Preoperative teaching for cesarean birth

Alison Allen, RN

Preoperative teaching for cesarean birth Preoperative counseling for cesarean birth provides an opportunity for the operating room nurse to participate directly in patient education. The patient must be prepared for major abdominal surgery and given the chance to cope with this alternate style of birth. The cesarean patient has many concerns for herself, her unborn child, her family, and her home. Marut and Mercer’s study comparing primiparas’ perception of vaginal and cesarean birth found that satisfaction

Alison Allen, R N , BSN, is a private scrub nurse in plastic and reconstructive surgery in Pasadena, Calif. When she wrote this article, she was a Red Cross nurse volunteer with the preoperative teaching program at the Wilford Hall US Air Force Medical Center, Lackland Air Force Base, Tex. She is a graduate of the Baylor University School of Nursing, Dallas. The author expresses her thanks to Major P Gaines, RN, Captain P Damler, R N , and the Department of Obstetrics and Gynecology at Wilford Hall Medical Center.

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with the birth experience was significantly lower among cesarean patients and among mothers having general anesthesia. They also found that cesarean patients perceive their birth experience as negative. The mothers described their deliveries as “abnormal” and as having a “social stigma.”l The main goal for the nurse who is doing preoperative teaching is to help the cesarean patient have a positive birth experience. To reach this goal, nurses need t o address fears concerning surgery so the mother can concentrate on the birth experience. This article describes the preoperative teaching program for cesarean patients at Wilford Hall USAF Medical Center (WHMC), Lackland Air Force Base, Tex. The operating room nurse provides preoperative teaching for cesarean patients in the obstetrical clinic. Since cesarean sections are performed in the obstetrical suite, a preoperative program was designed to offer surgical and obstetrical counseling for the cesarean patient. An operating room nurse was chosen to do the teaching because of her knowledge of surgery and her experience in perioperative teaching. The cesarean patient is defined as one who is undergoing a repeat cesarean section or is likely to require cesarean section. No emergency cesarean section patients participated in this program. The number of cesarean births is in-

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creasing each year, and most of these patients have not participated in a preoperative teaching program. The incidence of cesarean section has greatly increased over the last decade. Stichler and Affonso say that some areas report averages of 15% to 18% or up to 23% cesarean deliveries2 In our institution, there were 1,532 deliveries for 1979. Of these, 128 patients (8.4%) had a primary cesarean section, 69 (4.5%)a secondary cesarean, and 11 (0.7%) had a cesarean birth and a hysterectomy. Baskett reported that one-third of all cesarean births are repeat operation^.^ Although a safe vaginal delivery is possible after previous cesarean section, it is unlikely to become accepted practice in North America in the near future. Therefore, more repeat cesarean births can be expected in the coming years.4 Cesarean birth is major abdominal surgery and involves risks even though it is considered one of the safest surgical p r o ~ e d u r e s .Nevertheless, ~ many patients go into a delivery unprepared. There is a need for a formal and systematic preoperative teaching program for cesarean patients. Donovan and Allen point out that the main reason for poor birth experiences associated with operative delivery is lack of information and anxiety about the unknown.6 A preoperative teaching program was organized at WHMC in December 1979 because of the significant number of cesarean sections each year and because cesarean patients are generally dissatisfied with their birth experiences. All the patient teaching takes place in an office at the obstetric and gynecology clinic. The interview and patient teaching sessions are private conferences between the preoperative nurse and the patient. The nurse encourages the patient to include her husband for support if that is appropriate. A date for the patient interview is made about three weeks before sched-

uled surgery. This is always arranged on the same day as the next obstetrical appointment. This way, the patient is saved an extra trip to the clinic, and the preoperative nurse is present for additional questions during following clinic visits. The patient is told to allow for extra time at the clinic when the interview is scheduled. This preoperative program consists of a patient interview, patient teaching session, and a written evaluation completed by the cesarean patient. The purpose of the program is to reduce the anxiety level of the patient so effective learning can take place. In addition, the nurse must work toward relieving concerns about hospital procedure and surgery. Two major goals were determined for the program: (1) to achieve a positive experience for the family (2) to have the preoperative interview evaluated by the patient so patient care could be improved. Before the interview begins, the nurse carefully reviews the patient’s chart to become familiar with the obstetrical history and medical problems that might need to be discussed during the interview. For example, it would be important to know that the patient had a stillbirth with the last pregnancy or that she had diabetes or hypertension. Even though diabetic and hypertensive patients are under a physician’s care, the preoperative nurse usually answers the patient’s questions concerning special infant care and recovery medications. These factors may contribute to the patient’s psychological attitude toward her cesarean section. After reading the chart, the nurse should become acquainted with the patient and explain her title and position. Introductions are important in establishing the nurse’s role and opening communication. This way, the interview becomes an exchange of informa-

