• Severe reduction of amniotic fluid volume (typically less The mother is placed on an operating table.
If she is going to have an
than 500 ml at term); highly concentrated urine.
• Possibility of prolonged, dysfunctional labor (usually
beginning before term).
• Fetal risk: renal anomalies, pulmonary hyperplasia,
hypoxia, increased skeletal deformities, and wrinkled,
leathery skin.
Causes
• Exact cause is unknown.
• Any condition that prevents the fetus from making urine or
that blocks urine from going into the amniotic sac.
• Contributing factors: uteroplacental insufficiency,
premature rupture of membranes prior to labor onset,
maternal hypertension, maternal diabetes, intrauterine
growth restriction, postterm pregnancy, fetal renal genesis,
polycystic kidneys, and urinary tract obstructions.
Assessment
• Asymptomatic
• Lagging fundal height growth.
Test result
• Ultrasonography reveals no pockets of amniotic fluid larger
than 1 cm.
Treatment
• Close medical supervision of the mother and fetus.
• Fetal monitoring
• Amnioinfusion (infusion of warmed sterile normal saline or
lactated Ringer’s solution) to treat or prevent variable
decelerations during labor.
Nursing Interventions
1. Monitor maternal and fetal status closely, including vital
signs and fetal heart rate patterns.
2. Monitor maternal weight gain pattern, notifying the health
care provider if weight loss occurs.
3. Provide emotional support before, during, and after
ultrasonography.
4. Inform the patient about coping measures if fetal anomalies
are suspected.
5. Instruct her about signs and symptoms of labor, including
those she’ll need to report immediately.
6. Reinforce the need for close supervision and follow up.
7. Assist with amnioinfusion as indicated.
8. Encourage the patient to lie on her left side.
9. Ensure that amnioinfusion solution is warmed to body
temperature.
10. Continuously monitor maternal vital signs and fetal heart
rate during the amnioinfusion procedure.
11. Note the development of any uterine contractions, notify
the health care provider, and continue to monitor closely.
12. Maintain strict sterile technique during amnioinfusion.
epidural or spinal anesthesia for the cesarean, it is usually performed
at this time. If she will be receiving general anesthesia (being put to
sleep), the anesthesia is usually not administered until just before the
surgeon is ready to begin the surgery; this is done to minimize the
time the drugs circulate in the mother's bloodstream with the
potential to reach the baby. Although these drugs are not harmful to
the baby, they can make the baby somewhat slow to adapt to life and
can increase the risk for respiratory distress requiring resuscitation.
The mother's arms are typically placed on boards extending directly
out from her body. This allows easy access to the mother's veins, to
administer medicine. It also prevents the mother from unconsciously
reaching down to her belly during the surgery and contaminating the
operative field, thus increasing the risk for infection.
The first step in performing a cesarean section is what doctors call
"prepping" the abdomen. The abdomen is carefully washed and
disinfected to reduce the amount of bacteria on the skin and the
chances of infection following delivery. Next, sterile pieces of cloth
are draped over the patient leaving only the abdomen exposed. This
further reduces the risk of contamination of the incision site. A cloth
is hung from two poles at the mother's shoulders. Although this
prevents the mother from seeing the operation directly, it allows the
anesthesiologist to pay close attention to the mother's nose and mouth
and to administer medications without the chance of accidentally
dropping something into the operative field.
Operating rooms are purposely kept cold. This is because doctors
must wear surgical gowns and masks and stand under two or more
high-powered lamps while performing surgery. The room is kept cold
to keep the doctors from sweating and specifically to reduce the
chances of sweat dripping onto the operative field. This must be
balanced with the need to keep the mother warm. Sometimes these
competing factors can result in heated discussion between the
obstetrician and the anesthesiologist. The baby, when delivered, is
placed under a warmer that monitors the baby's temperature and
automatically adjusts to keep the baby's body temperature within the
normal range.
The surgeon and an assistant prepare for the operation by scrubbing
their hands, nails, and arms with a brush soaked in a special
disinfecting solution. A nurse or surgery technician assists them in
putting on sterile gowns and gloves. Surgical gloves are often made
of latex; therefore, people with latex allergies should notify their
physician so that a different type of glove can be used.
The doctor performing the cesarean stands on one side of the mother
and the assistant stands on the other side of the operating table.
The operation begins with an incision in the skin of the abdomen (the
outer layers of skin only). In most cases, the doctors perform a low
transverse incision, or a bikini incision. This incision is made just
above the pubic hairline and is approximately six inches long.
Occasionally the doctor makes an incision called a midline incision
(or an up-and-down incision). This sort of incision is performed
when the doctor suspects potential complications during the delivery
and the possible need for additional surgery. The midline incision
allows the surgeon more room to operate and can allow for quicker
delivery; however, it produces a less cosmetically appealing scar. The
majority of cesarean sections performed in the today utilize a bikini
incision.
After incising the skin, the doctor cuts through the layers of fat
tissues (which are present in all women, although in varying
amounts) and then through a thick fibrous layer called the fascia. The
doctor then makes an incision through a thin, filmy layer called the
peritoneum (the sac lining the abdominal cavity and containing the
organs). The uterus and bladder, among other organs, are now visible.
