CBL 9_Cesarean Birth, PostOp recovery, Sexual Health Flashcards
What are the chances of inoperative (immediate) risks of a C/S?
Complications in 12-15 % c/s
What are the chances of post-operative risks in C/S?
23-25 %
What are some long term risks for nb with c/s?
Asthma
What are some long term risks for birthing person w c/setion? (7)
-Ectopic pregnancies
-Bowel obstruction
-Nerve pain
-Low lying placenta
-Previa
-Acreta
-Increased risk of stillbirth in future pregnancies
What serious post-operative complication risks bw vag birth and cs? (7)
10 % after vag
17 % after c/s
Examples: (C/S higher than vag birth)
* uterine infection
* surgical wounds
* hemorrhage (slight increase)
* gallbladder disease
* genital/urinary complications (slight increase)
* heart/lung complications
* blood clots
Is there a difference bw risk of elective and emergent c/s?
Decreased risk to birther and fetus in comparison to an emergency cesarean
Why does an emergent c/s have higher risk?
Usually due to the reason, an emergency cesarean is indicated?
What might be more likely for nb transition in c/s?
TTN
What might RM be doing at C/S?
Don Gown, cap
remove other clothing, accessories, jewellery
client transfer
ongoing client and fetal monitoring
clip to remove excess hair, lens removal, dentures, IV access.
U cath usually when Regional A in place or GA
information, support, reassurance, documentation
Partner support and provide guidance.
What is usually given 30 mins prior to surgery?
Antacid PO or IV
Sodium citrate and ranitidine IV
What is given for analgesic in C/S?
Usually regional anesthesia (spinal or epidural)
What are contraindications for spinal/epidural? (3)
- Very low platelets
- Acute emergency such as bleeding
- Sometimes scoliosis
When can an epidural be used in c/s?
If coverage is good enough – if it can be topped up to nipple line/T4 – otherwise use spinal
What drugs are used for C/S?
Opioid and LA (exact mixture depends on hospital)
Bupivacaine, Lidocaine, and +/- fentanyl
What happens with synth oxytocin and C/S?
Where oxytocin has been used there is a risk of fluid overload secondary to decreased renal perfusion and decreased urine output.
If an intrapartum “emergency” CS is done for non-urgent indication such as labour dystocia, some surgeons will observe a period to allow the oxytocin to be cleared - known as an oxytocin washout.
Describe when epidurals could be used for C/S?
Epidurals used for labor pain, typically provide a sensory block extending to dermatome T10. For cesarean delivery, the sensory block needs to extend to dermatome T4.
An existing epidural, that is working well can be converted to meet the needs of operative anesthesia by adding additional doses of local anesthetic (bupivacaine with lidocaine +/- fentanyl).
Epidurals require these medications to diffuse to the spinal nerves and may not reach all of them and may therefore provide incomplete pain relief.
What drugs are used in GA? (3)
(IV/Inhalation)
- propofol (anaesthetic)
- thiopental (barbituate)
- ketamine (dissociative anaesthetic)
Most pressing assessments Immediate PP for birther after C/S?
Vitals (airway, breathing, circulation)
SPO2
How often VS/Fundus/Flow?
q15min x 2 hrs (at minimum)
What to include post-op C/S
VS incl SPo2
Incision- intact, approximation, inflammation, discharge, bruising
Fundus
PV loss
Sensory block/mobility/ambulation/body mechanics
BM
Breasts and nipples (STS)
Pain management
Emotional/psych
What assessment is usually done to see if pain meds are wearing off after c/s?
- Assess sensory level and modified Bromage Score q1h until return of full motor power and sensory level
- Call anesthesia if no change over 2 assessments or not fully recovered after 6 hours or increasing Bromage Scale
(Usually done by RN)
Midwife care role pp after c/s?
RM in all cases typically leads BF support for healthy babe under RM care.
D1 - removal of catheter & ability to void, PV loss/fundus, pain management, mobility/ambulation
Pain mgmt recommendations for after C/S
balance rest & ambulation
Ensure pain management adequate – both analgesics and anti-inflammatories that are safe for BF (minimize opioids)
Body mechanics, e.g. Hold abdomen with pillow for first 24hrs to not cause more discomfort
Activity to a minimum once home, avoid lifting anything heavier than baby
Continue pain meds 5-7 days gradually decreasing – BCWH post 48hrs=
acetaminophen 650 mg PO q4h PRN for pain (Maximum: 4000 mg/24 h)
ibuprofen 400 mg PO q4h PRN for pain (Maximum: 2400 mg/24 h)
Numbness normal around incision
Bleeding as per vaginal birth but rate of involution often slower (often time less bleeding)
Normal to have delayed vowel activity – encourage to eat, drink, stool softeners
Emotional/psych issues that may arise if CS unplanned
Can use tens machine on scar for pain mgmt.
RM incision care pp after c/s?
RM- may remove staples/sutures at home prn if not done in hospital/discharged early
-inspect incision during home assessments – dry, intact, min discharge, well approximated, non inflamed
How can we assess pp anxiety?
- Assess
- Believe
- Validate
- Offer appropriate support or refer as needed
Also Note TIMING of ?anxiety and how it may be more common at some time than others. For example, immediate postpartum anxiety is not common vs day 5 it is common -‘when the milk comes in the tears come in’.
And consider hx and meds
Birther assesments in visits pp?
VS
Breasts/Nipples
Fundus
Scar check
Breasts/Nipples Milk in? Damage
Skin Colour Belly fundus -1cm per day
Feeding
Bowel/Bladder
Urine & Stool
Output
Bottom
perineium, incision
Vitals Blues/Mood
Evidence on LAM?
LAM failure rate increases after 6 months – 2% failure rate is for within 6 months, no period, fully feeding (no more than 6 hour gap at night).
Lactation amenorrhea method
What do you include in your sexual health counselling with a client?
Resumption of sexual activity occurs at variable times following birth. A discussion of resuming sexual intercourse should occur at some point during the two to six weeks aer the birth. Encouraging the client to resume sexual activity when ready and comfortable is a key message. Vaginal discomfort is common in the postpartum period due to decreased hormone levels and decreased vaginal lubrication from the hormones of lactation. It is also normal to have little interest or energy for sexual activity due to fatigue and the physical recovery aer birth. Discussing the use of a vaginal lubricant, and positions during intercourse that minimise discomfort will be useful.
P and V doesn’t need to be the goal. Intimacy and fun and orgasms can happen lot’s of other ways.
When can you start to massage uterine scar?
After 6 wks and fully healed
Chance of serious post-operative risk in vag birth?
10 % after vag
Chance of serious post-operative risk in CS birth?
17 %
Takeaway on epigenetics and birth?
Birth experience can effect epigenetic
Mode of birth (for instance a planned c/s) can effect epigenetics
Can birth experience effect pp mental health?
Yes
Neg birth experience is associated with PPD
What are some factors that are protective for a positive birth experience? (5)
personal expectation
being well-informed and prepared
support from caregivers,
quality of care provider – client relationship
opportunity for client involvement in decision making during birth
