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 conditions such as pregnancy 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.
Indications 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
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.
The 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 Care Plans Related to C-Section
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 and the goal of nursing interventions is 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
Risk for Bleeding 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.
Risk for Bleeding 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 and the goal of nursing interventions is 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
Risk for Impaired Attachment 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.
Risk for Impaired Attachment 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.
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
Deficient Knowledge 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.
Deficient Knowledge 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.
References and Sources
- 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
- MedlinePlus – Health Information from the National Library of Medicine. (n.d.). Cesarean section | C section | MedlinePlus. https://medlineplus.gov/cesareansection.html
- National Center for Biotechnology Information. (2022). Cesarean section – StatPearls – NCBI bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK546707/
- Silvestri, L. A., & CNE, A. E. (2019). Prenatal Period. In Saunders comprehensive review for the NCLEX-RN examination (8th ed., pp. 637-664). Saunders.
