Cesarean Birth (C-Section) Nursing Care and Management

A cesarean is abdominal surgery on a woman who is also delivering a baby, so you are managing two patients and a surgical incision at once. Care looks different from a vaginal birth at every stage, from the preop workup through discharge teaching. Know what the surgery does to the body, what blood loss to expect, and what to watch for after.

What is a Cesarean Birth?

A cesarean birth, or C-section, delivers the baby through an incision in the mother's abdomen and uterus. You do it when vaginal delivery is unsafe or not feasible, either from a known condition or a labor complication. It can be planned ahead or done as an emergency.

Preoperative Assessment

Get a full health history. It drives everything that follows.

• Ask about past surgeries, secondary illnesses, food and drug allergies, prior anesthesia reactions, and current medications that raise surgical risk.
• The woman should be in the best physical and psychological state possible before surgery.
• Obesity with poor nutritional status slows wound healing. Fatty tissue is hard to suture, heals slower, and predisposes to infection and dehiscence.
• Obesity also makes early ambulation and turning harder after surgery, raising the risk for pneumonia and thrombophlebitis.
• Protein or vitamin deficiency means poorer healing, since both are needed for new cell formation at the incision.
• Age raises surgical risk through decreased circulatory and renal function.
• A secondary illness raises risk depending on its severity, because it can blunt the woman's ability to adapt to the demands of surgery.
• Review the full medication history. Some drugs interfere with anesthesia and increase surgical risk.
• A woman with lower than normal blood volume feels the effects of surgery more than one with normal volume. Example: a woman who started labor, then was told she needs a cesarean, may have had nothing to eat or drink for almost 24 hours.
• Start IV fluid replacement before and after surgery to prevent fluid and electrolyte imbalance.
• Frightened women need a detailed explanation of the procedure before going in. A frightened woman is at greater risk for cardiac arrest during anesthesia induction. Tell her the fear is normal so she can see it as expected.
• The newborn is at greater risk than one born vaginally. Cesarean infants develop some respiratory difficulty because they miss the chest compression of the birth canal that normally clears fluid from the lungs.

Preoperative Diagnostic Procedures

Run the workup the physician orders before surgery.

• Assess circulatory function, renal function, and fetal heart rate.
• Circulatory: complete blood count, PT, and PTT.
• Renal: urinalysis.
• Add vital signs, serum electrolytes and pH, blood typing and cross-matching, and ultrasound for fetal presentation and maturity.
• Prolonged labor can push the leukocyte count up to 20,000/mm3, so a high count here is not a reliable sign of infection.

Preoperative Measures

These steps protect the woman during surgery.

• Securing informed consent is the surgeon's responsibility, but everyone makes sure it happens. Witnesses may be asked to witness her signature.
• Consent must be informed. Explain risks and benefits in language she understands.
• On admission, give her a clean gown and pull her hair into a ponytail.
• Remove nail polish and acrylic nails. The nails are used to assess capillary refill.
• Give a gastric emptying agent before surgery to cut stomach secretions, since she lies supine and esophageal reflux and aspiration are real risks.
• An indwelling catheter is ordered before or after surgery to shrink the bladder and keep it out of the surgical field.
• Use good lighting when catheterizing a pregnant woman so the perineum is clearly visible.
• Keep urine draining freely and the bag below bladder level during transport to prevent backflow and the introduction of microorganisms.
• Start an IV solution such as Ringer's as ordered to keep her fully hydrated.
• Give only the minimum preoperative medication so you do not compromise fetal blood supply and the newborn is awake at birth and breathes spontaneously.
• Document care completely and factually through discharge.
• Transport her on her left side to prevent supine hypotension.
• Keep side rails up and cover her with a blanket.
• A support person may attend the birth and may need encouragement to watch.

