11 Cesarean Birth Nursing Care Plans

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Cesarean birth, also termed cesarean section, is the delivery of a neonate by surgical incision through the abdomen and uterus. The term cesarean birth is used in nursing literature rather than cesarean delivery to accentuate that it is a process of birth rather than a surgical procedure. This method may occur under planned, unplanned, or emergency conditions. Indications for cesarean birth may include abnormal labor, cephalopelvic disproportion, gestational hypertension or diabetes mellitus, active maternal herpes virus infection, fetal compromise, placenta previa, or abruptio placentae.

Nursing Care Plans

Cesarean section is currently the most common major surgical procedure in the United States. However, it carries risks to both the mother and the fetus. It also has a lengthy recovery period than vaginal birth. Some women may have difficulty attempting a vaginal birth later. Yet, many women can have a vaginal birth after a cesarean (VBAC). Hence, mothers need to work with health care providers to make the best decision for themselves and the baby.

Here are 11 nursing diagnoses and nursing care plans for cesarean birth: 

  1. Deficient Knowledge UPDATED!
  2. Acute Pain UPDATED!
  3. Risk for Infection UPDATED!
  4. Risk for Deficient Fluid Volume UPDATED!
  5. Risk for Disturbed Maternal-Fetal Dyad UPDATED!
  6. Risk for Injury UPDATED!
  7. Anxiety or Fear UPDATED!
  8. Risk for Situational Low Self-Esteem UPDATED!
  9. Powerlessness UPDATED!
  10. Risk for Ineffective Self Health Management UPDATED!
  11. Risk for Impaired Parenting UPDATED!
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Risk for Infection

If the cesarean birth is performed hours after the membranes rupture, a woman’s risk for infection will be higher than if the membranes were still intact. Amniotic fluid helps protect the fetus from infectious agents due to its inherent antibacterial properties. After the rupture of membranes, the cervical canal becomes the usual pathway for cervical and vaginal flora, causing infections. Additionally, the skin also serves as the primary line of defense against bacterial invasion, so when the skin is incised for a surgical procedure, this important line of defense is lost.

Nursing Diagnoses

  • Risk for Infection
  • Risk for Surgical Site Infection

Risk factors may include

  • Invasive procedures
  • Rupture of amniotic membranes
  • Break in the skin
  • Decreased hemoglobin due to excessive blood loss
  • Exposure to pathogens
  • Prolonged second stage of labor
  • Six or more vaginal exams before cesarean

Possibly evidenced by

A risk diagnosis is not evidenced by signs and symptoms, the presence of signs and symptoms establishes an actual/problem diagnosis. Nursing interventions are directed at prevention. 

Desired outcomes and goals

  • The client is free from infection.
  • The client is afebrile (temperature below 38℃/100.4℉) and free of purulent drainage or erythema of the surgical site.
  • The client achieves timely wound healing without complications.
  • The client’s amniotic fluid remains clear with a mild odor.

Nursing Assessment and Rationales

1. Assess history for preexisting conditions or risk factors. Note time of rupture of membranes.
Persons with a history of diabetes or hemorrhage have increased chances of infection and poor healing. The risk of chorioamnionitis increases while the pregnancy progresses, which may increase fetal risk contamination. 

2. Assess the client’s vital signs for signs and symptoms of infection. 
Rupture of membranes occurring 24 hours before the surgery may result in chorioamnionitis before surgical intervention and impair wound healing. An elevated temperature of at least 39℃ (102.2℉) or between 38℃ (100.4℉) and 39℃ (102.2℉)  within 30 minutes and one of the clinical symptoms are signs of clinical chorioamnionitis. Chorioamnionitis presents as a febrile illness associated with an elevated WBC count, uterine tenderness, abdominal pain, foul-smelling vaginal discharge, and fetal and maternal tachycardia (Fowler & Simon, 2021).

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3. Assess fetal heart rates regularly.
Fetal tachycardia (rate >160 beats per minute) may be the first sign of infection. Poor fetal oxygenation may also occur, especially with abnormal labor (Leifer, 2018). In the presence of fetoplacental infection or inflammation, the production of cytokines and other inflammatory mediators leads to an increase of the FHR baseline secondary to a dysregulation of the thermoregulatory center and the increased metabolic rate (Ghi et al., 2020). 

4. Assess amniotic fluid drainage for color, clarity, and odor.
Cloudy, yellow, or foul-smelling amniotic fluid suggests infection, and meconium (green) staining suggests fetal compromise but is also seen with prolonged pregnancy.

5. Observe for localized signs of infection at the surgical incision site.
Surgical site infection (SSI) occurs in up to 11% of women after cesarean birth and is manifested as wound infection, endometritis, or urinary tract infection. The Centers for Disease Control and Prevention (CDC) defined SSI as an infection occurring 30 days after the operative procedure. However, they may appear after discharge and are managed, outpatient. The skin and subcutaneous tissue may have purulent drainage, a positive culture, complaints of pain or tenderness, or evidence of swelling, redness, or heat (Burke & Allen, 2020).

