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.
- Deficient Knowledge UPDATED!
- Acute Pain UPDATED!
- Risk for Infection UPDATED!
- Risk for Deficient Fluid Volume UPDATED!
- Risk for Disturbed Maternal-Fetal Dyad UPDATED!
- Risk for Injury UPDATED!
- Anxiety or Fear UPDATED!
- Risk for Situational Low Self-Esteem UPDATED!
- Powerlessness UPDATED!
- Risk for Ineffective Self Health Management UPDATED!
- Risk for Impaired Parenting UPDATED!
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).
- 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).
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).
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.
Recommended nursing diagnosis and nursing care plan books and resources.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
- NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
- Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
- Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
- Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
- All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other care plans related to the care of the pregnant mother and her infant:
- Abruptio Placenta | 3 Care Plan
- Cesarean Birth | 10 Care Plans UPDATED!
- Cleft Palate and Cleft Lip | 6 Care Plans
- Dysfunctional Labor (Dystocia) | 4 Care Plans
- Elective Termination | 6 Care Plans
- Gestational Diabetes Mellitus | 8 Care Plans UPDATED!
- Hyperbilirubinemia | 4 Care Plans
- Labor Stages, Induced and Augmented Labor | 36 Care Plans UPDATED!
- Neonatal Sepsis | 5 Care Plans
- Perinatal Loss | 5 Care Plans
- Placenta Previa | 3 Care Plans
- Postpartum Hemorrhage | 8 Care Plans UPDATED!
- Postpartum Thrombophlebitis | 5 Care Plans UPDATED!
- Prenatal Hemorrhage | 9 Care Plans UPDATED!
- Prenatal Substance Dependence/Abuse | 6 Care Plans
- Precipitous Labor | 3 Care Plans
- Preeclampsia and Gestational Hypertension | 6 Care Plans UPDATED!
- Premature Dilation of the Cervix | 3 Care Plans
- Prenatal Infection | 3 Care Plans
- Preterm Labor | 7 Care Plans UPDATED!
- Puerperal Infection | 4 Care Plans
- Cultural Birthing Practices and Experiences. An eBook that details the different cultural and ethnic practices during childbirth in Australia. A great resource if you want to expand your knowledge about these practices.
- Intrapartum Care for a Positive Childbirth Experience. A resource by the WHO that details what they recommend and what they don’t during intrapartum care. Check out the executive summary!
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With contributions by Marianne Belleza RN.