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    Cesarean Delivery: Emergency (Maternal-Newborn) - CE

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    Feb.27.2020

    Cesarean Delivery: Emergency (Maternal-Newborn) - CE

    ALERT

    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

    OVERVIEW

    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.

    PATIENT AND SUPPORT PERSON EDUCATION

    • Instruct the patient and support person about the cesarean delivery process.
    • Inform the patient and support person that anesthesia will be used for the procedure.
    • Inform the patient and support person about the personnel who will be in the operating room (OR) and their roles.
      • Physician
      • Anesthesia provider
      • Pediatrician or neonatologist
      • Surgical staff
        • Circulating nurse
        • Pediatric or nursery nurse
        • Surgical assistant
        • Surgical scrub nurse or technician
    • Instruct the patient and support person about preparation of the support person (attire, location in OR).
    • Inform the patient about the preoperative preparations.
      • Fetal monitoring in the OR
      • Placement and maintenance of urinary catheter
      • Administration of preoperative medications
    • Tell the patient what to expect during the perioperative period.
      • Positioning with a wedge under her right or left hip
      • Safety straps on her upper and lower extremities
      • Sequential compression device, if indicated
      • Draping
      • Monitoring
      • Sensations to expect
    • Tell the patient what to expect during the postoperative period.
      • Placement of matching identification bands on her, her newborn(s), and her support person after delivery per the organization’s practice
      • Pain management
        • Medications
        • Splinting the incision
      • Postoperative exercises
        • Deep breathing and coughing with incisional splinting
        • Repositioning and leg exercises
      • Diet (nothing by mouth [NPO], clear liquids, advancing diet)
      • Ambulation
      • Expected length of recuperation
      • Incentive spirometry
      • Sequential compression devices
      • Fall risk during ambulation related to blood loss or regional anesthesia
    • Encourage questions and answer them as they arise.

    ASSESSMENT AND PREPARATION

    Assessment

    1. Perform hand hygiene before patient contact.
    2. Introduce yourself to the patient and support person.
    3. Verify the correct patient using two identifiers.
    4. Assess the patient’s cardiopulmonary status.
      1. Heart and breath sounds
      2. Vital signs
      3. History of pulmonary or cardiac disorders
    5. Determine the FHR pattern and uterine activity. Continue fetal monitoring until the time of the surgical skin preparation.
    6. Determine the time and amount of the last oral intake, both solids and liquids. Verify NPO status.
    7. Assess the patient for allergies to medications and materials.
    8. Assess the patient’s history of IV intake and output.
    9. Assess the patient for the risk of infection. Determine the patient’s Group Beta Streptococcus status.
    10. Assess the patient for the risk of anesthetic complications. Verify a patient or familial history of complications from anesthesia.

    Preparation

    1. Ensure that adult resuscitation equipment and other needed supplies, such as a postpartum hemorrhage cart, are readily available.
    2. Notify the charge nurse of the impending cesarean delivery.
      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.
    3. Obtain the ordered laboratory specimens.
    4. In the presence of the patient, label the specimens per the organization’s practice.11
    5. Prepare the specimens for transport.
      1. Place each labeled specimen in a biohazard bag.
      2. If a specimen requires ice for transport, place the specimen in a biohazard bag, then place the bag with the specimen into a second biohazard bag filled with ice slurry.
        Rationale: Placing the specimen in a separate bag protects the label from being damaged.
    6. Immediately transport the specimens to the laboratory.
    7. Review and report the results of laboratory testing to the physician and anesthesia provider.
    8. Comply with Universal Protocol. Use a standardized list to verify that all required items, including informed consent, are available.
    9. Ensure that the patient has a functioning IV line per anesthesia standards and the organization’s practice. The administration of emergency medications and blood products also requires IV access.

