Cesarean Birth

Cesarean Birth (C-Section) Nursing Care and Management

There are pregnant women who have complications in their pregnancy and are not allowed to give birth vaginally. Cesarean birth becomes the birth method of choice, which is entirely different from vaginal birth, so from assessment until discharge, healthcare professionals holistically adjust the care plan to accommodate the woman anticipating cesarean birth.

Preoperative Assessment

A nursing assessment of a pregnant woman about to undergo cesarean birth is also important to obtain health history that would become essential later on.

  • Assess the woman about past surgeries, secondary illnesses, allergies to foods or drugs, reaction to anesthesia, and medications that could increase any surgical risk.
  • The woman should be in the best possible physical and psychological state before undergoing any surgery.
  • An obese woman with poor nutritional status is at risk for a slow wound healing.
  • Tissue that contains extra fatty cells would be difficult to suture and the incision will heal much slower and predispose the woman to infection and dehiscence.
  • An obese woman would also have difficulty in initiating ambulation and turning after surgery as it will increase the risk for pneumonia or thrombophlebitis.
  • A woman with protein or vitamin deficiency is also at risk for poorer healing because these are needed for new cell formation at the incision site.
  • Age can also affect surgical risk because it can cause decreased circulatory and renal function.
  • A woman who has secondary illness is also at greater surgical risk depending on the extent of the disease because the secondary illness may affect the woman’s ability to adapt to the demands of the surgery.
  • The general medication history of the woman must also be assessed because there are drugs that could increase the surgical risk by interfering with the effects of anesthesia.
  • A woman with lower than normal blood volume might feel the effects of surgery more than a woman with normal blood volume.
  • An example of this is a woman who began labor and was told later on that she should undergo cesarean birth instead because she may not have had anything to eat or drink for almost 24 hours.
  • To prevent fluid and electrolyte imbalance, intravenous fluid replacement is initiated preoperatively and postoperatively.
  • There are women who are very worried about the procedure, so they need a very detailed explanation of the procedure before they can enter surgery without intense fear.
  • A woman who is frightened is at greater risk for cardiac arrest during anesthesia administration.
  • Acknowledge that the woman’s fear of surgery is normal so that she can view her feelings as expected which could increase her self-esteem.
  • The newborn is also at greater risk than those newborn born through vaginal delivery.
  • Infants born through cesarean delivery develop a degree of respiratory difficulty because when a fetus is pushed through the birth canal, pressure on the chest helps to rid the newborn lungs of fluid.

Preoperative Diagnostic Procedures

Before undergoing surgery, the woman must subject herself to the diagnostic procedures as recommended by her physician.

  • Diagnostic procedures that a woman must undergo before surgery include circulatory and renal function assessments and fetal heart rate.
  • For the circulatory system, diagnostic procedures include complete blood count, and PT and PTT.
  • For the renal function, assessment of urine is necessary.
  • Other diagnostic procedures include vital sign determination, serum electrolyte and pH, blood typing and cross matching, and ultrasound to determine the fetal presentation and maturity.
  • When a woman experiences prolonged labor, she may have an elevated leukocyte count of up to 20, 000/mm3, so this finding would not be a good indicator of infection.

Preoperative Measures

Preoperatively, there are measures that should be taken to ensure the woman’s safety during surgery.

