cesarean birth objectives and recovery8/24/2015 3 vaginal births after cesarean (vbac) delivery rate...
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Cesarean Birth and
RecoveryTracy Scoville BSN, RNC-OB
Clinical Nurse Educator
Providence Regional Medical Center Everett
Email:
Discuss current trends in cesarean section rates within the U.S. and Washington state
Review cesarean section rates around the globe
Verbalize indications for a Cesarean delivery
Describe roles of the Perinatal nurse in the continuum of care for a patient undergoing a Cesarean birth
Identify potential complications of Cesarean delivery
OBJECTIVES
Cesarean birth has been a part of both Western and non-Western cultures since ancient times
Initial purpose was to remove the infant from a dead or dying mother
Saving a mothers life became a possibility in the 19 th century.
HISTORY OF CESAREAN BIRTH
• 32.8% 1 of U.S. births were delivered by cesarean in 2012, a rate that has remain unchanged since 2010
• Prior to 2010 the cesarean rate increased every year since 1996 at which time the cesarean rate was 20.7% in the United States
• Cesarean section rate in Washington state rose by 73% from 1996 to 20071
–Third behind Rhode Island (83%) and Connecticut (75%)
TRENDS
Cesarean Delivery Rates United States
1991-20071
Global Cesarean Rates from the World Health Report 2010
Country Rate
Brazil 45.9%
Mexico 37.8%
United States 30.3%
Australia 30.3%
Canada 26.3%
United Kingdom 22.0%
Ukraine 14.2%
Kenya 4.0%
Ethiopia 1.0%
Chad 0.4%
CESAREAN SECTION RATES AROUND THE GLOBE
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Thi s i s a 6 bed Ma terni ty Wa rd i n Mdol o Vi l l a ge
There a re no opera ti ng rooms, no surgeons a nd no a nes thes ia provi ders
MATERNITY WARD IN MALAWI
S o ur c e : A m e r i c a n J o ur n a l o f O b s t e t r i c s & G y n e c o l o gy 2 1 0 4 : 2 1 0 : 1 7 9 - 1 9 3 ( D O I : 1 0 . 1 0 1 6 / j . a j o g .2 0 1 4 . 0 1 . 0 2 6 ) C o py r i g h t 2 0 1 4
United States Cesarean Delivery Rates by State 2010
Source: National Center for Health Statistics, final natality data. Retrieved February 25,
2014, from www.marchofdimes.com/peristats.
Total Cesarean Deliveries 3
Washington, 2008-2011 Average
Primary cesarean rate is the number of primary cesareans per 100 live births to women who have not had a previous cesarean. Primary cesarean rates based on the 2003 Revision of the U.S. Standard Certificate of Live Birth. Details available at: <a
href="http://www.marchofdimes.com/peristats/calculationsp.aspx?id=6"
target="_blank">http://www.marchofdimes.com/peristats/calc/dm</a>.
Source: National Center for Health Statistics, final natality data. Retrieved February 25, 2014, from www.marchofdimes.com/peristats.
Primary Cesarean Deliveries 3
Washington, 2008-2011 Average
TOLAC: Trial of Labor After Cesarean
VBAC: Vaginal Birth After Cesarean
•50% increase in VBAC’s reported in late 80s through mid 90s
•Since 1996 rate of VBAC deliveries has decreased significantly
TOLAC/VBACUS Delivery Rates 1989-2011
Source: American Journal of Obstetrics & Gynecology 2104: 210: 179-193
(DOI:10.1016/j.ajog.2014.01.026) Copyright 2014)
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Vaginal births after cesarean (VBAC) delivery rate is the number of VBAC deliveries per 100 live births to women with a previouscesarean. VBAC rates based on the 2003 Revision of the U.S. Standard Certificate of Live Birth. Details available at: <a
href="http://www.marchofdimes.com/peristats/calculationsp.aspx?id=6"
target="_blank">http://www.marchofdimes.com/peristats/calc/dm</a>. ** Suppressed due to missing data or insufficient numbers.
Source: National Center for Health Statistics, final natality data. Retrieved February 25, 2014, from www.marchofdimes.com/peristats.
