Cesarean Birth

Author: Daren Sachet, RNC, BSN, MPA

Cesarean Birth Objectives

Discuss the implications for cesarean birthList the components of providing a safe surgical

environmentDescribe potential complications related to cesarean

birth

Indications

Previous Uterine Scar Labor Dystocia

Cephalopelvic disproportion, arrest of labor

Fetal malposition or malpresentation e.g. breech, transverse lie

Fetal intolerance of labor Disease, or anomaly Fetal macrosomia Prolapsed Cord

Indications Continued

Active genital herpesUterine RupturePlacental abnormality

Placenta previaAbruptio placentaUterine Rupture

Total C/S Rates

C/S Rates in the U.S.National Vital Statistics Report Vol. 58, No. 16

Year 2006 2007 2008 2009

VBAC rate

8.5 (adjusted

)

Unavail Unavail Unavail

Primary C/S rate

28.4(adjusted

)

29.0(prelim)

Unavail Unavail

Previous C/S

92 Unavail Unavail Unavail

All C/S rate

31.1 31.8(prelim)

32.3(prelim)

32.9

VBAC/TOLAC VBAC---vaginal birth after cesareanTOLAC---trial of labor after cesarean

Decision makingNon-repeating condition (why was previous

cesarean done?)Desire to avoid cesarean birthAbility to do emergency cesarean birthBenefits mother by shortening recovery time

RisksPossibility of uterine rupture (what kind of incision

was made on uterus?)

Successful VBACHow can we help?

Review prenatal record for risksEnsure informed consent, Additional consent if

oxytocin is used, as risk increasesContinuous EFM and 1:1 nursing careAssess for normal labor progression and S/S

uterine ruptureMD must remain immediately available

throughout active laborEnsure ability to perform emergency C/S

Elective Cesarean SectionACOG definition:

A primary C/S at maternal request in the absence of any medical or obstetric indication.

Considerations:Not recommended for women desiring several

children.ACOG Committee Opinion 386: Nov 2007.

Maternal Morbidities Related to Multiple Repeat Cesarean Births

Placenta previa/accretaBlood transfusionHysterectomyInjury to bladder, bowel and other pelvic

organsLonger operating timeIncreased LOS

Obstet Gynecol June 2006;107:1226-32

Infant Morbidities Associated with Cesarean Births

Potential for hypoxiaTTNRespiratory distress syndromePulmonary hypertensionSkin lacerationsBroken clavicle, facial nerve palsy, and other

injuries related to failed vacuum or forceps use

Postpartum Maternal Complications Related to Cesarean Delivery

UTIWound complications

Hematoma, dehiscence, infection, necrotizing fasciitis

Thromboembolic disease Ileus and Bowel dysfunctionAtelectasisEndometritisAnesthetic Complications

Getting Ready Operating Room Preparation

Circulating RN is responsible for operating room readiness

Patients with the same health status and condition should receive a “comparable” level of care regardless of where that care is provided within the hospital.

Joint Commission “Comparable” care to that provided in the

main hospital surgical department is recommended by ASA (2006) and JCAHO (2007); however, “equivalent” care is not required.

Operating Room Preparation

Cleaning of the OREquipment and Supplies

Suction, medical gasesBlood products, implants, devices or special equipment

present?Electrosurgical unitCrash cart, MH suppliesPatient Positioning aidsMedications, are they secure?Are all the needed personnel in place?

Getting ReadyDocumentation required Prior to Surgery

Ensure a current H&P is on the chart

Informed Consent

Pre-Procedural Verification First step done prior to entering the OR.

It includes patient verification and OR readiness.

Second step completed in the OR prior to incision and when all personnel are present

Must be obtained for the Anesthetic procedure as well as for the surgical procedure

Preoperative Patient PreparationNPO, IV preload, Antacids and AntiemeticsFoleyHair Removal and Skin CleansingAntibiotics

“Prophylactic Antibiotic Received within one hour prior to surgical incision or at the time of birth for cesarean section” NQF

DVT ProphylaxisUS if breech

Teaching Patient/FamilyPre operative activities Intra operative expectationsPost operative course

LOSDietAmbulationFoley and IV removalPain controlDischarge planning

– Encourage questions

Personnel and RolesScrubbed Team Un-scrubbed Team Circulating RN

Duties?

