2. CESAREAN DELIVERY Cesarean delivery is the surgical removal
of the infant from the uterus through an incision made in the
abdominal wall and an incision made in the uterus.
3. Types of Cesarean Delivery A. Uterine Incisions 1. Low
segment transverseincision made transversely in lower segment of
uterus; incision of choice 2. Classicalvertical incision is made
directly into the wall of the body of the uterus; not frequently
done.
4. Indications for Cesarean Delivery 1. CPD(Cephalo-Pelvic
Disproportion) 2. Uterine dysfunction, inertia, inability of cervix
to dilate 3. Neoplasm obstructing birth canal or pelvis 4.
Malposition and malpresentation 5. Previous uterine surgery
(cesarean delivery, myomectomy, hysterotomy) or cervical
surgeryevaluated on an individual basis 6. Complete or partial
placenta previa 7. Premature separation of the placenta 8. Prolapse
of the umbilical cord 9. Fetal distress
5. Indications for Cesarean Delivery 10. Active herpes outbreak
11. Breech presentation 12. Indications for cesarean hysterectomy
a. Ruptured uterus b. Intrauterine infection c. Hemorrhage due to
uterine atony d. Laceration of major uterine vessel e. Severe
dysplasia or carcinoma in situ of the cervix f. Placenta accreta g.
Gross multiple fibromyomas
6. Management 1. NPO (except possibly ice chips) during labor
2. A blood sample should be typed and screened and available to be
crossmatched if needed; a CBC is obtained. 3. Anesthesia, regional
or general, depends on the indication for surgery. 4. A large-bore
IV is established. 5. Foley catheter is inserted. 6. Skin prep;
from apex to pubic line, both sideline are bed line
7. Cesarean section
8. Complications 1. Increase in morbidity and mortality
compared with a vaginal birth 2. Hemorrhage, endometritis 3.
Paralytic ileus, intestinal obstruction 4. Pulmonary embolism,
thrombophlebitis 5. Increased chance of prematurity 6. Respiratory
depression of the infant from anesthetic drugs 7. Possible delay in
maternal-infant bonding
9. Nursing Assessment A. Before Delivery 1. Assess knowledge of
procedure. 2. Monitor maternal and fetal vital signs. 3. Determine
maternal blood type and Rh. 4. Determine last time the woman ate.
5. Identify drug allergies.
10. Nursing Assessment B. After Delivery 1. Assess maternal
vital signs every 15 minutes the first hour, every 30 minutes the
second hour, and hourly until she is transferred to the postpartum
unit or per facility protocol. 2. Evaluate fundal position and
firmness along with vital signs. 3. Evaluate amount and type of
lochia along with vital signs. 4. Assess condition of the incision
line or dressing. 5. Monitor urinary output, presence of bowel
sounds. 6. Assess level and presence of anesthesia or pain. 7.
Auscultate lung sounds, maternal oxygen saturation. 8. Assess
maternal-infant bonding.
11. Nursing Diagnoses A. Anxiety related to cesarean delivery
B. Pain related to surgical procedure C. Risk for Infection related
to traumatized tissue D. Risk for Altered Parenting related to
interruption in bonding process
12. Nursing Interventions A. Relieving Anxiety 1. Explain the
reason for the cesarean delivery. 2. Answer any questions the woman
and her support person may have regarding a cesarean delivery. 3.
Explain all procedures before doing them. 4. Allow the support
person to attend the birth.
13. B. Promoting Comfort 1. Encourage use of relaxation
techniques after medication has been given for pain. 2. Monitor for
respiratory depression up to 24 hours following epidural narcotic
administration. 3. Use a back rub and a quiet environment to
promote the effectiveness of the medication. 4. Support/splint the
abdominal incision when moving or coughing and deep breathing. 6.
To reduce pain caused by gas, encourage ambulation and the use of a
rocking chair
14. C. Preventing Infection 1. Preoperatively skin preparation
includes; shaving, shave skin carefully, avoiding any nicks in the
skin. Then, carry out surgical skin preparation correctly. 2.
Postoperatively, use aseptic technique when changing dressings. 3.
Provide perineal care every 4 hours or as needed. 4. Provide
routine postoperative care measures to prevent urinary or pulmonary
infection.
15. D. Promoting Effective Bonding 1. Encourage the woman and
her support person to discuss their feelings regarding the cesarean
birth both before and after the delivery. 2. Encourage mother-child
bonding as soon as possible. 3. Emphasize that adjustments to
parenting under any circumstances are necessary and normal.
