Specific Nursing Care of the Woman Undergoing Emergency Caesarean Section - Essay Example

?Critically analyse the specific nursing care of the woman undergoing emergency caesarean section Introduction In managing emergency caesarean section patients, there are various concerns and duties which nurses have to note and be responsible for. These patients often display needs which affect the success of the procedure and the safety of the infant. This paper will critically discuss the specific nursing care of the woman undergoing emergency caesarean section. It will identify the patient’s needs and plan, indicating appropriate resources for each individual. Discussions on participation in the nursing care and management of obstetric client undergoing anaesthesia will also be established, including the preference for spinal anaesthesia over general anaesthesia. The anatomy and physiological changes referring to pregnancy will also be established, especially in terms of anaesthesia. My role in preoperative care, preparation of the room and equipment, as well as the positioning of the patient will be included in this essay. Body The needs of the individual patient in this case would refer to the operating room needs, with an operating room made ready, the assisting nurse scrubbed and gowned, and the appropriate instrument tray prepared. Informing the appropriate team for the caesarean section would also be essential (Murray and Huelsmann, 2009). Individuals requiring notice would be the operative assistant, the charge nurse, the nursing supervisor, the anaesthesiologist, the OR team, and paediatrician. Information to be transmitted would include indications, how immediate the surgery needs to be, the gestational age of the mother, major pregnancy problems, medications given in labour, and allergies (Murray and Huelsmann, 2009). It is also important for the anaesthesia machine and a radiant warmer to be set up in the OR. The roles of the nurses also need to be assigned. As soon as the patient delivers, sponge counts and instrument counts would have to be undertaken (Murray and Huelsmann, 2009). Post-operative care is also in order, after appropriate un-scrubbing procedures carried out. The patient is then wheeled into the recovery room, monitored based on doctor recommended intervals. Monitoring of bleeding and infection is also needed, along with the administration of due medications, including antibiotics and pain medications (Littleton and Engebretson, 2005). It is important for the nurse to participate completely in the nursing care of the caesarean section patient because emergency caesarean sections imply an immediate procedure which is threatened by possible foetal or maternal distress or any other issues or complications of pregnancy (Iyer, et.al., 2006). The assistance of the nurse is essential in these cases in order to ensure a speedy, safe, and efficient delivery. It would allow for the efficient use of hospital resources with the ultimate goal of achieving improved and stable patient outcomes. It is also the responsibility of the nurse to assist the anaesthesiologist during the induction of the anaesthesia as well as the monitoring of the patient during the surgery, mostly in terms of vital signs monitoring or any adverse reactions to the anaesthesia (Maaloe, et.al., 2012). Spinal anaesthesia is usually preferred over general anaesthesia for caesarean patients. Although both anaesthesia techniques provide effective anaesthesia during the delivery, spinal anaesthesia provides more benefits for both the mother and the infant. In a review by Krisanaprakornkit (2006), the author established that both methods proved effective in providing anaesthesia. For spinal anaesthesia, the surgery can be initiated sooner, however the risk of hypotension requiring treatment seems apparent in spinal anaesthesia. General anaesthesia also offers better postoperative control (Ng, et.al., 2004). In relation to other postoperative outcomes, including nausea, postoperative back pain, postdural puncture headache, no effective or definitive conclusion could be established (Krisanaprakornkit, 2006). Regional anaesthesia has also become the preferred anaesthesia technique for caesarean birth, especially as regional anaesthesia is associated with lower maternal mortality, direct birth experience, speedier maternal bonding, lower blood loss, fewer drugs needed, and better postoperative pain control (Villar, et.al., 2006). In relation to spinal anaesthesia, the epidural technique often requires more time and skill to carry out. It can also only be administered by well-trained anaesthesiologists. It may also not be favourable to use epidural techniques for caesarean sections, especially in under-resourced areas where there are no trained anaesthesiologists available (Dahlgren, et.al., 2005). In the case of spinal anaesthesia however, an obstetrician with experience in spinal block can induce the anaesthesia. In these instances, strict monitoring must be carried out. It is the responsibility of the nurse to prevent maternal hypotension once regional anaesthesia is administered (Desalu and Kushimo, 2005). In effect, it is important to preload the patient with a crystalloid solution. IV ephedrine administered through infusion or injection must also be prepared, with phenylephrine applied in order to secure reliable results in the prevention and management of hypotension (Desalu and Kushimo, 2005). Studies indicate that women who are given anaesthesia through spinal methods require more frequent management for hypotension when compared to those going through the epidural method. As hypotension mostly negatively impacts on the infants, future studies seeking to assess the impact of spinal anaesthesia on neonatal outcomes are essential (Krisanaprakornkit, 2006). The impact of postoperative pain management via neuroaxial opioid for regional