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 Disturbed Maternal-Fetal Dyad 

Cesarean birth places a fetus at a greater risk than vaginal birth. Respiratory depression is the main neonatal risk because drugs given to the mother may cross the placenta. Factors that may affect the maternal-fetal dyad include preeclampsia and compromised oxygen transport to the child, which are indications for cesarean birth. Pregnancy complications can cause maternal and fetal losses, resulting in the risk for disturbed maternal-fetal dyad (Gomes et al., 2020).

Nursing Diagnosis

  • Risk for Disturbed Maternal-Fetal Dyad

Risk factors may include

  • Altered blood flow to the placenta or through the umbilical cord

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 displays optimal FHR.
  • The client manifests normal variability on the monitor strip.
  • The client reduces the frequency of late or prolonged variable decelerations.

Nursing Assessment and Rationales

1. Note the presence of maternal factors that negatively affect placental circulation and fetal oxygenation.
Decreased circulating volume or vasospasms within the placenta decrease oxygen available for fetal uptake. Vasospasm in gestational hypertension impedes blood flow to the mother’s organs and placenta, reducing maternal blood flow and nutrition flow and decreasing available oxygen to the fetus.

2. Document fetal heart rate (FHR), note any changes or decelerations during and following contractions.
Owing to hypoxia, fetal distress may transpire; may be displayed by reduced variability, late decelerations, and tachycardia followed by bradycardia. Late decelerations suggest that the placenta is not delivering enough oxygen to the fetus. Infection from prolonged rupture of membranes also increases FHR (Ghi et al., 2020).

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3. Examine color and amount of amniotic fluid when membranes rupture.
Fetal distress in vertex presentation is manifested by meconium staining, resulting from a vagal response to hypoxia. Meconium staining is a common complication during labor and is a common cause for cesarean birth as shown by 5% to 25% of meconium-stained amniotic fluid cesarean deliveries (Hasan et al., 2021; Fernandez et al., 2018).

Nursing Interventions and Rationales

1. Document the presence of variable decelerations; change client’s position from side to side.
Variable decelerations suggest that there is inadequate amniotic fluid to cushion the cord or it is being compressed. Compression of the cord between the birth canal and presenting part may be relieved by position changes. The woman should be turned to her left side to relieve pressure on the umbilical cord and improve blood flow through it.

2. Auscultate FHR when membranes rupture.
In the absence of full cervical dilation, occult or visible prolapse of the umbilical cord may necessitate cesarean birth. Rates outside the normal range of 110 to 160 beats/minute for a term fetus suggest a prolapsed umbilical cord after an amniotomy was performed.

3. Monitor fetal heart response to preoperative medications or regional anesthesia.
Following delivery, narcotics normally reduce FHR variability and necessitate naloxone (Narcan) administration to reverse narcotic-induced respiratory depression. Maternal hypotension results from local anesthetic blockade of the sympathetic nervous system leading to vasodilation. Because uterine blood flow is not autoregulated, a decrease in maternal blood pressure decreases uteroplacental perfusion. Fetal bradycardia occurs within 15 to 45 minutes after initiation of both epidural and combined spinal-epidural (CSE) anesthesia (Galante, 2010).  

4. Apply internal lead, and monitor fetus electronically as indicated.
Gives more precise measurements of fetal response and condition. Continuous electronic fetal monitoring (EFM) allows the nurse to collect more data about the fetus, which is why it is used commonly in most hospitals. FHR and uterine contraction patterns are continuously recorded.

5. Administer supplemental oxygen to mother via mask.
Maximizes oxygen available for placental uptake. Administer 10L/min for 30 minutes to increase fetal oxygenation. Oxygen administration has also been used prophylactically in the second stage of labor on the assumption that this is a time of high risk for fetal distress (Fawole & Hofmeyr, 2012).

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6. Administer IV fluid bolus before initiation of epidural or spinal anesthesia.
Optimizes uteroplacental perfusion helps prevent a hypotensive response. Administer saline solution to improve cardiac output, circulatory volume, and uteroplacental perfusion. However, the nurse should observe for fluid volume overload and pulmonary edema.

7. Implement amniotransfusion, as indicated.
Amniotransfusion involves instilling a saline infusion by catheter into the uterine cavity to restore amniotic fluid volume to relieve umbilical cord compression that can interrupt fetal oxygenation.

8. Assist the healthcare provider with the elevation of the vertex, if required.
Position changes may reduce pressure on the cord. Manual elevation of the fetal presenting part using two fingers or the whole hand through the vagina can be done, as well as positioning the client into a steep Trendelenburg position, exaggerated Sim’s position or knee-chest position to relieve cord compression until cesarean birth is performed (Ahmed & Hamdy, 2018).