Vaginal Birth After Cesarean Deliveries 5
Washington, 2008-2011 Average
Examined safety and outcome of TOLAC and VBAC and factors associated with decreasing rates
Recommendation:
Trial of labor reasonable for many women with history on one prior low transverse uterine incision
Consider making public TOL policies and VBAC rates
Mitigate or eliminate current barriers to TOL
More research needed regarding short and long term outcomes of TOL and elective repeat cesarean section
NIH VAGINAL BIRTH AFTER CESAREAN:
NEW INSIGHTS6
• VBAC potential health advantages– Avoid major abdominal surgery
• Decreases risk of infection, hemorrhage, and has a shorter recovery period
– Those wishing larger families avoid potential consequences of multiple cesarean sections
• Hysterectomy
• Bowel or bladder injury
• Transfusion
• Infection
• Abnormal implantation of placenta
ACOG PRACTICE BULLETIN NO. 1157
A U G U S T 2 0 1 0
• Candidates for TOL after previous cesarean:
–One to two previous C/S with low transverse incision
–Prior low vertical uterine incision
–Twin gestation with one previous C/S with low transverse incision
–Consideration for:• Macrosomia
• > 40 weeks gestation
• One previous C/S with unknown uterine scar (unless high suspicion of classical uterine incision)
ACOG PRACTICE BULLETIN NO. 1157
INDICATION FOR CESAREAN INDICATIONS FOR CESAREAN
Late Deceleration
• Abnormal Fetal Heart Rate
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Failure to Progress
Macrosomia
Cephalopelvic Disproportion (CPD)
Active Genital Herpes
Prior Cesarean Delivery/Uterine Surgery
Cesarean Delivery on Maternal Request (CDMR)
INDICATIONS FOR CESAREAN
S o ur c e : A m e r i c a n J o ur n a l o f O b s t e t r i c s a n d G y n e c o l o gy 2 0 1 4 : 2 1 0 : 1 7 9 - 1 9 3 ( D O I : 1 0 . 1 0 1 6 / j . a j o g . 2 0 1 4. 0 1 . 0 2 6 )
C o py r i g h t 2 0 1 4
Indications for Primary Cesarean Delivery
ROLE OF THE PERINATAL NURSE IN CESAREAN SECTIONS
Perinatal units should maintain comparable care standards as the main hospital surgical suites/postanesthesia care unit (PACU) (ASA, 2003, 2006; JCAHO, 2007a) 8
STANDARDS
Admission Assessment NPO
Fetal Tracing
IV /Labs
Abdominal Clip
Consent
Plan of Care- Reassure!
PRE-OPERATIVE
Medications Antacid
Antibiotic prophylaxis9
Pneumatic Compression Devices 10,11,12,13
PRE-OPERATIVE
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Positioning
Alignment
Arm boards
Tilt
Safety strap
Fetal monitoring
Foley
INTRAOPERATIVE
• Grounding Pad
• Suction
• Counts
• Documentation
• Support Person
• Medication Safety
– Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings14
INTRAOPERATIVE
EpiduralPlaced in epidural space between 4 th and 5th
lumbar vertebrae
Dilute local or a local combined with preservative free opioid
Complete block occurs in about 15-20 minutes
ANESTHESIA
Epidural placement
SpinalInjected into subarachnoid space
Local anesthetic or local combined with preservative free opioid
Dense motor/sensory block
Rapid onset
ANESTHESIA
General anesthesia
Clinical state that is defined by degrees of effect in four criteria: Amnesia (loss of recall of event), analgesia (insensibility to pain),
hypnosis (unconsciousness), and muscle relaxation
ANESTHESIA SURGICAL PREP
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• The Joint Commission - Universal Protocol and Speak Up Program15
– Conduct time-out immediately before starting procedure– Standardized– Initiated by any team member– All members of team actively communicate during time out– All members agree, at a minimum on correct patient, correct site and
correct procedure to be done– Documentation of time out
• SCOAP – Surgical Care and Outcomes Assessment Program16
• WHO - Safe Surgery Saves Lives Program17
PRE-PROCEDURAL PAUSE
TYPES OF SKIN/UTERINE INCISION
“At birth, at least one person whose sole responsibility is neonatal resuscitation should be present to care for the newborn. Either this person or someone else who is immediately available should be able to perform complete resuscitation including endotracheal intubation and
medication administration”18
CARE OF THE NEONATE
• Brief huddle at the end of the procedure
• I tems to cover:
–Before closure: Are instrument, sponge, and needle counts correct?
