1. Surgical Delivery: Cesarean section

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.

32. Vacuum Delivery