Therapeutic Management for Intrapartum Complications PDF

THERAPEUTIC MANAGEMENT FOR I N T R A P A R TA LC O M P L I C A T I O N S JUVY G. REYES MAN, RN CU 3 Learning Oobjectives: 1. Describe the usual indications for cesarean birth. 2. Determine the therapeutic management for identified intrapartum complications. 3. Ana...

THERAPEUTIC MANAGEMENT FOR I N T R A P A R TA LC O M P L I C A T I O N S JUVY G. REYES MAN, RN CU 3 Learning Oobjectives: 1. Describe the usual indications for cesarean birth. 2. Determine the therapeutic management for identified intrapartum complications. 3. Analyze ways that nurses can help prevent complications of pregnancy while keeping care family centered.  INDUCTION AND AUGMENTATION OF LABOR When labor contractions are ineffective, intervention such as: a. Induction of labor b. Augmentation of labor with oxytocin c. Amniotomy (artificial rupture of the membranes) INDUCTION AND AUGMENTATION OF LABOR a. Induction of labor - labor is started artificially. Initiate labor before the time when it would have occurred spontaneously Fetus is in danger or because labor does not occur spontaneously Fetus appears to be at term A. INDUCTION OF LABOR The primary reasons for inducing labor includes: 1. Presence of pre-eclampsia; eclampsia 2. Severe hypertension 3. Diabetes 4. Rh sensitization 5. Prolonged rupture of the membranes 6. Intrauterine growth restriction 7. Post maturity (a pregnancy lasting beyond 42 weeks) b. AUGMENTATION OF LABOR b. Augmentation of labor - assisting labor that has started spontaneously but is not effective. Assistance to make uterine contractions stronger if the contractions are hypotonic or too weak or infrequent to be effective. b. Augmentation of Labor Before induction of labor the following conditions should be present: 1. The fetus is in a longitudinal lie 2. The cervix is ripe, or ready for birth. 3. A presenting part is engaged. 4. There is no CPD. b. Augmentation of labor 1. Cervical Ripening - a change in the cervical consistency from firm to soft The first step the uterus must complete in early labor, until dilatation and coordination of uterine contractions will not occur. INDUCTION OFLABOR TO DETERMINE WHETHER A CERVIX IS “RIPE,” OR READY FOR DILATATION Bishop Score (1964) – is a scoring system to assist in predicting whether induction of labor will be required Using this scale, if a woman’s total score is 8 or greater, the cervix is considered ready for birth and should respond to induction INDUCTION OF LABOR TO DETERMINE WHETHER A CERVIX IS “RIPE,” OR READY FOR DILATATION Methods to “ripen” a cervix: 1. Stripping the membranes -separating the membranes from the lower uterine segment manually, using a gloved finger in the cervix. easy procedure performed during an office visit.  INDUCTION OF LABOR METHODS TO “RIPEN” A CERVIX: 1. Stripping the amniotic membranes Possible complications: 1. Bleeding from an undetected low-lying placenta 2. Inadvertent rupture of membranes 3. Infection if membranes should rupture  METHODS TO “RIPEN” A CERVIX: 2. Application of catheter or suppository, or to the external surface by applying it to a diaphragm and then placing against the cervix METHODS TO “RIPEN” A CERVIX: 2. Application of a prostaglandin gel a. Misoprostol - two or three doses are usually adequate to cause ripening. Additional doses may be applied every 6 hours. METHODS TO “RIPEN” A CERVIX: 2. Application of prostaglandin gel Nursing intervention: 1. Instruct the client to remain in bed in a side-lying position to prevent leakage of the medication 2. Monitored FHR for at least 30 minutes after each application (up to 2 hours after vaginal insertion). Induction of Labor by Oxytocin 3. Administration of oxytocin - initiates contractions in uterus at pregnancy term Oxytocin is always administered intravenously - if hyperstimulation should occur, it can be quickly discontinued.  