Chapter 24: Nursing Care of a

Family During a Surgical

Intervention for Birth
A. Surgical Intervention
1. Amniotomy
is the artificial rupturing of membranes during labor if they do not rupture
spontaneously to allow the fetal head to contact the cervix more directly, which
possibly increases the efficiency of contractions and therefore increases the speed of
labor (Pilliteri & Silbert-Flagg, 2018). If the procedure is scheduled, a woman is
asked to assume a dorsal recumbent position and amniohook or a hemostat is passed
vaginally

 Disadvantage: it puts a fetus momentarily at risk for cord prolapse if a loop of cord
escapes into the vagina with the fluid.
2. Episiotomy
Is a surgical incision of the perineum made to prevent tearing of the perineum,
release pressure on the fetal head with birth, and possibly shorten the last portion of
the second stage of labor (Verghese, Champaneria, Kapoor, et.al., 2016)

 Types of episiotomoy
o Midline episiotomy – incision made in the midline of the perineum
 heal more easily, cause less blood loss, less postpartal discomfort.

o Mediolateral episiotomy – incision begun in the midline but directed laterally away
from the rectum.
 Less danger of a rectal mucosal tear which can result in loss of sphincter function
and fecal incontinence later in life.
3. Procedures for High-Risk Pregnancies
a. Internal Electronic Monitoring
- is the most precise method for assessing FHR and uterine contractions. It is
most often used to assess whether contractions are strong enough to cause
cervical change in the case of a prolonged labor course.
- This can be done by wireless telemetry but is usually managed by a
pressure-sensing catheter passed through the vagina after the membranes
have ruptured and the cervix has dilated to at least 3 cm
- It is then passed into the uterine cavity and alongside the fetus

b. Scalp Stimulation
 - Although not well studied, if a fetus shows an unresponsive heartbeat
during labor, vibroacoustic stimulation can be used the same as is done for
nonstress test during pregnancy to be certain a fetus is responding well to
labor
- This is done to be certain a fetus is responding well to labor. If FHR
variability appears to be depressed during labor, the welfare of a fetus can
be assessed by scalp stimulation. It can be done by applying pressure with
the fingers to the fetal scalp through the dilated cervix

c. Fetal Oxygen Saturation Level

 - This can be measured by an oxygen saturation sensor introduced into the
uterus and placed beside the fetus’s cheek after membranes have ruptured

d. Fetal Blood Sampling

- Monitoring of the fetal blood composition can reveal hypoxia in a fetus.
This is obtained from the fetal scalp following cervical dilatation during
labor.

B. Cesarean Birth
Although cesarean birth may be elected by some women, the procedure is used, most
often as a prophylactic measure to alleviate problems of birth such as cephalopelvic
disproportion, breech or multiple fetus births, or failure to progress in labor

1. Scheduled Cesarean Birth

- These are births that are planned. There is time for thorough
preparation for the experience throughout the antepartal period.
- In the past, many cesarean births were performed because the woman
had undergone a cesarean birth with a previous child; with the new
surgical techniques, particularly the use of low surgical incision, “once
a cesarean, always a cesarean” no longer applies. The majority of
woman who have had a cesarean birth within the past 10 years are
eligible to give birth vaginally in subsequent pregnancies if the
 circumstances are appropriate for vaginal birth. (Iriye, 2015).
- A woman who is admitted to the hospital for an anticipated cesarean birth
may be more worried about the procedure than a woman who is told
during labor an emergent cesarean is necessary. After the woman is
admitted, allow her time to talk about any fears she has. Encourage her to
do as much as possible for herself preoperatively to help her feel in control
and to diminish her fear

2. Emergent Cesarean Birth

- are done for reasons that arise suddenly in labor, such as placenta previa,
premature separation of the placenta, fetal distress, or failure to progress.
- With this second type of cesarean birth, preparation must be done rapidly
but with the same concern for fully informing a woman and her support
person about what circumstances created the need for the cesarean birth
and how the birth will proceed.
- Immediate preparation involves gaining an informed consent, application
of SCDs or elastic stockings, preparing the gastrointestinal tract, adding
bladder catheterization, and establishing an IV line.

