NCP Care Following Cesarean Birth (4 hours to 3 days postpartum

CLIENT ASSESSMENT DATA BASE

Review prenatal and intraoperative record, and the indication(s) for cesarean delivery.

Circulation

Blood loss during surgical procedure approximately 600–800 ml

Ego Integrity

May display emotional lability, from excitation, to apprehension, anger, or withdrawal.
Client/couple may have questions or misgivings about role in birth experience.
May express inability to deal with current situation.

Elimination

Indwelling urinary catheter may be in place; urine clear amber.
Bowel sounds absent, faint, or distinct.

Food/Fluid

Abdomen soft with no distension initially.
Mouth may be dry.

Neurosensory

Impaired movement and sensation below level of spinal epidural anesthesia

Pain/Discomfort

May report discomfort from various sources, e.g., surgical trauma/incision, afterpains, bladder/abdominal distension, effects of anesthesia

Respiratory

Lung sounds clear and vesicular

Safety

Abdominal dressing may have scant staining or may be dry and intact.
Parenteral line/saline lock when used, is patent, and site is free of erythema, swelling, and tenderness.

Sexuality

Fundus firmly contracted and located at the umbilicus.
Lochia flow moderate and free of excessive/large clots.

DIAGNOSTIC STUDIES

CBC, Hb/Hct: Assesses changes from preoperative levels and evaluates effect of blood loss in surgery.
Urinalysis (UA); Urine, Blood, Vaginal, and Lochial Cultures: Additional studies are based on individual need.

NURSING PRIORITIES

1. Promote family unity and bonding.
2. Enhance comfort and general well-being.
3. Prevent/minimize postoperative complications.
4. Promote a positive emotional response to birth experience and parenting role.
5. Provide information regarding postpartal needs.

DISCHARGE GOALS

1. Family bonding initiated
2. Pain/discomfort easing
3. Physical/psychological needs being met
4. Complications prevented/resolving
5. Positive self-appraisal regarding birth and parenting roles expressed
6. Postpartal care understood and plan in place to meet needs after discharge