Caesarean section (CS)
-is a life-saving surgical procedure when certain complications arise during
pregnancy and labour. It is the delivery of a fetus through surgical incisions
made through the abdominal wall (laparotomy) and the uterine wall
(hysterotomy).
( Although cesarean birth may be elected by some women, the procedure is
used most often as a prophylactic mea sure to alleviate problems of birth
such as cephalopelvic disproportion, breech or multiple fetus births, or failure
to progress in labor.)
Scheduled Cesarean Birth
- Scheduled cesarean births are planned, which means there is time for
thorough preparation for the experience through out the antepartal period.
( Some women are even able to take a childbirth preparation class specifi
cally for cesarean birth. Women who plan these need to be aware they will
need epi dural anesthesia, and the risk of injury to them from cesarean birth is
higher than that from vaginal birth. Scheduling cesar ean births this freely also
can result in preterm birth with the accompanying threats to the fetus or
newborn )
( In the past, many cesarean births were performed because the woman had
undergone a cesarean birth with a previous child; with new surgical
techniques, particularly the use of a low cervical incision, “once a cesarean,
always a cesarean” no longer applies. The majority of women who have had
a cesarean birth within the past 10 years are eligible to give birth vaginally in
subsequent pregnancies if the circumstances are appropriate for vaginal
birth)
( Yet other reasons for scheduled cesarean births are when there is a physical
indication such as transverse presentation, an infection that could be
contacted by the fetus if born vaginally, or cephalopelvic disproportion (Box
24.3). For instance, cesar ean birth reduces the transfer of the herpes type 2
from mother to newborn, so it is recommended for women who have this in
fection (Tita, 2012). It also can reduce mortality among infants presenting
breech (Cunningham, Leveno, Bloom, et al., 2010). )
Emergent Cesarean Birth
-Emergent cesarean births are done for reasons that arise suddenly in labor,
such as placenta previa, premature separation of the placenta, fetal distress,
or failure to progress.
(With this second type of cesarean birth, preparation must be done rap idly
but with the same concern for fully informing a woman and her support
person about what circumstances created the need for the cesarean birth
and how the birth will proceed. )
( An emergent cesarean birth carries with it the same risks of any emergent
surgery: the woman may not be a prime can didate for anesthesia and may
be psychologically unprepared for the experience. In addition, the woman
may have a fl uid and electrolyte imbalance and be both physically and emo
tionally exhausted from a long labor)
EFFECTS OF SURGERY ON A WOMAN
( Like any surgical procedure, cesarean birth has systemic effects. )
Stress Response
-This results in a release of epinephrine and norepinephrine from the adrenal
medulla.
( Epinephrine increases the heart rate, causes bronchial dila tation, and
elevates the blood glucose level. It also leads to peripheral vasoconstriction,
which forces blood to the cen tral circulation and increases blood pressure. In
the pregnant woman, such responses may minimize blood supply to the lower
extremities. Pregnant women are already prone to thrombophlebitis from
stasis of blood fl ow, so these responses compound or greatly increase
thrombophlebitis risk)
Interference With Body Defenses
(The skin serves as the primary line of defense against bacterial invasion, so
when skin is incised for a surgical procedure, this important line of defense is
lost. Strict adherence to aseptic tech niques during surgery and in the days
following the procedure are necessary to compensate for this impaired
defense. If the ce sarean birth is performed hours after the membranes
rupture, a woman’s risk for infection will be higher than if the membranes
were still intact. Many women receive prophylactic antibiotics, such as
ampicillin (Omnipen) or a cephalosporin, such as Ancef, to ensure protection
against postsurgical endometritis, even if the membranes remained intact )
Interference With Circulatory Function
( Although vessels that must be cut for surgery are immedi ately clamped and
ligated, some blood loss occurs with sur gery. Compared to other surgeries,
the amount of blood lost in a cesarean birth is comparatively high, caused by
the fact abdominal and pelvic vessels are congested with blood wait ing to
supply the placenta. During a vaginal birth, a woman loses 300 to 500 ml of
blood. This loss increases to 500 to 1,000 ml with a cesarean birth )
Interference With Body Organ Function
(When any body organ is handled, cut, or repaired in sur gery, it may respond
with a temporary disruption in func tion. Therefore, close postoperative
assessment, not only of the primary organ involved but also of total body
function, is necessary to determine the total degree of disruption present.
Because the uterus is handled during cesarean birth, it may not contract well
afterward, which can lead to postpartum hemorrhage. For a health care
provider to reach the uterus, the bladder must be displaced anteriorly. As a
result of this handling, the bladder may not sense fi lling as well as usual after
the procedure (Gungorduk, Asicioglu, Celikkol, et al., 2010). During surgery,
pressure is also felt by the intestine, so a paralytic ileus or halting of intestinal
function with obstruc tion may occur (Harma, Harma, Karadeniz, et al., 2011).
As mentioned previously, thrombophlebitis from impaired lower extremity
blood fl ow is yet another possibility. After a cesar ean birth, therefore, uterine,
bladder, intestinal, and lower extremity circulatory function must all be
carefully assessed.)