  • The most important responsibility of the surgeon is securing the informed consent from the patient.
  • It is everyone’s responsibility to see to it that the consent is obtained, and witnesses might be asked to witness the woman’s signature.
  • The consent must be informed, and the risks and benefits of the procedure must be explained in a language that the woman understands.
  • Upon admission, the woman is provided with a clean hospital gown and her hair is pulled into a ponytail.
  • The woman’s nails should be free from nail polish or any acrylic fingernails because nails are used to assess capillary refill.
  • To decrease stomach secretions, a gastric emptying agent is used before surgery, because the woman would be lying on her back during surgery which makes esophageal reflux and aspiration highly possible.
  • An indwelling catheter is prescribed before or after the surgery to reduce bladder size and keep the bladder away from the surgical field.
  • Make sure that you have good lighting when inserting a catheter on a pregnant woman to clearly reveal the perineum.
  • The urine should be draining freely, and the drainage bag should be kept below the level of the bladder during transport to prevent backflow and the introduction of microorganisms into the bladder.
  • To ensure that the woman is fully hydrated, an intravenous solution such as Ringer’s can be started as prescribed.
  • Only a minimum of preoperative medications is given to prevent compromising the fetal blood supply and make sure that the newborn is wide awake at birth and respirations are initiated spontaneously.
  • Documentation of nursing care up until the woman leaves the hospital must be complete and factual.
  • Upon transport to surgery, ensure that the woman is lying on her left side to prevent supine hypotension.
  • Ensure that the side rails are up, and the woman is covered with a blanket.
  • A support person may be needed during cesarean birth, and they also need encouragement to watch the birth live.

Intraoperative Measures

  • While anesthesia is being administered, a surgical nurse will assist the woman first to move from the transport stretcher to the operating table.
  • The anesthesia of choice is usually a regional block.
  • Encourage the woman to remain on her side or insert a pillow under her right hip to keep her body slightly tilted to the side to prevent supine hypotension.
  • In emergency cases, a spinal anesthesia is administered while the woman is sitting up.
  • It would be difficult for a woman in labor to remain in a curved position during administration of the anesthetic, so talk to her gently and let her lean on you while you gently restrain her.
  • Epidural anesthesia is administered while the woman is lying on her side, and it has an effect that lasts for 24 hours, so continuous pulse oximetry must be used 24 hours post surgery to detect respiratory depression.
  • For the skin preparation, shaving away abdominal hair and washing the skin over the incision site with soap and water could reduce the bacteria on the skin.
  • The woman is then positioned with a towel under her right hip to move abdominal contents away from the surgical field and lift her uterus away from the vena cava.
  • The woman would be covered by a sterile drape to block the flow of the bacteria from her respiratory tract to the incision site and also block the woman’s and support person’s lines of sight from the incision site.
  • The incision area is scrubbed by an antiseptic, and additional drapes are placed around the area so that only a small area of the skin is exposed.
  • Prepare the woman and the support person for the sights they might see.
  • A classic incision is made vertically through both the abdominal skin and the uterus.
  • A disadvantage of this type of incision is that it leaves a wide skin scar and also runs through the active contractile portion of the uterus.
  • The woman would not be able to have a subsequent vaginal birth because this type of scar could rupture during labor.
  • A low segment incision or low transverse incision is made horizontally across the abdomen just over the symphysis pubis and also horizontally across the uterus just over the cervix.
  • This is the most common type of incision and is also referred to as “bikini” incision.
  • It is less likely that this type of incision would rupture during labor, so it is possible for the woman to have VBAC in the future.
  • It results in less blood loss, easier to suture, decreases puerperal infections and less likely to cause postpartum gastrointestinal complications.
  • The disadvantage of this incision is that it takes longer to perform, making it inappropriate for an emergent cesarean birth.

