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 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 Indications Continued Active genital herpes Uterine Rupture Placental abnormality Placenta previa Abruptio placenta Uterine Rupture Total C/S Rates C/S Rates in the U.S. National Vital Statistics Report Vol. 58, No. 16 Year VBAC rate Primary C/S rate Previous C/S All C/S rate 2006 8.5 2007 2008 2009 Unavail Unavail Unavail 28.4 29.0 Unavail Unavail (adjusted) (prelim) 92 Unavail Unavail Unavail 31.1 31.8 32.3 32.9 (prelim) (prelim) (adjusted) 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?) Successful VBAC How 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 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. 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 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 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 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. 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? Getting Ready Documentation 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 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 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 Personnel and Roles Scrubbed Team Un-scrubbed Team Circulating RN Duties? Personnel and Roles Scrub Nurse or Tech Anesthesia Provider Surgical Assist Surgeon Personnel and Roles Neonatal Team Support Person Infection Control Cleaning the OR Attire in restricted & semi-restricted areas Personal Protective Equipment Personal Hygiene Skin preps Ventilation Traffic Patterns in the OR Communication in the OR Procedural Verification, TIME OUT Keep superfluous conversation to a minimum Respect the patient, even if “asleep” Prioritize & Standardize Surgical Safety Use a Surgical Safety Checklist Prioritize Activities Fire in the OR? Infection Control Skin Prep 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 Area of Abdominal Skin Prep Types of Skin preps Pre-surgical skin prep Betadine Chlorhexadine gluconate Technicare 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! Anesthesia Regional Spinal Epidural Local General 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 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? General Anesthesia Indications for General Anesthesia Goals and Precautions Circulator Duties 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 Phases of Anesthesia Induction Maintenance Emergence Recovery Commonly Used Induction Medications Inhalation Agents IV Anesthetics Muscle Relaxants 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. Selleck’s Maneuver (Cricoid Pressure) 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. 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. 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. Malignant Hyperthermia Triggers All volatile inhalation anesthetics Depolarizing muscle relaxants Succinylcholine 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 Treatment HELP! Stop the triggering agent(s) Dantrolene within 5 minutes Monitor & Supportive treatment Notify MHAUS Complicating Factors for Cesarean Section Obesity Multiple Repeats Over distended uterus Substance abuse Hemorrhage Organ Injury C-Hysterectomy Summary Indications Patient and Staff Safety Anesthesia Options Complicating factors Facts Standards Data C/S Rates Critical Thinking Interpersonal Skills Ethics Communication Technical Skills Skin Prep References 1. 2. 3. 4. 5. 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 OB PACU 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. 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 Standards for Staffing a PACU Phase I Level of Care Phase I is the immediate postanesthesia period, transitioning to phase II, the inpatient setting or to an intensive care setting for continued care. Two registered nurses, one who is a RN competent in phase I postanesthesia nursing, will be in the same unit where the patient is receiving phase I level of care at all times. ASPAN, 2010-2012 Standards for Staffing a PACU Phase I Level of Care Continued One nurse to one patient: At the time of admission, until critical elements* are met Requiring mechanical life support and/or artificial airway Any unconscious patient 8 yrs and under A second nurse must be able to assist Critical Elements for Mom One nurse to one patient until critical elements are met: Critical elements for Mom Report has been received from the anesthesia care provider, questions have been answered and the transfer of care has taken place. The patient is conscious The Patient has patent airway without assistance Initial assessment is complete and documented Patient is hemodynamically stable A second nurse must be available to assist as needed ASPAN, 2010-2012 AWHONN, 2010 Critical Elements for Baby One nurse to one patient until critical elements are met: Critical elements for Baby Report has been received from the baby nurse, questions have been answered and the transfer of care has taken place Initial assessment and care are completed and documented The