–Additional procedures performed, if any
–Specimens and labeling (cord gases?, placenta to path?, tubal ligation?, other?)
–Infant information (sex, weight, Agpars)
–Postop analgesia (duramorph, PCA, other)
–Recovery issues anticipated
–What could have been done better?
DEBRIEF
• Uterine atony
• Uterine hysterectomy
• Uterine rupture
• Bladder and/or bowel perforations
• Arterial bleeds
• Maternal cardiac arrest
• Anesthesia complications (i.e. Malignant Hyperthermia, Aspiration)
POTENTIAL CESAREAN COMPLICATIONS
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Maternal Co-morbidities
Multiple Repeats
Over Distended Uterus
Substance Abuse
COMPLICATING MATERNAL FACTORS
Risk of death caused by the operation of cesarean delivery is approximately 2 per 100,000 cesareans, compared with 0.2 per 100,000 deaths caused by vaginal births 10
Typical Sources:
Hemorrhage
Thromboembolism
Infection
MATERNAL MORTALITY/MORBIDITY
Most Common Preventable Errors10
Failure to adequately control BP in hypertensive women
Failure to adequately diagnose and treat pulmonary edema in women with preeclampsia
Failure to pay attention to vital signs following Cesarean section
Hemorrhage following Cesarean section
MATERNAL DEATH
• Patients should be accompanied to recovery by Anesthesiologist/CRNA
• Verbal report by Anesthesia provider includes:
–Name, age, surgical procedure, allergies
–Medical problems
–Most recent VS
–Mental status
–Communication barriers
–All medications given (pre-op, intra-op)
– I & O (EBL, IV fluid, urine, emesis)
–Any complications
–Orders for care
–Number to contact Anesthesia
RECOVERY HAND OFF
• Assessments performed according to hospital protocols in alignment with main hospital PACU
Review of systems
Dermatome level
LOC
Obstetric status
I & O
Pain
Anesthesia site
Safety
POST ANESTHESIA RECOVERY
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Systematic method of patient scoring help to provide an objective measurement for care.
• Can be applied immediately and repeatedly as a convenient means to evaluate progress in recovery from anesthesia
POST ANESTHESIA SCORINGPOST ANESTHESIA SCORING –
MODIFIED ALDRETE Consciousness Activity on command2 = Fully awake 2 = Moves all extremities1 = Responds to name 1 = Moves two extremities0 = No response 0 = No movement
Respiration2 = Free deep breathing1 = Dyspneic, hyperventilating, obstructed breathing0 = Apneic
Circulation2 = Blood pressure within 20% of pre-op level1 = Blood pressure within 50%–20% of pre-op level0 = Blood pressure 50%, or less, of pre-op level
Oxygen saturation2 = SpO2 >92% on room air1 = Supplemental O2 required to maintain SpO2 >92%0 = SpO2 <92% with O2 supplementation
Total Score = 109 needed to leave PACU
• Respiratory
• Cardiovascular
• Pain
• Thermoregulation
• Post-operative Agitation or Delirium
• Blood Sugar
• Post Operative Nausea and Vomiting (PONV)
POTENTIAL POST ANESTHESIA COMPLICATIONS
Occurs after recovery period and when the patient is stable per recovery discharge criteria
Utilizing Post Anesthesia scoring system to assess readiness
Anesthesia provider is involved in decision to discharge from recovery
Prior to discharge/transfer of patient, RN completes a final review of systems assessment
If care is transferred to another nurse, report is given utilizing standardized approach to hand off.
