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Cesarean Birth

Saturday, December 12, 2009


12:21 PM

 Hazardous than vaginal birth


 Caedore-to cut
 Mother's reasons
○ Reducing birth stress
○ Incontinence
○ Uterine prolapse
 Indications
○ Maternal factors
 Genital herpes or papilloma
 AIDS or HIV+ STATUS
 Dystocia
 CPD
 Cervical Cerclage
 Disabling conditions: severe hypertension, diabetes
mellitus, heart diseases or cervical cancer
 Failed induction or failure to progress labor
 Obstructive benign or malignant tumors
 Previous cesarean birth by classic incision
○ Placental factors
 Placenta previa
 PROM
 Abruptio placenta
 Cord prolapse
○ Fetal factors
 Macrosomic fetus in breech lie
 Extreme low birth weight
 Fetal distress or persistent nonreassuring FHR patterns
 Major fetal anomalies
 Multigestation or conjoined twins
 Fetal malpresentations: Transverse or Breech fetal lie
 Contraindications
○ Fetal death
○ Immaturity of fetus to survive
○ Maternal coaugalation defects
 Two types:
○ Scheduled
Reasons: Transverse presentation, genital herpes,
 CPD, avoidance of post-procedure stress
incontinence

○ Emergency
Reasons: Placenta previa, abruptio placenta, fetal

distress, failure to progress labor
 Effects of surgery to mother:
○ Stress response
 Results from release of catecholamine from the
adrenal medulla

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adrenal medulla
□ Epinephrine: increased heart rate, bronchial
dilation, and elevation of blood glucose level
□ Norepinephrine: peripheral vasoconstriction-->>
increased BP
 May antagonize the effects of anesthesia which is
aimed at minimizing body activity
 Minimizes blood supply to her lower extremities-->>
risk for thromboplebitis
○ Interference with body defenses
 Risk for infection because the skin as a primary line of
defense is intruded
 Strict aseptic technique should be followed
○ Interference with circulatory function
 Extreme blood loss-->> hypovolemia and decreased BP
 Blood loss:
□ Vaginal birth: 300-500 ml
□ Cesarean birth: 500-1000 ml
 Interference with body organ function
□ Uterus is handled and may not contract
normally-->> postpartum hemorrhage
□ Uterine function, bladder, intestine and lower
circulatory function must be carefully assessed
 Interference with self-image or self esteem
□ Scar- lowered self-esteem
 Nursing Care: Scheduled/Anticipated Cesarean Birth
○ Operative risk for the woman
 Poor nutritional status: vitamin deficiencies
 Age variations: age 40 above has lowered circulatory
functioning
 Altered general health: presence of secondary illness
could put woman at risk
 Fluid and electrolyte imbalance
 Fear
 Infection
 Hemorrhage
 Urinary tract trauma
 Thrombophlebitis
 Paralytic ileus
 Atelectasis
 Anesthesia compications such as aspiration of gastric
contents
○ Operative risk to newborn
 Higher instances of respiratory difficulties because in
vaginal delivery, the newborn's chest is compressed
thus getting rid of lung fluids-->> transient tachypnea
of the newborn
 Some newborn develop pulmonary hypertension
 Inadvertent preterm birth
□ Greatest risk is lung immaturity
 Transient tachypnea of the newborn caused by delayed
absorption of lung fluid
 Persistent pulmonary hypertension of the newborn
Injury such as laceration, bruising or other trauma

