Transcript OB PACU
Cesarean Birth
Author: Daren Sachet, RNC, BSN, MPA
Cesarean Birth Objectives
Discuss the implications for cesarean birth
List the components of providing a safe surgical
environment
Describe potential complications related to cesarean
birth
Indications
Previous Uterine Scar
Labor Dystocia
Cephalopelvic disproportion,
arrest of labor
Fetal malposition or
malpresentation e.g.
breech, transverse lie
Fetal intolerance of labor
Disease, or anomaly
Fetal macrosomia
Prolapsed Cord
Indications Continued
Active genital herpes
Uterine Rupture
Placental abnormality
Placenta previa
Abruptio placenta
Uterine Rupture
Total C/S Rates
C/S Rates in the U.S.
National Vital Statistics Report Vol. 58, No. 16
Year
VBAC
rate
Primary
C/S rate
Previous
C/S
All C/S
rate
2006
8.5
2007 2008
2009
Unavail
Unavail
Unavail
28.4
29.0
Unavail
Unavail
(adjusted)
(prelim)
92
Unavail
Unavail
Unavail
31.1
31.8
32.3
32.9
(prelim)
(prelim)
(adjusted)
VBAC/TOLAC
VBAC---vaginal birth after cesarean
TOLAC---trial of labor after cesarean
Decision making
Non-repeating condition (why was previous
cesarean done?)
Desire to avoid cesarean birth
Ability to do emergency cesarean birth
Benefits mother by shortening recovery time
Risks
Possibility of uterine rupture (what kind of incision
was made on uterus?)
Successful VBAC
How can we help?
Review prenatal record for risks
Ensure informed consent, Additional consent if
oxytocin is used, as risk increases
Continuous EFM and 1:1 nursing care
Assess for normal labor progression and S/S
uterine rupture
MD must remain immediately available
throughout active labor
Ensure ability to perform emergency C/S
Elective Cesarean Section
ACOG definition:
A primary C/S at maternal request in the absence of
any medical or obstetric indication.
Considerations:
Not recommended for women desiring several
children.
ACOG Committee Opinion 386: Nov 2007.
Maternal Morbidities Related to Multiple
Repeat Cesarean Births
Placenta previa/accreta
Blood transfusion
Hysterectomy
Injury to bladder, bowel and other pelvic
organs
Longer operating time
Increased LOS
Obstet Gynecol June 2006;107:1226-32
Infant Morbidities Associated
with Cesarean Births
Potential for hypoxia
TTN
Respiratory distress syndrome
Pulmonary hypertension
Skin lacerations
Broken clavicle, facial nerve palsy, and other
injuries related to failed vacuum or forceps
use
Postpartum Maternal Complications
Related to Cesarean Delivery
UTI
Wound complications
Hematoma, dehiscence, infection, necrotizing
fasciitis
Thromboembolic disease
Ileus and Bowel dysfunction
Atelectasis
Endometritis
Anesthetic Complications
Getting Ready
Operating Room Preparation
Circulating RN is responsible for operating
room readiness
Patients with the same health status and
condition should receive a “comparable”
level of care regardless of where that care is
provided within the hospital.
Joint Commission
“Comparable” care to that provided in the
main hospital surgical department is
recommended by ASA (2006) and JCAHO
(2007); however, “equivalent” care is not
required.
Operating Room Preparation
Cleaning of the OR
Equipment and Supplies
Suction, medical gases
Blood products, implants, devices or special equipment
present?
Electrosurgical unit
Crash cart, MH supplies
Patient Positioning aids
Medications, are they secure?
Are all the needed personnel in place?
Getting Ready
Documentation required Prior to Surgery
Ensure a current H&P is on the chart
Informed Consent
Pre-Procedural Verification
First step done prior to entering the OR.
It includes patient verification and OR
readiness.
Second step completed in the OR prior
to incision and when all personnel are
present
Must be obtained for the Anesthetic
procedure as well as for the surgical
procedure
Preoperative Patient Preparation
NPO, IV preload,
Antacids and Antiemetics
Foley
Hair Removal and Skin Cleansing
Antibiotics
“Prophylactic Antibiotic Received within one hour
prior to surgical incision or at the time of birth for
cesarean section” NQF
DVT Prophylaxis
US if breech
Teaching Patient/Family
Pre operative activities
Intra operative expectations
Post operative course
LOS
Diet
Ambulation
Foley and IV removal
Pain control
Discharge planning
– Encourage questions
Personnel and Roles
Scrubbed Team
Un-scrubbed Team
Circulating RN
Duties?
