Cesarean Delivery

Description
1. In this surgical procedure, the newborn is delivered through the abdomen from an incision made through the maternal abdomen and the uterine myometrium. 2. The surgery may be preplanned (elective) or arise from an unanticipated problem. 3. Two incisions are made: one in the abdominal wall (skin incision) and the other in the uterine wall. Either of two skin incisions is used: a midline vertical incision between the umbilicus and the symphysis or a Pfannenstiel incision just above the symphysis (Fig. 1). Three types of uterine incisions are possible (Fig. 2): (1) low transverse; (2) low vertical; and (3) classic, a vertical incision into the upper uterus. The low transverse uterine incision is preferred unless a very large fetus or placenta previa in the lower uterus prevents its use. The uterine incision does not always match the skin incision. For example, a woman may have a vertical skin incision and a low transverse uterine incision, particularly if she is very obese. 4. In subsequent pregnancies and delivery, a trial of labor and vaginal birth is increasingly regarded as safe and appropriate as long as cephalopelvic disproportion does not exist and the previous incision was low transverse. 5. Elective, repeat cesarean may be performed in the absence of a specific indication for operative delivery when either the physician or the client is unwilling to attempt vaginal delivery. 6. Anesthesia may be general, spinal, or epidural; preoperative and postoperative care will vary accordingly.

Positioning
Supine, with a small roll under the right hip (to reduce vena cava compression); arms extended on armboards.

Incision sites
Classic approach, vertical (low midline).

Packs/drapes
Extra drape sheet Towels Receiving pack for baby

Instrumentation
C-section tray Delivery forceps Cord clamp

Supplies/ Equipment
Basin set Blades Suction Neonatal receiving unit Self-contained oxygen I.D bands Bulb syringe Solutions Sutures

Procedure
1. Using the appropriate incisions, consistent with the estimated size of the fetus, the abdomen is opened, the rectus muscle are separated, and the peritoneum incised (similar to an abdominal hysterectomy), exposing the distended uterus. 2. Large vessels are clamped or cauterized, but usually no attempt to control hemostasis is made since it may delay delivery time ( 3-5 minutes after initial incision is ideal).

3. The scrub person must be ready with suction, dry laps, and a bulb syringe. 4. The bladder is retracted downward with the bladder blade of the balfour retractor and a small incision is made with the second knife and extended with a bandage scissors (blunt tip prevents injury to the babys head). 5. The amniotic sac is entered and immediately aspirated the fluid. 6. The bladder blade is removed, and the assistant will push on the patients upper abdomen while the surgeon simultaneously delivers the infants head in an upward position. 7. The babys airways are suctioned with the bulb syringe, and the baby is completely delivered and placed upon the mothers abdomen. 8. The umbilical cord is double clamped and cut. 9. The baby is wrapped in a sterile receiving blanket and transferred to the warming unit for immediate assessment and care. 10. Once the bay has been safely delivered, the emergent phase of the procedure has been ended. 11. Using a nonecrushing clamp, the uterine wall is grasped for traction during closure. 12. The closure is performed in two layers with a heavy absorbable suture, using a continuous stitch, the second overlapping the first. 13. Following closure of the uterus, the bladder flap is reperitonealized with a running suture, and the uterus is pushed back inside the pelvic cavity. 14. The cavity is irrigated with warm saline, and closed in layers. 15. Skin is closed with the surgeons preference. If a tubal ligation is to be performed, it is done prior to the abdominal closure sequence.

Perioperative Nursing Considerations

1. A C-section requires an additional uterine count of sponges, sharps, and instruments prior to its closure. 2. Oxytocin should be available for the anesthesiologist to administer I.V. 3. Once the uterus is opened, immediate suctioning is necessary. 4. A warm, portable isolette should be available to transport the infant to the newborn nursery.

Reasons For Performing A Cesarean Delivery

1. Maternal factors a. Cephalopelvic disproportion (CPD) b. Active genital herpes or papilloma c. Previous cesarean birth by classic incision d. Presence of severe disabling hypertension or heart disease 2. Placental factors a. Placenta previa b. Abruptio placental

3. Fetal factors a. Transverse fetal lie b. Extreme low birth weight c. Fetal distress d. Compound conditions, such as macrosomia and transverse lie.

Nursing Management
1. Perform a complete maternal and fetal assessment.

Obtain a complete obstetric history. If he client presents with labor determine frequency, duration, and intensity of contractions. Determine the condition of the fetus through fetal heart tones, fetal monitoring strips, fetal scalp blood sample, fetal activity changes, and presence of meconium in amniotic fluid.

2. Prepare the client for cesarean delivery in the same way whether the surgery is elective or emergency. Depending on hospital policy:

Shave or clip pubic hair. Insert a retention catheter to empty the bladder continuously. As prescribed, insert intravenous lines, collect specimens for laboratory analysis, and administer preoperative medications. Also as prescribed, provide an antacid (to prevent vomiting and possible aspiration of gastric secretions) and prophylactic antibiotics (to prevent endometritis). Assist the client to remove jewelry, dentures, and nail polish, as appropriate. As needed, reinforce the obstetricians explanation of the surgery, the expected outcome, and the anesthesiologists explanation of the kind of anesthetics to be used (depending on the clients cardiopulmonary status). Make sure the clients signed informed consent is on file. Continue assessing maternal and fetal vital signs in accordance with hospital policy until the client is transported to the operating room. Notify other health care team members of the pending delivery. Modify preoperative teaching to meet the needs of planned versus emergency cesarean birth; depth and breadth of instruction will depend on the circumstances and time available. If there is time, begin explaining what the client can expect postoperatively. Discuss pain relief, turning, coughing, deep breathing, and ambulation. Inform the client that intraoperative and postpartum care will be performed by the surgical and obstetric team, and that the newborn will receive care by the pediatrician and a nurse skilled in neonatal care procedures (ie, resuscitation).

3. Facilitate a family- centered cesarean birth by including , when possible, such activities as:

Preparing the partner for participation in the delivery. Reuniting the family as soon as possible following delivery. Providing for family time alone in the critical first hours after the mother and newborn are stabilized. Including the father and siblings (as possible) when demonstrating care of the newborn. Encouraging the mothers support person to remain with her as much as possible. In some cases, this person may accompany the client to the surgical suite and stay with her throughout the birth.

4. Provide physical and emotional support.

Anticipate parental feelings of failure related to cesarean rather than normal birth. In such a situation, provide time for them to relive and talk through the experience. Offer reassurance and support. Assist the family in planning for care of mother and newborn at home (Client and Family Teaching- Table 1)

Table 1 Client and Family Teaching

Explain to the mother, her partner, and other family members that recovery from a surgical cesarean delivery is slower, and often more painful, when compared with recovery from a normal vaginal delivery. The following considerations must be taken into account:

Need for increased rest (influenced by type of anesthesia, length of labor, and the type of abdominal or uterine incision) Need for increased pain medication and other pain-relieving techniques Inability to climb the stairs Inability to drive a car Difficulty with breast feeding the newborn in certain positions (e.g., cradle hold).teach the mother the best positions to use and how to use pillows to cushion the incision site. Difficulty with normal ADLs (e.g., dressing, bathing, toileting, and so on). Difficulty with providing normal newborn care (e.g., lifting, carrying, bathing, and dressing the newborn) and the need for assistance in caring for the newborn.