Intraoperative Measures

• As anesthesia is given, the surgical nurse helps move her from the stretcher to the operating table.
• Regional block is the usual anesthesia of choice.
• Keep her on her side, or place a pillow under her right hip to tilt her slightly and prevent supine hypotension.
• In emergencies, spinal anesthesia is given with the woman sitting up. Holding a curved position in labor is hard, so talk her through it and let her lean on you while you gently steady her.
• Epidural anesthesia is given with the woman on her side and lasts 24 hours, so use continuous pulse oximetry for 24 hours after surgery to catch respiratory depression.
• For skin prep, shave abdominal hair and wash the incision site with soap and water to reduce skin bacteria.
• Position a towel under her right hip to move abdominal contents off the surgical field and lift the uterus off the vena cava.
• Cover her with a sterile drape to block bacteria from her respiratory tract and to keep her and the support person from seeing the incision.
• Scrub the incision area with antiseptic and place additional drapes so only a small area of skin is exposed.
• Prepare the woman and support person for what they may see.
• A classic incision runs vertically through both the abdominal skin and the uterus. It leaves a wide scar and cuts through the active contractile portion of the uterus, so she cannot have a later vaginal birth because the scar could rupture during labor.
• A low segment or low transverse incision runs horizontally across the abdomen just above the symphysis pubis and horizontally across the uterus just over the cervix. This is the most common type, also called a "bikini" incision. It rarely ruptures in labor, so VBAC is possible later. It causes less blood loss, sutures more easily, lowers puerperal infection, and is less likely to cause postpartum GI complications. The downside: it takes longer, so it is not the choice for an emergent cesarean.

Postpartal Care

• The postpartal period after an emergent cesarean splits into two: the immediate recovery period and the extended postpartal period.
• After surgery, transfer her by stretcher to the postanesthesia care unit.
• With spinal anesthesia, her legs are fully anesthetized and she cannot move them.
• Pain control is the major early problem. Pain this intense interferes with moving and deep breathing, which leads to pneumonia or thrombophlebitis.
• Use a pain rating scale so she can rate her pain. Some women need patient-controlled analgesia or continued epidural injections.
• Supplement analgesics with comfort measures: reposition, straighten the linen.
• Have her ambulate. It is the most effective way to relieve gas pain.
• She should not take acetylsalicylic acid or aspirin, which interfere with clotting and healing.
• Have her place a pillow on her lap during feeding to keep the infant's weight off the suture line. The football hold does the same.
• In the extended period, GI function interference is the most common issue. Note her first bowel movement carefully. If none, the physician may order a stool softener, suppository, or enema.
• Teach a diet high in roughage and fluid and a goal of moving her bowels at least every other day to avoid constipation.
• Incisional pain limits use of the abdominal muscles, so a stool softener may be ordered. Caution her not to strain, which presses on the incision.
• Tell her to keep her water pitcher full as a reminder to drink.
• Reassure her that no bowel movement for 3 to 4 days postoperatively is normal, especially after a preop enema.

Surgical Considerations

Cesarean birth has systemic effects like any surgery. Watch the body's responses so you catch abnormalities early and intervene fast.

Body Defenses

• The skin is the primary barrier against bacterial invasion. The moment it is incised, that defense is gone, so use strict aseptic technique.
• Infection risk rises if the cesarean is done hours after membrane rupture.
• If membranes are intact, the physician may order prophylactic antibiotics such as ampicillin or cephalosporin to protect against postsurgical endometritis.

Body Organ Function

• Handling, damaging, or repairing an organ in surgery disrupts its normal function.
• Edema and inflammation further impair the organ and those around it. Edema that compresses blood vessels can starve distant organs of blood flow and reduce their function.
• The uterus may not contract well after being handled, which can cause postpartum hemorrhage.
• The bladder is displaced to reach the uterus, so afterward it may not sense filling.
• Paralytic ileus can follow because the intestines were under pressure during surgery.
• Thrombophlebitis is possible from impaired lower extremity blood flow.

Circulatory Function

• There is always blood loss, even though cut vessels are clamped and ligated immediately. Excessive loss leads to hypovolemia, low blood pressure, and poor tissue perfusion.
• A vaginal birth loses 300 to 500 mL of blood. A cesarean loses roughly 500 to 1000 mL, more because pelvic vessels are congested with blood waiting to supply the placenta.

Stress Response

• The body responds to physical and psychosocial stressors to preserve function. Stress releases epinephrine and norepinephrine from the adrenal medulla.
• Epinephrine raises heart rate, dilates the bronchi, elevates blood glucose, constricts peripheral vessels, and raises blood pressure. These responses antagonize anesthesia, which aims to minimize body activity, and they cut blood supply to the lower extremities.
• She is already prone to thrombophlebitis from venous stasis, so this raises that risk further.

Self-Esteem

• Surgery leaves an incisional scar. The cesarean scar is not very noticeable because it runs horizontally across the lower abdomen.
• A woman may still feel a loss of self-esteem if she believes the scar marks her as less because she could not deliver vaginally. Support her, and teach her what to expect at each step.