Cesarean birth
Cesarean birth: Excerpt from Professional Guide to Diseases (Eighth Edition)
Cesarean birth, also known as cesarean section, is delivery of a neonate by surgical incision through the abdomen and uterus. It can be performed as elective surgery or as an emergency procedure when conditions prohibit vaginal delivery.
Causes and incidence
The most common reasons for cesarean birth are malpresentation (such as shoulder or face presentation), fetal intolerance of labor distress, cephalopelvic disproportion ([CPD] the pelvis is too small to accommodate the fetal head), certain cases of toxemia, previous cesarean birth, and inadequate progress in labor (failure of induction).
Conditions causing fetal distress that indicate a need for cesarean birth include prolapsed cord with a live fetus, fetal hypoxia, abnormal fetal heart rate patterns, unfavorable intrauterine environment (from infection), and moderate to severe Rh isoimmunization. Less common maternal conditions that may necessitate cesarean birth include complete placenta previa, abruptio placentae, placenta accreta, malignant tumors, and chronic diseases in which delivery is indicated before term.
Cesarean birth may also be necessary if induction is contraindicated or difficult or if advanced labor increases the risk of morbidity and mortality.
In the case of a previous cesarean delivery, some physicians allow a subsequent vaginal delivery if the cesarean wasn’t classic or if the original reason for the cesarean no longer exists. However, vaginal delivery risks uterine rupture if the uterus is scarred.
The rising incidence of cesarean birth coincides with recent medical and technologic advances in fetal and placental surveillance and care. In the United States, 9% to 16% of all pregnancies terminate in cesarean births, rising to 17% to 25% in perinatal centers that handle high-risk deliveries.
Diagnosis
Special tests and monitoring procedures provide early indications of the need for cesarean birth:
❑ Magnetic resonance imaging or clinical pelvimetry reveals CPD and malpresentation.
❑ Ultrasonography shows pelvic masses that interfere with vaginal delivery and fetal position.
❑ Auscultation of fetal heart rate (by fetoscope, Doppler unit, or electronic fetal monitor) determines acute fetal intolerance of labor.
Treatment
The most common type of cesarean birth is the lower segment cesarean, in which a transverse incision across the lower abdomen opens the visceral peritoneum over the uterus. The lower anterior uterine wall is then incised (transversely or longitudinally) behind the bladder.
The classic cesarean — in which a longitudinal incision is made into the body of the uterus, extending into the fundus and opening the top of the uterus — is rarely performed because it exaggerates the risk of infection and of uterine rupture in subsequent pregnancies. Cesarean hysterectomy removes the entire uterus and is reserved for such cases as malignant tumors, severe infection, and placenta accreta.
Patients may have general or regional anesthetic for surgery, depending on the extent of maternal or fetal distress. Possible maternal complications of cesarean delivery include respiratory tract infection, wound dehiscence, thromboembolism, paralytic ileus, hemorrhage, and genitourinary tract infection.
Special considerations
Before cesarean delivery:
❑ Explain cesarean birth to the patient and her partner, and answer any questions they may have. Provide reassurance and emotional support. Cesarean birth is often performed after hours of labor have exhausted the patient.
❑ Administer preoperative medications as ordered.
❑ Prepare the patient by shaving her from below the breasts to the pubic region and the upper quarter of the anterior thighs. Make sure her bladder is empty, using an indwelling urinary catheter as ordered. Insert an I.V. line for fluid replacement therapy as ordered. Assess maternal temperature, pulse rate, respirations, and blood pressure and fetal heart rate.
❑ In the operating room, place the patient in a slight lateral position. Use of a 15-degree wedge reduces caval compression (supine hypotension) and subsequent fetal hypoxia.
After cesarean delivery:
❑ Check vital signs every 15 minutes until they stabilize. Maintain a patent airway. If general anesthetic was used, remain with the patient until she’s responsive. If regional anesthetic was used, monitor the return of sensation to the legs.
❑ Encourage parent-infant bonding as soon as practical.
❑ Gently assess the fundus. Check the incision and lochia for signs of infection such as a foul odor. Check frequently for bleeding and report it immediately. Keep the incision clean and dry.
❑ Observe the neonate for signs of respiratory distress (tachypnea, retractions, and cyanosis) until there’s evidence of physiologic stability. Keep resuscitative equipment available.
❑ Assess intake and output (some patients have indwelling urinary catheters in place up to 48 hours postoperative). Observe the patient closely for indications of bladder fullness or urinary tract infection.
❑ Administer pain medication, as ordered, and provide comfort measures for breast engorgement as appropriate. Offer reassurance and reduce anxiety by answering any questions. If the mother wishes to breast-feed, offer encouragement and help. Recognize afterpains in multiparas.
❑ Promote early ambulation to prevent cardiovascular and pulmonary complications.
❑ Provide psychological support. If the patient seems anxious about having had a cesarean delivery, encourage her to share her feelings with you. If appropriate, suggest that she participate in a cesarean birth sharing group. Encourage support from her family members as well.
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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