Postpartal Care

  • The postpartal care period of a woman who has undergone emergent cesarean birth is divided into two: immediate recovery period and extended postpartal period.
  • After surgery, the woman would be transferred by stretcher to the postanesthesia care unit.
  • If spinal anesthesia was used, the woman’s legs are fully anesthetized so she cannot move them.
  • Pain control is a major problem after birth because it was so intense that it interfered with the woman’s ability to move and deep breathe.
  • This may lead to complications such as pneumonia or thrombophlebitis.
  • Use a pain rating scale to allow a woman to rate her pain.
  • Some women may need patient controlled analgesia or continued epidural injections to relieve the pain.
  • Supplement the analgesics with comfort measures such as change in position or straightening of bed linen.
  • Instruct the woman to ambulate because this is the most effective method to relieve gas pain.
  • Inform the woman that she should not take acetylsalicylic acid or aspirin because this can interfere with blood clotting and healing.
  • Instruct the woman to place a pillow on her lap as she feeds the infant to deflect the weight of the infant from the suture line and lessen the pain.
  • Football hold for breast feeding is a way to keep the infant’s weight off the mother’s incision.
  • During the extended postpartal period, the woman most commonly experiences gastrointestinal function interference.
  • Note carefully the woman’s first bowel movement after surgery because if no bowel movement has been observed, the physician may order a stool softener, a suppository, or an enema to facilitate stool evacuation.
  • Teach the woman to eat a diet high in roughage and fluid and to attempt to move her bowels at least every other day to avoid constipation.
  • Incisional pain may interfere with the woman’s ability to use her abdominal muscles effectively, so the physician may prescribe a stool softener.
  • Caution the woman not to strain to pass stools because this puts pressure on their incision.
  • Advice the woman to keep their water pitcher full as a reminder for her to drink fluids.
  • Reassure the woman that it is normal not to have bowel movements for 3 to 4 days postoperatively, especially if there is enema administered before surgery.

Practice Quiz: Cesarean Birth


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Questions


1. What is an important measure to reduce the size of the bladder and keep it away from the surgical field during cesarean birth?

A. Administer an oxytocic to contract the bladder.
B. Restrict fluids in the woman for 4 hours before surgery.
C. Insert a urinary catheter to drain the bladder and decrease its size.
D. Give a diuretic to reduce the bladder to its smallest size.

2. The nurse administers ranitidine (Zantac) as ordered prior to a planned cesarean birth to:

A. Promote uterine contractions.
B. Decrease gastric secretions.
C. Delay uterine contractions.
D. Neutralize urine acidity.

3. The nurse instructs Mrs. Smith on deep breathing exercises as part of the preoperative teaching plan. The rationale for this exercise is to:

A. Stimulate the diaphragm to contract.
B. Promote involution on a traumatized uterus.
C. Prevent stasis of mucus in the lungs.
D. Prevent pulmonary edema.

4. What is the most important responsibility of the healthcare team before surgery starts?

A. Assessing the woman’s hygiene.
B. Inserting a urinary catheter.
C. Decreasing the stomach secretions.
D. Securing an informed consent and ensuring that it is obtained.

5. The nurse administers Ringer’s solution intravenously for what purpose?

A. To avoid urinary tract infection.
B. To ensure that the woman is fully hydrated.
C. To reduce bladder size.
D. To decrease urine specific gravity.

6. The surgeon plans to perform a low segment incision rather than a classic incision. This type of incision is more advantageous because:

A. The procedure is faster with the incision being made simultaneously through the abdomen and uterus.
B. The procedure is made with a vertical incision to decrease the chances of reopening.
C. It is made horizontally and high on the woman’s abdomen.
D. The likelihood of a postpartal uterine infection is decreased.

7. If oxytocin is ordered postoperatively for the client who has had a cesarean birth, the most important nursing intervention would be to:

A. Monitor the woman’s blood pressure.
B. Prevent infection at the incision site.
C. Implement measures to promote comfort.
D. Assess for increased lochia discharge.

8. Which of the following interventions would be most helpful to assist a woman to void after a cesarean birth?

A. Withholding prescribed analgesic.
B. Letting the woman void every 4 hours.
C. Running water from the tap within woman’s hearing distance.
D. Pouring cold water over her perineal area.

9. A woman has undergone a cesarean birth is to be discharged. The nurse would instruct the woman to notify her health care provider if she develops which of the following?