Personnel and Roles

Anesthesia

Provider

Scrub Nurse or Tech

Surgeon

Surgical Assist

Personnel and RolesNeonatal Team

Support Person

Infection Control

Cleaning the ORAttire in restricted & semi-restricted areasPersonal Protective EquipmentPersonal HygieneSkin prepsVentilationTraffic Patterns in the OR

Communication in the OR

Procedural Verification, TIME OUT

Keep superfluous conversation to a minimum

Respect the patient, even if “asleep”

Prioritize & Standardize

Surgical Safety

Use a Surgical Safety Checklist

Prioritize Activities

Fire in the OR?

Infection Control

Skin Prep

Types of Incisions

Know your incision site before you prep

Displace uterus in supine position

Skin incision: Vertical Low transverse

Uterine Incision: Low transverse Vertical T

Area of Abdominal Skin Prep

Types of Skin prepsPre-surgical skin prep

Betadine

Chlorhexadine gluconate

Technicare

Other Duties that Keep your Patient Safe

Specimen HandlingLabel fluids on the Sterile FieldSurgical CountsElectosurgical SafetyPositioningKnow the location of SuppliesKnow the InstrumentsDocument!

Anesthesia

RegionalSpinalEpiduralLocal

General

RegionalSpinal

Local anesthetic or local with opiod injected into subarachnoid space to produce motor/sensory block

Risk of hypotension (esp. if mother dehydrated) a bolus of 500cc – 1 L with isotonic solution prior to procedure

Potential for spinal headache

Regional

EpiduralDilute local anesthetic or local with preservative-free

opiod injected into epidural spaceSingle injection , repeat bolus or continuous infusion

Interrupts transmission of pain impulses along nerve roots.Lower doses allow motor function to remain intact

Sympathetic blockade is less than with a spinalIncreased chance for system toxicity related to larger

amount of drug used and absorbed than with a spinalLA Toxicity…what’s that?

General Anesthesia

Indications for General Anesthesia

Goals and Precautions

Circulator Duties

Assisting with General Induction

2 circulators are needed, one devoted to assisting anesthesiologist/CRNA.Positioning for safety and good oxygenation prior to

inductionSkin Prep/draping prior to inductionProtect airway (antacids, cricoid pressure, positioning,

suctioning)Patent IVFoley in place

Phases of Anesthesia

Induction

Maintenance Emergence

Recovery

Commonly Used Induction Medications

Inhalation Agents

IV Anesthetics

Muscle Relaxants

General Induction Sequence

Pre-oxygenate : 3-5 minutes

Pretreat: Induction of “Sleep” Surgeon is ready to cut.

Paralytic dose: of muscle relaxant is given.

Protect, position: Intubation occurs, with Selleck maneuver.

Selleck’s Maneuver (Cricoid Pressure)

General Induction Sequence Continued

Placement: Confirm placement of ET tube. Don’t let go until you are told to do so.

Anesthesia maintained with muscle relaxants, narcotics, inhalation agents.

General Induction Sequence Continued

Reversal of induction

Extubate when fully awake.

Pt moved to PACU when gag reflex, swallowing and spont ventilations are in

place.

Malignant Hyperthermia (MH)

An autosomal dominant inherited muscle disorder that can occur in susceptible people on exposure to certain drugs used to produce general anesthesia or muscle relaxation during anesthesia.

Theory is that MH reactions are set off by sudden release of large quantities of CA++

which increases metabolic activity of muscle. Body fuels are rapidly consumed.

Malignant Hyperthermia

TriggersAll volatile inhalation anestheticsDepolarizing muscle relaxantsSuccinylcholine

Malignant Hyperthermia

blood potassium =rapid, irregular heart rate and possible arrest.

