A Cesarean section (C-section) is the surgical removal of the baby from the abdomen. C-sections may be elective or required due to emergency complications.
There are several reasons a baby cannot or should not be delivered vaginally. For instance, a Cesarean delivery is frequently advised if the patient has a history of uterine rupture or a previous classical Cesarean scar. Labor that is not progressing as it should is the most common reason for a C-section.
Cesarean section is considered a major surgery as an incision is made through the abdomen and uterus. Risks include infection, blood loss, anesthesia reactions, and injury to other internal organs. C-sections require a longer hospital stay and recovery.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Deficient Knowledge
- Impaired Tissue Integrity
- Risk for Bleeding
- Risk for Impaired Attachment
Nursing Process
The nurse is heavily involved in the delivery process and caring for the mother and fetus before and after a c-section birth. A mother who is not prepared for a c-section delivery will require education and support from the nurse on what to expect and why it is necessary for the safety of the mother and baby. The nurse will continue to monitor the mother following surgery for potential complications.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to C-sections.
Review of Health History
1. Assess the indication for C-section.
- Maternal considerations include the following:
- Maternal pelvis deformities or disproportions
- Previous C-section
- Previous surgery or injury in the pelvis, reproductive or rectal area
- Existing tumor or mass in the reproductive area
- Transmittable diseases (such as herpes simplex or HIV)
- Conditions that may put the mother at risk during labor and delivery (such as cardiac or pulmonary diseases)
- Multiparity pregnancy
- Uterine/anatomical considerations include the following:
- Abnormal placenta (such as placenta previa, placenta accreta)
- Cervical issues
- Prior classical hysterotomy
- Fetal considerations include the following:
- Irregular fetal heart rate
- Fetal distress
- Umbilical problems (such as cord prolapse)
- Malpresentation
- Large fetus (macrosomia)
- Congenital anomaly
2. Ask the patient’s opinion about having a C-section.
Cesarean sections can be planned and prepared for before the delivery and are referred to as an elective Cesarean. Most mothers prefer a vaginal delivery and may feel disappointed if it isn’t possible. Prepare the mother for the possibility of a C-section if labor is not progressing.
3. Determine the risks C-sections may carry.
C-sections may increase the risk of the following:
- For babies:
- Breathing difficulties
- Fetal injury
- For mothers:
- Infection
- Blood loss
- General anesthesia effects
- Blood clots
- Surgical injury to the bowel or bladder
- Increased risk of complications in the next pregnancy
4. Document reports of pain.
Pain after delivery is expected due to surgical incision and uterine contraction. However, monitor closely for increased or unresolved pain that can indicate complications.
5. Assess for patient support to aid recovery.
Cesarean section is considered a major surgery as an incision is made through the abdomen and uterus. C-sections require a longer hospital stay with weeks of recovery after discharge. Inquire about the patient’s support system for the first days and weeks.
Physical Assessment
1. Assess the patient’s abdomen.
Assess the patient’s fundus and surgical incision. Look for signs of bleeding and return of the uterus to its original position and size.
2. Check for uterine involution.
Uterine involution is the return of the uterus to its pre-pregnancy state. Symptoms of normal uterine involution include:
- Afterpains from uterine contraction
- Presence of lochia (postpartum vaginal discharge)
- The amount of lochia decreases over the next two weeks and turns from dark red to pinked-brown to white or yellow
3. Monitor vital signs, urine output, and vaginal discharge.
Vital signs (heart, respiratory rate, and blood pressure), urine output, and vaginal discharge can reflect early signs of bleeding and hypovolemic shock.
4. Assess for postpartum depression.
A challenging labor or an unexpected C-section might bring on feelings of anxiety, depression, and guilt that affect maternal-infant bonding.
Diagnostic Procedures
1. Obtain laboratory tests prior to C-section.
Before having a Cesarean delivery, the following laboratory tests may be collected:
- Complete blood count
- Blood type and screen
- Cross-matching
- Screening tests for HIV, hepatitis B, syphilis
- Coagulation studies
2. Assess the fetus’ status.
Fetal position and an estimated fetal weight should be recorded during labor and delivery. The most frequent method for estimating fetal weight is ultrasound. Fetal macrosomia is an indication for C-section.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions related to C-sections.
