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Cesarean Birth

Cesarean Birth. Author: Daren Sachet, RNC, BSN, MPA. Cesarean Birth Objectives. Discuss the implications for cesarean birth List the components of providing a safe surgical environment Describe potential complications related to cesarean birth. Indications. Previous Uterine Scar

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Cesarean Birth

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  1. Cesarean Birth Author: Daren Sachet, RNC, BSN, MPA

  2. Cesarean Birth Objectives • Discuss the implications for cesarean birth • List the components of providing a safe surgical environment • Describe potential complications related to cesarean birth

  3. Indications • Previous Uterine Scar • Labor Dystocia • Cephalopelvic disproportion, arrest of labor • Fetal malposition or malpresentation e.g. breech, transverse lie • Fetal intolerance of labor • Disease, or anomaly • Fetal macrosomia • Prolapsed Cord

  4. Indications Continued • Active genital herpes • Uterine Rupture • Placental abnormality • Placenta previa • Abruptio placenta • Uterine Rupture

  5. Total C/S Rates

  6. C/S Rates in the U.S.National Vital Statistics Report Vol. 58, No. 16

  7. VBAC/TOLAC • VBAC---vaginal birth after cesarean • TOLAC---trial of labor after cesarean • Decision making • Non-repeating condition (why was previous cesarean done?) • Desire to avoid cesarean birth • Ability to do emergency cesarean birth • Benefits mother by shortening recovery time • Risks • Possibility of uterine rupture (what kind of incision was made on uterus?)

  8. Successful VBACHow can we help? • Review prenatal record for risks • Ensure informed consent, Additional consent if oxytocin is used, as risk increases • Continuous EFM and 1:1 nursing care • Assess for normal labor progression and S/S uterine rupture • MD must remain immediately available throughout active labor • Ensure ability to perform emergency C/S

  9. Elective Cesarean Section ACOG definition: A primary C/S at maternal request in the absence of any medical or obstetric indication. Considerations: Not recommended for women desiring several children. ACOG Committee Opinion 386: Nov 2007.

  10. Maternal Morbidities Related to Multiple Repeat Cesarean Births • Placenta previa/accreta • Blood transfusion • Hysterectomy • Injury to bladder, bowel and other pelvic organs • Longer operating time • Increased LOS Obstet Gynecol June 2006;107:1226-32

  11. Infant Morbidities Associated with Cesarean Births • Potential for hypoxia • TTN • Respiratory distress syndrome • Pulmonary hypertension • Skin lacerations • Broken clavicle, facial nerve palsy, and other injuries related to failed vacuum or forceps use

  12. Postpartum Maternal Complications Related to Cesarean Delivery • UTI • Wound complications • Hematoma, dehiscence, infection, necrotizing fasciitis • Thromboembolic disease • Ileus and Bowel dysfunction • Atelectasis • Endometritis • Anesthetic Complications

  13. Getting Ready Operating Room Preparation • Circulating RN is responsible for operating room readiness • Patients with the same health status and condition should receive a “comparable” level of care regardless of where that care is provided within the hospital. Joint Commission • “Comparable” care to that provided in the main hospital surgical department is recommended by ASA (2006) and JCAHO (2007); however, “equivalent” care is not required.

  14. Operating Room Preparation • Cleaning of the OR • Equipment and Supplies • Suction, medical gases • Blood products, implants, devices or special equipment present? • Electrosurgical unit • Crash cart, MH supplies • Patient Positioning aids • Medications, are they secure? • Are all the needed personnel in place?

  15. Getting ReadyDocumentation required Prior to Surgery • Ensure a current H&P is on the chart • Informed Consent • Pre-Procedural Verification • First step done prior to entering the OR. It includes patient verification and OR readiness. • Second step completed in the OR prior to incision and when all personnel are present • Must be obtained for the Anesthetic procedure as well as for the surgical procedure

  16. Preoperative Patient Preparation • NPO, IV preload, • Antacids and Antiemetics • Foley • Hair Removal and Skin Cleansing • Antibiotics • “Prophylactic Antibiotic Received within one hour prior to surgical incision or at the time of birth for cesarean section” NQF • DVT Prophylaxis • US if breech

  17. Teaching Patient/Family • Pre operative activities • Intra operative expectations • Post operative course • LOS • Diet • Ambulation • Foley and IV removal • Pain control • Discharge planning • Encourage questions

  18. Personnel and Roles • Scrubbed Team • Un-scrubbed Team • Circulating RN • Duties?

  19. Personnel and Roles Scrub Nurse or Tech Anesthesia Provider Surgical Assist Surgeon

  20. Personnel and Roles • Neonatal Team • Support Person

  21. Infection Control • Cleaning the OR • Attire in restricted & semi-restricted areas • Personal Protective Equipment • Personal Hygiene • Skin preps • Ventilation • Traffic Patterns in the OR

  22. Communication in the OR • Procedural Verification, TIME OUT • Keep superfluous conversation to a minimum • Respect the patient, even if “asleep” • Prioritize & Standardize