SELECTED INDICATIONS FOR CESAREAN BIRTH

 Active genital herpes or human papillomavirus
AIDS or HIV positive status
Cephalopelvic Disproportion
Cervical cerclage
Disabling conditions, such as severe gestational
Birth hypertension, that would prevent
pushing to accomplish the pelvic division of labor
Failed induction or failure to progress in labor
An obstructive benign or malignant tumor
Previous cesarean birth by classic incision
Fear of birth or wish to help prevent uterine prolapse or
urinary incontinence in
later years
Placenta previa
PlacentalFa
Premature separation of the placenta
ctors
Umbilical cord prolapse
Compound conditions such as macrosomic fetus in a
breech lie
Fetal distress
Fetal A major fetal anomaly, such as hydrocephalus
Factors
 Multigestation or conjoined twins
Transverse fetal lie and perhaps breech presentation

C. Effects of Surgery on a Woman

1. Stress Response
- Release of epinephrine and norepinephrine from the adrenal medulla
- Causes:
 Heart rate increases, bronchial dilatation, blood glucose level
elevates
 Leads to vasononconstriction; centralizes circulation, elevates
BP
 These responses increase the risk of thrombophlebitis.

2. Interference with Body Defenses

- The skin serves as the primary line of defense against bacterial invasion, so
when skin is incised for a surgical procedure, this important line of defense
is lost. Strict adherence to aseptic techniques during surgery and in the
days following the procedure is necessary to compensate for this impaired
defense.
- Causes: If the cesarean birth is performed hours after the membranes
rupture, a woman’s risk for infection will be higher than if the membranes
were still intact. Many women receive prophylactic antibiotics, such as
 ampicillin (Omnipen) or a cephalosporin, such as cefazolin (Ancef), to
ensure protection against postsurgical endometritis, even if the membranes
remained intact

3. Interference with Circulatory Function

- Although vessels that must be cut for surgery are immediately clamped
and ligated, some blood loss occurs with surgery.
- Causes: During a vaginal birth, a woman loses 300 to 500 ml of blood.
This loss increases to 500 to 1,000 ml with a cesarean birth

4. Interference with Body Organ Function

- Temporary disruption in function of the uterus. It may not contract well
after incision which can lead to postpartum hemorrhage.
- During surgery, pressure is also felt by the intestine so a paralytic ileus or
halting of intestinal function with obstruction may occur.

5. Interference with Self-Image or Self-Esteem

- Incisional scar may cause a woman to feel self-conscious
- A woman who had planned a vaginal birth may feel loss of self-esteem or
depression if she believes the procedure made her less capable than others
D. Nursing Care for a Woman Anticipating a Cesarean Birth
1. Preoperative Interview
- to obtain a health history and to make assessments and decisions for safety
of the procedure and the use of anesthesia. In addition to these, a nursing
assessment is also essential. Be certain to ask about any past surgeries,
secondary illnesses, allergies to foods or drugs, reactions to anesthesia,
bleeding problems, or current medications to help establish surgical risk,
and any body piercings that need to be removed because of the use of
electrosurgery or an arterial cauterizing machine

 Health history

 Past surgeries

 Secondary illnesses

 Allergies to food and drugs

 Reactions to anesthesia

 Bleeding problems

 Current medications

 Body piercing that needs to be removed

  Include questions to discover the woman’s knowledge about:

o What the procedure will entail

o Length of hospitalization anticipated o If she’s been told about any

postsurgical equipment to be used, such as an indwelling catheter or IV
fluid line

o Any special precautions that are being planned for her infant such as
high-risk nursery care

2. Operative Risk for a Woman

 Poor Nutritional Status
o Prolonged healing period increases the risk for infection and rupture
of the incision
o Increase workload of the heart
o Increased risk for respiratory or circulatory complication
 Age Variations
o Decreased circulatory and renal function
o Risk for gestational diabetes

 Altered General Health

 o A woman with secondary illness (cardiac disease, diabetes mellitus,
anemia, kidney or liver disease) may interfere with their ability to
physically adjust to the demands of surgery.
o General medication history may interfere with effect of an anesthetic
or with healing of tissue.

