Far Eastern University

Institute of Nursing

School year 2008-2009

Complete

Research

PAPER(With Reaction Paper)

mADe bY:

cHriSTiaN EsTrella

PreSenTed to:

Ma’Am ViLLanueva

Cesarean Birth

Birth accomplished through an incision into abdominal wall and uterus to deliver fetus. Currently, it is used most often as a prophylactic measure, to alleviate problems of birth

for conditions such as fetal distress, CPD, placenta previa and abruptio placenta, uterine dysfunction, prolapsed cord, diabetes, toxernia, malpresentation, etc.

The skin, underlying muscles and abdomen are opened first and then the uterus is opened allowing removal of the infant.

is a surgical procedure in which incisions are made through a mother's abdomen (laparotomy) and uterus (hysterectomy) to deliver one or more babies. It is usually performed when a vaginal delivery would put the baby's or mother's life or health at risk, although in recent times it has been also performed upon request for childbirths that could otherwise have been natural.

Facts about Cesarean birth Is one of the oldest types of surgical procedures known; a procedure always slightly more

hazardous than vaginal birth. One of the safest types of surgeries and one with few complications compared with other

surgical procedures. More hazards are associated with instrument births and cesarean sections than with

spontaneous births. Babies born by cesarean section are the quietest, crying less than those with born

spontaneously or with the aid of instruments and showing greater lethargy and decreased sensitivity.

Neonatal deaths are more frequent among those born by cesarean section than among those born spontaneously or with the aid of instruments.

A cesarean section or a precipitate labor is likely to result in anoxia, a temporary loss of oxygen in the brain.

Misconception about Cesarean Birth The old saying, “Once a Cesarean, always a Cesarean,” is no longer true.

Explanation: as long as cephalopelvic disproportion does not exist and the previous incision was a low transverse one

Selected Indications for Cesarean Birth

Maternal Factors Active genital herpes or papilloma- which could infect an infant being born

vaginally, and lead to its eventual death. AIDS or HIV-positive status Cephalopelvic disproportion Cervical cerclage-shirodkar suture-a purse string suture of strong non-absorbable

material inserted beneath the cervicovaginal mucosa Disabling conditions such as severe hypertension of pregnancy, that prevent pushing

to accomplish the pelvic division of labor Failed induction or failure to progress in labor expectant mother has diabetes mellitus- possible that there is weak baby; baby can be

hypoglycemic and diabetic Obstructive benign or malignant tumor- which obstruct the birth canal and weaken

the uterine wall. Previous cesarean birth by classical incision

Ruptured uterus Presence of weak uterine scars from previous surgery or cesarean Rapid toxemia--a condition in which high blood pressure can lead to convulsions in

late pregnancy Absence of effective uterine contractions after labor has begun Elective- no indicated risks

Placenta Factors Placenta Previa- when the placenta blocks the infant from being born. Abruptio Placenta- premature separation of the Placenta from the uterine wall and

hemorrhage occurs. Umbilical cord prolapse- when the cord is pushed out ahead of the infant, compressing

the cord and cutting off blood flow

Fetal Factors Compound conditions such as macrosomic fetus in a breech lie Extreme low birth weight Fetal distress- a condition often resulting in a cesarean--was more apt to be detected with

the introduction of electric fetal monitoring. Major fetal anomalies such as hydrocephalus Multigestation or conjoined twins-

Vaginal delivery: if the first presenting part is cephalic or vertex. CS: if the first presenting part is breech.

Transverse fetal lie Nonreassuring fetal heart rate Breech position-involves higher risks for the mother and child, regardless of whether the

delivery is vaginal or cesarean. Obstructed labor--which can occur with a fetus in the shoulder breech, or any other

abnormal position. "dystocia"- a catch-all term meaning difficult labor, was made more frequently and

handled more often with the cesarean operation.

Included under the dystocia, or difficult labor, diagnosis are the following three basic types of problems which may impede labor:

abnormalities of the mother's birth canal, such as a small pelvis; abnormalities in the position of the fetus, including breech position or large fetal size; and abnormalities in the forces of labor, including infrequent or weak uterine contractions.

Risks of Cesarean birth:a.) Hemorrhageb.) Visceral injury to the mother and babyc.) Thrombosisd.) Infection of the incision or the uterus.

e.) Blood clots in the mother’s legs. f.) Problems from the anesthesia, such as nausea, vomiting, and severe headache. g.) Breathing problems in the baby if it was delivered before its due date.