    PROCEDURE

    Preoperative Care

    1. Perform hand hygiene.
    2. Verify the correct patient using two identifiers.
    3. Explain the procedure to the patient and ensure that she agrees to treatment.
    4. Administer IV fluid preload and coload, as ordered by the anesthesia provider.
      Rationale: IV fluids help prevent hypotension associated with anesthesia.
    5. Perform hand hygiene and don sterile gloves.
    6. Insert an indwelling urinary catheter with a collection system.
      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.
    7. Discard supplies, remove gloves, and perform hand hygiene. Don clean gloves.
    8. If pubic or lower abdominal hair will interfere with the surgical site, remove the hair selectively with electric or battery-operated clippers or depilatory methods that minimize injury to the skin. Wash the area with soap and water or an organization-approved skin cleansing wipe.
      9. 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. 7
    9. Discard supplies, remove gloves, and perform hand hygiene.
    10. Administer antibiotics as ordered by the physician or anesthesia provider.
      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. 4
    11. Administer antacids, histamine-2 receptor antagonists, and gastrointestinal motility moderators as ordered by the physician or anesthesia provider.
      Rationale: Antacids and histamine-2 receptor antagonists lower gastric pH and decrease complications related to the potential for aspiration. 14
    12. Ensure that the patient’s jewelry (including body piercings), dental appliances, and contact lenses have been removed. Remove nail polish from at least one fingernail. If the patient wears glasses and they are available, encourage her to wear them to enhance her ability to see the newborn.
      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.
    13. Assist the support person with dressing for the OR and then assist the patient with donning a cap.
      Rationale: Street clothes, shoes, hair, nose, and mouth must be covered to maintain optimal cleanliness in the OR.
    14. Continue to monitor fetal status via fetal monitoring until abdominal sterile preparation begins1 and per the organization’s practice. If using internal fetal monitoring, continue using it until abdominal sterile preparation is completed or longer if indicated.2 When internal fetal monitoring is no longer indicated, if the lead cannot be removed, cut it as close as possible to the introitus so the remainder can be pulled up through the vagina and out through the abdominal incision during delivery of the newborn. Remove gloves and perform hand hygiene.
      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.
    15. When indicated by the anesthesia provider, transport the patient to the OR.
    16. Perform hand hygiene.
    17. Document preoperative care in the patient’s record and on a preoperative checklist.

