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After the decision to perform an emergent cesarean delivery, the procedure should be accomplished as expeditiously as possible. The decision-to-incision interval and mode of delivery should be based on the timing that best addresses maternal and fetal risks and benefits.undefined#ref3">3
Cesarean delivery is considered major surgery because of the potential risks to the patient and the fetus. Therefore, it should be performed after the physician has discussed the risks and benefits with the patient. The goals of emergency cesarean delivery include the birth of a viable newborn and protection of the mother’s health. Complications of labor that may indicate the need for an emergency cesarean delivery include Category III (abnormal) fetal heart rate (FHR) tracing characteristics (e.g., sinusoidal heart rate, recurrent late decelerations, and bradycardia), umbilical cord prolapse, hemorrhage, and uterine rupture. Maternal medical conditions, including hemorrhage, obesity, and cardiovascular compromise, may require time for maternal stabilization before the procedure.
An emergency cesarean delivery may have negative implications for the patient and her support person because the child’s birth does not take place as they had planned. The preparation for the procedure occurs so abruptly that a thorough explanation of the physiologic and surgical processes may not be possible, which can have further negative consequences. Focusing on the newborn’s birth rather than the surgery is important. As time allows, the patient should have an opportunity to discuss the birth experience, to express her feelings, and to have her questions answered in detail.
Rationale: In many organizations, the charge nurse is the designated person who notifies the nursing supervisor, anesthesia provider, surgical staff, and pediatrician of the impending cesarean delivery.
Rationale: Placing the specimen in a separate bag protects the label from being damaged.
Rationale: IV fluids help prevent hypotension associated with anesthesia.
Rationale: A urinary catheter decompresses the bladder, prevents bladder injuries during surgery, improves lower uterine segment exposure, eases operative steps during the performance of a cesarean delivery, allows easy assessment of the volume and color of urine output, and prevents postoperative urine retention.
6 In some cases, the catheter may be inserted after anesthesia induction.
Rationale: Hair removal enhances the physician’s view of the incision site and provides an area of skin where adhesive can be applied when the surgical dressing is placed; however, hair removal at the surgical site should be kept to a minimum and performed selectively. Performing the clip after the indwelling catheter has been inserted prevents the introduction of small hairs into the perineum. Cleansing the skin decreases bacteria at the surgical site.
Leaving hair in place at the surgical site is preferred to prevent skin trauma from hair removal and reduce the risk for surgical site infection. The presence of hair at the surgical site may increase the risk of a surgical fire, but this risk may be minimized by the application of a water-soluble gel to the hair.
Rationale: Administration of antibiotics should occur within 60 minutes before the procedure when possible unless the patient is already receiving an antibiotic regimen with an equivalent broad-spectrum coverage (e.g., for chorioamnionitis).
4 Antibiotics are administered prophylactically to prevent a surgically related infection.
When it is not possible to administer prophylactic antibiotics within 60 minutes before the start of a cesarean delivery, they should be administered as soon as possible after the incision is made.
Rationale: Antacids and histamine-2 receptor antagonists lower gastric pH and decrease complications related to the potential for aspiration.
Rationale: The patient should not wear anything with metal in case cautery is used in the surgical field. Dental appliances are removed to prevent damage if intubation is required. A fingernail without nail polish is needed to obtain accurate pulse oximetry readings. Contact lenses should be removed to prevent scratching the patient’s eyes in case general anesthesia is required.
Rationale: Street clothes, shoes, hair, nose, and mouth must be covered to maintain optimal cleanliness in the OR.
Document and report lead removal via the abdominal incision because of the potential for cross-contamination of the surgical wound and the increased risk of infection.
Rationale: Wearing gloves and gowns throughout the cesarean procedure provides protection against exposure to blood and other body fluids. Gloves should be removed, hand hygiene performed, and clean gloves donned as often as necessary during the procedure, especially if the gloves are visibly soiled.
Rationale: Placement of a wedge reduces pressure of the uterus on the vena cava, which can lead to supine hypotension syndrome.
Rationale: Monitoring catheter drainage helps detect increased blood loss.
Rationale: Completing surgical preparation before draping the patient decreases microorganism transmission at the incision site.
Rationale: The circulating nurse’s primary responsibility is to the surgical staff, the surgical field, and the patient.
If neonatal resuscitation is prolonged, call for additional personnel.
Rationale: Abduction and inadvertent switching of newborns are devastating events for families and pose risks to the organization. Therefore, reviewing and adhering to newborn identification and security procedures are important.
All identification bands must be filled out with the same information and correspond to the mother’s information. For newborn security, identification bands with incorrect information should not be applied.
Rationale: A distinct identifier may prevent misidentification of a newborn who may have a common name or is one of a multiple birth.
Rationale: Placing specimens in separate bags protects the labels from being damaged.
When there is a discrepancy in the count or counts adjusted for additional supplies, the circulating nurse should search the room, including the area near the sterile field, floor, kick buckets, and trash and linen receptacles, and recount with the scrub person until they can account for all supplies. The procedure should be immediately suspended if the condition of the patient permits while the physician performs a methodical wound examination looking for the missing supplies.
Ensure that there is a distinct identifier on the newborn’s band, such as the mother’s first and last names along with the newborn’s gender (e.g., Smith, Judy Girl; Smith, Judy Boy A).
Rationale: When cesarean delivery is performed for indications involving the fetus, pathologic evaluation of the placenta should be considered.
Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). (2019). Perioperative care of the pregnant woman: Evidence-based clinical practice guideline (2nd ed.). Washington, DC: AWHONN.
McKibben, R.A. and others. (2015). Practices to reduce surgical site infections among women undergoing cesarean section: A review. Infection Control & Hospital Epidemiology, 36(8), 915-921. doi:10.1017/ice.2015.116
*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.
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