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Table 1

Patient information for cesarean section I. Type of surgery A. Cesarean section, first time or multigravida B. Cesarean section with bilateral tuba1 ligation C. Cesarean section with hysterectomy I I . Hospital admission A. Admission procedure 5. Personal items for hospitalization C. Orientation to unit D. Rules about visiting Ill. Anesthesia A. Anesthesiologist to visit night before surgery. Ask questions now. Tell anesthesiologistof any adverse effects from previous anesthesia. B. Types of anesthesia 1. Epidural 2. Subarachnoid (spinal) block 3. General anesthesia C. Infant reaction to anesthesia IV. Preoperative patient care A. Operative consent and discussion with surgeon. Patient encouraged to ask questions now B. Night before surgery 1. Perineal and abdominal shave 2. Shower with povidone-iodine 3. Medication available for sleep 4. Nothingby mouth after midnight, including water C. Morning of surgery 1 . No water or food 2. Second shower with povidone-iodine 3. Clean hospital gown 4. Removal of all nail polish, jewelry, make-up, hair pins, and dental plates 5. Preoperative medication

t i o n and n o t a lecture. N e x t the nurse explains t h e purpose of t h e i n t e r v i e w a n d encourages the p a t i e n t t o ask questions.

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6. Foley catheter 7. Transport to labor and delivery D. Labor and delivery 1 . Intravenous infusion started 2. The room looks like an operating room, and the air is cold 3. After spinal anesthesia, patient tested for sensation; will be able to see baby and hear baby cry 4. With general anesthesia, patient will recover first and then see baby 5. Husbands not permitted in labor and delivery room by hospital policy 6. Husbands permitted to feed babies in nursery V. Recovery room A. All patients except those having general anesthesia to go to obstetrical recovery room; general anesthesia patients go to main recovery room and then to OB recovery room B. What to expect in recovery room 1. Time in recovery room 2. Intravenous infusion, Foley catheter, and abdominal dressing 3. May feel drowsy and tired; can see baby when feeling better 4. Patient monitoring C. Pain 1. Appropriate medication ordered by physician 2. Pain according to type of anesthesia D.Coughing and deep breathing for general anesthesia patients (to be taught preoperatively)

T h e p r o g r a m a t WHMC provides a n o u t l i n e o f subjects u s e d t o p r e v e n t forgetting topics and t o standardize information (Table 1). These interviews

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E. Discharge from recovery room 1 . Walked to room by nurse when

recovered; then expected to walk every day VI. Care of baby A. With spinal anesthesia, able to see baby immediately at birth 6. Baby fed in nursery during mother’s stay in recovery room. Medical center has rooming-in policy, socan see baby as soon as possible C. Nursery feeding schedule D. Who to ask for help and information about baby care E. Group lecture with pediatrician before discharge VII. Postoperative care A. Patient to walk and move about every day even if assistance is needed 6. May be tiring to feed and care for baby; call nurse for help C. Medications for pain, flatus, and sleep; medications for nonnursing mothers D. Diet resumed with normal bowel sounds E. Care of incision site F. Removal of intravenous infusion and Foley catheter G. Coughing and deep breathing if ordered H. Showers permitted VIII. Hospital discharge A. Car seat for infant B. Breast feeding problems or referrals C. Postpartum depression D. Sibling rivalry E. Home adjustment F. Book list

include details about admission, hospital procedure, and nursery care. The patient is given a general definition of her surgery and informed about standard

preoperative preparations. Special items such as Foley catheters, intravenous infusions, medication, and diet for hospital stay are also discussed. A general floor plan of labor and delivery, recovery, and the obstetric unit is drawn out for each patient. In addition, WHMC offers classes in parent orientation and a hospital tour for all pregnant mothers. At this point in the interview, the patient usually discusses previous cesarean section experiences. They may describe the experiences as “disasters” or “nightmares.” Statements such as, “I was surprised, disappointed, and helpless” are not uncommon responses to primary cesarean birth. These mothers remember feelings of failure, inadequacy, and deviation from the norm. Angry feelings seem to result from being unprepared for the cesarean section, because most patients expect to have a vaginal delivery. Many of the negative birth experiences stem from dealing with a n emergency. The patients’ apprehensions toward their scheduled cesarean operation are directly related to their past experience. Cesarean patients also say they had trouble coping with surgical recovery, especially complications such as postoperative infection and bladder atony. In addition, mothers state they were overwhelmed by trying t o cope with surgical pain, weakness, and fatigue as well as establishing a relationship with their infant. Listening and hearing what is said is important, especially if the previous cesarean section experience was negative. These mothers should be made to feel free t o discuss their fears and wishes so the nurse can assess their needs and ability to cope. Donovan and Allen describe the feelings of the family. Even with repeat cesarean parents, prior experience may have left them

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T

he cesarean patient often feels left out of education and support.

feeling sad, angry, frustrated or bitter; there is no guarantee that they will have more confidence or be better informed.’ Our interview meets these needs by providing accurate information in sequence and by allowing time for questions and reflections. Patient teaching is part of the preoperative discussion. Cesarean patients have the same fears as other surgery patients concerning their operation. The teaching includes instruction on coughing, deep breathing, and the incision. The nurse should assure the patient that proper coughing and deep breathing will not “open the incision.” Every patient is interested in the care and healing of the incision site. Many patients in this program are having repeat cesarean sections, and usually their new incision will be at the same site as that of the first cesarean. Two standard incisions are used for cesarean birth. In the operation of choice, a low transverse incision is made in the lower segment of the uterus. Advantages are minimal blood loss, reduced incidence of uterine rupture, and a more comfortable convalescence. The second type is the classical vertical abdominal incision directly into the wall of the body of the uterus. This incision is chosen in cases of anterior placenta previa or when the fetus is in a transverse lie. During the preoperative interview,