POST ANESTHESIA DISCHARGE
1. Martin, Joyc e A. , M.P.H. ; Hamilton, Brady E. , Ph.D. ; Osterman, Mic helle J .K. , M.H.S. ; Curtin, Sally C. M.A. , Mathew, T. J . , M.S. , Division of Vital Stat ist ic s, Volume 62, number 9, Dec ember 30, 2013
2. Centers for Disease Control and Prevention, MMWR Weekly, April 20, 2007/ 56(15);373
3. National Center for Health Stat ist ics , f inal natality data. Retr ieved February 24, 2014, from www.marc hofdimes.com/peristats .
4. Centers for Disease Control and Prevention, MMWR Weekly, January 21, 2005/ 54(02);46
5. National Center for Health Stat ist ics , f inal natality data. Retr ieved February 24, 2014, from www.marc hofdimes.com/peristats .
6. Bangdiwala, S. I . , Brown, S. S. , Cunningham, F. G. , Dean, T. M. , Frederiksen, M. , Hogue, C. J . , . . . Zimmet, S. C. (2010). NIH c onsensus development c onference draft statement on vaginal b irth after c esarean: New insights. NIH Consensus and State -o f -the-Science Statements, 27 (3)
7. Americ an College of Obstetr ic ians and Gynec ologists . (2010). ACOG prac tice bullet in no. 115: Vaginal b irth after previous c esarean delivery. Obstetrics and Gynecology, 116 (2 Pt 1) , 450-463. doi:10.1097/AOG.0b013e3181eeb251
REFERENCES
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8. Simpson, K. , Creehan , P.A. (2008). AWHONN Perinatal Nursing (3 rd
ed.) . New York: Lippinc ott.9. Committee opinion no. 465: Antimicrobial prophylaxis for c esarean
delivery: Timing of administrat ion. (2010). Obstetrics and Gynecology, 116 (3) , 791-792. doi:10.1097/AOG.0b013e3181f68086
10.Clark, S. L. , Belfort , M. A. , Dildy, G. A. , Herbst , M. A. , Meyers, J . A., & Hankins, G. D. (2008). Maternal death in the 21st century: Causes, prevention, and relationship to cesarean delivery. American Journal o f Obstetrics and Gynecology, 199 (1) , 36.e1-5; disc ussion 91-2. e7-11. doi:10.1016/j .a jog.2008.03.007
11.Bates, S. M. , Greer, I . A. , Pabinger, I . , Sofaer, S. , Hirsh, J . , & Americ an College of Chest Physic ians. (2008). Venous thromboembolism , thrombophilia , antithrombotic therapy, and pregnancy: Americ an c ollege of c hest physic ians evidenc e -based c linic al prac tice guidelines (8th edit ion). Chest, 133 (6 Suppl), 844S-886S. doi:10.1378/chest.08 -0761
12.Simpson, K. R. (2010). Thromboprophylaxis for c esarean birth.MCN.the American Journal o f Maternal Chi ld Nursing, 35 (4) , 244. doi:10.1097/NMC.0b013e3181dd7c95
13.Joint Commission Sentinel Event Alert #44; Preventing Maternal Death January (2010). Retr ieved from http : //www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_44.htm , Retrieved January 10, 2011.
REFERENCES
14.Joint Commission National Patient Safety Goal 3 – 03.04.01, Label ing in Procedural Area, Revised March 26, 2010. Retrieved from http://www.jointcommission.org/standards_information/jcfaqdetai ls.aspx, Retrieved January 10, 2011.
15.The Joint Commission (2010) Universal Protocol and Speak Up Program http://www.jointcommission.org/assets/1/18/UP_Poster.pdf
16.Surgical Care and Outcomes Assessment Program (2010) SCOAP Checklist http://www.scoap.org/downloads/SCOAP-Surgical-Checklist_v3_4.pdf
17.World Health Organization (2009) Surgical Safety Checklist http://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdf
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19.American Col lege of Obstetricians and Gynecologists (the Col lege) and the Society of Maternal -Fetal Medicine, American Journal of Obstetrics and Gynecology, Volume 210, Issue 3, Pgs 179-183 (March 2014)
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American Society of Anesthesiologistshttp://www.asahq.org
American Society of PeriAnesthesia Nurseshttp://www.aspan.org
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ADDITIONAL RESOURCES