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Cesarean Birth and

RecoveryTracy Scoville BSN, RNC-OB

Clinical Nurse Educator

Providence Regional Medical Center Everett

Email:

Tracy.scoville@providence.org

Discuss current trends in cesarean section rates within the U.S. and Washington state

Review cesarean section rates around the globe

Verbalize indications for a Cesarean delivery

Describe roles of the Perinatal nurse in the continuum of care for a patient undergoing a Cesarean birth

Identify potential complications of Cesarean delivery

OBJECTIVES

Cesarean birth has been a part of both Western and non-Western cultures since ancient times

Initial purpose was to remove the infant from a dead or dying mother

Saving a mothers life became a possibility in the 19 th century.

HISTORY OF CESAREAN BIRTH

• 32.8% 1 of U.S. births were delivered by cesarean in 2012, a rate that has remain unchanged since 2010

• Prior to 2010 the cesarean rate increased every year since 1996 at which time the cesarean rate was 20.7% in the United States

• Cesarean section rate in Washington state rose by 73% from 1996 to 20071

–Third behind Rhode Island (83%) and Connecticut (75%)

TRENDS

Cesarean Delivery Rates United States

1991-20071

Global Cesarean Rates from the World Health Report 2010

Country Rate

Brazil 45.9%

Mexico 37.8%

United States 30.3%

Australia 30.3%

Canada 26.3%

United Kingdom 22.0%

Ukraine 14.2%

Kenya 4.0%

Ethiopia 1.0%

Chad 0.4%

CESAREAN SECTION RATES AROUND THE GLOBE

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Thi s i s a 6 bed Ma terni ty Wa rd i n Mdol o Vi l l a ge

There a re no opera ti ng rooms, no surgeons a nd no a nes thes ia provi ders

MATERNITY WARD IN MALAWI

S o ur c e : A m e r i c a n J o ur n a l o f O b s t e t r i c s & G y n e c o l o gy 2 1 0 4 : 2 1 0 : 1 7 9 - 1 9 3 ( D O I : 1 0 . 1 0 1 6 / j . a j o g .2 0 1 4 . 0 1 . 0 2 6 ) C o py r i g h t 2 0 1 4

United States Cesarean Delivery Rates by State 2010

Source: National Center for Health Statistics, final natality data. Retrieved February 25,

2014, from www.marchofdimes.com/peristats.

Total Cesarean Deliveries 3

Washington, 2008-2011 Average

Primary cesarean rate is the number of primary cesareans per 100 live births to women who have not had a previous cesarean. Primary cesarean rates based on the 2003 Revision of the U.S. Standard Certificate of Live Birth. Details available at: <a

href="http://www.marchofdimes.com/peristats/calculationsp.aspx?id=6"

target="_blank">http://www.marchofdimes.com/peristats/calc/dm</a>.

Source: National Center for Health Statistics, final natality data. Retrieved February 25, 2014, from www.marchofdimes.com/peristats.

Primary Cesarean Deliveries 3

Washington, 2008-2011 Average

TOLAC: Trial of Labor After Cesarean

VBAC: Vaginal Birth After Cesarean

•50% increase in VBAC’s reported in late 80s through mid 90s

•Since 1996 rate of VBAC deliveries has decreased significantly

TOLAC/VBACUS Delivery Rates 1989-2011

Source: American Journal of Obstetrics & Gynecology 2104: 210: 179-193

(DOI:10.1016/j.ajog.2014.01.026) Copyright 2014)

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Vaginal births after cesarean (VBAC) delivery rate is the number of VBAC deliveries per 100 live births to women with a previouscesarean. VBAC rates based on the 2003 Revision of the U.S. Standard Certificate of Live Birth. Details available at: <a

href="http://www.marchofdimes.com/peristats/calculationsp.aspx?id=6"

target="_blank">http://www.marchofdimes.com/peristats/calc/dm</a>. ** Suppressed due to missing data or insufficient numbers.

Source: National Center for Health Statistics, final natality data. Retrieved February 25, 2014, from www.marchofdimes.com/peristats.