Interference With Self-Image or Self-Esteem
( Surgery always leaves an incisional scar that is noticeable to some extent
afterward, and its appearance may cause a woman to feel self-conscious.
Although most women accept cesarean birth well, a woman who was intent
on having a vaginal birth may feel a loss of self-esteem and depression if she
believes the procedure marks her as a woman less capable than oth ers
because she was unable to give vaginal birth ( Barbadoro, Cotichelli, Chiatti,
et al., 2012)
NURSING CARE FOR A WOMAN ANTICIPATING A CESAREAN BIRTH
Preoperative Assessments for Women
Preoperatively, both the primary care provider and the anesthesia team
conduct interviews to gather health history and assess safety for the
procedure and anesthesia use. A nursing assessment is also crucial and
should include inquiries about:
● Past surgeries, secondary illnesses, and allergies to foods or drugs.
● Reactions to anesthesia, bleeding problems, and current medications.
● Body piercings that need removal due to electrosurgery or arterial
cauterizing equipment.
Additionally, assess the woman's understanding of:
● What the procedure will entail.
● Length of hospitalization anticipated.
● Postsurgical equipment, such as an indwelling catheter or IV fluid line.
● Special precautions planned for her infant, like high-risk nursery care.
Operative Risks for Women
General Risks for Women: Women with poor physical or psychological
health face increased surgical risks unless risk factors are identified and
precautions are taken.
1. Poor Nutritional Status: Obesity complicates surgery by slowing
incision healing, increasing infection risk, and causing additional stress
on the heart. Deficiencies in protein, vitamins, or iron can delay
recovery and lead to complications such as extreme fatigue.
2. Age-Related Risks: Older women, especially those over 40, may face
higher surgical risks due to conditions like gestational diabetes,
although most pregnant women are young and in good health.
3. Secondary Illnesses: Conditions like cardiac disease, diabetes, or
anemia can heighten surgical risks. A thorough medical and
medication history is essential to identify potential complications.
4. Fluid and Electrolyte Imbalances: Women with low blood volume
due to prolonged labor, vomiting, or poor intake may require pre- and
postoperative IV fluid replacement to prevent serious complications.
5. Fear and Anxiety: Addressing fears through detailed explanations or
administering anti anxiety medication can help reduce anxiety,
normalize feelings, and improve the surgical experience.
Newborn Risks in Cesarean Birth: Cesarean delivery may result in
respiratory difficulties in newborns due to the absence of chest compression
during delivery, which helps clear fluid from the lungs.
(When a fetus is pushed through the birth canal, pressure on the chest helps
rid the newborn’s lungs of fl uid, making it easier for the baby to take a fi rst
breath. For this reason, more infants born by cesarean birth develop some de
gree of respiratory diffi culty for a day or two after birth than those born
vaginally )
Preoperative Diagnostic Procedures
• Vital sign determination
• Urinalysis (examination of urine to detect infections, kidney function issues,
or other abnormalities.)
• Complete blood count ( Blood test to evaluate overall health and detect
conditions like anemia or infection.)
• Coagulation profi le (prothrombin time [PT], partial thromboplastin time
[PTT]) (Tests to measure blood clotting ability and assess bleeding risks
during surgery.)
• Serum electrolytes and pH (Blood test to check electrolyte balance and
acid-base status, critical for maintaining bodily functions during surgery.)
• Blood typing and cross-matching (Identification of blood type and
compatibility testing to prepare for possible transfusions.)
(Remember blood values need to be evaluated in light of the changes that
occur with pregnancy. During pregnancy, for ex ample, a woman (particularly
one who was in prolonged labor) can have an elevated leukocyte count (up to
20,000 cells/mm3), so this fi nding is not as helpful an indicator for the
presence of infection in the pregnant woman as it is in others)
(A normal white blood cell (WBC) count for pregnant women is 5,700–15,000
cells per microliter of blood.)
Preoperative Teaching
(Preoperative teaching for a cesarean birth focuses on informing the woman
about the procedure and any equipment used. Begin by assessing her
knowledge, especially if she’s had a cesarean before, to refresh and clarify
any gaps. Use simple, non-medical language to explain procedures like
surgical skin prep, fasting, premedication, and epidural catheter placement.
For scheduled cesareans, also include information on post-surgery activities
to maintain respiratory and skeletal function, like early ambulation, to prevent
complications. Teach preventive exercises during the preoperative period
when the woman is pain-free and can focus. Use visual aids to enhance
understanding, but avoid overwhelming her with detailed books on
complications. The goal is to give her a positive outlook and a sense of
control.)
Health teaching about postoperative Breathing and Movement
Techniques
● Deep Breathing: Prevents lung mucus stasis and reduces infection
risk. Involves taking 5-10 deep breaths hourly, fully inhaling and
exhaling to avoid light-headedness from hyperventilation.
● Incentive Spirometry: A common device used three to four times a
day postoperatively to encourage deep breathing is an incentive
spirometer. These devices, which cause a small Ping–Pong-like ball to
rise in a narrow tube or cause lights to flash, are both easy and fun to
operate and give a woman a sense of reward for her effort. The initial
impression of most people is that the device works by blowing into it.