2 Types of Cesarean Birth

Scheduled Cesarean Birth There is time for thorough preparation for the experience throughout the antepartal

period.

Emergency Cesarean Birth Preparation must be done much more rapidly but with the same concern for fully

informing a woman and her support person about what circumstances created the need for a cesarean birth and how the birth will proceed.

Effects of Surgery on a woman

1. Stress Response Whenever the body is subjected to stress, it responds with measures to preserve

the function of major body systems Release of epinephrine and norepinephrine from the adrenal medulla.

2. Interference with Body Defense Strict adherences to aseptic technique during surgery and in the days following the

procedure are necessary to compensate for the impaired skin integrity.3. Interference with Circulatory Function

Extensive blood loss can lead to hypovolemia and lowered blood pressure. This could lead to ineffective perfusion of all body tissues if the problem is not quickly recognized and corrected.

The amount of blood loss in cesarean birth is comparatively high because pelvic vessels are congested with blood waiting to supply the placenta.

4. Interference with the body organ When body organ is handled, cut or repaired in surgery, it may respond with a

temporary disruption in function. Pressure from edema or inflammation as fluid moves into the injured area further

impairs function of the primary organ involved, as well as that of surrounding organs. If blood vessels become compressed as a result of edema, distant organs may be

deprived of blood flow leading to reduced function in those organs.5. Interference with self-image or Self-Esteem

The incisional scar resulting from cesarean birth is not overly noticeable, but its appearance may cause a woman to feel self-conscious later

Although most women accept cesarean birth well, a woman may feel a loss of self-esteem if she believes it marks her as a woman less than others because she was unable to give vaginal birth

NURSING CARE OF A WOMAN ANTICIPATING A CESAREAN BIRTH

Preoperative Interview Done by anesthesiologist or nurse anesthetist Done to obtain a health history and make an assessment and decision for safe use of

anesthesia. Questions and information needed in pre-op interview

1. past surgeries2. allergies to foods or drugs3. current medications4. woman’s knowledge about the procedure5. the length of hospitalization anticipated

6. Any postsurgical equipment to be used (e.g. indwelling catheter or IV fluid line7. any special precautions that will be necessary for her infant

Preoperative Teaching Deep Breathing exercises Incentive Spirometry Turning Ambulation

OPERATIVE RISK FOR A WOMAN AND NEWBORN

Surgical risk assessment includes assessment of:

1. nutritional status2. age3. general health4. fluid and electrolyte balance5. psychological condition

Pre-operative assessment measures usually include:1. vital sign determination2. urinalysis3. blood studies such as CBC, electrolytes, blood typing and cross-matching and sonogram

to determine fetal presentation and maturity

IMMEDIATE PRE-OPERATIVE CARE MEASURES

Informed Consent Overall hygiene Gastrointestinal tract Preparation Baseline I/O determinations Hydration Pre-operative Medication Patient Chart and Presurgery Checklist Transport to surgery Roles of the support Person

NURSING CARE OF A WOMAN HAVING AN EMERGENCY CESAREAN BIRTH

INTRAOPERATIVE CARE MEASURES1. Administration of Anesthesia2. Skin Preparation3. Surgical Incision

TYPES OF CESAREAN INCISION

depends on the presentation of the fetus and the speed with which the procedure will be performed

1. Classic Cesarean Incision The incision is made vertically through both the abdominal skin and the

uterus. It is made high on the uterus so that it can be used with a placenta previa,

to avoid cutting the placenta Advantages: any fetus(es) regardless of uterine orientation

can be delivered; lower segment varicosities or myomas can be bypassed.

Disadvantages: 1. leaves a wide skin scar and also runs through the active contractile

portion of the uterus.2. trial of labor in a subsequent pregnancy is unsafe; the risk of

bleeding and adhesions is higher.

Once the mother has delivered via classical type of CS, the rest of the deliveries will be classical as well to prevent uterine rupture.

2. Low segment Incision Is one made horizontally across the abdomen just over the symphysis

pubis and also horizontally across the uterus just over the cervix This is the most common type of cesarean incision currently used and

also referred as Pfannenstiel incision or a “bikini” incision. Advantages: trial of labor in a subsequent pregnancy is safe; the risk of

bleeding and adhesion is less. Disadvantages: fetus(es) must be in longitudinal lie; the lower segment

must be developed. Done for aesthetic purposes. Vaginal birth (VBAC) is possible after this type of C-section.

