyte
count of up to 20, 000/mm3, so this finding would not be a good indicator of infection.

Preoperative Measures
Preoperatively, there are measures that should be taken to ensure the woman’s safety
during surgery.

The most important responsibility of the surgeon is securing the informed consent
from the patient.
It is everyone’s responsibility to see to it that the consent is obtained, and witnesses
might be asked to witness the woman’s signature.
The consent must be informed, and the risks and benefits of the procedure must be
explained in a language that the woman understands.
Upon admission, the woman is provided with a clean hospital gown and her hair is
pulled into a ponytail.
The woman’s nails should be free from nail polish or any acrylic fingernails because
nails are used to assess capillary refill.
To decrease stomach secretions, a gastric emptying agent is used before surgery,
because the woman would be lying on her back during surgery which makes
esophageal reflux and aspiration highly possible.
An indwelling catheter is prescribed before or after the surgery to reduce bladder size
and keep the bladder away from the surgical field.
Make sure that you have good lighting when inserting a catheter on a pregnant woman
to clearly reveal the perineum.
The urine should be draining freely, and the drainage bag should be kept below the
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 level of the bladder during transport to prevent backflow and the introduction of
microorganisms into the bladder.
To ensure that the woman is fully hydrated, an intravenous solution such as Ringer’s
can be started as prescribed.
Only a minimum of preoperative medications is given to prevent compromising the
fetal blood supply and make sure that the newborn is wide awake at birth and
respirations are initiated spontaneously.
Documentation of nursing care up until the woman leaves the hospital must be
complete and factual.
Upon transport to surgery, ensure that the woman is lying on her left side to prevent
supine hypotension.
Ensure that the side rails are up, and the woman is covered with a blanket.
A support person may be needed during cesarean birth, and they also need
encouragement to watch the birth live.

Intraoperative Measures
While anesthesia is being administered, a surgical nurse will assist the woman first to
move from the transport stretcher to the operating table.
The anesthesia of choice is usually a regional block.
Encourage the woman to remain on her side or insert a pillow under her right hip to
keep her body slightly tilted to the side to prevent supine hypotension.
In emergency cases, a spinal anesthesia is administered while the woman is sitting up.
It would be difficult for a woman in labor to remain in a curved position during
administration of the anesthetic, so talk to her gently and let her lean on you while you
gently restrain her.
Epidural anesthesia is administered while the woman is lying on her side, and it has an
effect that lasts for 24 hours, so continuous pulse oximetry must be used 24 hours post
surgery to detect respiratory depression.
For the skin preparation, shaving away abdominal hair and washing the skin over the
incision site with soap and water could reduce the bacteria on the skin.
The woman is then positioned with a towel under her right hip to move abdominal
contents away from the surgical field and lift her uterus away from the vena cava.
The woman would be covered by a sterile drape to block the flow of the bacteria from
her respiratory tract to the incision site and also block the woman’s and support
person’s lines of sight from the incision site.
The incision area is scrubbed by an antiseptic, and additional drapes are placed around
the area so that only a small area of the skin is exposed.
Prepare the woman and the support person for the sights they might see.
A classic incision is made vertically through both the abdominal skin and the uterus.
A disadvantage of this type of incision is that it leaves a wide skin scar and also runs
through the active contractile portion of the uterus.
The woman would not be able to have a subsequent vaginal birth because this type of
scar could rupture during labor.
A low segment incision or low transverse incision is made horizontally across the
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 abdomen just over the symphysis pubis and also horizontally across the uterus just
over the cervix.
This is the most common type of incision and is also referred to as “bikini” incision.
It is less likely that this type of incision would rupture during labor, so it is possible for
the woman to have VBAC in the future.
It results in less blood loss, easier to suture, decreases puerperal infections and less
likely to cause postpartum gastrointestinal complications.
The disadvantage of this incision is that it takes longer to perform, making it
inappropriate for an emergent cesarean birth.

Postpartal Care
The postpartal care period of a woman who has undergone emergent cesarean birth is
divided into two: immediate recovery period and extended postpartal period.
After surgery, the woman would be transferred by stretcher to the postanesthesia care
unit.
If spinal anesthesia was used, the woman’s legs are fully anesthetized so she cannot
move them.
Pain control is a major problem after birth because it was so intense that it interfered
with the woman’s ability to move and deep breathe.
This may lead to complications such as pneumonia or thrombophlebitis.
Use a pain rating scale to allow a woman to rate her pain.
Some women may need patient controlled analgesia or continued epidural injections
to relieve the pain.
Supplement the analgesics with comfort measures such as change in position or
straightening of bed linen.
Instruct the woman to ambulate because this is the most effective method to relieve
gas pain.
Inform the woman that she should not take acetylsalicylic acid or aspirin because this
can interfere with blood clotting and healing.
Instruct the woman to place a pillow on her lap as she feeds the infant to deflect the
weight of the infant from the suture line and lessen the pain.
Football hold for breast feeding is a way to keep the infant’s weight off the mother’s
incision.
During the extended postpartal period, the woman most commonly experiences
gastrointestinal function interference.
Note carefully the woman’s first bowel movement after surgery because if no bowel
movement has been observed, the physician may order a stool softener, a suppository,
or an enema to facilitate stool evacuation.
Teach the woman to eat a diet high in roughage and fluid and to attempt to move her
bowels at least every other day to avoid constipation.
Incisional pain may interfere with the woman’s ability to use her abdominal muscles
effectively, so the physician may prescribe a stool softener.
Caution the woman not to strain to pass stools because this puts pressure on their
incision.
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Advice the woman to keep their water pitcher full as a reminder for her to drink fluids.
Reassure the woman that it is normal not to have bowel movements for 3 to 4 days
postoperatively, especially if there is enema administered before surgery.

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