OB PACU

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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.
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