Provide Preoperative Care
1. Provide health teaching to the patient.
Patients and their partners should be informed about the possibility of Cesarean delivery as part of prenatal care. Expectations before, during, and after C-sections should be explained to the patient. The mother should be made aware of possible complications from a C-section, such as infection, blood loss, organ injury, as well as maternal or fetal death. The mother should be made aware that C-sections increase the risk of the following with future pregnancies:
- The need for future C-sections
- Uterine rupture
- Placenta abnormalities
- Ectopic pregnancies
- Stillbirth
- Preterm labor
2. Provide pre-op instructions.
In the event of scheduled C-sections, provide thorough pre-op instructions, including when to stop eating and drinking before the procedure, medications safe to take before surgery, hygiene care the night before, and what items to bring to the hospital.
3. Administer pre-op meds.
Preoperative medications include:
- Antacids
- Histamine H2 antagonist
- Pain medication
- Antibiotic prophylaxis
4. Prep and disinfect the site.
Chlorhexidine has proven efficient for preparing the abdominal skin to reduce infection following Cesarean.
Implement Postoperative Care
1. Prevent post-operative complications.
Any maternal comorbidities (anemia, diabetes, hypertension, obesity) increase the risk of complications and should be monitored closely.
2. Manage pain.
A C-section often necessitates a two- to three-day hospital stay. Options for pain management will be discussed with the patient. Administer prescribed pain medications and institute non-pharmacological pain interventions.
3. Resume oral intake as ordered.
Encourage oral fluids after the anesthetic starts to wear off. The patient will need to consume a regular diet without vomiting before discharge.
4. Encourage early ambulation.
Early ambulation encourages the patient to move around within 6 hours following surgery. Early ambulation benefits include:
- Reduced need for opiate painkillers
- Bowel motility to prevent constipation
- Decreased risk of deep vein thrombosis
- Improved oxygenation and blood flow
5. Perform wound care.
Observe the incision for signs of infection, such as swelling, erythema, or drainage. The incision site will be sore initially. Instruct the patient to gently wash the area at home and not submerge in a bathtub.
6. Avoid heavy lifting and chores.
Advise the patient to lift only things less than the baby’s weight for the first six to eight weeks. Utilize others for assistance with household chores.
7. Consult about sex and contraceptives.
Advise the patient and her partner that they can resume sexual intercourse after six weeks. Consult with the healthcare provider regarding contraception.
8. Encourage breastfeeding.
Initiate breastfeeding as soon as possible. Refer to a lactation nurse or consultant to teach the patient how to support the baby and position herself comfortably.
9. Allow expression of feelings and emotions.
Allow verbalizations and expression of feelings and emotions. Some mothers will feel relieved, while others may feel sad or guilty about having a C-section. Listen to the patient and her partner and intervene if emotions are concerning for signs of depression.
10. Teach the patient when to seek medical attention.
Seek medical attention if the following signs are present:
- Persistent and increasing pain
- Vaginal bleeding that becomes heavier and consists of large clots
- Inflamed (mastitis) and engorged breasts
- Swelling, pain, or redness in one leg (deep vein thrombosis)
- Infection
- Fever
- Chills
- Unusual discharge from the incision site
- Postpartum depression
- Difficulty bonding with baby
- Insomnia
- Loss of appetite
- Hopelessness
11. Remind the patient about their follow-up care.
Follow-up appointments after discharge will be scheduled 2 to 3 weeks after the C-section. Continuous postpartum evaluation will be done within 12 weeks after delivery.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for C-sections, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for C-setions.
Deficient Fluid Volume
Patients who underwent C-section delivery can have problems with deficient fluid volume due to blood loss during or after the surgery. There is a higher risk for excessive bleeding for C-section delivery due to a noncontracted uterus, surgical incision, and internal blood vessels that were not securely closed during the procedure.
Nursing Diagnosis: Deficient Fluid Volume
Related to:
- Blood loss
- Surgical procedure
- Loss of vascular integrity
- Insufficient fluid intake
As evidenced by:
- Alteration in skin turgor
- Decreased blood pressure
- Decreased pulse volume
- Decreased pulse pressure
- Decreased venous filling
- Decreased urine output
- Dry mucous membranes
- Dry skin
- Increased heart rate
- Increased body temperature
- Weakness
Expected outcomes:
- Patient will maintain blood pressure, heart rate, and body temperature within normal limits.
- Patient will display a urine output of 0.5 to 1.5 mL/kg/hr.