9. Implement measures to reduce uterine activity, as prescribed.
Excess uterine activity (tachysystole) is more than five contractions in 10 minutes, averaged over 30 minutes (the normal is five contractions or fewer in 10 minutes). Discontinuing oxytocin or administering tocolytics that decrease the healthcare provider may prescribe uterine activity.

10. Administer tocolytic drugs as prescribed by the healthcare provider.
Tocolytics had been used to decrease the uterine contractions, relieve the pressure in the case of a prolapsed umbilical cord, and improve the placental perfusion and hence the blood supply to the fetus. However, the nurse should monitor uterine atony postpartum because tocolytics can cause uterine atony (Ahmed & Hamdy, 2018).

11. Plan the presence of a pediatrician and neonatal intensive care nurse in the delivery room for both scheduled and emergency cesarean births.
Due to underlying maternal conditions and alternative birth, the neonate may be preterm or experience altered responses, necessitating immediate care or resuscitation.

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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

  1. Abdelraheim, A. R., Gomaa, K., Ibrahim, E. M., Mohammed, M. M., Khalifa, E. M., Youssef, A. M., Abdelhakeem, A. K., Hassan, H., Alghany, A. A., & Gelany, S. E. (2019, July 8). Intra-abdominal infection (IAI) following cesarean section: a retrospective study in a tertiary referral hospital in Egypt. BMC Pregnancy and Childbirth, 19(234). https://doi.org/10.1186/s12884-019-2394-4
  2. Ahmadi, Z. (2020, 03 20). Identifying and explaining experiences of fear of childbirth and coping strategies: A qualitative study. Journal of Qualitative Research in Health Sciences, 9(1), 47-58. 10.22062/JQR.2020.90993
  3. Ahmed, W. A. S., & Hamdy, M. A. (2018, August 21). Optimal management of umbilical cord prolapse. International Journal of Women’s Health, 10, 459-465. 10.2147/IJWH.S130879
  4. Akalpler, O., & Okumus, H. (2018, Sept-Oct). Gum chewing and bowel function after Caesarean section under spinal anesthesia. Pakistan Journal of Medical Sciences, 34(5), 1242-1247. 10.12669/pjms.345.15772
  5. Asim, M., Alkadi, M. M., Asim, H., & Ghaffar, A. (2019, January 21). Dehydration and volume depletion: How to handle the misconceptions. World Journal of Nephrology, 8(1), 23-32. 10.5527/wjn.v8.i1.23
  6. Bonnet, M. P., & Benhamou, D. (2016, June 27). Management of postpartum haemorrhage. NCBI. Retrieved January 12, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4926727/
  7. Boushra, M., & Rahman, O. (2021, July 15). Postpartum Infection – StatPearls. NCBI. Retrieved January 9, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK560804/
  8. Bryanton, J., Beck, C. T., & Morrison, S. (2021, April 22). When Fear Surrounding Childbirth Leads Women to Request a Planned Cesarean Birth. Western Journal of Nursing Research. 10.1177/01939459211010192
  9. Burke, C., & Allen, R. (2020, March/April). Complications of Cesarean Birth Clinical Recommendations for Prevention and Management. The American Journal of Maternal/Child Nursing, 45(2), 92-99. 10.1097/NMC.0000000000000598
  10. Carvalho, B., & Habib, A.S. (2019). Personalized analgesic management for cesarean delivery. International Journal of Obstetric Anesthesia, 40, 91-100. https://doi.org/10.1016/j.ijoa.2019.02.124
  11. Caughey, A. B., Wood, S. L., Macones, G. A., Wrench, I. J., Huang, J., Norman, M., Pettersson, K., Fawcett, W. J., Shalabi, M. M., Metcalfe, A., Gramlich, L., Nelson, G., & Wilson, D. (2018, December). Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery After Surgery Society Recommendations (Part 2). American Journal of Obstetrics and Gynecology, 219(6), 533-544. https://doi.org/10.1016/j.ajog.2018.08.006
  12. Chen, H., & Tan, D. (2019, February 21). Cesarean Section or Natural Childbirth? Cesarean Birth May Damage Your Health. frontiers in Psychology, 10(351). https://doi.org/10.3389/fpsyg.2019.00351
  13. Chokshi, A., Sifri, Z., Cennimo, D., & Horng, H. (2019, Jan-Mar). Global Contributors to Antibiotic Resistance. Journal of Global Infectious Diseases, 11(1), 36-42. 10.4103/jgid.jgid_110_18
