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 Deficient Fluid Volume

bleeding-doubles-for-the-postpartum-client-because-she-may-not-only-hemorrhage-vaginally-from-a-noncontracted-uterus-but-also-internally-from-blood-vessels-not-yet-securely-closed”>Cesarean birth always poses a risk for deficient fluid volume from surgery due to blood loss until all blood vessels that were cut and ligated during surgery have thrombosed, sclerosed, and permanently sealed close. The risk of heavy bleeding doubles for the postpartum client because she may not only hemorrhage vaginally from a noncontracted uterus but also internally from blood vessels not yet securely closed.

Nursing Diagnosis

  • Risk for Deficient Fluid Volume

Risk factors may include

  • Excessive blood loss during surgery
  • Nausea and vomiting
  • Loss of vascular integrity
  • Postsurgical fluid restriction

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 remains normotensive, with fewer than 800 ml blood loss.
  • The client displays stable vital signs, good quality, palpable pulses, normal skin turgor, moist mucous membranes, and appropriate urine output.
  • The client has scant to no bleeding on the surgical dressing.
  • The client’s urine-specific gravity remains between 1.003 and 1.030.
  • The client’s weight loss is not more than 5 to 10 lbs (11 to 22 kgs).

Nursing Assessment and Rationales

1. Assess the client’s intake and output and document for at least 24 hours.
Keep an accurate intake and output record of the client to ensure an adequate fluid balance has been achieved. A full uterus can obstruct a full bladder and fetal head; therefore, encourage voiding every two (2) hours if possible or catheterize if the bladder is distended and the client cannot void.

2. Assess the client’s respirations, BP, and pulse before, during, and after surgery.
To detect the earliest signs of bleeding, monitor blood pressure, pulse, and respiratory rate approximately every 15 minutes for the first hour after surgery, every 30 minutes for the next 2 hours, every hour for the next 4 hours, or as specifically prescribed. A minimal but continued change in vital signs is as ominous a sign of hemorrhage as is a sudden alteration in these measurements.

3. Assess for signs indicative of possible hemorrhage.
Observe for signs of hemorrhage, which include falling blood pressure (more than 20 mmHg systolic), systolic blood pressure less than 80 mmHg, or a drop of 5 to 10 mmHg over several readings; a change in pulse rate greater than 110 beats/minute or less than 60 beats/minute; respirations more rapid and stressed from previous readings; and restlessness and a sense of thirst. Notify the healthcare provider of any changes in vital signs that may indicate hemorrhage.

4. Assess the client’s dressing on the incision site and check for excessive vaginal discharges.
Inspect the dressing over the client’s surgical incision for blood staining each time vital signs are assessed to document no incisional bleeding. Observe the perineal pad for lochia flow and palpate fundal height each time to document uterine contraction. Blood oozing vaginally or from a surgical wound can pool considerably under the client before being otherwise visible.

5. Assess the client’s fundal height and abdomen regularly.
A client who has had spinal or epidural anesthesia will not experience pain on uterine palpation until the anesthesia has worn off. Therefore, uterine palpation should not increase her pain. Palpate gently enough once the anesthesia has worn off to not cause increased pain but thoroughly enough to determine uterine consistency. Assess the remainder of the abdomen for softness. A hard, “guarded” abdomen is one of the first signs of peritonitis.

6. Note the shift in behavior or mental status and cyanosis of mucous membranes.
Oxygen deficits are manifested first by changes in mental status, later by cyanosis. The presentation may include altered cognitive and neuromuscular function in clients with severe fluid volume depletion. Altered mentation can be both a cause and a consequence of volume depletion (Asim et al., 2019).

Nursing Interventions and Rationales

1. Remove nail polish on fingernails and toes.
Removal of nail polish allows the nurse to visualize the nail beds for assessing circulatory status. During the capillary refill test, pressure is applied on the nail bed until it turns white. Then, the pressure is released, and the amount of time it takes for the blood to return is measured. 

2. Place a towel or wedge under the client’s hip.
Placing a towel wedge shifts the uterus off of the inferior vena cava and increases venous return. Compression caused by obstruction of the inferior vena cava and aorta by the gravid uterus in a supine position may cause as much as a 50% decrease in cardiac output (Kim & Wang, 2015).

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3. Encourage the client to increase fluid intake, as indicated.
Introduce oral fluid slowly (e.g., ice chips for the first hour, then sips of clear liquid such as ginger ale, Jell-O, tea, or flavored ice). Teach the client to continue to drink large quantities of fluid after they return home (at least 6 glasses daily) so they have adequate body fluid to make breastfeeding successful.

4. Administer supplemental oxygen via a mask, as indicated.
Oxygen administration increases the oxygen available for maternal and fetal uptake. Maintaining adequate uterine perfusion can optimize fetal oxygenation, prevent acidosis, deliver nutrients, and eliminate waste products from the uterine myometrium (Caughey et al., 2018). 

5. Administer IV fluids with or without oxytocin, as indicated.
It is important to infuse IV fluids during cesarean birth at a monitored rate. Rapid infusion can lead to cardiac overload, while slow infusion can lead to inadequate circulatory compensation. Oxytocin may be added, as prescribed, to the first one or two liters of IV fluid after surgery to ensure firm uterine contraction. Oxytocin aids myometrium contraction and reduces blood loss from exposed endometrial blood vessels. Be aware that the client is prone to hemorrhage when the oxytocin is discontinued. This is the first time her uterus is asked to maintain contraction on its own, so monitor the client’s vital signs carefully.

6. Administer blood and blood products as indicated.
A strong recommendation on blood transfusion in postpartum hemorrhage is that the client receives RBCs as soon as possible in case of massive hemorrhage. Additionally, the early treatment of coagulopathy with fresh frozen plasma (FFP) and platelets determines maternal morbidity and mortality. Fibrinogen plasma level has been a good predictor of hemorrhage severity because it plays a critical role in maintaining and achieving hemostasis. Fibrinogen concentrates offer rapid restoration of the fibrinogen concentration with a small-volume infusion with minimal preparation time (Bonnet & Benhamou, 2016). 

7. Administer tranexamic acid as prophylaxis, as prescribed.
Studies show that prophylactic use of tranexamic acid at cesarean birth had a biologic effect, in that calculated estimated blood loss was significantly lower among clients who received the drug than those who received placebo. Tranexamic acid has fibrinolytic effects that are achieved at least in part by promoting hemostasis, and it also reduces bleeding-related mortality among clients with postpartum hemorrhage. The survival benefit associated with the earlier administration of the drug suggests that it may prevent coagulopathy after delivery rather than treat it (Sentilhes et al., 2021).

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Recommended 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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