INDUCTION OF LABOR BY OXYTOCIN 3. Administration of Oxytocin: Pitocin is mixed in the proportion of 10 IU in 1000 mL of Ringer’s lactate (10,000 milliunits) each milliliter of this solution contains 10 mU of oxytocin. An alternative dilution method is to add 15 IU of oxytocin to 250 mL of an IV solution; this yields a concentration of 60 mU/1 mL. INDUCTION OF LABOR BY OXYTOCIN After cervical dilatation reaches 4 cm, artificial rupture of the membranes may be performed to induce labor, and the infusion may be discontinued at that point. INDUCTION OF LABOR BY OXYTOCIN 1. ADMINISTRATION OF OXYTOCIN infusion is continued through full dilatation Side effect of Oxytocin: Extreme hypotension Nursing Responsibilities: a. Take the pulse and blood pressure every 15 minutes. b. Monitor uterine contractions and FHR conscientiously. INDUCTION OF LABOR BY OXYTOCIN 1. ADMINISTRATION OF OXYTOCIN Stopping the oxytocin infusion does not stop the hyperstimulation Terbutaline sulfate (Brethine) or Magnesium sulfate - prescribed to decrease myometrial activity. Oxytocin has an antidiuretic side effect that can result in decreased urine flow, possibly leading to water intoxication. INDUCTION OF LABOR BY OXYTOCIN 1. ADMINISTRATION OF OXYTOCIN Side effect of Oxytocin: 2. Water intoxication - is first manifested by headache and vomiting during induction of labor (Seizures, coma, and death) Nursing Responsibilities: a. Report immediately and halt the infusion. b. Accurate intake and output record c. Test and record urine specific gravity throughout oxytocin d. administration to detect fluid retention. INDUCTION OF LABOR BY OXYTOCIN 1. ADMINISTRATION OF OXYTOCIN Side effect of Oxytocin: 2. Water intoxication Nursing Responsibilities: d. Limit the amount of IV fluid being given to 150 mL/hr. by ensuring that the main IV fluid line is infusing at a rate not greater than 2.5 mL/min. INDUCTION OF LABOR BY OXYTOCIN Augmentation by Oxytocin Augmentation of labor is required if labor contractions begin spontaneously but then become so weak, irregular, or ineffective (hypotonic) assistance is needed to strengthen them. ACTIVE MANAGEMENT OF LABOR 1. Administration of oxytocin increases of 6 mU/min rather than 1 or 2 mU/min) to shorten labor to 12 hours, which reduces the incidence of Cesarean birth and postpartum infection. The maximum dosage of oxytocin used may be as high as 36 to 40 mU/min. ACTIVE MANAGEMENT OF LABOR FORCEPS DELIVERY Obstetrical forceps - steel instruments constructed of two blades that slide together at their shaft to form a handle. One blade is slipped into the woman’s vagina next to the fetal head, and then the other is slipped into place on the other side of the head. ACTIVE MANAGEMENT OF LABOR FORCEPS DELIVERY Obstetrical forceps the shafts of the instrument are brought together in the midline to form the handle. The physician then applies pressure on the handle to manually extract the fetus from the birth canal. ACTIVE MANAGEMENT OF LABOR FORCEPS DELIVERY Forceps may be necessary if any of the following conditions occur: 1. Woman who receives regional anesthesia or has a spinal cord injury. 2. Cessation of descent in the second stage of labor occurs. 3. A fetus is in an abnormal position 4. A fetus is in distress from a complication such as a prolapsed cord. ACTIVE MANAGEMENT OF LABOR FORCEPS DELIVERY 1. Low forceps birth – is used to indicate that the fetal head is at a + 2 station or more. 2. Mid forceps birth – the fetal head is engaged but at less than 2 station ACTIVE MANAGEMENT OF LABOR FORCEPS DELIVERY Midforceps birth - this type of forceps extraction is associated with: a. Birth trauma to both the woman and the fetus, and cesarean birth involves less risk b. Some anesthesia (Pudendal block) - to achieve pelvic relaxation and reduce pain. c. Episiotomy is performed to prevent perineal tearing pressure on the perineum. ACTIVE MANAGEMENT OF LABOR FORCEPS DELIVERY Before forceps are applied, 1. Membranes must be ruptured 2. CPD must not be present. 