all right um we are going to finish up all of this interpartum content with taking a look at [Music] um C-sections and some of the interpartum and a little bit of the postpartum care that we do for them right again objectives you can go over those on your own as you so desire um but it's stuff that we'll cover with the rest of this um lecture um so definition of a C-section is really a delivery of a baby via the abdomen versus uh vaginal and something that is occurring is there is an increasing rate of cesarean sections here in the United States um in the early mid 90s the C-section rate across the country was about 23 and today it is closer to 33 35 percent um and part of that is over the V back rates which we'll talk about in just a second and part of it is just other circumstances falling into that which we'll talk about a little bit also [Music] um the rate at Southeast um for where you're doing clinicals is a couple years ago it was right around 56 I I don't know in the past couple years if that has come down but even 56 versus a national rate of 33 35 percent is a significant difference and that 33 35 includes um tertiary centers and places with high-risk populations which would drive that rate up so keep that in mind as you look at different um organizations and practice and that kind of thing just something to be aware of um so some of the things that are affecting this increasing rate is the decrease oh sorry um is the decrease um rate of vaginal birth after cesarean which we talked about a little bit before um so VB AC stands for vaginal birth after cesarean and how that practice had kind of gone away in the mid 2000s um more recent research has shown that it actually is a very safe practice if we do it um according to a standard of care and as we follow that it is safe for women to in fact do uh trial for vaginal birth after cesarean um so we're starting to see that come back a little bit especially in hospitals where they have um in-house obes and in-house anesthesiologists 24 hours a day another thing that we're seeing along with this decreased rate of feedback is this increase rate of cesarean delivery on maternal requests so cdmr so these are women that come in and are wanting a C-section for no reason other than they want a C-section versus a vaginal delivery they are choosing not to go through Labor is really what's happening and um Physicians are um providing that service to them there is a lot of stuff and we'll discuss a little bit of this in class because I think it's a good discussion to have as far as what this really looks like and um the ethics of this and that kind of thing so just be aware that there is this increased request of women to have cesarean sections instead of vaginal deliveries so indications for C-section okay so these are approved indications for C-section um previous C-sections uterine surgery so if they had like a myomectomy or fibroids removed that kind of thing if there's a previous scar on the uterus then the that is an indication for a potential C-section um severe maternal disease pelvic tumors or trauma active herpes we've talked a lot about that one a multiple gestation uh just because those deliveries are much more complex and a lot of times those babies are in positions that warrant a C-section malpresentation so breech babies transverse lie CPD is self pelvic disproportion which we talked about um but this needs to be documented appropriately especially if they're talking about like a failure to progress or a failure to descend um have the contractions been adequate enough to illicit cervical change and that hasn't happened and if that's documented appropriately then yes it in fact is a CPD um prolapsed cord cleaning fetal distress fetal anomalies and the variety of distortions all of that stuff on here you do see that an indication is not physician or maternal request s okay those aren't right now approved indications for cesarean um when we do see sections when we document them we have two different kinds we have scheduled C-sections which are ones that are medically indicated um their mildly preeclamptic and they decide she's termed let's go ahead and get her delivered so they put her on schedule for next Tuesday when she's going to be 39 weeks um or an elective repeat so she had a C-section with her first two babies we're gonna put her on the schedule for 39 weeks next Wednesday um elective primary C-section so these are the ones that are the maternal requested but that would be a scheduled C-section so scheduled really is anything that happens before she goes into labor okay unscheduled is three different classifications we have emergent urgent and non-urgent so this woman comes in she's either in labor there's something else going on and they decide to do a C-section emergent is something like our court prolapse where there is an acute event we have to get this baby out as soon as possible okay when we document an emergency C-section that means from the time we say we're doing it to the time the baby is delivered has to be under 30 minutes okay it's that group of an event an urgency section is something where um maybe mom is getting infected and they'd say that we need to go ahead and do it we don't have that 30 minute time frame but we need to do it as quickly as we can within a reasonable amount of time but it's not stuck to that 30 minute