  23. Surgical Safety Use a Surgical Safety Checklist Prioritize Activities Fire in the OR? Infection Control

  24. Skin Prep

  25. Types of Incisions • Know your incision site before you prep • Displace uterus in supine position • Skin incision: • Vertical • Low transverse • Uterine Incision: • Low transverse • Vertical • T

  26. Area of Abdominal Skin Prep • Types of Skin preps • Pre-surgical skin prep • Betadine • Chlorhexadine gluconate • Technicare

  27. Other Duties that Keep your Patient Safe • Specimen Handling • Label fluids on the Sterile Field • Surgical Counts • Electosurgical Safety • Positioning • Know the location of Supplies • Know the Instruments • Document!

  28. Anesthesia • Regional • Spinal • Epidural • Local • General

  29. Regional • Spinal • Local anesthetic or local with opiod injected into subarachnoid space to produce motor/sensory block • Risk of hypotension (esp. if mother dehydrated) a bolus of 500cc – 1 L with isotonic solution prior to procedure • Potential for spinal headache

  30. Regional • Epidural • Dilute local anesthetic or local with preservative-free opiod injected into epidural space • Single injection , repeat bolus or continuous infusion • Interrupts transmission of pain impulses along nerve roots. • Lower doses allow motor function to remain intact • Sympathetic blockade is less than with a spinal • Increased chance for system toxicity related to larger amount of drug used and absorbed than with a spinal • LA Toxicity…what’s that?

  31. General Anesthesia • Indications for General Anesthesia • Goals and Precautions • Circulator Duties

  32. Assisting with General Induction • 2 circulators are needed, one devoted to assisting anesthesiologist/CRNA. • Positioning for safety and good oxygenation prior to induction • Skin Prep/draping prior to induction • Protect airway (antacids, cricoid pressure, positioning, suctioning) • Patent IV • Foley in place

  33. Phases of Anesthesia • Induction • Maintenance • Emergence • Recovery

  34. Commonly Used Induction Medications • Inhalation Agents • IV Anesthetics • Muscle Relaxants

  35. General Induction Sequence • Pre-oxygenate : 3-5 minutes • Pretreat: Induction of “Sleep” Surgeon is ready to cut. • Paralytic dose: of muscle relaxant is given. • Protect, position: Intubation occurs, with Selleck maneuver.

  36. Selleck’s Maneuver (Cricoid Pressure)

  37. General Induction Sequence Continued • Placement: Confirm placement of ET tube. Don’t let go until you are told to do so. • Anesthesia maintained with muscle relaxants, narcotics, inhalation agents.

  38. General Induction Sequence Continued • Reversal of induction • Extubate when fully awake. • Pt moved to PACU when gag reflex, • swallowing and spont ventilations are in place.

  39. Malignant Hyperthermia (MH) • An autosomal dominant inherited muscle disorder that can occur in susceptible people on exposure to certain drugs used to produce general anesthesia or muscle relaxation during anesthesia. • Theory is that MH reactions are set off by sudden release of large quantities of CA++ which increases metabolic activity of muscle. Body fuels are rapidly consumed.

  40. Malignant Hyperthermia • Triggers • All volatile inhalation anesthetics • Depolarizing muscle relaxants • Succinylcholine

  41. Malignant Hyperthermia •  blood potassium =rapid, irregular heart rate and possible arrest. •  CO2 = rapid, deep breathing •  O2 = brain damage •  myoglobin can block kidneys=kidney failure •  heat= fever, may reach 110F within minutes

  42. Treatment • HELP! • Stop the triggering agent(s) • Dantrolene within 5 minutes • Monitor & Supportive treatment • Notify MHAUS

  43. Complicating Factors for Cesarean Section • Obesity • Multiple Repeats • Over distended uterus • Substance abuse • Hemorrhage • Organ Injury • C-Hysterectomy

  44. Summary • Indications • Patient and Staff Safety • Anesthesia Options • Complicating factors

  45. References • Association of Obstetricians and Gynecologists. Vaginal Birth after previous Cesarean Delivery, Practice Bulletin #115. August 2010. • Association of Operating Room Nurses. Perioperative Standards and Recommended Practices, current edition. • National Vital Statistics, Volume 58, No 16, electronic version • World Health Organization, Surgical Safety Checklist URL http://www.who.int/patientsafety/safesurgery/en • American Academy of Pediatrics and American College of OB GYN Guidelines for Perinatal Care, current edition

  46. OB PACU

  47. OBJECTIVES • Discuss PACU Standards of care as related to the OB Unit. • Describe patient assessments and nursing interventions required in the PACU. • Discuss potential complications in the recovery period through case study.

  48. Standards for Staffing a PACU • A registered nurse is present when any patient is recovering. Nurse to patient staffing ratios are based on patient condition and are consistent with other post anesthesia units in the institution. ASPAN, 2010-2012

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