Because its purpose is to fully aerate lung spaces, however, most
models are triggered by inhalation, not exhalation. A gauge can be set
to monitor levels and tabs to set goals
● Turning: Postoperative turning helps prevent respiratory and
circulatory stasis.
● Ambulation: Early walking, once epidural effects subside, stimulates
lower extremity circulation, reducing the risk of blood clots. Support
devices like sequential compression devices (SCDs) or antiembolic
stockings (TEDS) may also be prescribed.
Immediate Preoperative Care Measures
Informed Consent
Informed consent ensures the patient understands the risks and benefits of
the procedure, which is primarily the healthcare provider's responsibility.
Nurses confirm the consent is obtained before surgery and may witness the
patient's signature. Before signing as a witness, ensure the patient has been
properly informed using terms they can understand. Emancipated minors can
provide their own consent for cesarean births, depending on state laws.
Overall Hygiene
The patient is given a clean hospital gown, and hair is tied back to fit under a
surgical cap, reducing the spread of microorganisms. Jewelry, contact lenses,
and nail polish are removed, as these items can interfere with surgery or
assessments. Acrylic nails, if present, can remain if toenails are free of polish
for capillary refill checks. These measures help ensure surgical safety and
hygiene.
Gastrointestinal Tract Preparation
Medications like gastric emptying agents (e.g., metoclopramide), histamine
blockers (e.g., ranitidine), or oral antacids (e.g., Bicitra) are prescribed to
prevent esophageal reflux and aspiration. These are necessary because the
supine position during surgery increases the risk of reflux. This preparation
minimizes potential complications during the cesarean birth.
Baseline Intake and Output Determinations
An indwelling catheter is inserted to empty the bladder and keep it away from
the surgical field. Proper lighting ensures clear visualization for insertion, and
urine flow must be confirmed as fetal pressure might impede it. The catheter
drainage bag is kept below bladder level to prevent backflow. If
catheterization is difficult, it can be done after anesthesia is administered.
Monitoring urine output is crucial to detect kidney function issues caused by
surgical stress or low blood pressure.
Hydration
An IV line, typically with lactated Ringer’s solution, is started before surgery
to maintain hydration and prevent hypotension from epidural anesthesia or
blood loss. The IV is usually placed in the nondominant hand so the patient
can hold the baby post-surgery. A large catheter (18 or 20 gauge) is used to
allow for potential blood transfusions if needed.
Preoperative Medication
Minimal medication is administered preoperatively to avoid compromising
fetal oxygenation and ensure the newborn is alert and can breathe
spontaneously at birth. Nurses must be aware of any prior medications given
during labor to prevent interactions. This careful approach supports both
maternal and fetal safety.
Patient Chart and Presurgery Checklist
The patient’s nursing care is documented, and a presurgery checklist
ensures that all necessary measures are completed. The checklist includes
verification of informed consent, hygiene preparation, medication
administration, and IV line placement. Signing off on the checklist ensures a
comprehensive review of preoperative care.
Transport to Surgery
The patient is transported to surgery on a stretcher or bed, positioned on her
left side to prevent supine hypotension syndrome. Side rails are raised, and
the patient is covered to prevent chills. Ensure proper identification and that
the chart or electronic records are securely transferred with the patient. These
steps ensure safety and comfort during transport.
NURSING CARE FOR A WOMAN HAVING AN EMERGENT CESAREAN
BIRTH
INTRAOPERATIVE CARE MEASURES
Administration of Anesthesia
Anesthesia for a cesarean is typically regional, such as epidural anesthesia,
to keep the woman awake during surgery. The nurse assists with positioning
and administering the anesthesia, ensuring the woman remains on her side to
prevent hypotension. Epidural anesthesia is commonly used, and medications
like Duramorph may be added for pain relief, requiring respiratory monitoring
post-surgery.
Skin Preparation
Skin preparation aims to reduce bacteria around the incision site to prevent
infection. This involves cleaning the area over the incision and possibly
shaving abdominal hair. Some women may choose to wax ahead of time to
avoid shaving.
Surgical Incision
Two types of incisions are used in cesarean births: the classic vertical
incision, which is more risky for future labor, and the low segment horizontal
incision, which is more common and less likely to rupture, allowing for the
possibility of vaginal birth after cesarean (VBAC). The low segment incision is
less invasive and generally preferred for elective cesareans.
Birth of the Infant
Once the incision is made, the baby’s head is manually delivered, and the
mouth and nose may be suctioned. Oxytocin is administered to reduce blood
loss. The woman’s partner may be allowed to cut the umbilical cord, and
additional procedures like tubal ligation or IUD insertion can be done at this
time.
Introduction of the Newborn
After confirming the baby’s breathing, the newborn is shown to the mother
and support person, with immediate holding allowed. Breastfeeding can occur
after surgery but may be delayed until recovery to avoid complications, as it
can trigger uterine contractions.
POSTPARTAL CARE MEASURES