Personnel and Roles
Scrub Nurse or Tech
Anesthesia
Provider
Surgical
Assist
Surgeon
Personnel and Roles
Neonatal Team
Support Person
Infection Control
Cleaning the OR
Attire in restricted & semi-restricted areas
Personal Protective Equipment
Personal Hygiene
Skin preps
Ventilation
Traffic Patterns in the OR
Communication in the OR
Procedural Verification, TIME OUT
Keep superfluous conversation to a minimum
Respect the patient, even if “asleep”
Prioritize & Standardize
Surgical Safety
Use a Surgical Safety Checklist
Prioritize Activities
Fire in the OR?
Infection Control
Skin Prep
Types of Incisions
Know your incision site
before you prep
Displace uterus in supine
position
Skin incision:
Vertical
Low transverse
Uterine Incision:
Low transverse
Vertical
T
Area of Abdominal Skin Prep
Types of Skin preps
Pre-surgical skin prep
Betadine
Chlorhexadine gluconate
Technicare
Other Duties that Keep your
Patient Safe
Specimen Handling
Label fluids on the Sterile Field
Surgical Counts
Electosurgical Safety
Positioning
Know the location of Supplies
Know the Instruments
Document!
Anesthesia
Regional
Spinal
Epidural
Local
General
Regional
Spinal
Local anesthetic or local with opiod injected into
subarachnoid space to produce motor/sensory block
Risk of hypotension (esp. if mother dehydrated) a bolus
of 500cc – 1 L with isotonic solution prior to procedure
Potential for spinal headache
Regional
Epidural
Dilute local anesthetic or local with preservative-free opiod
injected into epidural space
Single injection , repeat bolus or continuous infusion
Interrupts transmission of pain impulses along nerve roots.
Lower doses allow motor function to remain intact
Sympathetic blockade is less than with a spinal
Increased chance for system toxicity related to larger
amount of drug used and absorbed than with a spinal
LA Toxicity…what’s that?
General Anesthesia
Indications for General
Anesthesia
Goals and Precautions
Circulator Duties
Assisting with General Induction
2 circulators are needed, one devoted to assisting
anesthesiologist/CRNA.
Positioning for safety and good oxygenation prior to
induction
Skin Prep/draping prior to induction
Protect airway (antacids, cricoid pressure, positioning,
suctioning)
Patent IV
Foley in place
Phases of Anesthesia
Induction
Maintenance
Emergence
Recovery
Commonly Used Induction
Medications
Inhalation Agents
IV Anesthetics
Muscle Relaxants
General Induction Sequence
Pre-oxygenate : 3-5 minutes
Pretreat: Induction of “Sleep” Surgeon is
ready to cut.
Paralytic dose: of muscle relaxant is given.
Protect, position: Intubation occurs, with
Selleck maneuver.
Selleck’s Maneuver
(Cricoid Pressure)
General Induction Sequence
Continued
Placement: Confirm placement of ET tube. Don’t
let go until you are told to do so.
Anesthesia maintained with muscle relaxants,
narcotics, inhalation agents.
General Induction Sequence
Continued
Reversal of induction
Extubate when fully awake.
Pt moved to PACU when gag reflex,
swallowing and spont ventilations are in
place.
Malignant Hyperthermia (MH)
An autosomal dominant inherited muscle
disorder that can occur in susceptible people
on exposure to certain drugs used to produce
general anesthesia or muscle relaxation during
anesthesia.
Theory is that MH reactions are set off by
sudden release of large quantities of CA++
which increases metabolic activity of muscle.
Body fuels are rapidly consumed.
Malignant Hyperthermia
Triggers
All volatile inhalation anesthetics
Depolarizing muscle relaxants
Succinylcholine
Malignant Hyperthermia
blood potassium =rapid, irregular heart rate
and possible arrest.
CO2 = rapid, deep breathing
O2 = brain damage
myoglobin can block kidneys=kidney failure
heat= fever, may reach 110F within minutes
Treatment
HELP!