Assessment:
1. Assess for any signs of bleeding.
Bleeding can occur at the incision site, from a noncontracted uterus, or damage to internal organs. The nurse must remain aware of signs of intravascular fluid loss, such as hypotension, tachycardia, and alterations in lab values.
2. Assess for any signs and symptoms of hypovolemia.
Signs and symptoms of hypovolemia include cyanosis, cold, clammy skin, confusion, restlessness, weak thready pulse, and oliguria. These symptoms occur due to the compensatory mechanism as the body moves fluid from the interstitial space into the vascular compartment.
3. Monitor urine output.
Patients undergoing C-section delivery often have a urinary catheter inserted that remains for at least 8 hours post-op. The nurse should closely monitor the patient’s intake and output for alterations in fluid balance.
Interventions:
1. Administer IV fluid replacement as indicated.
Fluid replacement, including crystalloid solutions, is given to resolve fluid volume deficiency in C-section patients who are bleeding and dehydrated.
2. Encourage adequate fluid intake.
While there is no specific time to restart an oral diet after a C-section, most women will be allowed ice chips and sips before resuming a light diet 8 hours later.
3. Administer medications as indicated.
Oxytocin is routinely administered in patients after vaginal or C-section delivery to prevent postpartum hemorrhage and prevent possible fluid volume deficit complications.
4. Perform fundal massage as indicated.
Fundal massage can help initiate uterine contractions that address uterine atony and help with the expulsion of retained placenta and clots. This action counteracts bleeding in patients who deliver vaginally or via C-section.
Deficient Knowledge
Deficient knowledge associated with Cesarean delivery can be caused by a lack of information or misinterpretation regarding expectations, postoperative care, and self-care needs.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Inadequate knowledge of Cesarean delivery
- Misinterpretation of Cesarean delivery
- Unpreparedness for changes during and after delivery
- Lack of information about postpartum care
- Insufficient knowledge of postoperative needs
As evidenced by:
- Verbalization of concerns
- Inquiries about what to expect with Cesarean delivery
- Misconceptions about Cesarean delivery
- Inaccurate or insufficient instructions in postoperative self-care
- Development of preventable complications
Expected outcomes:
- Patient will be able to verbalize understanding of expected body changes after C-section.
- Patient will be able to identify behavior and lifestyle modifications required during the recovery from C-section.
Assessment:
1. Identify the patient’s knowledge level.
Before customizing health education, the nurse must first gauge the patient’s familiarity with C-sections and her expectations after the delivery. The nurse can then create the proper instructions.
2. Set realistic goals and expectations.
Goals and expectations should be defined for adherence and to identify areas for development.
3. Assess for myths and cultural beliefs about C-sections.
Cultural beliefs may impact the understanding of C-sections. The nurse must recognize cultural norms to filter the information and distinguish between facts and myths. Prioritize correct information while simultaneously remaining unbiased throughout health teaching.
Interventions:
1. Create a birth plan.
Every pregnancy is unique, and every mother has different expectations for delivery. A birthing plan needs to be flexible, but assisting the mother in identifying her expectations will reduce stress and promote readiness.
2. Provide information through different resources.
Some mothers might need information that is easier to understand or available in videos, while others prefer written leaflets or booklets. Provide verbal instructions using plain language.
3. Discuss post-op care.
Provide education on pain control following surgery, monitoring and cleaning the incision, and not performing strenuous activities to allow for healing. Full recovery usually takes 4-6 weeks.
4. VBAC after C-section.
Many women inquire about the ability to have a Vaginal Birth After Cesarean section (VBAC). This is a possibility as 60-80% of women do have vaginal births after a C-section. Educate the patient on their unique risk factors and considerations.
Impaired Tissue Integrity
C-section or Cesarean birth is a surgical intervention used to deliver a baby by making an incision to the abdomen and uterus. With this surgical incision, skin and tissue integrity is disrupted, and it will take approximately 6 weeks to heal from the procedure completely.
Nursing Diagnosis: Impaired Tissue Integrity
Related to:
- Surgical procedure
- Risk for infection
- Insufficient knowledge about maintaining tissue integrity
As evidenced by:
- Surgical incision
- Poor wound healing
- Presence of abscess
- Surgical site bleeding
- Dehiscence
- Incision swelling
- Incision erythema
- Incision drainage
- Prolonged incision pain
Expected outcomes:
- Patient will perform appropriate wound care interventions to protect and heal surgical incisions.
