CBL 9_Cesarean Birth, PostOp recovery, Sexual Health

Question 1

What are the chances of inoperative (immediate) risks of a C/S?

Answer 1

Complications in 12-15 % c/s

Question 2

What are the chances of post-operative risks in C/S?

Answer 2

23-25 %

Question 3

What are some long term risks for nb with c/s?

Answer 3

Asthma

Question 4

What are some long term risks for birthing person w c/setion? (7)

Answer 4

-Ectopic pregnancies
-Bowel obstruction
-Nerve pain
-Low lying placenta
-Previa
-Acreta
-Increased risk of stillbirth in future pregnancies

Question 5

What serious post-operative complication risks bw vag birth and cs? (7)

Answer 5

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

Question 6

Is there a difference bw risk of elective and emergent c/s?

Answer 6

Decreased risk to birther and fetus in comparison to an emergency cesarean

Question 7

Why does an emergent c/s have higher risk?

Answer 7

Usually due to the reason, an emergency cesarean is indicated?

Question 8

What might be more likely for nb transition in c/s?

Answer 8

TTN

Question 9

What might RM be doing at C/S?

Answer 9

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.

Question 10

What is usually given 30 mins prior to surgery?

Answer 10

Antacid PO or IV
Sodium citrate and ranitidine IV

Question 11

What is given for analgesic in C/S?

Answer 11

Usually regional anesthesia (spinal or epidural)

Question 12

What are contraindications for spinal/epidural? (3)

Answer 12

• Very low platelets
• Acute emergency such as bleeding
• Sometimes scoliosis

Question 13

When can an epidural be used in c/s?

Answer 13

If coverage is good enough – if it can be topped up to nipple line/T4 – otherwise use spinal

Question 14

What drugs are used for C/S?

Answer 14

Opioid and LA (exact mixture depends on hospital)
Bupivacaine, Lidocaine, and +/- fentanyl

Question 15

What happens with synth oxytocin and C/S?

Answer 15

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.

Question 16

Describe when epidurals could be used for C/S?

Answer 16

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.

Question 17

What drugs are used in GA? (3)

Answer 17

(IV/Inhalation)

• propofol (anaesthetic)
• thiopental (barbituate)
• ketamine (dissociative anaesthetic)

Question 18

Most pressing assessments Immediate PP for birther after C/S?

Answer 18

Vitals (airway, breathing, circulation)
SPO2

Question 19

How often VS/Fundus/Flow?

Answer 19

q15min x 2 hrs (at minimum)

Question 20

What to include post-op C/S

Answer 20

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

Question 21

What assessment is usually done to see if pain meds are wearing off after c/s?

Answer 21

• 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)

Question 22

Midwife care role pp after c/s?

Answer 22

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

Question 23

Pain mgmt recommendations for after C/S

Answer 23

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.

Question 24

RM incision care pp after c/s?

Answer 24

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

Question 25

How can we assess pp anxiety?

Answer 25

* 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

Question 26

Birther assesments in visits pp?

Answer 26

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

Question 27

Evidence on LAM?

Answer 27

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

Question 28

What do you include in your sexual health counselling with a client?

Answer 28

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 aer 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 aer 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.

Question 29

When can you start to massage uterine scar?

Answer 29

After 6 wks and fully healed

Question 30

Chance of serious post-operative risk in vag birth?

Answer 30

10 % after vag

Question 31

Chance of serious post-operative risk in CS birth?

Answer 31

17 %

Question 32

Takeaway on epigenetics and birth?

Answer 32

Birth experience can effect epigenetic Mode of birth (for instance a planned c/s) can effect epigenetics

Question 33

Can birth experience effect pp mental health?

Answer 33

Yes Neg birth experience is associated with PPD

Question 34

What are some factors that are protective for a positive birth experience? (5)

Answer 34

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