Stop the triggering agent(s)
Dantrolene within 5 minutes
Monitor & Supportive treatment
Notify MHAUS
Complicating Factors for Cesarean Section
Obesity
Multiple Repeats
Over distended uterus
Substance abuse
Hemorrhage
Organ Injury
C-Hysterectomy
Summary
Indications
Patient and Staff Safety
Anesthesia Options
Complicating factors
Facts
Standards
Data
C/S Rates
Critical Thinking
Interpersonal Skills
Ethics
Communication
Technical Skills
Skin Prep
References
1.
2.
3.
4.
5.
Association of Obstetricians and Gynecologists. Vaginal Birth after previous
Cesarean Delivery, Practice Bulletin #115. August 2010.
Association of Operating Room Nurses. Perioperative Standards and
Recommended Practices, current edition.
National Vital Statistics, Volume 58, No 16, electronic version
World Health Organization, Surgical Safety Checklist URL
http://www.who.int/patientsafety/safesurgery/en
American Academy of Pediatrics and American College of OB GYN Guidelines for
Perinatal Care, current edition
OB PACU
OBJECTIVES
Discuss PACU Standards of care as related to the OB
Unit.
Describe patient assessments and nursing
interventions required in the PACU.
Discuss potential complications in the recovery
period through case study.
Standards for Staffing a PACU
A registered nurse is present when any
patient is recovering. Nurse to patient staffing
ratios are based on patient condition and are
consistent with other post anesthesia units in
the institution.
ASPAN, 2010-2012
Standards for Staffing a PACU
Phase I Level of Care
Phase I is the immediate postanesthesia
period, transitioning to phase II, the inpatient
setting or to an intensive care setting for
continued care.
Two registered nurses, one who is a RN
competent in phase I postanesthesia nursing,
will be in the same unit where the patient is
receiving phase I level of care at all times.
ASPAN, 2010-2012
Standards for Staffing a PACU
Phase I Level of Care Continued
One nurse to one patient:
At the time of admission, until critical
elements* are met
Requiring mechanical life support and/or
artificial airway
Any unconscious patient 8 yrs and under
A second nurse must be able to assist
Critical Elements for Mom
One nurse to one patient until critical elements
are met:
Critical elements for Mom
Report has been received from the anesthesia care
provider, questions have been answered and the
transfer of care has taken place.
The patient is conscious
The Patient has patent airway without assistance
Initial assessment is complete and documented
Patient is hemodynamically stable
A second nurse must be available to assist as
needed
ASPAN, 2010-2012
AWHONN, 2010
Critical Elements for Baby
One nurse to one patient until critical elements
are met:
Critical elements for Baby
Report has been received from the baby nurse, questions have been
answered and the transfer of care has taken place
Initial assessment and care are completed and documented
The baby is conscious and has a patent airway without assistance
The baby is stable
Initial assessment is complete and documented
Identification Bracelets have been placed
A second nurse must be available to assist as
needed
ASPAN, 2010-2012
AWHONN, 2010
Staffing a PACU
Phase I Level of Care
When can we have one nurse to two patients in OB
PACU?
When must we have two nurses to one patient?
ACLS QUALIFIED OR NOT?
Recovery
aka
Post Anesthesia Care
How Long?
Defined by patient status, not by time frame
ASPAN 2010-2012
Recovery
aka
Post Anesthesia Care
Where?
Admission to the OB PACU
Room Set up and Equipment
For Phase I each patient bedside needs to have present
the following items.
Artificial airways and means to deliver O2
Constant and Intermittent Suction
Means to monitor BP,T, EKG and Pulse oxymetry
IV Supplies and stock medications
Admission to the OB PACU
Room Set up and Equipment
Stock supplies such as dressings, gloves, emesis basins,
tape, etc.
Adjustable lighting and mode of warming a patient
Emergency Cart with defibrillator and ventilator available
Malignant Hyperthermic Supplies
Patient Privacy
On transfer to Recovery (OB PACU)
Report
Rapid assessment
Dismiss Anesthesia Provider
Respiratory
Assessment
Inspection, Auscultation/Listening, Pulse oxymetry
Supportive Respiratory Equipment
Bag-Valve with mask or ET Tube, LMA, ET Tubes, Nasal
Trumpets, Oral Airways, suction and oxygen
Nursing Interventions
Prevent atalectasis and venous stasis
Stimulate to take cough & deep breath every 10-15
minutes. Record RR at least every 15 minutes while in
recovery
Use incentive spirometer for smokers.