Vaginal Birth After Cesarean Deliveries 5

Washington, 2008-2011 Average

Examined safety and outcome of TOLAC and VBAC and factors associated with decreasing rates

Recommendation:

Trial of labor reasonable for many women with history on one prior low transverse uterine incision

Consider making public TOL policies and VBAC rates

Mitigate or eliminate current barriers to TOL

More research needed regarding short and long term outcomes of TOL and elective repeat cesarean section

NIH VAGINAL BIRTH AFTER CESAREAN:

NEW INSIGHTS6

• VBAC potential health advantages– Avoid major abdominal surgery

• Decreases risk of infection, hemorrhage, and has a shorter recovery period

– Those wishing larger families avoid potential consequences of multiple cesarean sections

• Hysterectomy

• Bowel or bladder injury

• Transfusion

• Infection

• Abnormal implantation of placenta

ACOG PRACTICE BULLETIN NO. 1157

A U G U S T 2 0 1 0

• Candidates for TOL after previous cesarean:

–One to two previous C/S with low transverse incision

–Prior low vertical uterine incision

–Twin gestation with one previous C/S with low transverse incision

–Consideration for:• Macrosomia

• > 40 weeks gestation

• One previous C/S with unknown uterine scar (unless high suspicion of classical uterine incision)

ACOG PRACTICE BULLETIN NO. 1157

INDICATION FOR CESAREAN INDICATIONS FOR CESAREAN

Late Deceleration

• Abnormal Fetal Heart Rate

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Failure to Progress

Macrosomia

Cephalopelvic Disproportion (CPD)

Active Genital Herpes

Prior Cesarean Delivery/Uterine Surgery

Cesarean Delivery on Maternal Request (CDMR)

INDICATIONS FOR CESAREAN

S o ur c e : A m e r i c a n J o ur n a l o f O b s t e t r i c s a n d G y n e c o l o gy 2 0 1 4 : 2 1 0 : 1 7 9 - 1 9 3 ( D O I : 1 0 . 1 0 1 6 / j . a j o g . 2 0 1 4. 0 1 . 0 2 6 )

C o py r i g h t 2 0 1 4

Indications for Primary Cesarean Delivery

ROLE OF THE PERINATAL NURSE IN CESAREAN SECTIONS

Perinatal units should maintain comparable care standards as the main hospital surgical suites/postanesthesia care unit (PACU) (ASA, 2003, 2006; JCAHO, 2007a) 8

STANDARDS

Admission Assessment NPO

Fetal Tracing

IV /Labs

Abdominal Clip

Consent

Plan of Care- Reassure!

PRE-OPERATIVE

Medications Antacid

Antibiotic prophylaxis9

Pneumatic Compression Devices 10,11,12,13

PRE-OPERATIVE

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Positioning

Alignment

Arm boards

Tilt

Safety strap

Fetal monitoring

Foley

INTRAOPERATIVE

• Grounding Pad

• Suction

• Counts

• Documentation

• Support Person

• Medication Safety

– Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings14

INTRAOPERATIVE

EpiduralPlaced in epidural space between 4 th and 5th

lumbar vertebrae

Dilute local or a local combined with preservative free opioid

Complete block occurs in about 15-20 minutes

ANESTHESIA

Epidural placement

SpinalInjected into subarachnoid space

Local anesthetic or local combined with preservative free opioid

Dense motor/sensory block

Rapid onset

ANESTHESIA

General anesthesia

Clinical state that is defined by degrees of effect in four criteria: Amnesia (loss of recall of event), analgesia (insensibility to pain),

hypnosis (unconsciousness), and muscle relaxation

ANESTHESIA SURGICAL PREP

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• The Joint Commission - Universal Protocol and Speak Up Program15

– Conduct time-out immediately before starting procedure– Standardized– Initiated by any team member– All members of team actively communicate during time out– All members agree, at a minimum on correct patient, correct site and

correct procedure to be done– Documentation of time out

• SCOAP – Surgical Care and Outcomes Assessment Program16

• WHO - Safe Surgery Saves Lives Program17

PRE-PROCEDURAL PAUSE

TYPES OF SKIN/UTERINE INCISION

“At birth, at least one person whose sole responsibility is neonatal resuscitation should be present to care for the newborn. Either this person or someone else who is immediately available should be able to perform complete resuscitation including endotracheal intubation and

medication administration”18

CARE OF THE NEONATE

• Brief huddle at the end of the procedure

• I tems to cover:

–Before closure: Are instrument, sponge, and needle counts correct?

–Additional procedures performed, if any

–Specimens and labeling (cord gases?, placenta to path?, tubal ligation?, other?)

