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 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.

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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).

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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).

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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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