Intrapartum and Postpartum Care of Cesarean Birth Families ch 11 Flashcards
Cesarean birth
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.
Cesarean Delivery on Maternal Request (CDMR)
- 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.
Indications for Cesarean Birth
- Labor arrest: 34%
- Nonreassuring fetal tracing: 23%
- Malpresentation: 17%
- Multiple gestation: 7%
- Maternal-fetal: 5%
- Macrosomia: 4%
- Other obstetric indications: 4%
- Preeclampsia: 3%
- 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
Obesity and Cesarean Births
“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.
Preventing the First Cesarean Birth
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
Interventions and Strategies for Preventing Primary Cesarean Births
- Implement the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine’s definition and management of labor dystocia.
- Develop standardized fetal heart rate interpretation and management.
- Use cervical ripening agents when labor is induced in women with an unfavorable cervix.
- 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.
- Use nonmedical interventions such as continuous labor support by nurse or doula.
- External cephalic version for breech presentation.
- No elective inductions until 39 weeks.
- Trial labor for women with twin gestations when first twin is in a vertex presentation.
CLASSIFICATION OF CESAREAN BIRTHS
Cesarean births are classified as either scheduled (planned) or unscheduled (unplanned). Unscheduled cesarean births include emergent, urgent, and nonurgent cesarean births.
Scheduled cesarean births
● 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.
● Emergent cesarean birth
Emergent cesarean birth indicates an immediate need to deliver the fetus (e.g., prolapse of umbilical cord or rupture of uterus).
Urgent cesarean birth
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.
● Nonurgent cesarean birth
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.
RISKS RELATED TO CESAREAN BIRTH
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.
Risks Related to Repeat Cesarean Birth
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.
Trial of Labor After Cesarean Section
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.
PERIOPERATIVE CARE
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.
Scheduled Cesarean Birth
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.
Evidence-Based Practice Guidelines
AWHONN’s perioperative care of the pregnant woman. This guideline describes evidence-based practice to ensure the following:
- Patient safety measures for perioperative care of the pregnant woman
- Family-centered education and care practices
- Assessment and interventions appropriate during preoperative, intraoperative, and postoperative periods for women undergoing cesarean birth
Medical Management -scheduled c-section
● 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.
Anesthesia Management-Scheduled c-section
● 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.
Nursing Actions- scheduled c-section
● 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.