CO2 = rapid, deep breathing O2 = brain damage myoglobin can block kidneys=kidney failure heat= fever, may reach 110F within minutes

Treatment

HELP! Stop the triggering agent(s)Dantrolene within 5 minutesMonitor & Supportive treatmentNotify MHAUS

Complicating Factors for Cesarean Section

ObesityMultiple RepeatsOver distended uterusSubstance abuseHemorrhageOrgan InjuryC-Hysterectomy

Summary

IndicationsPatient and Staff Safety Anesthesia OptionsComplicating factors

FactsStandards

DataC/S Rates

Interpersonal SkillsCommunication

Technical SkillsSkin Prep

Critical ThinkingEthics

References1. Association of Obstetricians and Gynecologists. Vaginal Birth after previous

Cesarean Delivery, Practice Bulletin #115. August 2010.2. Association of Operating Room Nurses. Perioperative Standards and

Recommended Practices, current edition. 3. National Vital Statistics, Volume 58, No 16, electronic version4. World Health Organization, Surgical Safety Checklist URL

http://www.who.int/patientsafety/safesurgery/en5. American Academy of Pediatrics and American College of OB GYN Guidelines for

Perinatal Care, current edition

OB PACU

OBJECTIVES

Discuss PACU Standards of care as related to the OB Unit.

Describe patient assessments and nursing interventions required in the PACU.

Discuss potential complications in the recovery period through case study.

Standards for Staffing a PACU

A registered nurse is present when any patient is recovering. Nurse to patient staffing ratios are based on patient condition and are consistent with other post anesthesia units in the institution.

ASPAN, 2010-2012

Standards for Staffing a PACUPhase I Level of Care

Phase I is the immediate postanesthesia period, transitioning to phase II, the inpatient setting or to an intensive care setting for continued care.

Two registered nurses, one who is a RN competent in phase I postanesthesia nursing, will be in the same unit where the patient is receiving phase I level of care at all times.

ASPAN, 2010-2012

Standards for Staffing a PACUPhase I Level of Care Continued

One nurse to one patient:At the time of admission, until critical

elements* are metRequiring mechanical life support and/or

artificial airwayAny unconscious patient 8 yrs and underA second nurse must be able to assist

Critical Elements for Mom

One nurse to one patient until critical elements are met:

Critical elements for MomReport has been received from the anesthesia care

provider, questions have been answered and the transfer of care has taken place.

The patient is consciousThe Patient has patent airway without assistanceInitial assessment is complete and documentedPatient is hemodynamically stable

A second nurse must be available to assist as needed

ASPAN, 2010-2012AWHONN, 2010

Critical Elements for Baby

One nurse to one patient until critical elements are met:

Critical elements for Baby Report has been received from the baby nurse, questions have been

answered and the transfer of care has taken place Initial assessment and care are completed and documented The baby is conscious and has a patent airway without assistance The baby is stable Initial assessment is complete and documented Identification Bracelets have been placed

A second nurse must be available to assist as needed

ASPAN, 2010-2012AWHONN, 2010

Staffing a PACUPhase I Level of Care

When can we have one nurse to two patients in OB PACU?

When must we have two nurses to one patient?

ACLS QUALIFIED OR NOT?

Defined by patient status, not by time frameASPAN 2010-2012

Recoveryaka

Post Anesthesia CareHow Long?

Recoveryaka

Post Anesthesia CareWhere?

Admission to the OB PACU Room Set up and Equipment

For Phase I each patient bedside needs to have present the following items.

Artificial airways and means to deliver O2

Constant and Intermittent Suction

Means to monitor BP,T, EKG and Pulse oxymetry

IV Supplies and stock medications

Admission to the OB PACU Room Set up and Equipment

Stock supplies such as dressings, gloves, emesis basins, tape, etc.

Adjustable lighting and mode of warming a patientEmergency Cart with defibrillator and ventilator available

Malignant Hyperthermic Supplies

Patient Privacy

On transfer to Recovery (OB PACU)

Report

Rapid assessment

Dismiss Anesthesia Provider

Respiratory

AssessmentInspection, Auscultation/Listening, Pulse oxymetry

Supportive Respiratory EquipmentBag-Valve with mask or ET Tube, LMA, ET Tubes, Nasal

Trumpets, Oral Airways, suction and oxygen

Nursing InterventionsPrevent atalectasis and venous stasisStimulate to take cough & deep breath every 10-15 minutes.