window okay and then a non-urgent is maybe somebody who's been an induction for a couple of days she has made no progress whatsoever um the baby looks stable on the fetal monitor um so we know we're going to do it but if we have people scheduled for sections or we have other things going on before them this is going to be the one that can wait for a little while all right we're going to do it but there isn't an urgency to it okay risks related to C-section we've talked about a lot of the stuff and a lot of this is just risks related to surgery in general so you guys have been um learned about a lot of that stuff related to you um surgical outcomes a couple things in addition for maternal maternal risks are going to be big ones like um infection right bleeding um we can Nick other organs like bowel and bladder and that can cause issues um we could also have afterward with an infection like a wounded dehisenza wound opening that kind of thing feel risks um depending on the kind of anesthesia if baby goes under if Mom goes under General there could be fetal where baby goes to sleep also and then that turns into a needle neonatal risk for resuscitation other fetal risk would be just like we can now bow and bladder um they're using a scalpel to get through the layers of the uterus they could accidentally cut the baby because the baby's right there um neonatal risks really would be resuscitative measures or if there was injury to the fetus because of the surgery okay risks related to repeat C-sections a lot of that has to do with the uterus and being able to heal scars and that kind of thing um actions to reduce risks we always want to keep all of this as safe as possible we don't want to do procedures that are unnecessary because there are risks involved we want to make sure um we provide antibiotics we provide adequate um fluid replacement um accurate assessments all of that kind of thing okay we also want to do our um timeouts all of that kind of stuff make sure we're doing what we're supposed and everybody is present who's supposed to be present all of that stuff to provide a safe surgical environment um pre-op Care Medical Management the docs should be coming in getting informed consent truly explaining what the procedure is all of the risks involved okay anesthesia as well should come in and have a conversation with the patient do an assessment do a history all of that explain the procedure and all the risks and benefits and falls nursing care we go in reiterate what has been said by the providers um if they have us have the patient signed the consent forms all we're doing is witnessing the signature to the consent we are not getting informed consent as nurses the informed consent should have been done by the providers prior to us getting there all we're doing is making sure that the patient signs the consent if the patient has additional questions it's our responsibility to call the surgeon or the anesthesiologist back have them come back in and re-explain or better explain whatever it is a question had um the patient has questions about we are going to take care of any physical emotional needs of the patient and her support um IV fluids before the procedure we're going to give antibiotics and BTE prophylaxis um before we get into the OR okay if we need to shave we will shave put the fully in all of that stuff before we go into the OR okay the kind of anesthesia we give is going to be dependent on um the patient situation um so if she is a patient who's been in labor and has an epidural ideally we will just anesthesia will come in give a big bonus of that epidural raise the level of numbness in her in the patient's body or in the patient system to cover a C-section versus just a labor epidural um and we'll use the epidural for the anesthesia for the C-section if anesthesia is not able to get an adequate dose achieved or an adequate level achieved or if the patient does not have an epidural then we would probably go ahead and do a spinal for the C-section only because it's quicker it provides good coverage um and it's a little bit easier to do so spinal if they're either a scheduled C-section where they come in and they don't have an epidural or if it's a patient in labor who does not have an epidural the more can likely do a spinal if this is an emergency um and they don't and the patient does not have an epidural they will probably do General if it's an emergency she has an epidural and they aren't able to achieve a proper level very quickly they will also put her under General um when the patient goes under General we need to be aware that as a patient goes under General this baby goes under General they need to work very quickly to get that baby delivered because the longer the baby is inside the woman's belly with the woman under General the more compromised this baby is going to be at delivery so we need to be very careful with our patients who we put under general policies um nursing care uh the circulating nurse is going to be responsible for managing the room she um is caring for the woman partner if the partners in the room and also responsible for starting to get things set up for the neonate during a C-section usually there will be a baby nurse and probably a pediatrician or neonatologist in the room as well to receive with a neonate um just a picture of the different places where they