3. The cervix must be fully dilated 4. The woman’s bladder must be empty ACTIVE MANAGEMENT OF LABOR FORCEPS DELIVERY 1. Record FHR before forceps application 2. Assess FHR again immediately after application. 3. Assess woman’s cervix after forceps birth to be certain that no laceration has occurred. 4. To rule out bladder injury, record the time and amount of the first voiding.  ACTIVE MANAGEMENT OF LABOR FORCEPS DELIVERY 5. Assess the newborn to be certain that no facial palsy or subdural hematoma exist. A forceps birth may leave a transient erythematous mark on the newborn’s cheek. This mark will fade in 1 to 2 days with no long- term effects ACTIVE MANAGEMENT OF LABOR VACUUM EXTRACTION (VENTOUSE) Ventouse - is a method to assist delivery of a baby using a vacuum device. It is used in the second stage of labor if it has not progressed adequately. It may be an alternative to a forceps delivery and caesarean section.  ACTIVE MANAGEMENT OF LABOR VACUUM EXTRACTION fetus is positioned far enough down the birth canal, with the fetal head at the perineum, a disk-shaped cup is pressed against the fetal scalp, over the posterior fontanelle. ACTIVE MANAGEMENT OF LABOR VACUUM EXTRACTION When vacuum pressure is applied, air beneath the cup is suctioned out and the cup then adheres so tightly to the fetal scalp that traction on the cord leading to the cup extracts the fetus. ACTIVE MANAGEMENT OF LABOR VACUUM EXTRACTION Advantages of forceps birth: 1. Little anesthesia is necessary leaving the fetus with less respiratory depression at birth 2. Fewer lacerations of the birth canal occur ACTIVE MANAGEMENT OF LABOR VACUUM EXTRACTION Disadvantages: 1. It causes a marked caput on the newborn head that may be noticeable as long as 7 days after birth. 2. Tentorial tears from extreme pressure also have occurred ACTIVE MANAGEMENT OF LABOR VACUUM EXTRACTION Contraindication: 1. Fetal scalp blood sampling was used (suction pressure can cause severe bleeding at the sampling site) 2. Preterm infants because of the softness of the preterm skull. ACTIVE MANAGEMENT OF LABOR CESAREAN BIRTH Cesarean birth is used as a prophylactic measure, to alleviate problems of birth such as Cephalopelvic disproportion or failure to progress in labor. ACTIVE MANAGEMENT OF LABOR CESAREAN BIRTH A. Scheduled Cesarean Birth Two types of Cesarean birth a. Scheduled – (Elective) there is time for thorough preparation for the experience throughout the antepartal period. b. Emergent - preparation must be done more rapidly and concern for fully informing a woman and her support person about what circumstances. ACTIVE MANAGEMENT OF LABOR CESAREAN BIRTH Cesarean birth is mandatory: 1. Transverse presentation 2. Genital herpes 3. Cephalopelvic disproportion 4. Human immunodeficiency virus (HIV), Hepatitis C, or Herpes type 2 from mother to newborn ACTIVE MANAGEMENT OF LABOR CESAREAN BIRTH Advantages: 1. It can reduce mortality among infants presenting breech 2. Preterm birth to avoid pressure on the fetal head 3. To avoid post procedure stress incontinence but whether this last procedure helps is controversial 4. It is contraindicated when there is a documented dead fetus (labor can be induced to avoid a surgical procedure). ACTIVE MANAGEMENT OF LABOR CESAREAN BIRTH B. Emergent Cesarean Birth Risks: 1. Psychologically unprepared for the experience. 