 Fluid and Electrolyte Imbalance

o Recent vomiting, diarrhea, or a chronic fluid intake may add to the
risk
o Low blood volume may increase the risk of blood loss.

 Fear
o Fear increases anxiety level

3. Operative Risk to the Newborn

 Increases the risk of developing a respiratory difficulty

4. Preoperative Diagnostic Procedures

 Ultrasound assessment
 Circulatory and renal function assessment
 Vital sign determination
 Urinalysis
  Complete blood count
 Coagulation profile
 Serum electrolytes and pH
 Blood typing and cross matching

5. Preoperative Teaching
 Preoperative teaching is aimed at acquainting a woman with the cesarean
procedure and any special equipment to be used so she is as informed as possible
 Assess woman’s knowledge about the procedure
 Explain immediate preoperative measures:
o Skin preparation
o Eating nothing before the time of surgery o Premedication o Method
of transport to surgery
o Review the necessity of in dwelling catheter and IV fluid
administration.
o Explain the procedure to the patient o Explain activities needed to
maintain respiratory and skeletal function and to prevent postsurgical
complications, such as:

a) Deep breathing decreases the change of forming pneumonia, take

5-10 deep breaths every hour
 b) Incentive spirometer 3-4 times a day, most models are triggered by
inhalation which causes lungs to aerate.
c) Turning to prevent resp/circulatory stasis
d) Ambulation stimulates BLE circulation after surgery; SCDs and
TED hose may be used also

6. Immediate Preoperative Care Measures

a) Informed consent
- You witness a mom's signature that indicates she understands the risks and
benefits of the procedure

b) Overall hygiene
- Braid the hair if long
- Clean gown; prep bath; surgical cap
- Look at institutions protocols regarding jewelry, nail polish or contact
lenses

c) Gastrointestinal Tract Preparation

- A gastric emptying agent, such as metoclopramide (Reglan), to speed
stomach emptying or a histamine blocker, such as ranitidine (Zantac), to
decrease stomach secretions may be prescribed prior to surgery. Yet,
another possibility is an oral antacid such as citric acid and sodium citrate
(Bicitra), which acts to neutralize acid stomach secretions
d) Baseline Intake and Output Determinations
- To reduce bladder size and keep the bladder away from the surgical field,
an indwelling urinary catheter may be prescribed before transport for
surgery or after arrival in the surgical suite

e) Hydration
- Doing so helps to ensure a woman will be fully hydrated and will not
experience hypotension from epidural anesthesia administration,
temporary use of a supine position, or blood loss at birth.
f) Preoperative Medication
- To prevent compromising the fetal blood supply and to ensure that the
newborn is wide awake at birth and can initiate respirations spontaneously.
- Be aware if a woman has been in labor, what medications, if any, she has
already received to help prevent a drug interaction.

g) Patient Chart and Presurgery Checklist

- Documentation of nursing care up until the time a woman leaves the
nursing care unit or labor room must be completed before a woman leaves
for the surgical suite.

h) Transport to Surgery
 - A woman may be transferred to surgery in her bed, or she may be helped
to move to a stretcher.
- Urge her to lie on her left side during transport to prevent supine
hypotension syndrome.
- Ensure additional safety by raising the side rails.
- Cover her with a blanket or sheet to avoid her feeling chilled.
- Check that her identification is secure before she leaves the patient unit.
- Make certain, even though steps are being completed rapidly, that her chart
or electronic record remains secure and will be available to OR personnel.

i) Role of the Support Person

- A support person may need more encouragement to watch a cesarean than
a vaginal birth, because he or she may believe the surgery will be much
bloodier than it actually is.