The bladder usually sits on top of the uterus and must be carefully
moved before the doctor can make the incision on the uterus and
deliver the baby. After the uterus is opened, the delivery can proceed.
As with the initial skin incision into the abdomen, there are two types
of incisions that can be made into the uterus. The most common type,
the low transverse incision, is like the bikini cut. The second type,
the vertical or classical incision, is similar to the midline incision
discussed earlier. While the uterine incisions are similar to the skin
incisions in appearance, the doctor's reasons for choosing between the
uterine incisions are completely different. In most cases, the low
transverse incision is preferred. This incision has less blood loss and
generally heals better than the classical incision; it also allows a
woman to consider vaginal birth in subsequent pregnancies. On the
other hand, the classical incision provides more room for delivering
the baby. It is generally chosen when the baby is in an unusual
position and especially when the baby is very small. In such cases, a
classical incision may allow a more gentle delivery. The
disadvantages of the classical incision include the tendency for the
mother to lose more blood and an increased risk for uterine rupture
during subsequent labors. For this reason, women who have had a
classical uterine incision must deliver all subsequent pregnancies by
cesarean section. Of note, the type of incision made on the skin does
not necessarily reflect the type of incision that is made on the uterus.
After the uterus has been opened, the amniotic sac is ruptured. It is
then time for the doctor to reach into the uterus and pull the baby out.
This is not as easy as it sounds. The doctor must take great care to
deliver the baby gently without twisting the head, neck, body, or
limbs in the process. As soon as possible the doctor suctions the
amniotic fluid from the baby's mouth. This should be done before the
baby's first breath; otherwise, the baby could breathe fluid into the
lungs, which can result in breathing problems that can last for a day
or two (called transient tachypnea of the newborn).
Even though the baby has been removed from the uterus, the baby is
still attached to the mother through the umbilical cord. The doctor
puts two clamps on the umbilical cord and cuts the cord between the
two clamps. This prevents bleeding from either side of the cut
umbilical cord. The obstetrician then passes the baby off the
operating table into a sterile towel that is waiting. In this manner, the
sterile operative field is not interrupted. A nurse or pediatrician then
wipes off and wraps up the baby. If mom is able, she can then hold
her newborn baby.
The obstetrician still has important work to do. The mother will be
bleeding from the cut in the uterus. It is critical to repair the incision
as soon as possible. First, however, the placenta must be removed. In
most cases, the doctor reaches into the uterus and peels the placenta
off of the uterine wall. On the other hand, if the bleeding is not too
heavy, some doctors prefer to gently pull on the umbilical cord. In
most cases as the uterus begins to contract, the placenta will fall away
by itself. After the placenta is removed, the doctor wipes the inside of
the uterus with a cloth (called a lap sponge) to remove any remaining
pieces of placenta or membrane. It is then time to close the uterus.
The doctor sews the uterus shut with suture (surgical thread) that is
absorbable and therefore does not need to be removed. Absorbable
suture is very strong when it is first used and it retains its strength
long enough to allow the tissues to heal. The body will gradually
break down the suture so that it is completely dissolved within two to
four weeks after the operation.
The bladder, which may have been lifted off of the uterus, does not
need to be reattached-this will happen naturally within a few weeks.
Of course, the bladder has remained attached to the kidneys and
urethra, leaving bladder function intact. In a similar manner, the
peritoneum (the thin lining of the abdominal cavity) also heals
spontaneously.
The next step in closing the wound is repair of the fascia (the thick
fibrous layer of tissue that envelops the body beneath the skin). The
fascia is usually closed with absorbable suture; however, a suture that
retains its strength longer than that used to close the uterus is usually
used because the fascia heals a bit slower. In cases where healing is
likely to be slow, the surgeon may use a permanent suture to close the
fascia. This suture is made of nylon or a similar substance that does
not dissolve; it will remain in place for the rest of the patient's life.
Fortunately, permanent sutures generally cause no problems and most
patients are completely unaware of whether a permanent or
absorbable suture has been used.
After the layer of fascia has been closed, the doctor makes sure there
is no bleeding in the layers beneath the skin or in the fat. In most
cases, it is not necessary to close the fat layer. Occasionally, when the
layer of fat is very thick, the surgeon may sew it together with
absorbable suture.
There are two options for closing the skin. Today, most surgeons use
staples; the staples are made of titanium that close the wound without
much effort and generally yield a thin scar. The staples need to be
removed three to five days after the operation. Both the staples and
the special staple remover are designed for painless removal. The
other option is for the surgeon to sew the skin shut with absorbable
subcuticular suture. This very thin suture is sewn just beneath the
surface of the skin and dissolves automatically after a few weeks
when the skin is healed. While the scar left by a skin suture is no
better than that left by staples, the suture does not have to be removed
later. Nevertheless, most doctors have found no advantage to suture
and prefer to use skin staples. Suturing also prolongs the operation
and can require the entire incision to be opened if an infection
develops.
Under rare circumstances, other methods of closing the skin are used.
In cases of wound infection, the skin may be left open for a few days
and closed later. The incision usually heals well by itself given proper
care and leaves a scar that is not much different from those seen after
an uncomplicated skin closure.
After a light bandage is applied to the incision, the mother is
transferred from the operating table to a bed and taken to the recovery
room, usually with the baby in her arms.