2. Fluid and electrolyte imbalance 3. Physically and emotionally exhausted from a long labor. ACTIVE MANAGEMENT OF LABOR CESAREAN BIRTH B. Emergent Cesarean Birth Indication: 1. Placenta previa 2. Premature separation of the placenta (Abruptio placenta) 3. Fetal distress 4. Failure to progress in labor  EFFECTS OF SURGERY ON A WOMAN 1. Stress Response subjected to stress, either physical or psychosocial results in release of epinephrine and norepinephrine causes an increased heart rate, bronchial dilatation, and elevation of the blood glucose level. It leads to peripheral vasoconstriction, which forces blood to the central circulation and increases blood pressure. EFFECTS OF SURGERY ON A WOMAN 2. Interference With Body Defenses Strict adherence to aseptic technique during surgery and in the days following the procedure to compensate for impaired defense. prophylactic antibiotics, (ampicillin or a cephalosporin to ensure protection against postsurgical endometritis, even if the membranes were intact EFFECTS OF SURGERY ON A WOMAN 3. Interference With Circulatory Function Extensive blood loss can lead to hypovolemia and lowered blood pressure 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 EFFECTS OF SURGERY ON A WOMAN 4. Interference With Body Organ Function 1. Pressure from edema or inflammation impairs function of the organs. 2. 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. EFFECTS OF SURGERY ON A WOMAN 5. INTERFERENCE WITH SELF-IMAGE OR SELF-ESTEEM Surgery leaves an incisional scar that will be noticeable to some extent afterward. The scar resulting from cesarean birth Horizontal one across is not overly noticeable, but its appearance may cause a woman to feel self-conscious later. Teaching to Prevent Complications TEACHING TO PREVENT COMPLICATIONS Deep breathing exercises prevent the stasis of lung mucus from the prolonged time spent in the supine position during surgery. It take 5 to 10 deep breaths every hour. Teach the client to do inhaling as deeply as possible, holding her breath for a second or two, then exhaling as deeply as possible. TEACHING TO PREVENT COMPLICATIONS B. Incentive Spirometry Incentive spirometer – a device used postoperatively to encourage deep breathing and help the lungs to recover after surgery It promote expansion of the alveoli to prevent or treat atelectasis. TEACHING TO PREVENT COMPLICATIONS c. Turning - postoperatively is important to prevent both respiratory and circulatory stasis. d. Ambulation - the most effective way to stimulate lower extremity circulation after a cesarean birth Surgeons prefer a woman to be out of bed and walking by 4 hours after surgery (as soon as the effect of the epidural anesthesia has worn off). TEACHING TO PREVENT COMPLICATIONS Some women may be prescribed ant embolic stockings to support and encourage venous return in addition to ambulation. OPERATIVE RISK FOR A WOMAN OPERATIVE RISK FOR A WOMAN 1. Poor Nutritional Status a. Obesity - interferes with wound healing. Tissue that contains an abundance of fatty cells is difficult to suture, incision may take longer to heal. Prolonged healing period increases the risk for infection and rupture of the incision (Dehiscence). OPERATIVE RISK FOR A WOMAN 1. Poor Nutritional Status b. Increased risk for development of respiratory or circulatory complications such as pneumonia or thrombophlebitis OPERATIVE RISK FOR A WOMAN 1. Poor Nutritional Status c. Protein or vitamin C and D deficiency is at risk for poorer wound healing, for new cell formation at the incision site. d. Vitamin K is necessary for blood clotting after surgery. OPERATIVE RISK FOR A WOMAN 2. Age Variations - age affects surgical risk because it can cause decreased circulatory and renal function. Most pregnant women fall within the young adult age group, are excellent candidates for surgery. A woman older than 40 years falls into a category of slightly higher risk.  OPERATIVE RISK FOR A WOMAN 3. Altered General Health Secondary illness (Cardiac disease, diabetes mellitus, anemia, kidney or liver disease is at greater surgical risk, depending on the extent of disease Secondary illnesses is an essential component of a Preoperative Nursing History.  