    Intraoperative Care–Circulating Nurse’s Responsibilities

    1. Don cap, shoe covers, gown, and mask with eye protection before entering the OR. Perform hand hygiene and don gloves.
      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.
    2. Receive the patient for care, record the time of arrival, and complete the preoperative checklist. Verify the correct patient using two identifiers.
    3. Comply with Universal Protocol. Use a standardized list to ensure that all required items, including informed consent, are available.
    4. Assist with transferring the patient onto the OR table.
    5. Comply with Universal Protocol: Perform a time-out to verify the correct patient, correct site, and correct procedure.
    6. Assist the anesthesia provider as needed.
      1. If indicated, position the patient per the anesthesia provider’s preference for the administration of spinal or epidural analgesia (normally in a sitting position on the OR table).
      2. Support the patient and assist the anesthesia provider, as requested, during anesthesia induction.
        1. Place the cardiac monitoring leads.
        2. Place the pulse oximetry lead and automatic blood pressure cuff.
      3. After regional anesthesia has been initiated, place the patient in the supine position with a wedge under her right or left hip.
        Rationale: Placement of a wedge reduces pressure of the uterus on the vena cava, which can lead to supine hypotension syndrome.
    7. If ordered, apply a sequential compression hose or device and connect it.
    8. Place a warm blanket on the patient’s lower extremities and secure her with safety straps across her upper thighs before removing the labor bed, stretcher, or wheelchair from the room. Confirm that bony prominences are cushioned.
    9. Place a warm blanket on the upper half of the patient’s torso and upper extremities. Apply safety straps to the patient’s forearms per the organization’s practice.
    10. Place an electrocautery or dispersive grounding pad on the patient’s lateral thigh and plug it into the electrocautery unit. Ensure that the settings on the electrocautery unit are correct per the physician’s preference.
      1. If an alternative site is needed, avoid bony prominences when applying the grounding pad.
      2. If excess hair is observed in the area, remove it before placing the pad.
    11. Ensure that the indwelling catheter is in place and patent and that the drainage bag is placed where it can be observed.
      Rationale: Monitoring catheter drainage helps detect increased blood loss.
    12. Comply with Universal Protocol. Perform a time-out to verify the correct patient, correct site, and correct procedure.
    13. Verify fetal status after anesthesia administration and before abdominal preparation by auscultating the FHR or observing the fetal monitor.
    14. Remove gloves, perform hand hygiene, and don clean or sterile gloves per the organization’s practice for abdominal cleansing and preparation.
    15. Perform abdominal cleansing and preparation.
      Rationale: Completing surgical preparation before draping the patient decreases microorganism transmission at the incision site.
    16. Discard supplies, remove gloves, and perform hand hygiene. Don clean gloves.
    17. Ensure the functionality of suction and oxygen equipment for the patient and the newborn.
    18. Verify that the neonatal resuscitation team is present.
    19. Call for the support person to be brought to the OR and tell him or her where to stand or sit.
    20. Remain available to add supplies to the sterile field, assist the surgical staff and anesthesia provider as indicated, and support the patient and support person as needed.
    21. Perform surgical counts of sponges, sharps, and instruments before the start of the procedure.
    22. Record the times of membrane rupture and fluid characteristics, delivery of the newborn, and delivery of the placenta.
    23. Assist the nursery nurse and pediatrician, neonatologist, or other neonatal resuscitation team members, as needed, with neonatal resuscitation.
      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.
    24. In the presence of the mother, create and apply identification bands that have two identifiers and are unique to the mother and newborn.
      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. 2
      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.
      1. Ensure that the identification bands have a distinct identifier for the newborn by including the mother’s first and last names along with the newborn’s gender (e.g., Smith, Judy Girl; Smith, Judy Boy A).10
        Rationale: A distinct identifier may prevent misidentification of a newborn who may have a common name or is one of a multiple birth.
      2. After verifying the accuracy of the identification band information with the mother’s and support person’s identification bands and a second nurse, apply one band to the mother, one band to the support person, and apply one band to the newborn’s wrist and the other to the opposing ankle, or per the organization’s practice.
      3. If there are multiple newborns, have the mother and support person wear an identification band that corresponds to each newborn’s unique identification band.
      4. Footprint the newborn per the organization’s practice.
      5. Consider using signage or other communication tools to alert health care team members to newborns with similar names.10
    25. Remove gloves, perform hand hygiene, and don clean gloves.
    26. In the presence of the patient, label the specimens (e.g., fallopian tube segments, umbilical cord blood, arterial or venous umbilical cord blood for gas values) per the organization’s practice.11 If bilateral tubal ligation is performed during the cesarean delivery, collect the segments of the right and left tubes in different containers and label them correctly.
    27. Prepare the specimens for transport.
      1. Place labeled specimens in biohazard bags.
      2. If specimens require ice for transport, place the specimens in biohazard bags, then place the bags with the specimens into second biohazard bags filled with ice slurry.
        Rationale: Placing specimens in separate bags protects the labels from being damaged.
    28. Immediately have a health care team member transport the specimens to the laboratory or, if appropriate, take the specimens to the laboratory after the procedure is completed.
    29. Discard supplies, remove gloves, and perform hand hygiene. Don clean gloves.
    30. Add additional sponges, sharps, and instruments to the operating field as requested. Count additions with the scrub person and add them to the count document or electronic record.
    31. Bring any medications, irrigation fluids, or surgical supplies that are requested to the operating field using sterile technique.
    32. Monitor conditions in the OR. Ensure that any breaks in sterile technique are reported and corrected.
    33. Perform surgical counts of sponges, sharps, and instruments:8
      1. Before the closure of a cavity within a cavity (e.g., uterus)
      2. When wound closure begins
      3. At skin closure or at the end of the procedure when counted items are no longer being used
      4. When the scrub person or circulating nurse is permanently relieved (even if direct observation of all items is not possible)
        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. 8
    34. Notify the physician immediately if the surgical count is not correct and take corrective action per the organization’s practice.
    35. Remove gloves, perform hand hygiene, and don clean gloves.
    36. When surgery is completed, assist with cleansing the operative site, maintaining the incision site integrity as much as possible, and applying a surgical dressing.
    37. Remove the safety straps and check the patient’s skin integrity.
    38. Assess lochia while massaging the fundus as necessary to control uterine bleeding.
    39. Assess the patient for signs of postpartum hemorrhage.
      1. Vaginal bleeding that is heavy or suddenly gushes, a slow constant flow of blood, or an oozing of blood12
      2. Quantification of blood loss (QBL) of 1000 ml or more or blood loss between 500 and 999 ml and clinical indications for treatment5,13
      3. Change in mentation
      4. Tachycardia, tachypnea, hypotension, or other change in vital signs (late signs)
      5. Change in level of consciousness (alertness, confusion, lethargy, obtundation, stupor, coma)
      6. Persistent, severe perineal pain or pressure, possibly accompanied by a discolored swollen mass in the vulvar or perineal area
    40. If evidence of postpartum hemorrhage exists, initiate the obstetric hemorrhage protocol. Call for help and notify additional personnel, including the practitioner and a second labor and delivery nurse.9
    41. If QBL (Box 1)Box 1 is excessive, attempt to identify the source of bleeding. Use “the 4 T’s” mnemonic to consider whether the bleeding is related to tone (uterine atony), trauma (lacerations, hematomas, or uterine rupture), tissue (retained placental tissue), or thrombin (coagulation factors).5
      1. If blood is dark red, assess the patient for superficial lacerations.
      2. If blood is bright red, assess the patient for deep lacerations (i.e., lacerations in the cervix).
      3. If blood spurts and clots, assess the patient for uterine atony or partial placental separation.
      4. If blood does not clot, assess for coagulopathies, including idiopathic or immune thrombocytopenic purpura, von Willebrand disease, or disseminated intravascular coagulation.12
    42. If there is no evidence of postpartum hemorrhage or excessive QBL, clean the perineum and apply a perineal pad.
    43. Reapply the safety straps until the team is ready to transfer the patient onto a stretcher for transport.
    44. Remove gloves, perform hand hygiene, and don clean gloves.
    45. Remain with the anesthesia provider and patient if general anesthesia was administered. Assist the anesthesia provider during removal of the artificial airway, as needed.
    46. Assist with transferring the patient to the postpartum bed or transport gurney using a roller or transfer device.
    47. Accompany the patient and anesthesia provider to the postanesthesia care unit (PACU) and report the patient’s status and surgical outcomes to the perianesthesia nurse.
    48. On arrival in the PACU, before giving the newborn to the mother or support person, identify him or her using two identifiers. Compare the bands applied to the newborn’s wrist and ankle to the mother’s or support person’s corresponding identification bands.
      1. Band number
      2. Distinct name
        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). 10
    49. Discard supplies, remove gloves, and perform hand hygiene.
    50. Document the procedure in the patient’s record and on the operative record in compliance with the organization’s practice.

