THE GOAL OF THIS CESAREAN SECTION CONTINU- ING EDUCATION PROGRAM is to provide evidence-based guidelines to nurses who care for patients after a cesarean sec- tion. After studying the information presented here, you will be able to:

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Provide presurgical interventions to reduce the risk of infection after surgery

Apply evidence-based, family-centered care to the post- partum patient who has undergone a C-section

Identify common neonatal concerns related to C-section birth

By Elaine Brown, MS, RNC-OB, EFM-C

any women in our society approach labor with a pre- conceived idea of how their baby will enter the world. Women prepare for birth by attending prenatal classes, reading books and developing a birth plan. Unfortunately, the ideal vaginal birth is not always the outcome. Nurses who have received instruction in how to prepare the patient both emotionally and physically for an alternate birth will be able to better care for the patient during one of the most exciting times in her life.


The need for education In 1996, the rate of cesarean delivery was 20.7%. During the following 13 years, a dramatic increase occurred until 2013, when the number plateaued to 32.7%.1

Since that time, many guidelines

have been put in place to decrease this rate. The American Congress of Obstetricians and Gynecologists has set practice standards discouraging elective induction before 39 weeks’ gestation. This movement has been supported by many accrediting agencies including The Joint Commission by requiring documentation for any nonmedically indicated induction before 41 weeks.2 C-sections can be categorized as planned/elective, urgent Planned C-sections usually occur when there

and emergent.3

is a known antepartum indication (such as breech position) and is scheduled to meet the needs of the family or provider team. Urgent C-sections occur once labor has begun and are usually associated with perceived fetal compromise or failure to progress in labor. If the perceived threat becomes immediate, then an emergent section may be performed when there is a serious risk to the mother or fetus. The pathway to a cesarean section can occur for many diff erent

reasons. Studies have shown that women who have undergone a primary C-section will have about a 90% chance of having a repeat C-section versus attempting a vaginal birth.1


reasons including provider attitude toward cesarean section and maternal fear of childbirth accounted for 38% of C-sections in 2005.3-5

Other reasons for choosing a planned primary or

repeat C-section include breech presentation, macrosomia and uterine factors.3,4 Because more than one-third of all deliveries occur through

surgical intervention, planning and education can help a mother be prepared for the physical and emotional impact of a cesare- an birth and have the opportunity to set realistic goals for the experience.1,6

The ability to ambulate or breastfeed her infant

following surgery can disrupt the family bonding time in the postpartum period.7

Nurses caring for patients in the prenatal

period can help overcome some of the fears of surgical birth as well as prepare patients for what to expect after delivery.

The surgical aspect Many complications of a cesarean section may be mitigated through education and direct interventions before the day of the actual surgery. Many hospitals use specifi c standards of care for every patient. These “bundles,” as they are commonly called, refer to a set of orders that a patient should follow before surgery at home and in the preoperative period. Although initially developed for patients undergoing spine or joint surgery, some facilities have adopted this same practice for their obstetric patients with the hope of reducing post-cesarean infection. Some segments of a perioperative bundle are dictated by ac-

crediting standards such as the The Joint Commission surgical site infection prevention National Patient Safety Goal recommends the use of antibiotic prophylaxis before surgery, excellent hand hygiene and hair removal that has been proven safe through research (such as clippers instead of razors).8

Other criteria can be based on research

and evidence, including the use of chlorhexidine wipes preoperatively as well as systematic site cleansing immediately before surgery.

C-Section incision

A low-transverse C-section incision involves an abdominal incision and a uterine incision. Care should be taken to prep the entire suprapubic area adequately to decrease the risk of infection.

Before surgery The use of perioperative bundles can help streamline patient care and decrease the risk of infection.8

include components such as: • A surgical infection prevention team, including pro- viders, nurses and care team assistants

• Written education for patients, including instructions on presurgical measures, such as the use of chlor- hexidine wipes and bathing

• Limitation of the use of razors for the removal of hair at the incision site

• Standardization of the preoperative scrub immedi- ately before surgery using a chlorhexidine solution

• Administration of antibiotics within one hour of incision time

• Patient education for aftercare, including care of the incision site

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Perioperative bundles may

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