baby is conscious and has a patent airway without assistance The baby is stable Initial assessment is complete and documented Identification Bracelets have been placed A second nurse must be available to assist as needed ASPAN, 2010-2012 AWHONN, 2010 Staffing a PACU Phase I Level of Care When can we have one nurse to two patients in OB PACU? When must we have two nurses to one patient? ACLS QUALIFIED OR NOT? Recovery aka Post Anesthesia Care How Long? Defined by patient status, not by time frame ASPAN 2010-2012 Recovery aka Post Anesthesia Care Where? Admission to the OB PACU Room Set up and Equipment For Phase I each patient bedside needs to have present the following items. Artificial airways and means to deliver O2 Constant and Intermittent Suction Means to monitor BP,T, EKG and Pulse oxymetry IV Supplies and stock medications Admission to the OB PACU Room Set up and Equipment Stock supplies such as dressings, gloves, emesis basins, tape, etc. Adjustable lighting and mode of warming a patient Emergency Cart with defibrillator and ventilator available Malignant Hyperthermic Supplies Patient Privacy On transfer to Recovery (OB PACU) Report Rapid assessment Dismiss Anesthesia Provider Respiratory Assessment Inspection, Auscultation/Listening, Pulse oxymetry Supportive Respiratory Equipment Bag-Valve with mask or ET Tube, LMA, ET Tubes, Nasal Trumpets, Oral Airways, suction and oxygen Nursing Interventions Prevent atalectasis and venous stasis Stimulate to take cough & deep breath every 10-15 minutes. Record RR at least every 15 minutes while in recovery Use incentive spirometer for smokers. Encourage and assist position changes Respiratory Complications and Nursing Actions Aspiration Mechanical Obstruction Laryngospasm Bronchospasm Pulmonary Edema Pulmonary Embolism Cardiovascular Cardiovascular Assessment Inspection Auscultation Monitor B/P, I&O, Pulse rate/quality& EKG Reproductive Assessment Potential Complications Nursing Interventions Emergency medications Renal/Fluids and electrolytes Assessment I&O, appearance of urine Edema, Chemistries Potential changes in pregnancy Magnesium Influence on Action of Nondepolarizing Neuromuscular Blocking agents Increase will potentiate Decrease in Serum Calcium Prolongs effects Dehydration Potentiates action Sodium deficit Prolong the block Gastrointestinal Female Assessment Interventions 20% 1 point Nonsmoker 20% 1 point HX PONV 20% 1 point Postop 20% 1 opiods point Chance for 80% 4 PONV points Neuromuscular/Sensory Assessment LOC Emotional Status DTRs Temperature Dermatome levels Motor movement Respirations Neuromuscular/Sensory Potential Complications Safety Measures Comfort and Pain Control Assessment Attitudes Nursing Actions Maternal/Infant Attachment Attachment and Interaction Nursing Actions Putting It All Together Frequency of Assessments for Mom BP, P, RR, O2 sat should be monitored every 15 minutes for at least 2 hours Vaginal Bleeding should be evaluated continuously Frequency of Assessments for Baby T, HR, RR, skin color, adequacy of peripheral circulation, type of respiration, LOC, tone/activity should be monitored and documented at least every 30 minutes until the newborns condition has remained stable for 2 hours Discharge criteria: Stability of Systems AAP& ACOG 2007 Discharge criteria should be developed in consultation with and approved by the anesthesia and medical staff. ASPAN 2010-2012 Modified Aldrete Score Activity Voluntarily moves all limbs =2 Voluntarily moves 2 limbs = 1 Unable to move = 0 Respiration Breaths deep coughs on own = 2 Dyspnea/hypoventilation = 1 Apnic = 0 Circulation BP +/- 20 mm Hg of pre-anesthetic levels = 2 Bp > 20-50 mm Hg of pre-anesthetic levels = 1 BP > 50 mm HG of pre-anesthetic levels = 0 Consciousness Fully awake = 2 Arousable = 1 Unresponsive = 0 Color Natural = 2 Pale/blotchy = 1 Cyanotic = 0 Score Putting It All Together Documentation Per institutional guidelines Transfer of patient notation Giving Report Standardize bedside handover Include safety checks Patient status Transfer of care documentation Scenario 1 A G2P1 delivers by unscheduled repeat C/S. The delivery was uneventful. She was given a rapid sequence mask induction because of advanced labor, previous classical incision and maternal anxiety. Upon arrival in PACU, she is in right recumbent position,briefly arrousable, maintaining her airway with good air exchange. VS are stable, O2 saturation is 97% on room air. After about 10 minutes, you hear gurgling sounds and note she has vomited, then gasped. She begins to cough and gag. You suction her mouth and throat, then administer an antiemetic. She is more awake and has no recurring N/V. Soon, she begins to breath more rapidly and says, “I can’t get enough air.” You notice crowing/stridor on inspiration. Her O2 sat drops to 80’s. Her voice is hoarse and panicky. What do you suspect? What do you need to know? What do you do? After your interventions, she is breathing more rapidly. Her saturation is 82%. She is fully conscious. What do you do next? Scenario 2 A 28 year old G2P1 at