anaesthesia has to be managed in terms of their side effects including nausea/vomiting, and pruritus. Such side-effects often affect maternal well-being as well as the mother’s ability to breast feed. Pregnancy leads to major anatomical changes in the woman’s body. Understanding these changes is important in ensuring the safe administration of anaesthesia (Tham, et.al., 2010). Most of these changes are caused by hormones with the later stages of pregnancy causing metabolic and mechanical changes. These hormone changes include the release of progesterone with the placenta producing human chorionic gonadotropin to sustain the pregnancy (Anaesthesia UK, 2006). At 6 to 8 weeks of pregnancy, the placenta becomes the source of progesterone. The placental lactogen is also produced and usually leads to maternal insulin resistance. Hypertrophy of the thyroid gland may also manifest. Metabolic rates also increase during pregnancy with atleast 12 kg in weight gained at the time of the pregnancy (Anaesthesia UK, 2006). For the respiratory system, dyspnoea is a common issue, mostly because of hormonal and mechanical elements. The intubation may be more common in term patients. This may be attributed to increased breast size making insertion of laryngoscope difficult (Anaesthesia UK, 2006). Airway mucosal oedema would also make the laryngoscopy difficult. Smaller ET tubes are recommended in these cases. Nasal intubation is also not recommended because of nasal congestion. Cardiac output is also increased by the 5th week of pregnancy (O’Gorman, 2006). The heart is usually displaced upward and to the left of the uterus. As a result, murmurs are often detected. Systemic vascular resistance may also be seen because of the vasodilatory impact of progesterone (O’Gorman, 2006). Blood flow to the uterus is increased, including blood flow to the kidneys and skin. Blood pressure usually decreases even with higher cardiac output, mostly due to the decreased SVR. Diastolic pressure also falls to a more significant extent than the systolic pressure (O’Gorman, 2006). The pregnant uterus also impacts on the inferior vena cavae when the pregnant woman is a supine position with the venous blood flowing instead to the collaterals, especially the vertebral venous plexus and then draining to the azygous system (Anaesthesia UK, 2006). This is a crucial piece of information when the patient is being positioned on the operating table. In cases of regional anaesthesia, the impact of the aorta-caval compression would be increased because of the failure of compensatory reflexes following the sympathetic block. This can cause hypotension (Chestnut, 2004). It is often essential therefore to place a wedge under the patient’s right flank or to tilt the operating table to the left in order to manage the effects. In instances of severe hypotension, the patient can then be turned into a left lateral position. Plasma volume rises up to 50% by the time the baby is ready to be delivered. RBC volume also rises, especially with the increased production of erythropoietin (Anaesthesia UK, 2006). A decrease in measured haemoglobin would also be apparent with blood viscosity decreased. Renal changes are also apparent during pregnancies. The metabolic load is increased due to the foetus and also because of the obstruction in the flow of the ureters caused by the expanding uterus (O’Gorman, 2006). The glomerular filtration rate rises by 50% during pregnancy. Consequently, the release of urea, uric acid and creatinine is increased, with the serum concentrations decreased during the pregnancy. Gastric changes are also seen during pregnancy (Chestnut, 2004). The lower oesophageal sphincter is relaxed and the intra-gastric pressure is increased by the expanding uterus. As a result, heartburn may be reported by most pregnant women. An increased risk in gastric regurgitation and aspiration during induction of general anaesthesia may also be observed. Pregnancy prolongs gastric emptying time (Walton and Melachuri, 2006). These elements indicate that rapid sequence induction is mandatory in cases of general anaesthesia at the third trimester and within the 48 hours following delivery. The minimal alveolar concentration of volatile anaesthetics is reduced during pregnancy. This may be seen following high levels of progesterone and with the rise in B endorphin levels (Anaesthesia UK, 2006). An increase in sensitivity to opioids, sedatives, and local anaesthetics may also be observed. The impact of local anaesthetics when applied with neuroaxial anaesthesia is increased secondary to the mechanical elements in the epidural and subarachnoid space. The compression of the inferior vena cavae causes the diversion of blood with the vertebral venous plexus which is in the epidural space (O’Gorman, 2006). This leads to the expansion of the epidural veins with the subarachnoid volume decreasing. In effect, like amount of local anaesthetic would be absorbed more extensively in the pregnant patient (Walton and Melachuri, 2006). The partner can also be made part of the birthing process. Their presence in the operating room however would have to be under sterile conditions. They also have to be scrubbed, masked, and gowned before they can enter the operating room (Young, et.al., 2012). It is the responsibility of the nurse to ensure that the partner is sterile and that he is instructed about the proper protocol and rules of behaviour inside the operating room. Caesarean section deliveries have become more common in recent years and more husbands or partners have also become an essential part of the delivery process (Gutman and Tabak, 2011). The ultimate goal for their presence mostly refers to relieving of the mother’s anxiety, providing moral support to the mother, as well as providing further validation to patient autonomy in decision making (Gutman and Tabak, 2011)). Partners’ right