  14. Chung, F.-F., Wan, G.-H., Kuo, S.-C., Lin, K.-C., & Liu, H.-E. (2018, September 6). Mother-infant interaction quality and sense of parenting competence at six months postpartum for first-time mothers in Taiwan: a multiple time-series design. BMC Pregnancy and Childbirth, 18(365). https://doi.org/10.1186/s12884-018-1979-7
  15. Cripe, E. T. (2017, March 29). “The Scarlet C”: Exploring Caesarean Section Stigma. Health Communication, 33(6), 782-785. 10.1080/10410236.2017.1298953 
  16. Damanabad, Z. H., Valizadeh, L., Hosseini, M., Abdolalipour, M., & Jafarabadi, M. A. (2021, July 23). Comparing the Effects of Face‑to‑Face and Video‑Based Educations on Hand Hygiene Knowledge and Performance among Mothers in Neonatal Intensive Care Unit: A Randomized Controlled Trial. Nursing and Midwifery Studies, 10(3), 158-164. 10.4103/NMS.nms_18_20
  17. Fawole, B., & Hofmeyr, G. (2012, December 12). Maternal oxygen administration for fetal distress. Cochrane Database of Systematic Reviews, (12). 10.1002/14651858.CD000136.pub2
  18. Fernández, V. R., y Cajal, C. N. L. R., Ortiz, E. M., & Naveira, E. C. (2018). Intrapartum and perinatal results associated with different degrees of staining of meconium-stained amniotic fluid. European Journal of Obstetrics & Gynecology and Reproductive Biology, 228, 65-70.
  19. Fowler, J. R., & Simon, L. V. (2021, September 8). Chorioamnionitis – StatPearls. NCBI. Retrieved January 9, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK532251/
  20. Galante, D. (2010, March 10). Considerations on labor analgesia and drug complications. British Journal of Anaesthesia, 105(eLetters Supplement). https://doi.org/10.1093/bja/el_5617
  21. Ghi, T., Pasquo, E. D., Dall’Asta, A., Commare, A., Melandri, E., Casciaro, A., Fieni, S., & Frusca, T. (2020, October 13). Intrapartum fetal heart rate between 150 and 160 bpm at or after 40 weeks and labor outcome. Acta Obstetricia et Gynecologica Scandinavica, 100(3), 548=554. https://doi.org/10.1111/aogs.14024
  22. Gibbs, B. G., Forste, R., & Lybbert, E. (2018, January 31). Breastfeeding, Parenting, and Infant Attachment Behaviors. Maternal and Child Health Journal, 22, 579-588. https://doi.org/10.1007/s10995-018-2427-z
  23. Grant, E. K., Gattamorta, K. A., & Foronda, C. L. (2020, March 21). Reducing the risk of unintended retained surgical sponges: A quality improvement project. Perioperative Care and Operating Room Management, 21. https://doi.org/10.1016/j.pcorm.2020.100099
  24. Hasan, F., Ahmed, N., Jamil, R., Ali, L., & Khan, F. A. (2021, 06 30). Frequency and Indications of Primary Cesarean Section. Journal of Surgery Pakistan, 26(1). 10.21699/jsp.26.1.2.
  25. Ilska, M., Banas, E., Gregor, K., Salmeri, A. B., Ilski, A., & Cnota, W. (2020, August). Vaginal delivery or cesarean section – Severity of early symptoms of postpartum depression and assessment of pain in Polish women in the early puerperium. Midwifery, 87. https://doi.org/10.1016/j.midw.2020.102731
  26. Kim, D. R., & Wang, E. (2015, August 15). Prevention of supine hypotensive syndrome in pregnant women treated with transcranial magnetic stimulation. Psychiatry Research, 218, 1-2. 10.1016/j.psychres.2014.04.001
  27. Kjerulff, K. H., & Brubaker, L. H. (2017, October 20). New mothers’ feelings of disappointment and failure after cesarean delivery. Birth, 45(1), 19-27. https://doi.org/10.1111/birt.12315
  28. Kruse, A. R., Lauszus, F. F., Forman, A., Kesmodel, U. S., Rugaard, M. B., Knudsen, R. K., Persson, E.-K., Uldbjerg, N., & Sundtoft, I. B. (2020, November 11). Effect of early discharge after planned cesarean section on recovery and parental sense of security. A randomized clinical trial. Acta Obstetricia et Gynecologica Scandinavica, 100(5), 955-963. https://doi.org/10.1111/aogs.14041
  29. Labor, S., & Maguire, S. (2008, December). The Pain of Labour. Reviews in Pain, 2(2), 15-19. 10.1177/204946370800200205
  30. Leifer, G. (2018). Introduction to Maternity and Pediatric Nursing (8th ed.). Elsevier.