Today, the low transverse cervical incision is used almost exclusively. It has thelowest incidence of hemorrhage during surgery as well as the least chance of rupturing in later pregnancies.

Sometimes, because of fetal size (very large or very small) or position problems (breech or transverse), a low vertical cesarean may be performed.

In the classical operation, a vertical incision allows a greater opening and is used for fetal size or position problems and in some emergency situations. This approach involves more bleeding in surgery and a higher risk of abdominal infection. Although any uterine incision may rupture during subsequent labor, the classical is more likely to do so and more likely to result in death for the mother and fetus than a cervical incision.

VAGINAL BIRTH AFTER CESAREAN SECTION If you have had a cesarean delivery (also called a C-section) before, you may be

able to deliver your next baby vaginally.

“Trial of Labor” If you and your doctor agree to try a VBAC

This means that you plan to go into labor with the goal to deliver vaginally.

But as in any labor, it is hard to know if a VBAC will work. You still may need a C-section. As many as 4 out of 10 women who have a trial of labor need to have a C-section

Is a VBAC trial of labor safe to try?

You and your doctor may think about a VBAC trial of labor if:

you have had only one cesarean delivery You have only one low, side-to-side scar from a C-section. You have had 2 cesareans before, but you have also had a

vaginal delivery. The hospital has the staff and tools to do a quick C-section in case you need one. You don't have a reason for a cesarean in this pregnancy, such as a placenta

previa. VBAC is considered safe if you are older than 35, you have a large fetus, or your

pregnancy goes beyond 40 weeks. But these things do lower your chance of being able to deliver vaginally.

VBAC is not considered safe if you have:

Two C-section scars and have not delivered vaginally before. Three or more C-section scars. Any scarring above the lower, thinner part of your uterus.

What are the benefits of a VBAC?

The benefits of a VBAC compared to a C-section include:

Avoiding another scar on your uterus. This is important if you are planning on a future pregnancy-the more scars on the uterus, the greater the chance of problems with a later pregnancy.

Less pain after delivery. Fewer days in the hospital and a shorter recovery at home. A lower risk of infection. A more active role for you and your birthing partner in the birth of your child.

What are the risks of VBAC?

1. The most serious risk of a VBAC is that a C-section scar could come open during . This is very rare, but when it does happen, it can be very serious for both the mother and the baby. The risk that a scar will tear open is very low during VBAC when you have just one low cesarean scar and your labor is not started with medicine. This risk is why VBAC is only offered by hospitals that can do a rapid emergency C-section.

2. If you have a trial of labor and need to have a C-section, your risk of infection is slightly higher than if you just had a C-section.

POST-PARTAL CARE MEASURES

To keep a woman safe after the procedure, remember that she is both a postsurgical and a postpartum patient. Make assessments to ensure that neither postpartum nor post-surgical complications occur.

Adequate pain management is important to allow a woman a sense of control and comfort and bonding with her newborn.

Women are physically exhausted after cesarean birth and may be psychologically exhausted because of the emergency nature of the experience. Provide rest time to relieve the physical strain and a chance to verbalize the experience to help relieve the psychological pain.

A major intervention after cesarean birth is early ambulation to prevent complications. Incisional pain may make this difficult, so strong nursing support and adequate pain management are necessary

REFERENCES

BOOKS Maternal and Child Health Nursing. Care of the Childbearing and

Childrearing family (5th edition) by Adele Pillitteri Developmental Psychology by Elizabeth Hurlock (5th edition) Fundamentals of Nursing by Barbara Kozier et. al. seventh edition

INTERNET www.wikipedia.org www. the-health-pages.com /topics/education/ cesarean .html www. webmd.com /baby/tc/vaginal- birth -after- cesarean -vbac-overview www. webmd.com /baby/tc/ cesarean -section-topic-overview

Reaction Paper

My OR experience was unforgettable and awesome. Standing inside the OR room and function as one of the member of surgical team is not an easy task especially when you’re experiencing it for the first time. I was so nervous when one of our groupmate called me and said that we’re the next one to go to the OR room and function as a scrub

nurse and circulating nurse. I was really tense that time. It was obvious in my action(as you can see while I’m doing the surgical handscrub.) I know the principles, Yes but when you’re now in the real scenario, there will be a temporary block in your mind. I don’t know. But I think I’m not the only one who experience this. At first, I am so hesitant to be a scrub nurse. Of course, there are so many things to do when you’re a scrub nurse. You should know and memorize all the equipments in the mayo table.