OPERATIVE RISK FOR A WOMAN 4. Fluid and Electrolyte Imbalance - a woman who enters surgery with a lower than normal blood volume will feel the effect of surgical blood loss more than a woman who has a normal blood volume. RISK: a. Vomiting, diarrhea, or a chronic poor fluid intake b. Intravenous fluid replacement is initiated Preoperatively and continued postoperatively to prevent fluid and electrolyte imbalances. OPERATIVE RISK FOR A WOMAN 5. Fear - need a detailed explanation of the procedure before they can enter surgery without intense fear. performed under epidural anesthesia, so they are less frightening for women than when general anesthesia was used.  OPERATIVE RISK TO THE NEWBORN Risk: When a fetus is pushed through the birth canal, pressure on the chest helps to rid the newborn’s lungs of fluid. This makes respirations more likely to be adequate at birth than if a fetus had not been subjected to this pressure. More infants born by cesarean birth develop some degree of respiratory difficulty for a day or two after birth than those born vaginally NURSING CARE OF A WOMAN ANTICIPATING A CAESARIAN BIRTH NURSING CARE OF A WOMAN ANTICIPATING A CAESARIAN BIRTH 1. Preoperative Interview Physician, anesthesiologist or nurse-anesthetist will interview a woman preoperatively to obtain a health history and make an assessment and decision for safe use of anesthesia. Nursing assessment: a. Past surgeries b. Secondary illnesses c. Allergies to foods or drugs, reactions to anesthesia d. Bleeding problems, and current medications to help establish surgical risk.  NURSING CARE OF A WOMAN ANTICIPATING A CAESARIAN BIRTH 2. PREOPERATIVE DIAGNOSTIC PROCEDURES a. Vital sign determination b. Urinalysis, Complete blood count c. Coagulation profile (Prothrombin time [PT], partial thromboplastin time) d. Serum electrolytes and pH e. Blood typing and cross-matching f. Ultrasound to determine fetal presentation and maturity NURSING CARE OF A WOMAN ANTICIPATING A CAESARIAN BIRTH 3. PREOPERATIVE TEACHING a. Preoperative teaching Activities that help maintain respiratory and skeletal muscle function, to prevent postsurgical complications NURSING CARE OF A WOMAN ANTICIPATING A CAESARIAN BIRTH NURSING CARE OF A WOMAN ANTICIPATING A CAESARIAN BIRTH PREOPERATIVE TEACHING 1. Surgical skin preparation 2. NPO before the time of surgery 3. Premedication 4. Method of transport to surgery. 5. Review the necessity for an indwelling catheter, intravenous fluid administration, Epidural catheter (if used for post procedural pain relief), and advantage of early ambulation afterward. NURSING CARE OF A WOMAN ANTICIPATING A CAESARIAN BIRTH IMMEDIATE PREOPERATIVE CARE MEASURES A. Informed Consent Operative consent is the surgeon’s responsibility to explain the procedure Nurse – as witness and before signing as a witness, risks and benefits of the procedure were explained in terms the woman could easily understand. NURSING CARE OF A WOMAN ANTICIPATING A CAESARIAN BIRTH IMMEDIATE PREOPERATIVE CARE MEASURES B. Overall Hygiene On admission provide a clean hospital gown and surgical cap removing nail polish, jewelry, contact lenses, piercings, or hair ornaments before surgery. NURSING CARE OF A WOMAN ANTICIPATING A CAESARIAN BIRTH IMMEDIATE PREOPERATIVE CARE MEASURES C. Gastrointestinal Tract Preparation 1. Metoclopramide (Reglan) – a gastric emptying agent to speed stomach emptying 2. Ranitidine ( Zantac) or a histamine blocker used to decrease stomach secretions prescribed prior to surgery 3. Sodium citrate (Bicitra) - an oral antacid acts to neutralize acid stomach secretions, making esophageal reflux NURSING CARE OF A WOMAN ANTICIPATING A CAESARIAN BIRTH IMMEDIATE PREOPERATIVE CARE MEASURES d. Baseline Intake and Output Determinations an indwelling urinary