16. Patient Education/Health Maintenance 1. Teach the woman the
"football hold" for breastfeeding so that the infant is not lying
on her abdomen. 2. Teach the woman to observe for signs of
infection (foul-smelling lochia, elevated temperature, increased
pain, redness and edema at the incision site) and to report them
immediately. 3. Assist the woman in planning for the assistance of
friends, family, or hired help at home during the period
immediately after discharge.
17. Evaluation A. Verbalizes an understanding of the cesarean
birth procedure and postdelivery care B. Reports relief of pain C.
Has no signs of infection D. Participates in care of self and
infant
18. EPISIOTOMY An episiotomy is an incision of the perineum
during delivery to: Substitute a straight surgical incision for the
laceration that may otherwise occur Facilitate repair of laceration
and promote healing Spare the infant's head from prolonged pressure
and pushing against the rigid perineum, which may result in brain
damage, especially in the premature infant Shorten the second stage
of labor
19. Types of Episiotomies A. Median (Midline) 1. Incision is
made in the middle of the perineum and directed toward the rectum
2. This method is believed to heal with few complications, is more
comfortable for the woman during healing, is easy to repair, and is
associated with minimal blood loss. 3. If a larger incision is
needed during delivery, however, it may necessitate incision into
anal sphincter.
20. B. Mediolateral 1. Incision is made laterally in the
perineum. 2. This method avoids the anal sphincter if enlargement
is needed. 3. Women find it extremely uncomfortable during healing.
4. Associated with increased blood loss 5. Necessitates longer
wound healing time
21. Management 1. Pain relief a. The stretching of the perineum
and pressure from the fetal head may provide a natural numbing
effect. b. Local perineal infiltration with lidocaine provides
anesthesia for performing and repairing the episiotomy. c. A
pudendal block provides anesthesia to the lower two thirds of the
perineum and vagina using lidocaine injection into the vaginal
walls. d. Epidural anesthesia provides anesthesia from the level of
of the umbilicus to the mid-thigh area. 2. The episiotomy is
performed when the fetal head is about 3 to 4 cm visible with a
contraction. 3. The repair of the episiotomy usually begins after
the delivery of the placenta.
22. Complications 1. Infection 2. Increased risk of blood loss
3. Third and fourth degree lacerations 4. Episiotomy pain 5. Risk
for hematoma 6. Dyspareunia (pain during intercourse), which may
last up to 6 months
23. Nursing Assessment During the recovery period the
episiotomy should be evaluated every 15 minutes and three times a
day after this. 1. Describe and document the degree of healing. 2.
Assess for infection, which may be indicated by edema, redness,
purulent drainage at the site; increased temperature. 3. Notify
health care provider of bleeding at site, other than slight oozing.
4. Monitor for hematoma formation.
24. Nursing Diagnoses A. Risk for Infection related to
traumatized tissue B. Pain related to surgical procedure
25. Nursing Interventions A. Preventing Infection 1. Instruct
the woman to cleanse from the front to the back. 2. Provide
instructions on techniques used for perineal care 3. Explain the
importance of changing the perineal pad each time after urination
and defecation and of not touching the inner surface of the pad. 4.
Explain the importance of proper handwashing before and after
perineal care. 5. Explain that perineal care should be carried out
after urination and defecation and at least every 4 hours during
the day. 6. Encourage a diet that is high in protein and vitamin C
and encourage at least 2,000 mL of fluid each day.
26. Hand washing saves lives!
27. B. Promoting Comfort 1. Apply ice packs to the perineal
area for the first 24 hours after delivery. The ice packs should
not remain in place longer than 30 minutes at a time to get the
maximum benefit for the treatment. 2. Encourage sitz baths with
either warm or cool water. The warm water is soothing, whereas the
cool water helps to decrease pain sensation and edema. 3.
Administer pain medication and topical anesthetics as ordered. 4.
Instruct the woman to tighten her buttocks and perineal muscles
before sitting in a chair and to release the muscles once
seated.
28. Evaluation A. No evidence of infection; afebrile B.
Demonstrates increase in comfort
29. FORCEPS DELIVERY Obstetric forceps are designed for
rotating or extracting the fetal head. Forceps consist of two
pieces: a right blade, which is slipped into the right side of the
mother's pelvis, and a left blade, which is slipped into the left
side.
30. Forcep Delivery
31. VACUUM EXTRACTION A vacuum extractor applies suction to the
fetal head, creating an artificial caput within the suction cup,
thus allowing adequate traction for delivery of the infant's head.
Classification is the same as for forceps delivery.