Procedural Manual For Delivery Cases

Indications for Cesarean Section:

• Abnormal birth presentation.
• Inability of the fetus to pass through the birth canal (disproportionate fetal head and maternal pelvis).
• Maternal health conditions like preeclampsia or diabetes.
• Active herpes infection in the mother, which could pose a risk to the baby.
• Previous cesarean section or uterine surgery.
• Fetal complications, such as cord prolapse or abnormal position.

Risks of Cesarean Section:

• Maternal risks: Anesthesia complications, respiratory problems, bleeding, blood clots, injury to the urinary system, bowel injury, and infection.
• Fetal risks: Prematurity complications, respiratory issues, and superficial injuries.

Preoperative Nursing Care for Cesarean Section:

• Complete patient assessment on admission (e.g., maternal history, current pregnancy details).
• Electronic fetal heart monitoring for 20-30 seconds.
• Explain the surgical process to the mother and her support person.
• NPO (nothing by mouth) for 4-6 hours before surgery.
• Obtain necessary blood tests and prepare the skin for surgery.
• Establish IV access and urinary catheter insertion, if needed.
• Administer preoperative medications according to the doctor’s orders.
• Monitor fetal heart rate if active labor is occurring.

Postoperative Nursing Care for Cesarean Section:

• Ensure the airways are clear.
• Monitor vital signs frequently (every 15 minutes for the first 2 hours, then every 30 minutes for the next 2 hours, then every hour for 4 hours).
• Administer fluids and medications as ordered by the doctor.
• Assess the patient's level of consciousness, skin color, and hydration.
• Inspect the surgical site for any abnormal discharge or infection.
• Encourage early ambulation (within 6 hours after surgery).
• Provide pain management and support.
• Assist with breastfeeding, and provide guidance on newborn care.

Postpartum and Newborn Care

Nursing care for mothers after birth (postpartum) is essential to ensure recovery and support for the newborn.

Importance of Postpartum Nursing Care:

• To ensure the safety and well-being of both mother and newborn.
• To prevent complications like hemorrhage and infection.
• To provide emotional support to the mother and family in adjusting to the new baby.

Changes During Postpartum:

• Temperature: A slight increase within the first 24 hours, but it should not exceed 38°C.
• Pulse: Decreases in the first two days, then returns to normal after day three.
• Urine Output: Increases in the first five days due to excess fluid loss.
• Skin: Sweating increases, and skin changes like melasma fade.
• Bowel Movements: Constipation may occur due to relaxed intestinal muscles and fluid loss.

Psychological Needs of Postpartum Mothers:

• Emotional and physical adjustment to new responsibilities, including caring for the newborn.
• Providing guidance on self-care, infant care, and family adjustment.

Simple postpartum discomforts include abdominal pain, hemorrhoids, urinary retention, delayed uterine involution, constipation, and sore nipples. 

Nursing care should address both physical and emotional needs, ensure proper wound healing, and prevent complications during the postpartum period.

Role of the Nurse in Postpartum Care

The nurse's role in caring for the postpartum woman (nifas) involves following the nursing process to assess the health of both the mother and the newborn in order to identify their needs and problems. The following steps should be taken:

1. Collecting a Comprehensive Health History:
• Take a thorough health history of the mother, especially regarding her recent birth history.
2. General Physical Examination: The nurse should conduct a comprehensive examination that includes the following:
• Skin: Inspect the skin for color and condition (paleness, jaundice, dryness, excessive sweating).
• Observation for Fatigue: Look for signs of fatigue, loss of appetite, or dehydration.
• Vital Signs: Measure vital signs such as temperature, pulse, respiration, and blood pressure.
• Eyes and Tongue: Check for signs of anemia.
• Extremities: Examine for signs of thrombophlebitis (inflammation of veins and blood clot formation).
• Breast Examination: Assess the size, abnormal changes, nipple type, discharge, and any signs of infection.
• Abdominal Examination: Check the level of the uterine fundus, its firmness, shape, and position.
• Perineal Examination: Observe the perineum every 15 minutes after delivery to detect any signs of bleeding or hematoma formation.
• Lochia Examination: Assess the amount, color, odor, and composition of the lochia (postpartum discharge). It is normal for lochia to be blood-tinged for the first 4 days, then the color lightens and the amount decreases, turning into yellowish mucus after about 10 days. This should continue for 3-4 weeks.

This assessment is crucial to identify any complications early and ensure proper care for both the mother and her newborn.

Immediate Nursing Care After Delivery (First Two Hours Post-Delivery)

• Follow infection control procedures for all nursing interventions. • Position the patient in a comfortable position with warmth (Avoid placing her in the supine position to prevent posterior tilting of the uterus. It is preferable to place her in a semi-sitting position as it helps with the drainage of lochia). • Observation and documentation of:

• Vital signs
• Amount of blood lost
• Uterine tone (firm or relaxed)
• Condition of the perineum (tears, swelling, redness, bleeding)
• Height of the uterine fundus (gentle uterine massage every 15 minutes)
• Bladder condition
• Proper nutrition and increased fluids
• Encouraging breastfeeding
• Encouraging early movement • Administer vitamin A capsules immediately after delivery and iron tablets.