- Patient will exhibit incision healing, including approximation without signs of infection.
Assessment:
1. Assess the surgical incision and note for signs of poor healing.
Wound characteristics like color, size, drainage, and odor must be assessed to determine if a developing infection is present. Pale tissue color can indicate circulatory and oxygenation problems, while erythema, swelling, drainage, or foul odor can indicate infection.
2. Assess laboratory test results.
Laboratory test results, including WBC, albumin, prealbumin, and protein levels, can indicate malnutrition and infection, which disrupts wound healing and recovery.
3. Assess the patient’s pain characteristics.
Surgical incisions can be very painful, especially after the effects of anesthesia have faded. Pain that does not decrease over time signals a concern with tissue perfusion.
4. Assess the patient’s nutritional status.
Poor nutritional intake can increase the risk of delayed wound healing and impaired tissue integrity from C-section surgery. Protein is especially important for new cell formation at the surgical incision site.
Interventions:
1. Encourage proper wound care.
The incision site must be cleaned as instructed to improve tissue integrity and promote proper wound healing.
2. Instruct the patient to avoid driving, lifting, or performing strenuous activities.
Strenuous activities can add pressure on the abdomen and the surgical site and may cause complications like bleeding, wound dehiscence, and delayed healing.
3. Administer medications as indicated.
Antibiotics and pain medications are indicated to help with pain control and infection prevention in patients who underwent C-section delivery. Pain that is not adequately controlled causes stress and disrupts the healing process.
4. Encourage ambulation.
Ambulation promotes circulation, which promotes wound healing, improves tissue integrity at the incision site, reduces pain, and promotes timely recovery after C-section delivery.
5. Encourage the use of abdominal splints, especially during breastfeeding.
Abdominal splints like pillows placed on the surgical site are encouraged to help deflect the infant’s weight from the suture line, lessen pain, and improve mobility.
Risk for Bleeding
Risk for bleeding associated with Cesarean delivery can be caused by severe blood loss after delivery (postpartum hemorrhage) and pregnancy-related complications.
Nursing Diagnosis: Risk for Bleeding
Related to:
- Increasing maternal age
- Obesity or high body mass index
- Previous uterine scar
- Pregnancy-related conditions such as preeclampsia
- Placenta previa
- Placental abruption
- Multiple fetuses
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will not experience heavy post-surgical bleeding.
- Patient will demonstrate an expected amount of lochia daily after delivery.
- Patient will be able to manifest signs of uterine involution.
Assessment:
1. Determine risk factors for bleeding.
A thorough assessment of the bleeding risk includes the past and present medical history of bleeding disorders before and during pregnancy.
2. Assess coagulation factors.
Lab work can be monitored such as aPTT and PT to assess coagulation factors and the risk for bleeding.
3. Assess the uterus.
For women who try a vaginal delivery after a previous C-section, the chance of the uterus rupturing along the scar line (uterine rupture) increases.
4. Assess for signs and symptoms of bleeding.
- Increased heart rate (tachycardia)
- Dyspnea
- Bruising on the skin of the abdomen other than the incision site
- Bloated or distended abdomen
- Abdomen that is painful to the touch
- Faintness or dizziness
- Cold, clammy extremities
- Severe vaginal bleeding (more than one pad an hour)
- Passing large clots
5. Assess the patient’s intake and output.
Autoregulatory systems divert blood flow primarily to the brain, heart, and adrenal system in the early stages of hypovolemic shock. Patients may initially exhibit lower urine production because the flow is diverted from less vital organs.
6. Monitor blood pressure.
In the early stages of hypovolemic shock, there is a decrease in blood pressure due to blood vessel constriction.
7. Assess lochia characteristics.
After C-section, the bleeding should lessen over the next few days. After a few weeks, the lochia’s color will change from red to brown, lighter red to pale pink, and eventually white. Additionally, a few residual clots should be released, but they should be smaller and appear less often than in the first few days following delivery.
Interventions:
1. Perform fundal assessment.
The size, level of firmness, and rate of descent of the uterus can be assessed postpartum by palpating the uterine fundus, measured in fingerbreadths above or below the umbilicus.
2. Evaluate the incision.
The C-section incision should appear consistent in color as it begins to transition from red to pink. As healing occurs, the c-section scar should become less sensitive to touch.
