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 transverse—incision made
transversely in lower segment of uterus;
incision of choice
2. Classical—vertical 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
surgery—evaluated 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
9. 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
10. 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.
11. 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.
12. 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
13. 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.
14. 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
15. 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.
16. 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.
17. 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.
18. 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
19. 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
20. 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.
21. 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
22.
23. 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.
24. 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
25. 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.
26. Nursing Diagnoses
A. Risk for Infection related to traumatized
tissue
B. Pain related to surgical procedure
27. 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.
29. 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.
31. 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.
33. 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.
