NCP Cesarean Birth

Cesarean birth is an alternative to vaginal birth only when the safety of the mother and/or fetus is compromised.

CLIENT ASSESSMENT DATA BASE


ACTIVITY/REST

Fatigue may be present.

CIRCULATION

Hypertension (escalating PIH)
Hypotension, ashen color, cool/clammy skin (uterine rupture)

EGO INTEGRITY

May view anticipated procedure as a sign of failure and/or as a negative reflection on abilities as a female
May actually fear intervention/view surgery as life-threatening
Irritable/emotional tension, (emotional response to prolonged labor; physiological response to PIH)

FOOD/FLUID

Excessive weight gain, nausea/vomiting, generalized edema (PIH)

PAIN/DISCOMFORT

Prolonged/dysfunctional contractile pattern (dystocia).
Uterine tenderness may be present; severe abdominal pain (uterine rupture).
Right upper quadrant (RUQ)/epigastric pain (PIH).
Headache (PIH).

NEUROSENSORY

Visual disturbance/scotomata (spots in visual field) (PIH)
Seizure activity (eclampsia)
Hyperreflexia, clonus (PIH)

SAFETY

Elevated temperature (infectious process/dehydration).
Active STD (e.g., herpes).
Severe Rh incompatibility.
Prolapsed cord.
Fetal distress.
Impending delivery of premature fetus.
Fetal macrosomia (estimated >4000 g).
Unsuccessful external cephalic version to rotate breech presentation, or transverse lie.
Membranes may have been ruptured for 24 hr or longer.

SEXUALITY

CPD; tumor/neoplasm obstructing the pelvis/birth canal
Multiple pregnancies or gestations (overdistended uterus)
Substantial vaginal bleeding (placenta previa/abruptio placentae)
Previous cesarean delivery with classical incision; previous uterine or cervical surgery

TEACHING/LEARNING
Presence of maternal complication/risk factors, such as severe PIH, diabetes, renal or cardiac disease, or ascending infection; prenatal abdominal trauma; maternal age >35 yr.
Procedure may or may not be planned, affecting client’s preparation and understanding of procedure.
Failed induction.
Maternal age.

DIAGNOSTIC STUDIES

Complete Blood Count (CBC), Blood Typing (ABO) and Cross-match, Coombs’ test: Preoperative screening tests.
Urinalysis: Determines albumin/glucose levels.
Cultures: Identify presence of herpes simplex virus type II.
X-ray Pelvimetry: Determines CPD, flexion of head in breech position.
Amniocentesis: Assesses fetal lung maturity.
Ultrasonography: Locates placenta; determines fetal growth, lie, and presentation, as well as fetal anomalies/malformations favoring cesarean delivery.
Nonstress Test (NST) or Contraction Stress Test (CST): Assesses fetal response to movement/stress of uterine contractions.
Continuous Electronic Monitoring: Validates fetal status/uterine activity.

NURSING PRIORITIES

1. Promote maternal/fetal well-being.
2. Provide client/couple with necessary information.
3. Support client’s/couple’s desires to participate actively in birth experience.
4. Prepare client for surgical procedure.
5. Prevent complications.