Record RR at least every 15 minutes while in recovery Use incentive spirometer for smokers.Encourage and assist position changes

Respiratory Complications and Nursing Actions

AspirationMechanical ObstructionLaryngospasmBronchospasmPulmonary EdemaPulmonary Embolism

Cardiovascular

Cardiovascular AssessmentInspectionAuscultationMonitor B/P, I&O, Pulse rate/quality& EKG

Reproductive

Assessment

Potential Complications

Nursing Interventions

Emergency medications

Renal/Fluids and electrolytes

Assessment I&O, appearance of urine Edema, Chemistries

Potential changesin pregnancy

Influence on Action of Non-depolarizingNeuromuscular Blockingagents

Magnesium Increase will potentiate

Decrease in SerumCalcium

Prolongs effects

Dehydration Potentiates action

Sodium deficit Prolong the block

Gastrointestinal

Assessment

Interventions

Female 20% 1 point

Nonsmoker

20% 1 point

HX PONV 20% 1 point

Postop opiods

20% 1 point

Chance for PONV

80% 4 points

Neuromuscular/Sensory

AssessmentLOCEmotional StatusDTRsTemperatureDermatome levelsMotor movementRespirations

Neuromuscular/Sensory

Potential Complications

Safety Measures

Comfort and Pain Control

Assessment

Attitudes

Nursing Actions

Maternal/Infant Attachment

Attachment and Interaction

Nursing Actions

Putting It All Together

Frequency of Assessments for Mom BP, P, RR, O2 sat should be monitored every 15 minutes for at least 2

hours Vaginal Bleeding should be evaluated continuously

Frequency of Assessments for BabyT, HR, RR, skin color, adequacy of peripheral circulation,

type of respiration, LOC, tone/activity should be monitored and documented at least every 30 minutes until the newborns condition has remained stable for 2 hours

AAP& ACOG 2007

Discharge criteria: Stability of Systems Discharge criteria should be developed in consultation

with and approved by the anesthesia and medical staff.ASPAN 2010-2012

Modified Aldrete ScoreActivity Voluntarily moves all limbs =2

Voluntarily moves 2 limbs = 1Unable to move = 0

Respiration Breaths deep coughs on own = 2Dyspnea/hypoventilation = 1Apnic = 0

Circulation BP +/- 20 mm Hg of pre-anesthetic levels = 2Bp > 20-50 mm Hg of pre-anesthetic levels = 1BP > 50 mm HG of pre-anesthetic levels = 0

Consciousness Fully awake = 2Arousable = 1Unresponsive = 0

Color Natural = 2Pale/blotchy = 1Cyanotic = 0

Score

Putting It All Together

DocumentationPer institutional guidelinesTransfer of patient notation

Giving ReportStandardize bedside handover

Include safety checksPatient statusTransfer of care documentation

Scenario 1 A G2P1 delivers by unscheduled repeat C/S. The delivery was uneventful.

She was given a rapid sequence mask induction because of advanced labor, previous classical incision and maternal anxiety. Upon arrival in PACU, she is in right recumbent position,briefly arrousable, maintaining her airway with good air exchange. VS are stable, O2 saturation is 97% on room air.

After about 10 minutes, you hear gurgling sounds and note she has vomited, then gasped. She begins to cough and gag. You suction her mouth and throat, then administer an antiemetic. She is more awake and has no recurring N/V. Soon, she begins to breath more rapidly and says, “I can’t get enough air.” You notice crowing/stridor on inspiration. Her O2 sat drops to 80’s. Her voice is hoarse and panicky.

What do you suspect? What do you need to know? What do you do? After your interventions, she is breathing more rapidly. Her saturation is

82%. She is fully conscious. What do you do next?

Scenario 2

A 28 year old G2P1 at term is receiving an epidural anesthetic prior to scheduled Cesarean Section. She has no allergies, is in good health with an unremarkable prenatal history.

You assist the woman into a fetal position on her side, and attach monitoring equipment. A liter of LR is hanging and you open it to provide a bolus.

The anesthesiologist proceeds with the epidural. As he finishes injecting the epidural, the woman’s B/P drops to 80/37, her heart rate drops from 84 to 52 and O2 sat falls. She says,”I can’t breathe, my chest is heavy.”