  31. Li, L., Wen, J., Li, Y., & Li, Y. (2010, December 23). Is routine indwelling catheterization of the bladder for cesarean section necessary? A systematic review. BJOG: An /International Journal of Obstetrics and Gynecology, 118(4), 400-409. https://doi.org/10.1111/j.1471-0528.2010.02802.x
  32. Macones, G. A., Caughey, A. B., Wood, S. L., Wrench, I. J., Huang, J., Norman, M., Pettersson, K., Fawcett, W. J., Shalabi, M. M., Metcalfe, A., Gramlich, L., Nelson, G., & Wilson, D. (2019, September). Guidelines for postoperative care in cesarean delivery: Enhanced Recovery After Surgery (ERAS) Society recommendations (part 3). American Journal of Obstetrics and Gynecology, 221(3), 247. https://doi.org/10.1016/j.ajog.2019.04.012
  33. Miovech, S. M., Knapp, H., Borucki, L., Roncoli, M., Arnold, L., & Dorothy Brooten. (n.d.). Major Concerns of Women After Cesarean Delivery. NCBI. Retrieved January 14, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3694506/
  34. Mostafayi, M., Imani, B., Zandi, S., & Jongi, F. (2021, June). The effect of familiarization with preoperative care on anxiety and vital signs in the patient’s cesarean section: A randomized controlled trial. European Journal of Midwifery, 5, 1-7. https://doi.org/10.18332/ejm/137366
  35. Nanthiphatthanachai, A., & Insin, P. (2020). Effect of chewing gum on gastrointestinal function recovery after surgery of gynecological cancer patients at Rajavithi Hospital: a randomized controlled trial. Asian Pacific journal of cancer prevention: APJCP, 21(3), 761.
  36. Pillitteri, A., & Silbert-Flagg, J. (2018). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family (8th ed.). Wolters Kluwer.
  37. Puia, D. (2018, Winter). First-Time Mothers’ Experiences of a Planned Cesarean Birth. The Journal of Perinatal Education, 27(1), 50-60. 10.1891/1058-1243.27.1.50 
  38. Rookesh, Z., Kaviani, M., Zarshenas, M., & Akbarzadeh, M. (2021, October 22). Comparison of Maternal-Infant Attachment in Cesarean Delivery Based on Robson Classification: A Cross-Sectional Study. Iranian Journal of Nursing and Midwifery Research, 26(6), 500-507. 10.4103/ijnmr.IJNMR_230_19
  39. Salam Ramadan, S. A. E., & Farrag, R. E. (2018, October). UTILIZATION OF SELF CARE GUIDELINE TO PROMOTE QUALITY OF LIFE AMONG WOMEN UNDERGOING CESAREAN SECTION. The Malaysian Journal of Nursing, 10(2). :10.31674/mjn.2018.v10i02.007
  40. Sentilhes, L., Senat, M. V., Le Lous, M., Winer, N., Rozenberg, P., Kayem, G., Verspyck, E., Fuchs, F., Azria, E., Gallot, D., Korb, D., & Desbriere, R. (2021, April 29). Tranexamic Acid for the Prevention of Blood Loss after Cesarean Delivery. The New England Journal of Medicine, 384(17). 10.1056/NEJMoa2028788
  41. Shen, D., Moriyama, M. H., Ishida, K., Fuseya, S., Tanaka, S., & Kawamata, M. (2020, May 12). Acute postoperative pain is correlated with the early onset of postpartum depression after cesarean section: a retrospective cohort study. Journal of Anesthesia, 34, 607-612. https://doi.org/10.1007/s00540-020-02789-5
  42. Solehati, T., & Rustina, Y. (2015, June 22). Benson Relaxation Technique in Reducing Pain Intensity in Women After Cesarean Section. Anesthesiology and Pain Medicine, 5(3). 10.5812/aapm.22236v2
  43. Tennant, K., & Rivers, C. L. (2021, September 21). Sterile Technique – StatPearls. NCBI. Retrieved January 9, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK459175/
  44. Vafaeenejad, Z., Elyasi, F., Moosazadeh, M., & Shahhosseini, Z. (2019, April 9). Psychological factors contributing to parenting styles: A systematic review. F1000Research, 7(906). https://doi.org/10.12688/f1000research.14978.2
  45. Wilson, R. D., Caughey, A. B., Wood, S. L., Macones, G. A., Wrench, I. J., Huang, J., Norman, M., Pettersson, K., Fawcett, W. J., Shalabi, M. M., Metcalfe, A., Gramlich, L., & Nelson, G. (2018, December). Guidelines for Antenatal and Preoperative care in Cesarean Delivery: Enhanced Recovery After Surgery (ERAS) Society Recommendations (Part 1). American Journal of Obstetrics and Gynecology, 219(6), 523.e1-523.e15. https://doi.org/10.1016/j.ajog.2018.09.015

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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