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 Injury such as laceration, bruising or other trauma
○ Preoperative Diagnostic Procedures
 Vital signs assessment both mother and fetus (specially
FHR pattern)
 Urinalysis
 Complete blood count
 Coagulation profile (PT, PTT)
 Serum electrolytes and pH
 Blood typing and cross matching
 Sonogram-->> fetal maturation and maturity
○ Preoperative teaching
 Aimed at acquainting the woman with the procedure
and any special equipment to be used, allowing her to
be as informed as possible TO REDUCE FEAR
 Teaching to prevent complications
□ importance of maintaining good respiratory and
circulatory function in avoiding postoperative
complications
 Deep breathing: 5-10 deeps breaths per
hour postoperatively Helps decrease the
possibility of lung infection
 Incentive spirometry: blowing
 Turning: important to prevent respiratory
and circulatory stasis
 Ambulation: stimulates lower extremity
circulation; 4hours after operation
○ Immediate Preoperative Care Measures
 Informed consent: woman is informed with risk and
benefits of the procedure in terms that she could
understand
 Overall hygiene
 Gastrointestinal tract preparation: enema and
medications
□ Medications:
 Metoclopramide-speeds stomach emptying
 Ranitidine-histamine blocker that decrease
stomach secretions
 Sodium citrate and famotidine- oral antacid
to neutralize stomach acid secretions
□ These precautions are necessary because the
woman will be lying on her back during the
procedure posing high risks to esophageal reflux
and aspiration
 Baseline intake and output determinations
□ Urinary catheter may be inserted to reduce
anterior bladder size and keep it away from the
surgical field
 Be sure that urine is draining because fetal
pressure may reduce the flow of urine
considerably
 Hydration
□ IV fluid: lactated Ringer's solution
 Ensures that the woman is hydrated and
reduces the possibility of hypotension from

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reduces the possibility of hypotension from
epidural anesthesia
 Preoperative medications
 Patient chart and Presurgery checklist
 Transport to surgery: urge her to lie on her left side to
prevent supine hypotension syndrome
 Role of the support person: encourage them also
 Nursing Care: Emergency Cesarean Birth
○ Preoperative preparations: vital signs, urinalysis, blood works
○ Immediate preparations: informed consent, application of
elastic stockings, GIT preparation, bladder catheterization, IV
line
○ Document what was thought so that the nurse who will care
postoperatively will be aware of the need for additional
teaching
 Intraoperative Care Measures
○ Administration of Anesthesia
○ Skin Preparation
○ Surgical Incision
 Nursing Care
Put towel under left Moves abdominal content up
hip and lifts her uterus off the
vena cava
Screen at shoulder Blocks the flow of bacteria
level covered with a from the woman's respiratory
sterile drape tract to the incision site
Block the patient and the
support person's line of vision
to prevent additional anxiety
Scrub abdomen and Exposes only minimal area of
place appropriate skin
drapes a incision area
 Types of Cesarean incisions:
□ Decision is based on the fetal presentation and
the speed at which the procedure will be
performed
□ Skin (abdominal wall) incisions:
Classic  (I) incision is made vertically
through both the abdominal skin
and the uterus
 Made high on the uterus so that
it can be used with a placenta
previa to avoid cutting the
placenta
 Leaves a wide scar
 Scar could rupture during labor
thus woman will not be able to
have a subsequent vaginal birth
 Advantages:
○ Quicker to perform
○ Better visualization of the
uterus

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uterus
○ Can quickly extend upward
for greater visualization if
needed
○ Often more appropriate for
obese women
 Disadvantages:
○ Easily visible when healed
○ Greater chance of
dehiscence and hernia
formation

Low  (-) incision is made horizontally


segment across the abdomen just over the
incision symphysis pubis and also across
the uterus just over the cervix
 Most common type of incision
commonly done
 Also referred to as Pfannenstiel
incision or bikini incision
 Less likely to rupture in
subsequent vaginal births
because incision is located at the
nonactive portion of the uterus
 Results in less blood loss
 Easier to suture
 Decreases postpartal uterine
infections and less likely to cause
postpartal GIT infections
 Advantages:
○ Less visibility when healed
and the pubic hair grows
back
○ Less chance of dehiscence
or formation of hernia
 Disadvantages:
○ Less visualization of the
uterus
○ Cannot be done as quickly,
which may be important in
emergency cesarean birth
○ Cannot easily be extended
to give greater operative
exposure
○ Re-entry at a subsequent
ceaserean birth may
require more time

Sources:  Pilliteri, Adele. Maternal and Child


Health Nursing: Care of the
Childbearing and Childrearing
Family, 4th Ed. Philippines:
Lippincott Williams and Wilkins.
 Murray, et. al. Foundations of