Encourage and assist position changes
Respiratory Complications and Nursing Actions
Aspiration
Mechanical Obstruction
Laryngospasm
Bronchospasm
Pulmonary Edema
Pulmonary Embolism
Cardiovascular
Cardiovascular Assessment
Inspection
Auscultation
Monitor B/P, I&O, Pulse rate/quality& EKG
Reproductive
Assessment
Potential Complications
Nursing Interventions
Emergency medications
Renal/Fluids and electrolytes
Assessment
I&O, appearance of urine
Edema, Chemistries
Potential changes
in pregnancy
Magnesium
Influence on Action of Nondepolarizing
Neuromuscular Blocking
agents
Increase will potentiate
Decrease in Serum
Calcium
Prolongs effects
Dehydration
Potentiates action
Sodium deficit
Prolong the block
Gastrointestinal
Female
Assessment
Interventions
20% 1
point
Nonsmoker 20% 1
point
HX PONV
20% 1
point
Postop
20% 1
opiods
point
Chance for 80% 4
PONV
points
Neuromuscular/Sensory
Assessment
LOC
Emotional Status
DTRs
Temperature
Dermatome levels
Motor movement
Respirations
Neuromuscular/Sensory
Potential Complications
Safety Measures
Comfort and Pain Control
Assessment
Attitudes
Nursing Actions
Maternal/Infant
Attachment
Attachment and Interaction
Nursing Actions
Putting It All Together
Frequency of Assessments for Mom
BP, P, RR, O2 sat should be monitored every 15 minutes for at least 2
hours
Vaginal Bleeding should be evaluated continuously
Frequency of Assessments for Baby
T, HR, RR, skin color, adequacy of peripheral circulation,
type of respiration, LOC, tone/activity should be
monitored and documented at least every 30 minutes
until the newborns condition has remained stable for 2
hours
Discharge criteria: Stability of Systems
AAP& ACOG 2007
Discharge criteria should be developed in consultation
with and approved by the anesthesia and medical staff.
ASPAN 2010-2012
Modified Aldrete Score
Activity
Voluntarily moves all limbs =2
Voluntarily moves 2 limbs = 1
Unable to move = 0
Respiration
Breaths deep coughs on own = 2
Dyspnea/hypoventilation = 1
Apnic = 0
Circulation
BP +/- 20 mm Hg of pre-anesthetic levels = 2
Bp > 20-50 mm Hg of pre-anesthetic levels = 1
BP > 50 mm HG of pre-anesthetic levels = 0
Consciousness
Fully awake = 2
Arousable = 1
Unresponsive = 0
Color
Natural = 2
Pale/blotchy = 1
Cyanotic = 0
Score
Putting It All Together
Documentation
Per institutional guidelines
Transfer of patient notation
Giving Report
Standardize bedside handover
Include safety checks
Patient status
Transfer of care documentation
Scenario 1
A G2P1 delivers by unscheduled repeat C/S. The delivery was uneventful.
She was given a rapid sequence mask induction because of advanced
labor, previous classical incision and maternal anxiety. Upon arrival in
PACU, she is in right recumbent position,briefly arrousable, maintaining
her airway with good air exchange. VS are stable, O2 saturation is 97% on
room air.
After about 10 minutes, you hear gurgling sounds and note she has
vomited, then gasped. She begins to cough and gag. You suction her
mouth and throat, then administer an antiemetic. She is more awake and
has no recurring N/V. Soon, she begins to breath more rapidly and says, “I
can’t get enough air.” You notice crowing/stridor on inspiration. Her O2
sat drops to 80’s. Her voice is hoarse and panicky.
What do you suspect? What do you need to know? What do you do?
After your interventions, she is breathing more rapidly. Her saturation is
82%. She is fully conscious.
What do you do next?
Scenario 2
A 28 year old G2P1 at term is receiving an epidural anesthetic
prior to scheduled Cesarean Section. She has no allergies, is
in good health with an unremarkable prenatal history.
You assist the woman into a fetal position on her side, and
attach monitoring equipment. A liter of LR is hanging and you
open it to provide a bolus.
The anesthesiologist proceeds with the epidural. As he
finishes injecting the epidural, the woman’s B/P drops to
80/37, her heart rate drops from 84 to 52 and O2 sat falls.
She says,”I can’t breathe, my chest is heavy.”