3. Advise early ambulation.
Early ambulation after C-section ensures appropriate uterine involution, promotes the descent of the lochia, and improves the function of the bladder, intestines, and blood circulation, preventing thrombosis.
5. Count the pads.
After giving birth, pads must be replaced every hour or two. Over the next two days, this will decrease to every three or four hours. Soaking more than one pad an hour is abnormal.
Risk for Impaired Attachment
Risk for impaired attachment associated with Cesarean delivery can be caused by separation and a difficult pregnancy/birth. It may also occur postpartum due to a situational crisis (such as surgery, physical complications interfering with first interaction, anxiety, etc.).
Nursing Diagnosis: Risk for Impaired Attachment
Related to:
- Separation
- Existing health conditions of the mother or infant
- Lack of privacy
- Unfamiliarity with parental role
- Trauma from surgery/difficult birth
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will be able to verbalize an understanding of conditions that disturb the maternal-fetal dyad.
- Patient will demonstrate nurturing measures toward infant.
- Patient will engage in mutually beneficial interactions with infant.
Assessment:
1. Identify causative factors.
Identify possible factors that can cause impaired attachment such as depression, family dynamics, and a difficult birthing process.
2. Assess the parent and newborn interaction.
Take note of the parent’s behavior toward the child. Watch for any hesitancy or lack of interest in feeding or changing the newborn’s diaper.
3. Assess family support.
Financial constraints, lack of participation in groups or particular resources, and absence of immediate and extended family support can make it more challenging to develop an attachment to the newborn.
Interventions:
1. Encourage mother-newborn bonding time.
Keeping the baby in a bassinet by the bedside and instructing the parents on how to care for the newborn (such as feeding, holding, swaddling, and bathing their baby) gives them plenty of opportunities to bond.
2. Assess for postpartum depression.
A difficult birthing process or an emergency C-section can delay bonding and cause feelings of fear, depression, and guilt.
4. Encourage time for the mother.
Remind the mother to find healthy outlets for their needs and take breaks. Plenty of support is required while recovering from C-section surgery.
5. Offer resources.
Recovering from a C-section without the support of a partner or family raises additional difficulties. Provide community and hospital resources to help with the transition.
References
- C-section (Cesarean section): Procedure, risks & recovery. (2022, August 14). Cleveland Clinic. Retrieved May 2023, from https://my.clevelandclinic.org/health/treatments/7246-cesarean-birth-c-section
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Kolås, T., Øian, P., & Skjeldestad, F. E. (2010). Risks for preoperative excessive blood loss in cesarean delivery. Acta Obstetricia et Gynecologica Scandinavica, 89(5), 658-663. https://doi.org/10.3109/00016341003605727
- Martinez, L. (2022, November 21). Going home after a C-section. MedlinePlus – Health Information from the National Library of Medicine. Retrieved May 2023, from https://medlineplus.gov/ency/patientinstructions/000624.htm
- Mayo Clinic. (2022, June 16). C-section. Retrieved May 2023, from https://www.mayoclinic.org/tests-procedures/c-section/about/pac-20393655
- MedlinePlus – Health Information from the National Library of Medicine. (n.d.). Cesarean section | C section | MedlinePlus. https://medlineplus.gov/cesareansection.html
- Milton Keynes University Hospital. (2021, March 16). Caring for your wound after having a caesarean section. Retrieved May 2023, from https://www.mkuh.nhs.uk/patient-information-leaflet/caring-for-your-wound-after-having-a-caesarean-section
- National Center for Biotechnology Information. (2022). Cesarean section – StatPearls – NCBI bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK546707/
- Saint Louis, H. (2022, April 14). Cesarean delivery: Overview, preparation, technique. Diseases & Conditions – Medscape Reference. Retrieved May 2023, from https://emedicine.medscape.com/article/263424-overview#showall
- Silvestri, L. A., & CNE, A. E. (2019). Prenatal Period. In Saunders comprehensive review for the NCLEX-RN examination (8th ed., pp. 637-664). Saunders.
- Stanford Medicine. (n.d.). Default. Stanford Medicine Children’s Health – Lucile Packard Children’s Hospital Stanford. Retrieved May 2023, from https://www.stanfordchildrens.org/en/topic/default?id=meconium-aspiration-90-P02384
- Sung, S., & Mahdy, H. (2022, September 18). Cesarean section – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved May 2023, from https://www.ncbi.nlm.nih.gov/books/NBK546707/