to be in the operating room has sometimes extended to close relatives or any other relatives the delivering mother requests in the room. In some instances, the increased number of guests in the operating room seems to bring about unfavourable consequences especially as their presence may interfere with the work of the staff members as well as their decision-making (Ellison, 2003). The work of doctors and nurses in the operating room is often based on their occupational training, their cultural background, and prior experiences with partners inside the operating room (Ellison, 2003). Nurses have also been known to report that they often felt uncomfortable with family members watching them in the operating room (Ainslie, 2005). It is important to note however that the main element affecting a staff member’s behavioural attitudes would be his behavioural intention. Behavioural intention is based on behavioural attitudes as well as the work itself (Gutman and Tabak, 2011). How the intention is improved to allow partners inside the operating room during caesarean deliveries would be by changing the individual attitudes of nurses and staff members, including the environmental elements surrounding the issue (Kotkis, 2005). In effect, staff training must be managed based on materials meant to ensure awareness of the advantages seen in partners being in the operating rooms during the deliveries. Under these conditions, it is important for the nurses to understand that the presence of the partner would be a significant adjustment to the surgical process (Kotkis, 2005). Reduction of staff anxiety is therefore an important concern for nurses. As nurse leaders, it is important for nurses to take the initiative towards changing attitudes in the operating rooms. Moreover, initiatives also need to be made by the nurses in terms of infection control for the partners in the operating room. Instructions must be clearly laid out to the partners, indicating what they may or may not touch, the area they may or may not access, as well as the sterile procedures they have to observe (Ainslie, 2005). It is also the responsibility of the nurses to inform the partner of the appropriate behaviour required of him in the operating room in order to eliminate interference with the staff’s work. It is also up to the nurses to make the necessary adjustments in the OR to accommodate the husband (Gutman and Tabak, 2011). This would include a space preferably at the head part of the operating table where the husband can easily talk, coach, and reassure his/her partner. In some instances, training of the operating room staff may be needed in order to support the active participation of the partner during the Caesarean section. The training process would help ensure participation of the partners in the operating room while still protecting the protocols and standards for a successful surgery (Gutman and Tabak, 2011). The training process would allow for the staff to understand the importance of partner support during the caesarean delivery. As the staff members understand the role of partners in the operating room, they would be more accommodating of the adjustments they need to make for these partners. My role as a nurse assisting in the emergency caesarean section would be to ensure that the patient is prepped for the surgery. This would include the changing of the mother’s garments, from street clothes to the surgical gown and turban (Gagnon, 2007). I have to work fast and efficiently during these times because of the emergency nature of the procedure. The patient’s OR preparation would also include the vital signs check before the induction of the anaesthesia in order to establish baseline levels (Gagnon, 2007). Pain monitoring would also have to be carried out including the monitoring of contractions, and if possible, the foetal heart beat. Depending on the nature of the emergency causing the Caesarean surgery, the necessary assessment procedures and monitoring processes have to be carried out by the nurse. As such, the patient may be monitored for bleeding, signs of consciousness, pain, and other vital signs. As soon as the patient is wheeled into the operating room, the operating room staff would likely undertake their necessary procedures for the surgery (Spry, 2009). Part of my functions would be to check the instruments to be used during the surgery, including the functionality of the suction machine, the anaesthesia machine, the vital signs monitor, and other equipment necessary for the surgery. Some obstetricians may also have specific needs during the surgery, and these requirements must be prepared in order to avoid any delays during the surgery. In instances where the patient may also be suffering from bleeding, the nurse must make the proper request with the hospital blood bank for blood packs to be brought to the operating room (Spry, 2009). Depending on the physician’s orders, a blood transfusion may be indicated for the patient. Aside from independent nursing functions, my role as a nurse is also to assist the operating room staff, especially the physicians in order to make the surgery successful. References Ainslie, T. (2005). Teaching clinical ethics using case study resuscitation. Critical Core Nurse, 25(1), pp. 38–44. Anaesthesia UK (2006). Anatomical and Physiological Changes in Pregnancy Relevant to Anaesthesia [online]. Available at: http://www.frca.co.uk/article.aspx?articleid=100641 [Accessed 24 May 2013]. Chestnut, D. (2004). Obstetric anesthesia: principles and practice. London: Elsevier Health Sciences. Dahlgren, G., Granath, F., Pregner, K., and Rosblad, P. (2005). Colloid vs. crystalloid preloading to prevent maternal hypotension during spinal anesthesia for elective cesarean section. Acta Anaesthesiol Scand, 49, pp. 1200-1206. Desalu, I. and Kushimo, O. (2005). 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