Scenario 3
A 26 year old southeast Asian woman at about 32 weeks,
arrives in the recovery room after an emergency C/S, under
rapid induction sequence, for abruption. As you proceed with
your initial assessment, you note that a red string is tied
around her upper abdomen and a pattern of old scars on the
woman’s abdomen that look like burns. You know from a
class on Transcultural nursing that it is believed this string
placed during pregnancy forms a protective circle keeping the
baby from harm and that burning the skin allows illnesses
and evil out of the mother during her pregnancy.
Scenario 3 (cont)
As you continue with your assessment, the woman’s jaw
dislocates. You call for the anesthesiologist to assist in
realigning her jaw. Recovery proceeds with 2 more incidence
of jaw dislocation.
When the woman has recovered from anesthesia and is
stable, you prepare to move to her room. You feel that the
language barrier has hindered your communication with this
woman. Before she leaves you, she tries to tell you
something. Frustrated, you are glad an interpreter has been
called in for the nurse who is taking over her care. You give
report to the new RN. The pt is reunited with her husband in
her postpartum room.
Scenario 4
24 yr old G1 with no prenatal care presents to
the Birth Center with a prolapsed cord and
non-reassuring fetal heart rate pattern. She is
taken for emergency C/S. Rapid sequence
induction is initiated using propofol and
succinylcholine. The anesthesiologist finds he
cannot open the pt’s mouth, but can
bag/mask ventilate.
Scenario 4 (cont)
After a few minutes of ventilation and
propofol boluses, the jaw relaxes and pt is
intubated. Anesthesia is maintained with 50%
Nitrous Oxide in O2, rocuronium and 1%
isoflourane. Baby delivers, surgery is
completed and mother is taken to PACU. HR
140, R26, T104
Scenario 5
A 31 year old G2/1 is having a scheduled
repeat C/S. Significant Hx is anxiety, breech
presentation with this pregnancy and obesity.
She has been taken to the operating room
where the anesthesiologist is placing an
epidural. You are assisting with positioning the
patient. After several unsuccessful attempts,
the anesthesiologist final gets the epidural
placed. With each attempt your patient
becomes more anxious. You are now helping
to position her in left lateral tilt, and have
called the surgeon into the room.
Scenario 5 Continued
Just as you are placing a bolster under the
patient’s right hip, she says, “ What is
happening to me? I feel really strange. “ She
is becoming more restless.
What do you think might be happening? How
can you help her?
Scenario 5 Continued
Your patient becomes very restless. Her
monitors are difficult to read due to her
agitation. You notice some twitching of her
facial muscles and she tells you “I taste
something weird”. Now what do you think is
happening?
Scenario 5 Continued
Your patient begins to seize. The
anesthesiologist is attempting to protect her
airway. What can you do to help? What could
happen next? How will you prepare?
Perioperative Nursing in the OB Setting
Facts
Standards
Data
Critical Thinking
Interpersonal Skills
Technical Skills
References
1. American College of Obstetricians and Gynecologists. (August 2010).Vaginal Birth After
Previous Cesarean Delivery, Practice Bulletin, Clinical Management Guidelines for
Obstetrician-Gynecologists, Number115, Washington DC: Author.
2. American Society of Perianesthesia Nurses (ASPAN). (2010-2012). Perianesthesia Nursing
Standards and Practice Recommendations. Authors.
3. American Society of Perianesthesia Nurses (ASPAN), current edition. Competency Based
Credentialing Program. Authors.
4. Association of Women’s Health Obstetric and Neonatal Nurses Position Statement, (June
2010). Advanced Life Support in Obstetric Settings . Authors
5. Association of Women’s Health Obstetric and Neonatal Nurses. (2010). Guidelines for
Professional Registered Nurse Staffing for Perinatal Units. Authors.
6. Association of Women’s Health, Obstetric and Neonatal Nurses. Standards and Guidelines
for Professional Nursing Practice in the Care of Women and Newborns, 5th Edition.
Authors.
7. Bates, SM, et al. Chest 2008; 133:844-886
8. Joint Commission, Updated Universal Protocol, April 2009
9. Joint Commission, Specifications Manual for Joint Commission National Quality Core
Measures, (2010). http://manual.jointcommission.org/releases/TJC2010A/MIF0167.html
10. Malignant Hyperthermia Association of the United States (MHAUS). Current edition.
Understanding Malignant Hyperthermia. Authors.