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 Murray, et. al. Foundations of
Maternal-Newborn Nursing, 3rd Ed.
Philadelphia: W. B. Saunders
Company

□ Uterine incisions:
Low  Preferred type of incision
Transverse  Not suitable for a very large fetus
 Length of incision is limited
because the uterine artery is and
vein enter the uterus at its lower
right and left sides
 The low transverse incision may
not be large enough to deliver a
large baby without tearing these
large babies
 Sometimes, a vertical incision
must be added to a transverse
one (making an inverted T) to
deliver a very large baby
 Advantages:
○ Unlikely to rupture during a
subsequent birth
○ Makes
○ Makes VBAC possible for
subsequent pregnancy
○ Less blood loss
○ Easier to repair
○ Less adhesion formation
 Disadvantages
○ Limited ability to extend
laterally to enlarge the
incision
Low  Advantages:
Vertical ○ Can be extended upward to
make a larger incision if
needed
 Disadvantages
○ Slightly more likely to
rupture during a
subsequent birth
○ A tear may extend the
incision downward into the
cervix
Classic  Vertical incision into the upper
uterus
 More likely to rupture during
later pregnancies
 Advantages:
○ May be the only choice in
these situations:
 Implantation of a
placenta previa on

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placenta previa on
the lower anterior
uterine wall
 Presence of dense
adhesions from
previous surgery
 Transverse lie of a
large fetus with the
shoulder impacted in
the mother's pelvis
 Disadvantages:
○ Most likely of the uterine
incisions to rupture during
a subsequent birth
○ Eliminates VBAC as an
option for birth of a
subsequent infant
Source:  Murray, et. al. Foundations of
Maternal-Newborn Nursing, 3rd Ed.
Philadelphia: W. B. Saunders
Company.
□ Sometimes, a skin incision is made horizontally
and then the uterine incision is made vertically or
vice versa
 During a future pregnancy, do not assume
that just because a woman has a small skin
incision she will have a small uterine
incision as well
○ Birth of the infant
 Retractors- allows good visualization if the uterus and
internal incision
 Sterile towels may be placed in the incision to separate
the uterus from other organs
 The uterus is then cut and the child's head may be
delivered manually or by application of forceps
 Mouth and nose of the baby are suctioned by a bulb
syringe before the remainder of the child is delivered
 Oxytocin is administered intravenously by the
anesthesiologist as the child or placenta is delivered
to increase iterine contractions and reduce blood loss
 In many instances, the woman's partner can be allowed
to cut the umbilical cord
 After full birth, the uterus is pulled forward onto the
abdomen and covered with moist gauze
 The internal cavity of the uterus is inspected and the
membranes and placenta are manually removed
 If the woman wishes to have a tubal ligation, it can be
done at this time
 The uterus, subcutaneous tissue and skin incision can
now be closed
□ Metal staples are used are usually used on the
exterior skin because they leave the least
amount of scarring
Introduction of the newborn

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○ Introduction of the newborn
 Once the newborn is determined to be breathing
spontaneously, he or she is shown to the mother and
support person just as is done in vaginal delivery
 Breastfeeding is usually delayed until the woman is has
been moved to a recovery room, because
breastfeeding initiates uterine contraction and may
interfere with suture placement
 Postpartal Care Measures
○ Women who deliver by cesarean birth have additional care
concern in the immediate postpartal period because they are
not only postpartal patients but postsurgical one as well
○ Due to the strain of the unexpected procedure, they may
have increased difficulty bonding with their new infant
○ There is little time for teaching because of shortened hospital
stays
○ Postpartal phase
 Immediate recovery period
 Extended postpartal period

Sources:
 Pilliteri, Adele. Maternal and Child Health Nursing: Care of
the Childbearing and Childrearing Family, 4th Ed. Philippines:
Lippincott Williams and Wilkins.
 Murray, et. al. Foundations of Maternal-Newborn Nursing,
3rd Ed. Philadelphia: W. B. Saunders Company

Prepared by:
Edward Arlu V. Dinoy CNU-CN 2012

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