will put the different blocks in so spinal goes a little bit higher epidural a little bit more okay epidural goes into this little yellow area of the epidural space the spinal actually goes into this General I just told you most of this stuff before but it's not given to us it's an emergency and the infant has to be delivered quickly and it just really increases the risks of for Mom and fetus with uh deep decrease respiratory effort okay if a woman is being put to sleep they usually will not allow the partner to be in the room because a woman is asleep anyway so the reason for the partner to be there to provide support for the woman is not there so usually they will not let a support person in the room if a woman is being put under General for the C-section incisions um we're going to talk about this in class but we'll start it here there are two different incisions that are made during a C-section okay so two different incisions the first one is on the skin so this is the one we see right so there is either what we call a fan and steel incision which is the bikini cut and it's a um for a central incision okay the vertical is just what it says it's a vertical incision usually goes from like the belly button down to the synthesis okay but this is the skin incision that's doing that's what we see on her belt on her belly or on her abdomen the incision we're really concerned about and what dictates whether or not a woman can have a vaginal birth after cesarean later on or what puts her at greater risk for complications in future pregnancies is the incision that's on her uterus okay um so we have a couple different kinds we have a low transfers okay which is a smaller horizontal incision we have a low vertical which is a smaller vertical incision we have a classical which is a bigger vertical incision and then we have what we call a t incision and it looks like that and we have a j incision which looks like this or like this we can show you a picture in just a second and talk about these some more so several different kinds of uterus incisions and it's important when you have a patient who has had a C-section prior that you look back at the record because somewhere in there it should be documented um what her previous uterine incision is and we need to know that information to know whether or not it's safe for her to have contractions in the current or upcoming pregnancies okay so here is just an example of the incision so these are skin okay it's what we see on the outside of her um it's what she's concerned about because this is the scar that people see so you see that the vertical incision is much bigger most people anymore will do a fan and steel just because it's a prettier incision and it's usually hidden by either underwear or bikini okay vertical you can see it regardless of that um they may do a vertical if it's an emergency because you can cut through layers of tissue much quicker with this incision versus this one this one just takes longer to dissect down to the uterus and delivery right these down here are our uterine incisions okay these are the ones that dictate whether or not um this uterus should be contracting in a pregnancy in a later pregnancy okay so low Trends first it's okay for her to have a vaginal delivery after cesarean okay her vaginal birth after cesarean this is this little transverse okay it's in the lower segment of the uterus the chances of this is she's having contractions which startup in her fundus he ruptured this scar are very low okay this low vertical it's higher it goes more into the midline of this uterus this is not okay all right she cannot have contractions or have a visual delivery of necessary or vaginal birth up your Caesarean your chances of rupture are higher we almost never see this incision a lot of times this incision is done in other countries um it's not usually done in the U.S then the last one is a classic a classical incision um this is indicating your belly button okay and the incision usually the incision is bigger than this but it goes this way many times a classical incision is done um in either another country or in babies who have been preemies um just because a preemie baby if you think about it the uterus isn't as big there's not as much Universe to cut to get the baby out so they end up with a classical incision and this one absolutely is not okay this woman should not have contractions in a future pregnancy because of the increased risk of a uterine rupture okay so really the only one that can do a vbac um and if future pregnancy would be the lung transverse that's the only one that is safe to do that we will review these in class so um if I if you have questions about them we can go over them some post-op here um think of your post-op um C-section patients or like any other normal surgical patients so you're looking for infection you're looking for leading all of that kind of stuff respirations um incision site all of that kind of thing but you're adding on to that your postpartum assessment also so that's kind of what it looks like all right all right that was actually very quick and very easy it wasn't it compared to the other two lectures um all right so this is all of intrapartum and we will get into more in depth and how this actually looks in patient scenarios when we get into class um later in the week all right thanks you guys