    MONITORING AND CARE

    1. Assess the contents of and the amount and color of urine in the catheter collection bag
    2. Per the physician’s order, discard the placenta or send placental specimens as well as other specimens to the laboratory.
      Rationale: When cesarean delivery is performed for indications involving the fetus, pathologic evaluation of the placenta should be considered. 1
    3. Per the physician’s order, send cord blood to the laboratory.
    4. Assess, treat, and reassess pain.

    EXPECTED OUTCOMES

    • Preservation of maternal well-being (absence of hypothermia, infection, injury, and retained foreign bodies; reduction of anxiety)
    • Preservation of fetal well-being

    UNEXPECTED OUTCOMES

    • Maternal injury
      • Aspiration
      • Atelectasis
      • Complications related to anesthesia
      • Hemorrhage
      • Infection
      • Injuries to bowel
      • Injuries to bladder, ureters, or other abdominal organs
      • Injury related to electrocautery
      • Pulmonary embolism
      • Retained foreign body
      • Skin breakdown
      • Thrombophlebitis
    • Maternal death
    • Fetal injury
      • Cardiopulmonary compromise
      • Physical injuries related to surgical procedure (e.g., laceration from scalpel)
      • Transient tachypnea of the newborn
    • Fetal death
    • Unresolved maternal feelings of inadequacy
      • Fear
      • Disappointment
      • Frustration
      • Sense of loss of control
      • Anger

    DOCUMENTATION

    • Rationale for performing cesarean delivery
    • Decision time of cesarean delivery and consent process
    • Communication with health care team members, including physician, nurse-midwife, pediatrician, neonatologist, or neonatal nurse practitioner, anesthesia provider, pediatric or nursery nurse, surgical team members, other team members (e.g., respiratory therapist)
    • Patient and support person education
    • All health care team members and patient support persons in the OR during the procedure
    • Patient’s vital signs before transport to the OR
    • FHR and uterine activity
      • Before transport to the OR
      • After anesthesia induction
      • Before abdominal preparation
    • Time and amount of oral intake
    • Preoperative checklist including allergies
    • Time patient was transported to OR, mode used, and staff accompanying patient
    • Time patient entered OR, time of anesthesia provider’s arrival, time of anesthesia induction, time of time-out before incision, incision time, time of birth, time of placenta expulsion, time procedure was completed, and time patient exited the OR
    • Medications administered
    • IV access, fluids infused, and amount infused
    • Indwelling catheter placement
    • Hair clipping at surgical site
    • Internal fetal monitoring lead removed or not removed via the abdominal incision
    • Abdominal preparation
    • Placement of sequential compression device, if indicated
    • Placement of electrocautery or dispersive grounding pad and condition of site before and after placement
    • Lot number of grounding pad placed on patient
    • Electrocautery unit number and settings
    • Patient positioning
    • Indwelling catheter drainage upon patient's arrival in OR, during surgery, and postoperatively
    • Patient’s response to the procedure
    • Specimens and cultures obtained and their disposition
    • Each count of instruments, sharps, sponges, and supplies and resolution and actions if counts incorrect
    • Addition or removal of instruments, supplies, or medications
    • Informed consent
    • Location and types of drains, catheters, and wound dressings
    • Administration of medications, blood products, and irrigations
    • Wound and surgical classification
    • All procedural time-outs conducted
    • Mode of anesthesia administration
    • Patient status on arrival in OR and on discharge from OR
    • Disposition of patient and transfer method
    • Disposition of newborn and status at transfer
    • Neonatal resuscitation team members present and their titles
    • Communication with support person
    • Delivery record per the organization’s practice
    • Unexpected outcomes and related nursing interventions