E. Intraoperative Care Measures

1. Administration of Anesthesia
- A surgical nurse will assist a woman to move from the transport stretcher
or bed to the OR table and will remain with her while anesthesia is
administered.
 - If the woman has an epidural catheter in place from labor, be careful not to
dislodge it while she is being moved.
- During transport and while in surgery, encourage the woman to remain on
her side, or place a pillow under her right hip to keep her body slightly
tilted to the side, to prevent supine hypotension syndrome.
- If a spinal anesthetic (which may be used in an emergency) is to be
administered, the anesthesiologist usually will do this with the woman
sitting up. The anesthesiologist may then ask you to help the woman curve
her back to separate the vertebrae and facilitate entry of the spinal needle.
- Talking to her while letting her lean against you is the most effective
means of helping her maintain this position.
- Epidural anesthesia is usually administered with the woman lying on her
side.
- Duramorph is a form of morphine commonly used in addition to a local
anesthesia in epidurals. Its effect lasts up to 24 hours, but because it can
cause late occurring respiratory depression, respirations should be assessed
every 2 hours postsurgery

2. Skin Preparation
- Shaving away abdominal hair, if indicated, and washing the skin area over
the incision site with soap and water accomplishes this.
 - Be certain to follow agency policy. To avoid being shaved, some women
who are scheduled for a planned cesarean birth choose to have a bikini
wax done 3 or 4 days before surgery.

3. Surgical Incision
- After the anesthetic administration, a woman is positioned with a towel
under her right hip to move abdominal contents away from the surgical
field and to lift her uterus off the vena cava.
- The incision area on the woman’s abdomen is then scrubbed with an
antiseptic such as iodine, and appropriate drapes are placed around the area
so that only a small area of skin is left exposed. Sponge and instrument
counts are simplified by the use of prepackaged cesarean birth component
- Types of Cesarean Incision:
a) Classic cesarean incision – an incision made vertically through both
the abdominal skin and the uterus
Disadvantage: leaves a wide skin scar and also runs through the active
contractile portion of the uterus.
b) Low segment incision ( Misgav-Ladach or a bikini incision) – an
incision made horizontally across the abdomen just over the
symphisis pubis and also horizontally across the uterus just over the
cervix.
The low segment incision is preferred because it:
• Results in less blood loss
 • Is easier to suture
• Decreases postpartal uterine infections
• Is less likely to cause postpartum gastrointestinal complications
Disadvantage: takes longer to perform, possibly making it impractical
for an emergent cesarean birth

4. Birth of Infant
- Once the surgical incision is complete, the uterus is then cut and the
child’s head is born manually (Fig. 24.6).
- The mouth and nose of the baby may be suctioned by a bulb syringe,
before the remainder of the child is born.
 - Oxytocin (Pitocin) is administered via IV by the anesthesiologist as the
child or placenta is delivered to increase uterine contraction and reduce
blood loss.

5. Introduction of the Newborn

- Once it is determined the newborn is breathing spontaneously, he or she is
shown to the mother and support person, just as is done after a vaginal
birth
- Both the support person and the mother may hold the baby immediately.

F. Postpartal Care Measures (See page 635)

G. Discharge Planning
Be certain to discuss home care arrangements, emphasizing the need for adequate help
with her newborn and other responsibilities at home.

Be sure a woman is aware of any restrictions on exercise or activity she needs to follow
(common restrictions are not to lift any object heavier than 10 lb or walk upstairs more
than once a day for the first 2 weeks).
Also teach her to recognize signs of possible complications directly related to the surgery
that should be reported to her primary care provider because they may require
readmission, including:
• Redness or drainage at the incision line
• Lochia heavier than a normal menstrual period
• Abdominal pain (other than suture line or afterpain discomfort)
• Temperature greater than 38°C (100.4°F)
• Frequency or burning on urination