A. Drainage at her incision line.
B. No bowel movement for 2 days.
C. Decrease in lochia.
D. Pain on the incision site.

10. Which of the following is a complication of pain that occurs postoperatively?

A. Constipation
B. Pneumonia
C. Hypotension
D. Fever

Answers and Rationale


1. Answer: C. Insert a urinary catheter to drain the bladder and decrease its size. 

  • C: Inserting a urinary catheter would drain the urine from the bladder and decrease its size.
  • A: Oxytocin would contract the uterus and not the bladder.
  • B: Fluids will be restricted but this could not decrease the size of the bladder especially if the bladder is already full.
  • D: The woman may have difficulty in voiding even if a diuretic is administered.

2. Answer: B. Decrease gastric secretions. 

  • B: Zantac decreases gastric secretions to decrease the risk for esophageal reflux and aspiration.
  • A: Uterine contractions are promoted by oxytocic agents.
  • C: Uterine contractions are delayed by uterine relaxants such as magnesium sulfate.
  • D: Zantac could not neutralize urine acidity.

3. Answer: C. Prevent stasis of mucus in the lungs.

  • C: Periodic deep breathing exercises fully aerate the lungs to prevent stasis of mucus.
  • A: The uterus should be stimulated to contract and not the diaphragm.
  • B: Involution is promoted by breastfeeding the infant.
  • D: Pulmonary edema cannot be prevented by deep breathing exercises.

4. Answer: D. Securing an informed consent and ensuring that it is obtained.

  • D: Informed consent is the most important responsibility because the patient must provide consent for the surgeons to operate on his body before they can start the procedure.
  • A: The woman’s hygiene must be checked thoroughly, yet it is not on the top of the list of responsibilities for healthcare providers before surgery.
  • B: The urinary catheter is inserted to reduce bladder size and keep the bladder away from the surgical field.
  • C: Decreasing stomach secretions is not a primary responsibility yet a part of preoperative measures.

5. Answer: B. To ensure that the woman is fully hydrated.

  • B: Intravenous fluid helps hydrating the woman and avoids hypotension or extreme blood loss.
  • A: UTI can be prevented by drinking a large amount of water every day.
  • C: Bladder size can be reduced by inserting a catheter.
  • D: Urine specific gravity can be decreased by drinking large amount of matter.

6. Answer: D. The likelihood of a postpartal uterine infection is decreased.

  • D: Uterine infection is less likely in a low segment incision because the incision is made horizontally across the uterus.
  • A: The incision is not done simultaneously through the abdomen and uterus.
  • B: A classic incision is made vertically.
  • C: Low segment incision is made horizontally just below the symphysis pubis.

7. Answer: A. Monitor the woman’s blood pressure.

  • A: Oxytocin can increase blood pressure so it must be monitored conscientiously.
  • B: Oxytocin causes the uterus to contract and it does not predispose the woman to infection.
  • C: Measures for comfort can be implemented, however it is not a priority i=during oxytocin administration.
  • D: Lochia discharge might increase if oxytocin is administered because it evacuates the remaining contents inside the uterus.

8. Answer: C. Running water from the tap within woman’s hearing distance.

  • C: Urinary elimination can be stimulated when the woman hears running water so she can void.
  • A: Prescribed analgesic should not be withheld because it might cause discomfort to the woman.
  • B: The woman should void every 2 hours.
  • D: Warm water can be used to stimulate urination.

9. Answer: A. Drainage at her incision line.

  • A: Drainage at the incision line might lead to infection at the site.
  • B: Having no bowel movement 2 or 3 days postoperatively is normal.
  • C: Lochia normally decreases until it stops flowing.
  • D: Pain on the incision site is normal after surgery.

10. Answer: B. Pneumonia

  • B: Pain may interfere with the woman’s mobility and the ability to deep breathe so pneumonia might become a complication.
  • A: Constipation is not a complication; it may develop if the woman’s diet is inappropriate.
  • C: Hypotension must be prevented postoperatively.
  • D: Fever is a complication of infection.

Giving birth to an infant through cesarean section needs careful assessment and precise care measures to ensure the optimum safety of the woman even before the procedure is done. Cesarean birth has its own risks, and as health care providers, we must make sure that not one of these risks would occur.