11 Cesarean Birth Nursing Care Plans


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!

Risk for Injury

Cesarean birth is a major surgery that involves greater risks than vaginal birth. The risk for injury during cesarean birth involves a decrease in the functioning of the bowel, injury to the bladder, trauma to the tissues caused by surgery, and the effects of the anesthesia on the client. As a major abdominal surgery, cesarean birth is frequently followed by a reduction in bowel functions as an effect of the anesthesia administered. Additionally, the bladder can be injured during the surgical procedure as the incision could be extended towards it. Therefore, the nurse must identify the possible risk factors predisposing the client to these injuries to implement preventive measures.

Nursing Diagnosis

  • Risk for Injury (Maternal)

Risk factors may include

  • Decreased bladder sensation
  • Delayed gastric motility
  • Effects of medication
  • Tissue trauma

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 mother is free of injury.

Nursing Assessment and Rationales

1. Assess and record the time of first bowel sounds auscultated after the surgery. 
During surgery, the intestine can feel pressure, resulting in a paralytic ileus or halting of intestinal function with obstruction. Late-onset of bowel movements after cesarean birth with spinal anesthesia can cause discomfort to the mother and prolonged hospital stay (Akalpler & Okumus, 2018). 

2. Assess the client’s voiding pattern, including frequency, output, appearance, and time of the first postoperative output.
An indwelling catheter will be inserted during cesarean delivery to reduce bladder injury and increase time to first voiding, leading to early catheter removal and reducing incidences of urinary tract infection (Macones et al., 2019). Additionally, after removing the catheter, the woman should void in 4 to 8 more hours. Assess for bladder refilling by palpation to determine urinary retention, which can be potentially dangerous because a full bladder may inhibit the uterus from contracting, increasing the risk for postpartum hemorrhage. 

3. Assess the surgical incision every 8 hours for every nursing shift.
Surgical incisions heal by primary intention. The nurse should routinely assess the surgical incision to ensure that the wound edges are approximated, and there are no signs of infection such as erythema or purulent discharges.


4. Assess the client’s vital signs, especially the respiratory rate, every 15 minutes for the first 1 to 2 hours and then every 30 minutes for 1 hour according to hospital policy.
The nurse should closely monitor the client for depressed respiratory function, especially if general anesthesia has been administered. There is a greater potential for postoperative sedation with general anesthesia than regional anesthesia (Caughey et al., 2018).

5. Assess the client’s lower extremity reflexes to return sensation to the lower limbs. 
The administration of spinal or epidural anesthesia during cesarean birth produces numbness to the lower extremities that should disappear after a few hours. To assess for return of sensation, the nurse may elicit the knee-jerk reflex or the Achilles reflex by striking the plantar surface of the foot with a reflex hammer while creating a 90-degree angle.

Nursing Interventions and Rationales

1. Remove prosthetic devices before surgery.
Before surgery, follow hospital protocols regarding removing jewelry, contact lenses, piercings, hair ornaments, acrylic nails, or nail polish. These accessories can become accidentally dislodged or damaged during surgery. Nail polish should be removed to allow healthcare providers to assess for a capillary refill during the procedure.

2. Monitor urine output following insertion of an indwelling catheter.
An indwelling catheter reduces bladder size and keeps the bladder away from the surgical field. Catheterization may prevent bladder injury and postoperative urinary retention. A distended bladder is also expected to interfere with exposure and complicate surgery (Li et al., 2010). Additionally, the physiologic stress of surgery or lack of blood flow to the kidneys due to decreased blood pressure can cause kidney failure. All reproductive tract surgery also puts the ureter flow at risk because the edema that collects in the surgical area can press on the ureters.

3. Obtain the urine specimen for routine analysis, protein, and specific gravity. Ensure that laboratory results are available before surgery is started.
Preoperative assessment procedures for the client may include circulatory and renal function tests, complete blood count, coagulation profile, serum electrolytes, and blood typing and crossmatching. Keep in mind that blood values need to be evaluated in light of the changes in pregnancy.