term is receiving an epidural anesthetic prior to scheduled Cesarean Section. She has no allergies, is in good health with an unremarkable prenatal history. You assist the woman into a fetal position on her side, and attach monitoring equipment. A liter of LR is hanging and you open it to provide a bolus. The anesthesiologist proceeds with the epidural. As he finishes injecting the epidural, the woman’s B/P drops to 80/37, her heart rate drops from 84 to 52 and O2 sat falls. She says,”I can’t breathe, my chest is heavy.” Scenario 3 A 26 year old southeast Asian woman at about 32 weeks, arrives in the recovery room after an emergency C/S, under rapid induction sequence, for abruption. As you proceed with your initial assessment, you note that a red string is tied around her upper abdomen and a pattern of old scars on the woman’s abdomen that look like burns. You know from a class on Transcultural nursing that it is believed this string placed during pregnancy forms a protective circle keeping the baby from harm and that burning the skin allows illnesses and evil out of the mother during her pregnancy. Scenario 3 (cont) As you continue with your assessment, the woman’s jaw dislocates. You call for the anesthesiologist to assist in realigning her jaw. Recovery proceeds with 2 more incidence of jaw dislocation. When the woman has recovered from anesthesia and is stable, you prepare to move to her room. You feel that the language barrier has hindered your communication with this woman. Before she leaves you, she tries to tell you something. Frustrated, you are glad an interpreter has been called in for the nurse who is taking over her care. You give report to the new RN. The pt is reunited with her husband in her postpartum room. Scenario 4 24 yr old G1 with no prenatal care presents to the Birth Center with a prolapsed cord and non-reassuring fetal heart rate pattern. She is taken for emergency C/S. Rapid sequence induction is initiated using propofol and succinylcholine. The anesthesiologist finds he cannot open the pt’s mouth, but can bag/mask ventilate. Scenario 4 (cont) After a few minutes of ventilation and propofol boluses, the jaw relaxes and pt is intubated. Anesthesia is maintained with 50% Nitrous Oxide in O2, rocuronium and 1% isoflourane. Baby delivers, surgery is completed and mother is taken to PACU. HR 140, R26, T104 Scenario 5 A 31 year old G2/1 is having a scheduled repeat C/S. Significant Hx is anxiety, breech presentation with this pregnancy and obesity. She has been taken to the operating room where the anesthesiologist is placing an epidural. You are assisting with positioning the patient. After several unsuccessful attempts, the anesthesiologist final gets the epidural placed. With each attempt your patient becomes more anxious. You are now helping to position her in left lateral tilt, and have called the surgeon into the room. Scenario 5 Continued Just as you are placing a bolster under the patient’s right hip, she says, “ What is happening to me? I feel really strange. “ She is becoming more restless. What do you think might be happening? How can you help her? Scenario 5 Continued Your patient becomes very restless. Her monitors are difficult to read due to her agitation. You notice some twitching of her facial muscles and she tells you “I taste something weird”. Now what do you think is happening? Scenario 5 Continued Your patient begins to seize. The anesthesiologist is attempting to protect her airway. What can you do to help? What could happen next? How will you prepare? Perioperative Nursing in the OB Setting Facts Standards Data Critical Thinking Interpersonal Skills Technical Skills References 1. American College of Obstetricians and Gynecologists. (August 2010).Vaginal Birth After Previous Cesarean Delivery, Practice Bulletin, Clinical Management Guidelines for Obstetrician-Gynecologists, Number115, Washington DC: Author. 2. American Society of Perianesthesia Nurses (ASPAN). (2010-2012). Perianesthesia Nursing Standards and Practice Recommendations. Authors. 3. American Society of Perianesthesia Nurses (ASPAN), current edition. Competency Based Credentialing Program. Authors. 4. Association of Women’s Health Obstetric and Neonatal Nurses Position Statement, (June 2010). Advanced Life Support in Obstetric Settings . Authors 5. Association of Women’s Health Obstetric and Neonatal Nurses. (2010). Guidelines for Professional Registered Nurse Staffing for Perinatal Units. Authors. 6. Association of Women’s Health, Obstetric and Neonatal Nurses. Standards and Guidelines for Professional Nursing Practice in the Care of Women and Newborns, 5th Edition. Authors. 7. Bates, SM, et al. Chest 2008; 133:844-886 8. Joint Commission, Updated Universal Protocol, April 2009 9. Joint Commission, Specifications Manual for Joint Commission National Quality Core Measures, (2010). http://manual.jointcommission.org/releases/TJC2010A/MIF0167.html 10. Malignant Hyperthermia Association of the United States (MHAUS). Current edition. Understanding Malignant Hyperthermia. Authors.