    REFERENCES

    1. American Academy of Pediatrics (AAP) Committee on Fetus and Newborn, American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice, and others. (2017). Chapter 7: Intrapartum care of the mother. In Guidelines for perinatal care (8th ed., pp. 227-278). Elk Grove Village, IL: AAP. (Level VII)
    2. American Academy of Pediatrics (AAP) Committee on Fetus and Newborn, American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice, and others. (2017). Chapter 10: Care of the newborn. In Guidelines for perinatal care (8th ed., pp. 347-408). Elk Grove Village, IL: AAP. (Level VII)
    3. American College of Obstetricians and Gynecologists (ACOG). (2010, reaffirmed 2019). ACOG practice bulletin no. 116: Management of intrapartum fetal heart rate tracings. Obstetrics & Gynecology, 116(5), 1232-1240. doi:10.1097/AOG.0b013e3182004fa9 (Level VII)
    4. American College of Obstetricians and Gynecologists (ACOG). (2018). ACOG practice bulletin no. 199: Use of prophylactic antibiotics in labor and delivery. Obstetrics & Gynecology, 132(3), e103-e119. doi:10.1097/AOG.0000000000002833 (Level VII) (Errata published 2019, Obstetrics & Gynecology, 134(4), 883-884. doi:10.1097/AOG.0000000000003499)
    5. American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins—Obstetrics. (2017, reaffirmed 2019). ACOG practice bulletin no. 183: Postpartum hemorrhage. Obstetrics & Gynecology, 130(4), e168-e186. doi:10.1097/AOG.0000000000002351 (Level VII)
    6. Aref, N.K. (2019). Does timing of urinary catheter removal after elective cesarean section affects postoperative morbidity? A prospective randomized trial. The Journal of Maternal-Fetal & Neonatal Medicine. Epub ahead of print. doi:10.1080/14767058.2019.1569619 (Level II)
    7. Association of periOperative Registered Nurses (AORN). (2019a). Preoperative patient skin antisepsis. In Guidelines for perioperative practice (pp. 579-606). Denver: AORN. (Level VII)
    8. Association of periOperative Registered Nurses (AORN). (2019b). Prevention of retained surgical items. In Guidelines for perioperative practice (pp. 765-814). Denver: AORN. (Level VII)
    9. California Maternal Quality Care Collaborative (CMQCC). (2015). Obstetric hemorrhage 2.0 toolkit. Retrieved November 26, 2019, from https://www.cmqcc.org (Level VII)
    10. Joint Commission, The. (2018). R3 report: Requirement, rationale, reference: Distinct newborn identification requirement. Retrieved November 26, 2019, from https://www.jointcommission.org/assets/1/18/R3_17_Newborn_identification_6_22_18_FINAL.pdf (Level VII)
    11. Joint Commission, The. (2019). National patient safety goals: Hospital accreditation program. Retrieved November 26, 2019, from https://www.jointcommission.org/assets/1/6/NPSG_Chapter_HAP_Jan2019.pdf (Level VII)
    12. Lanning, R.K. (2020). Chapter 33: Postpartum complications. In D.L. Lowdermilk and others (Eds.), Maternity and women’s health care (12th ed., pp. 721-815). St. Louis: Elsevier.
    13. Main, E.K. and others. (2015). National Partnership for Maternal Safety: Consensus bundle on obstetric hemorrhage JOGNN: Journal of Obstetric, Gynecologic and Neonatal Nursing, 44(4), 462-470. doi:10.1111/1552-6909.12723 (Level VII)
    14. Paranjothy, S. and others. (2014). Interventions at cesarean section for reducing the risk of aspiration pneumonitis. Cochrane Database of Systematic Reviews, 2, Art. No.: CD004943. doi:10.1002/14651858.CD004943.pub4 (Level I) (classic reference)*

    ADDITIONAL READINGS

    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.

    Elsevier Skills Levels of Evidence

    • Level I - Systematic review of all relevant randomized controlled trials
    • Level II - At least one well-designed randomized controlled trial
    • Level III - Well-designed controlled trials without randomization
    • Level IV - Well-designed case-controlled or cohort studies
    • Level V - Descriptive or qualitative studies
    • Level VI - Single descriptive or qualitative study
    • Level VII - Authority opinion or expert committee reports
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