Nursing Interventions and Rationales

1. Provide perineal care per protocol, particularly once membranes have ruptured.
Decreases risk of ascending infection. Assist the client in maintaining good perineal hygiene by wiping from front to back. Good hygiene reduces the possibility of introducing bacteria into the birth canal. Vaginal cleansing with a 10% solution of povidone-iodine swab stick for 30 seconds should be considered for women in labor, especially those with ruptured membranes (Burke & Allen, 2020).

2. Strictly adhere to preoperative skin preparation; scrub according to protocol.
Decreases risk of skin contaminants entering the operative site, reducing the risk of preoperative infection. High-quality studies found that betadine and chlorhexidine as skin antisepsis preparation are sufficient and optimal when the solution is allowed to dry, per the manufacturer’s instructions (Burke & Allen, 2020).

3. Record hemoglobin and hematocrit and estimated blood loss during the surgical procedure.
The risk of post-delivery infection and poor healing increases if hemoglobin levels are low and blood loss is excessive. Compared with vaginal birth, women having a cesarean birth, especially a repeat cesarean, incur the highest risk for postpartum hemorrhage (PPH) (Burke & Allen, 2020). Excessive blood loss reduces immunity and leads to a lowering of hemoglobin concentration, which increases the risk of infection by negatively affecting macrophage activity and impeding wound healing (Abdelraheim et al., 2019). Greater blood loss is associated with classic incision than lower uterine segment incision.

4. Stress proper handwashing techniques by all caregivers between therapies/clients. 
Hand hygiene is the single most effective way to prevent infections. The World Health Organization (WHO) and the CDC recommend hand hygiene as the first, simplest, and most cost-effective technique for infection control. Healthcare providers, clients, and their family members in the healthcare setting need to closely adhere to hand hygiene guidelines to prevent and minimize nosocomial infections (Damanabad et al., 2021).

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5. Maintain sterile techniques for invasive procedures. 
Using a sterile technique on invasive procedures (e.g., IV start, urinary catheterization, etc.) reduces the microbial count and creates a sterile field that helps prevent infections. Breaks in the technique can lead to infections in the client, leading to higher healthcare costs and severe complications (Tennant & Rivers, 2021).

6. Encourage early ambulation after cesarean birth.
Early mobilization is often part of a surgical bundle “fast track” or “enhanced recovery after surgery” (ERAS). It is recommended to improve many short-term outcomes after surgery, including a rapid return of bowel function and decreased length of hospital stay, thereby reducing the risk for infection (Macones et al., 2019).

7. Instruct client and family about techniques to protect the skin’s integrity and prevent the spread of infection.
Surgical site infections occur in approximately 10% of clients, >80% of which develop after discharge, which indicates a need for the client and their family to be provided with comprehensive information on the normal discharge course, signs and symptoms of infection, activity restrictions, and instructions on when to seek medical attention (Macones et al., 2019). Symptoms to watch out for that may indicate SSI are fever, pain, tenderness, purulent drainage of abscess on the incision site, and evidence of swelling, redness, or heat (Burke & Allen, 2020).

8. Emphasize the necessity of taking antibiotics as directed and using “leftover” drugs.
Premature discontinuation of treatment when the client feels well may yield reinfection and antibiotic resistance. The major contributors to resistance development include clinical misuse, self-medication, ease of availability of antibiotics, and poor hospital-based antibiotic use regulation in both developing and developed countries (Chokshi et al., 2019).

9. Administer parenteral, intravenous antibiotics within 60 minutes before cesarean birth skin incision, as indicated.
A prophylactic antibiotic may be requested to prevent the development of an infectious process or as a treatment for an identified infection, especially if the client has had prolonged rupture of membranes. In all women, a first-generation cephalosporin is recommended; in women in labor or with ruptured membranes, the addition of azithromycin confers an additional reduction in postoperative infections (Caughey et al., 2018).

10. Obtain blood, vaginal, and placental cultures, as indicated.
Evaluate the results of blood and wound cultures before the initiation of antibiotics to help determine the infecting organisms and degree of involvement. Laboratory findings typical of infection include leukocytosis with neutrophilia, a left shift, and lactic acidosis. However, no postpartum infection can be excluded based on lab work alone (Boushra & Rahman, 2021).

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Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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See also

Other recommended site resources for this nursing care plan:

Other care plans related to the care of the pregnant mother and her infant:

References and Sources

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With contributions by Marianne Belleza RN.

Gil Wayne graduated in 2008 with a bachelor of science in nursing. He earned his license to practice as a registered nurse during the same year. His drive for educating people stemmed from working as a community health nurse. He conducted first aid training and health seminars and workshops for teachers, community members, and local groups. Wanting to reach a bigger audience in teaching, he is now a writer and contributor for Nurseslabs since 2012 while working part-time as a nurse instructor. His goal is to expand his horizon in nursing-related topics. He wants to guide the next generation of nurses to achieve their goals and empower the nursing profession.
  • This one is valuable for nurse-midwifery trainees. It’s good for to us make an advanced care plan and easy to work in the OB ward.

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