–Infant information (sex, weight, Agpars)

–Postop analgesia (duramorph, PCA, other)

–Recovery issues anticipated

–What could have been done better?

DEBRIEF

• Uterine atony

• Uterine hysterectomy

• Uterine rupture

• Bladder and/or bowel perforations

• Arterial bleeds

• Maternal cardiac arrest

• Anesthesia complications (i.e. Malignant Hyperthermia, Aspiration)

POTENTIAL CESAREAN COMPLICATIONS

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Maternal Co-morbidities

Multiple Repeats

Over Distended Uterus

Substance Abuse

COMPLICATING MATERNAL FACTORS

Risk of death caused by the operation of cesarean delivery is approximately 2 per 100,000 cesareans, compared with 0.2 per 100,000 deaths caused by vaginal births 10

Typical Sources:

Hemorrhage

Thromboembolism

Infection

MATERNAL MORTALITY/MORBIDITY

Most Common Preventable Errors10

Failure to adequately control BP in hypertensive women

Failure to adequately diagnose and treat pulmonary edema in women with preeclampsia

Failure to pay attention to vital signs following Cesarean section

Hemorrhage following Cesarean section

MATERNAL DEATH

• Patients should be accompanied to recovery by Anesthesiologist/CRNA

• Verbal report by Anesthesia provider includes:

–Name, age, surgical procedure, allergies

–Medical problems

–Most recent VS

–Mental status

–Communication barriers

–All medications given (pre-op, intra-op)

– I & O (EBL, IV fluid, urine, emesis)

–Any complications

–Orders for care

–Number to contact Anesthesia

RECOVERY HAND OFF

• Assessments performed according to hospital protocols in alignment with main hospital PACU

Review of systems

Dermatome level

LOC

Obstetric status

I & O

Pain

Anesthesia site

Safety

POST ANESTHESIA RECOVERY

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Systematic method of patient scoring help to provide an objective measurement for care.

• Can be applied immediately and repeatedly as a convenient means to evaluate progress in recovery from anesthesia

POST ANESTHESIA SCORINGPOST ANESTHESIA SCORING –

MODIFIED ALDRETE Consciousness Activity on command2 = Fully awake 2 = Moves all extremities1 = Responds to name 1 = Moves two extremities0 = No response 0 = No movement

Respiration2 = Free deep breathing1 = Dyspneic, hyperventilating, obstructed breathing0 = Apneic

Circulation2 = Blood pressure within 20% of pre-op level1 = Blood pressure within 50%–20% of pre-op level0 = Blood pressure 50%, or less, of pre-op level

Oxygen saturation2 = SpO2 >92% on room air1 = Supplemental O2 required to maintain SpO2 >92%0 = SpO2 <92% with O2 supplementation

Total Score = 109 needed to leave PACU

• Respiratory

• Cardiovascular

• Pain

• Thermoregulation

• Post-operative Agitation or Delirium

• Blood Sugar

• Post Operative Nausea and Vomiting (PONV)

POTENTIAL POST ANESTHESIA COMPLICATIONS

Occurs after recovery period and when the patient is stable per recovery discharge criteria

Utilizing Post Anesthesia scoring system to assess readiness

Anesthesia provider is involved in decision to discharge from recovery

Prior to discharge/transfer of patient, RN completes a final review of systems assessment

If care is transferred to another nurse, report is given utilizing standardized approach to hand off.

POST ANESTHESIA DISCHARGE

1. Martin, Joyc e A. , M.P.H. ; Hamilton, Brady E. , Ph.D. ; Osterman, Mic helle J .K. , M.H.S. ; Curtin, Sally C. M.A. , Mathew, T. J . , M.S. , Division of Vital Stat ist ic s, Volume 62, number 9, Dec ember 30, 2013

2. Centers for Disease Control and Prevention, MMWR Weekly, April 20, 2007/ 56(15);373

3. National Center for Health Stat ist ics , f inal natality data. Retr ieved February 24, 2014, from www.marc hofdimes.com/peristats .

4. Centers for Disease Control and Prevention, MMWR Weekly, January 21, 2005/ 54(02);46

5. National Center for Health Stat ist ics , f inal natality data. Retr ieved February 24, 2014, from www.marc hofdimes.com/peristats .