4. Ensure early, if not immediate, removal of indwelling catheter after cesarean birth.
Clients without indwelling catheters had a shorter mean ambulation time and length of hospital stay. Even though the urinary catheter was removed 12 hours after surgery, the incidence of urinary tract infection was still significantly higher. Additionally, there is a higher incidence of discomfort and increased time to first voiding in clients with indwelling catheters, according to a Cochrane review (Macones et al., 2019).

5. Encourage enhanced recovery after surgery (ERAS) sham feeding (chewing gum) as appropriate after cesarean birth.
Problems such as constipation, postoperative ileus, and abdominal distention may be seen as an effect of anesthesia after abdominal surgery. Sham postoperative feeding with chewing gum after abdominal surgery appeared to reduce the time to recover gastrointestinal function (Macones et al., 2019). Chewing gum activates the cephalic vagal reflex and stimulates the digestive cephalic phase by imitating eating (Akalpler & Okumus, 2018).


6. Encourage early mobilization after cesarean birth, as indicated.
Early mobilization can improve many short-term outcomes after surgery, including the rapid return of bowel function, reduced risk of thrombosis, and decreased length of stay (Macones et al., 2019).

7. Restrict oral intake up to 6 hours before surgery, as indicated.
The client may be encouraged to drink clear fluids until 2 hours before surgery. A light meal may be eaten up to 6 hours before surgery. The European Society of Anesthesiology Guideline recommended that adults are allowed clear fluid intake 2 hours before elective surgeries (including cesarean births), and solid food is prohibited for 6 hours (Wilson et al., 2018). 

8. Encourage the use of compression stockings as ordered by the healthcare provider.
Pregnant and postpartum women are at an increased risk of venous thromboembolism due to decreased physical mobility after major abdominal surgery. Pneumatic compression stockings may be used to prevent thromboembolic disease in clients who underwent cesarean birth (Macones et al., 2019).

9. Administer ephedrine or phenylephrine and antiemetics to prevent nausea and vomiting, as prescribed.
Nausea and vomiting are common symptoms experienced during a cesarean birth, and that happens during the surgery if the client is awake. Nausea and vomiting can increase the potential risk of aspiration, which is a recognized cause of maternal death. Maternal hypotension from regional anesthesia is a common cause of nausea and vomiting. A Cochrane review study revealed that the use of colloid or crystalloid preloading, intravenous administration of ephedrine or phenylephrine, and lower limb compression reduced the incidence of spinal anesthesia-related hypotension. Antiemetic agents also effectively prevent postoperative nausea and vomiting during cesarean birth (Macones et al., 2019).

10. Administer IV fluids such as lactated Ringer’s solution before surgery.
IV fluids ensure that the client is fully hydrated and will not experience hypotension from epidural anesthesia administration. If possible, start a line at the client’s non-dominant hand using a large-size catheter or needle (18 or 20 gauge), so blood replacement therapy can be administered by the same line if needed. Learn more about IV fluids here

11. Maintain specific instrument and sponge counts at critical times during closure, according to hospital protocol.
Guarantees that all equipment and sponges are accounted for and not accidentally left in the client’s body. Preventing retained surgical items requires using combined evidence-based strategies supported by nursing leaders who value safe, patient-centered care by increasing the staff members’ knowledge with an effective safety-sponge technology system (Grant et al., 2020).

12. Assist with positioning for anesthesia; support legs in postoperative transfer to stretcher. Document the client’s response during and after anesthesia.
The sitting and lateral decubitus positions are usually used for epidural anesthesia. The client with epidural or spinal anesthesia may acquire weakness or decreased sensation of lower extremities. Postdural puncture headache may occur after, which is a common complication associated with epidural and spinal anesthesia (Folino & Mahboobi, 2021).


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:

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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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