catheter may be prescribed before transport for surgery or after arrival in the surgical suite e. Preoperative Medication - used to prevent compromising the fetal blood supply and to ensure that the newborn is wide awake at birth and can initiate respirations spontaneously NURSING CARE OF A WOMAN ANTICIPATING A CAESARIAN BIRTH IMMEDIATE PREOPERATIVE CARE MEASURES f. Patient Chart and Pre surgery Checklist Documentation of nursing care must be completed before a woman leaves for the surgical suite. Make sure that her chart with the surgical checklist accompanies her. NURSING CARE OF A WOMAN ANTICIPATING A CAESARIAN BIRTH IMMEDIATE PREOPERATIVE CARE MEASURES g. Transport to Surgery transferred in her bed, or move to a stretcher. If a stretcher is used, be certain to hold it tightly against the side of the woman’s bed or use a slide board for safe transfer. Cover her with a blanket or sheet to avoid her feeling chilled. Check that her identification is secure before she leaves the patient unit. NURSING CARE OF A WOMAN ANTICIPATING A CAESARIAN BIRTH 4. IMMEDIATE PREOPERATIVE CARE MEASURES h. Hydration intravenous fluid line begun before surgery with a fluid such as lactated Ringer’s solution. helps to ensure that a woman is fully hydrated and will not experience hypotension from epidural anesthesia administration NURSING CARE OF A WOMAN ANTICIPATING A CAESARIAN BIRTH IMMEDIATE PREOPERATIVE CARE MEASURES i. Role of the Support Woman’s family can be as involved in a cesarean birth A support person need more encouragement to watch a cesarean birth than a vaginal one, because he or she may believe that the surgery will be much bloodier than it actually is. NURSING CARE OF A WOMAN HAVING AN EMERGENT CAESARIAN BIRTH Preoperative preparation measures: a. Vital signs, urinalysis, and blood work b. Informed consent c. Application of elastic stockings (if appropriate) d. Gastrointestinal tract preparation e. Bladder catheterization f. Establishment of an intravenous line Intraoperative Care Measures NURSING CARE OF A WOMAN HAVING AN EMERGENT CAESARIAN BIRTH Intraoperative Care Measures 1. Administration of Anesthesia A surgical nurse will assist a woman to move from the stretcher to the operating room table and will remain with her while anesthesia is administered.  NURSING CARE OF A WOMAN HAVING AN EMERGENT CAESARIAN BIRTH Skin Preparation Reducing the number of bacteria on the skin before surgery Shaving abdominal hair and washing the skin area over the incision site with soap and water NURSING CARE OF A WOMAN HAVING AN EMERGENT CAESARIAN BIRTH Intraoperative Care Measures 1. Administration of Anesthesia Patient is awake during the anesthesia usually a regional block. If the woman has an epidural catheter in place from labor, be careful not to dislodge it while she is being moved. NURSING CARE OF A WOMAN HAVING AN EMERGENT CAESARIAN BIRTH Intraoperative Care Measures 1. Administration of Anesthesia The anesthesiologist may ask the nurse to help the woman curve her back to separate the vertebrae and facilitate entry of the spinal needle.  NURSING CARE OF A WOMAN HAVING AN EMERGENT CAESARIAN BIRTH Intraoperative Care Measures 1. Administration of Anesthesia 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. NURSING CARE OF A WOMAN ANTICIPATING A CAESARIAN BIRTH 4. IMMEDIATE PREOPERATIVE CARE MEASURES Catheterizing a pregnant woman NURSING CARE OF A WOMAN HAVING AN EMERGENT CAESARIAN BIRTH Surgical Incision The incision area on the woman’s abdomen is then scrubbed with an antiseptic. NURSING CARE OF A WOMAN HAVING AN EMERGENT CAESARIAN BIRTH Types of Cesarean Incision: 1. Classic cesarean incision - incision is made vertically Disadvantage of this type of incision: It leaves a wide skin scar and this type of scar could rupture during labor, the woman will not be able to have a subsequent vaginal