6. Bangdiwala, S. I . , Brown, S. S. , Cunningham, F. G. , Dean, T. M. , Frederiksen, M. , Hogue, C. J . , . . . Zimmet, S. C. (2010). NIH c onsensus development c onference draft statement on vaginal b irth after c esarean: New insights. NIH Consensus and State -o f -the-Science Statements, 27 (3)

7. Americ an College of Obstetr ic ians and Gynec ologists . (2010). ACOG prac tice bullet in no. 115: Vaginal b irth after previous c esarean delivery. Obstetrics and Gynecology, 116 (2 Pt 1) , 450-463. doi:10.1097/AOG.0b013e3181eeb251

REFERENCES

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8. Simpson, K. , Creehan , P.A. (2008). AWHONN Perinatal Nursing (3 rd

ed.) . New York: Lippinc ott.9. Committee opinion no. 465: Antimicrobial prophylaxis for c esarean

delivery: Timing of administrat ion. (2010). Obstetrics and Gynecology, 116 (3) , 791-792. doi:10.1097/AOG.0b013e3181f68086

10.Clark, S. L. , Belfort , M. A. , Dildy, G. A. , Herbst , M. A. , Meyers, J . A., & Hankins, G. D. (2008). Maternal death in the 21st century: Causes, prevention, and relationship to cesarean delivery. American Journal o f Obstetrics and Gynecology, 199 (1) , 36.e1-5; disc ussion 91-2. e7-11. doi:10.1016/j .a jog.2008.03.007

11.Bates, S. M. , Greer, I . A. , Pabinger, I . , Sofaer, S. , Hirsh, J . , & Americ an College of Chest Physic ians. (2008). Venous thromboembolism , thrombophilia , antithrombotic therapy, and pregnancy: Americ an c ollege of c hest physic ians evidenc e -based c linic al prac tice guidelines (8th edit ion). Chest, 133 (6 Suppl), 844S-886S. doi:10.1378/chest.08 -0761

12.Simpson, K. R. (2010). Thromboprophylaxis for c esarean birth.MCN.the American Journal o f Maternal Chi ld Nursing, 35 (4) , 244. doi:10.1097/NMC.0b013e3181dd7c95

13.Joint Commission Sentinel Event Alert #44; Preventing Maternal Death January (2010). Retr ieved from http : //www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_44.htm , Retrieved January 10, 2011.

REFERENCES

14.Joint Commission National Patient Safety Goal 3 – 03.04.01, Label ing in Procedural Area, Revised March 26, 2010. Retrieved from http://www.jointcommission.org/standards_information/jcfaqdetai ls.aspx, Retrieved January 10, 2011.

15.The Joint Commission (2010) Universal Protocol and Speak Up Program http://www.jointcommission.org/assets/1/18/UP_Poster.pdf

16.Surgical Care and Outcomes Assessment Program (2010) SCOAP Checklist http://www.scoap.org/downloads/SCOAP-Surgical-Checklist_v3_4.pdf

17.World Health Organization (2009) Surgical Safety Checklist http://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdf

18.American Academy of Pediatrics & American Col lege of Obstetricians and Gynecologists (2008). Guidelines for Perinatal Care (6 th ed.)

19.American Col lege of Obstetricians and Gynecologists (the Col lege) and the Society of Maternal -Fetal Medicine, American Journal of Obstetrics and Gynecology, Volume 210, Issue 3, Pgs 179-183 (March 2014)

REFERENCES

American College of Obstetricians and Gynecologists Committee Committee on Patient Safety and Quality Improvement. (2009). ACOG committee opinion no. 447: Patient safety in obstetrics and gynecology. Obstetrics and Gynecology, 114(6), 1424-1427. doi:10.1097/AOG.0b013e3181c6f90e

American Society of Anesthesiologistshttp://www.asahq.org

American Society of PeriAnesthesia Nurseshttp://www.aspan.org

Association of Perioperative Registered Nurses (AORN) http://www.aorn.org

Association of Womens Health, Obstetrics, and Neonatal Nurses (AWHONN) http://www.awhonn.org

Cunningham, G., et al. (2005). Williams Obstetrics (22nd ed.). New York: McGraw-Hill.

Deneux-Tharaux, C, et al: Postpartum Maternal Mortality and Cesarean Delivery. Obstetrics & Gynecology, 2010, 108(3): 541-548.

ADDITIONAL RESOURCES