Scenario 3

A 26 year old southeast Asian woman at about 32 weeks, arrives in the recovery room after an emergency C/S, under rapid induction sequence, for abruption. As you proceed with your initial assessment, you note that a red string is tied around her upper abdomen and a pattern of old scars on the woman’s abdomen that look like burns. You know from a class on Transcultural nursing that it is believed this string placed during pregnancy forms a protective circle keeping the baby from harm and that burning the skin allows illnesses and evil out of the mother during her pregnancy.

Scenario 3 (cont)

As you continue with your assessment, the woman’s jaw dislocates. You call for the anesthesiologist to assist in realigning her jaw. Recovery proceeds with 2 more incidence of jaw dislocation.

When the woman has recovered from anesthesia and is stable, you prepare to move to her room. You feel that the language barrier has hindered your communication with this woman. Before she leaves you, she tries to tell you something. Frustrated, you are glad an interpreter has been called in for the nurse who is taking over her care. You give report to the new RN. The pt is reunited with her husband in her postpartum room.

Scenario 4

24 yr old G1 with no prenatal care presents to the Birth Center with a prolapsed cord and non-reassuring fetal heart rate pattern. She is taken for emergency C/S. Rapid sequence induction is initiated using propofol and succinylcholine. The anesthesiologist finds he cannot open the pt’s mouth, but can bag/mask ventilate.

Scenario 4 (cont)

After a few minutes of ventilation and propofol boluses, the jaw relaxes and pt is intubated. Anesthesia is maintained with 50% Nitrous Oxide in O2, rocuronium and 1% isoflourane. Baby delivers, surgery is completed and mother is taken to PACU. HR 140, R26, T104

Scenario 5A 31 year old G2/1 is having a scheduled repeat

C/S. Significant Hx is anxiety, breech presentation with this pregnancy and obesity. She has been taken to the operating room where the anesthesiologist is placing an epidural. You are assisting with positioning the patient. After several unsuccessful attempts, the anesthesiologist final gets the epidural placed. With each attempt your patient becomes more anxious. You are now helping to position her in left lateral tilt, and have called the surgeon into the room.

Scenario 5 ContinuedJust as you are placing a bolster under the

patient’s right hip, she says, “ What is happening to me? I feel really strange. “ She is becoming more restless.

What do you think might be happening? How can you help her?

Scenario 5 Continued

Your patient becomes very restless. Her monitors are difficult to read due to her agitation. You notice some twitching of her facial muscles and she tells you “I taste something weird”. Now what do you think is happening?

Scenario 5 Continued Your patient begins to seize. The

anesthesiologist is attempting to protect her airway. What can you do to help? What could happen next? How will you prepare?

Perioperative Nursing in the OB Setting

FactsStandards

Data

Interpersonal Skills

Technical Skills

Critical Thinking

References1. American College of Obstetricians and Gynecologists. (August 2010).Vaginal

Birth After Previous Cesarean Delivery, Practice Bulletin, Clinical Management Guidelines for Obstetrician-Gynecologists, Number115, Washington DC: Author.

2. American Society of Perianesthesia Nurses (ASPAN). (2010-2012). Perianesthesia Nursing Standards and Practice Recommendations. Authors.

3. American Society of Perianesthesia Nurses (ASPAN), current edition. Competency Based Credentialing Program. Authors.

4. Association of Women’s Health Obstetric and Neonatal Nurses Position Statement, (June 2010). Advanced Life Support in Obstetric Settings . Authors

5. Association of Women’s Health Obstetric and Neonatal Nurses. (2010). Guidelines for Professional Registered Nurse Staffing for Perinatal Units. Authors.

6. Association of Women’s Health, Obstetric and Neonatal Nurses. Standards and Guidelines for Professional Nursing Practice in the Care of Women and Newborns, 5th Edition. Authors.

7. Bates, SM, et al. Chest 2008; 133:844-8868. Joint Commission, Updated Universal Protocol, April 20099. Joint Commission, Specifications Manual for Joint Commission National Quality

Core Measures, (2010). http://manual.jointcommission.org/releases/TJC2010A/MIF0167.html

10.Malignant Hyperthermia Association of the United States (MHAUS). Current edition. Understanding Malignant Hyperthermia. Authors.