birth. NURSING CARE OF A WOMAN HAVING AN EMERGENT CAESARIAN BIRTH 2. Low segment incision (Low transverse incision) is one made horizontally across the abdomen just over the symphysis pubis most common type It is also referred to as a Pfannenstiel incision or a “bikini” incision NURSING CARE OF A WOMAN HAVING AN EMERGENT CAESARIAN BIRTH 2. Low segment incision (Low transverse incision) incision is through the nonactive portion of the uterus (the part that contracts minimally with labor it is less likely to rupture in subsequent labors. Disadvantage: It takes longer to perform, possibly making it impractical for an emergent cesarean birth. NURSING CARE OF A WOMAN HAVING AN EMERGENT CAESARIAN BIRTH Birth of the Infant Once the surgical incision is complete, retractors (long, curved, metal instruments) are slipped into the incision. Gentle traction on the handles by an assistant keeps the incision spread apart, allowing good visualization of the uterus and the internal incision. NURSING CARE OF A WOMAN HAVING AN EMERGENT CAESARIAN BIRTH The uterus is then cut, and the child’s head is born manually or by the application of forceps. NURSING CARE OF A WOMAN HAVING AN EMERGENT CAESARIAN BIRTH The mouth and nose of the baby are suctioned by a bulb syringe before the remainder of the child is born.  NURSING CARE OF A WOMAN HAVING AN EMERGENT CAESARIAN BIRTH Oxytocin is administered intravenously by the anesthesiologist as the child or placenta is delivered, to increase uterine contraction and reduce blood loss.  NURSING CARE OF A WOMAN HAVING AN EMERGENT CAESARIAN BIRTH The internal cavity of the uterus is inspected, and the membranes and placenta are manually removed. If the woman wishes to have a tubal ligation, it can be done at this time. NURSING CARE OF A WOMAN HAVING AN EMERGENT CAESARIAN BIRTH The uterus, subcutaneous tissues, and skin incisions are then closed. Metal staples are usually used on the exterior skin, because they leave the least amount of scarring NURSING CARE OF A WOMAN HAVING AN EMERGENT CAESARIAN BIRTH After full birth, the uterus is pulled forward into the abdomen and covered with gauze INTRODUCTION OF THE NEWBORN Once it is determined that the newborn is breathing spontaneously, he or she is shown to the mother and support person The support person may hold the baby immediately.  INTRODUCTION OF THE NEWBORN initial breastfeeding is usually delayed until the woman has been moved to a recovery room breastfeeding initiates uterine contractions and that may interfere with suture placement INTRODUCTION OF THE NEWBORN Post Partal Care Measures Due to the strain of the unexpected procedure, they may have increased difficulty bonding with their new infant. They have postsurgical pain in additional to afterpains, can be divided into an immediate recovery period and an extended postpartal period.  DISCHARGE PLANNING emphasized the need for adequate help with her newborn and other responsibilities at home, before discharge. Be sure a woman is aware of any restrictions on exercise or activity, 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). DISCHARGE PLANNING Teach her to recognize signs of possible complications related to the surgery, such as: 1. Redness or drainage at the incision line 2. Lochia heavier than a normal menstrual period 3. Abdominal pain (other than suture line or afterpain discomfort) 4. Temperature greater than 38° C (100.4° F) 5. Frequency or burning on urination  DISCHARGE PLANNING A woman can plan on resuming coitus as soon as the act is comfortable for her, possibly as early as 1 week after discharge. Cesarean birth does not interfere with future fertility so be sure that she has contraceptive information, if desired. Ensure that she has an appointment for a return visit with her health care provider for both herself and her newborn. Wk. 3 Prelim