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the nurse must be prepared to talk about postoperative pain, fatigue, breast feeding, and holding and caring for the infant after surgery. Often sibling rivalry, home adjustment, and postpartum depression are discussed at this time. The nurse gives the patient a reading list of books about child care and the postpartum period. The nurse can refer the patient to the hospital personnel who would be most helpful in answering questions while the patient is hospitalized. The cesarean patient often feels left out of the mainstream of education and support.8 Most classes for prepared childbirth are mainly directed toward vaginal delivery. In the study by Marut and Mercer, 20 cesarean patients reported their delivery as a “shock,”a “big disappointment,” and “something totally different from what I expe~ted.”~ All these factors challenge the nurse to prepare and teach the patient so she knows what to expect. Fear is a major problem. Most patients will express some fears about anesthesia or having a deformed infant, but Stichler and Affonso report that cesarean patients also fear death. They suggest that the nurse’s role is to verify exactly what the patient fears and then provide information to decrease that threat. Death fears should be talked about and brought into the open. The nurse must not forget that husbands have death fears, too.l0 Dziurbejko and

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A surgical orientation for obstetrical nurses In early 1980, the obstetrical staff at St Joseph’s Hospital, Milwaukee, decided to begin performing cesarean sections in the OB department. This was no small task for a hospital where nearly 4,000 babies are born each year. Nursing staff would have to be prepared, and a delivery room would have to be converted into a surgical room. The operating room could not spare the staff or an instructor to orient at least 40 obstetrical RNs, so I was hired that June to instruct the nurses. My background as an OR inservice instructor and head nurse in two other area hospitals helped to prepare me for the position. In the next six weeks, I accumulated materials and wrote self-learning modules. Conveniently, the labor and delivery department had moved into a new addition, and two old labor rooms were turned into an office and classroom. Our c-section orientation classes began Oct 1. Our basic learning schedule consists of two labor and delivery nurses spending four days per week in class for three weeks. The first three days of class consist of reading the self-learning modules, accompanied by audiovisuals and discussions. This knowledge is reinforced on the fourth day by viewing actual cesarean sections and attending a learning lab in the afternoon. The learning lab consists of scrubbing, gowning, and gloving and setting up the back table and Mayo stand for a c-section. Instruments are introduced and reviewed. Most of the nurses have some knowledge of at least the names of common instruments. Also introduced are instrument care and handling and suture. This “hands-on” experience is invaluable in the coming two weeks. Each nurse will scrub and circulate on at least six to eight c-sections, a couple of abdominal hysterectomies, and occasionally a dilatation and curettage.

During the first and second weeks of class, video tapes are helpful. Tapes on suture and cautery were made with the aid of area industry representatives. A lecture tape on pelvic anatomy and related gynecologic surgery was borrowed from the operating room. We are preparing to have an anesthesiologist do a tape on drugs and responsibilities of the registered nurse in surgery. A tape on scrubbing, gowning, and gloving is gathering dust, however. We found it inadequate and frustrating for the nurses because they could not remember the sequence of skills without a participative learning experience. Charting, counting, anesthesia responsibilities, suture, cautery, and instruments are taught, demonstrated, and reviewed repeatedly during the three weeks. For the most part, I have been the only formal instructor in the program. At the beginning of the scrubbing experience, I scrub in with each nurse, and an experienced obstetrical nurse circulates with the one who is learning. By the end of the second week, they are able to scrub alone, although I usually remain in the room. By the third week, I remain in the room only until the baby is stable; the last day or two, I remain in the department but at a distance. Because all labor and delivery nurses staff the recovery room, each nurse is required to spend time in the surgery recovery room until she is comfortable removing endotracheal tubes. Circulating nurses are taught to accompany their patients to the recovery room, not only to give a report to the nurse there, but often to stay with the patient. Each nurse’s evaluation consists of written tests in the self-learning modules, the instructor’s evaluation of technical and cognitive skills, and a combined oral and written exam on the last afternoon of class. Motor skills are evaluated and reinforced continuously throughout the program, and cognitive development is evaluated by periodic discussions with the instructor as

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the self-learning modules are being read. The number of c-sections done in the delivery room increased according to the number of nurses progressing through the orientation. Our original intention was to orient all day shift nurses, then all evening shift nurses, and finally, all night shift nurses. Before long, it became obvious this would not work. Physicians and residents who did c-sections in the delivery room during the day were cooperative and patient with the program. Soon they wanted to do the night emergency cases in the delivery room, too. Since the hospital is a Level I l l perinatal care center, the neonatologists were especially happy to have their smallest and sickest babies being born 100 feet from the neonatal intensive care unit. They added to the pressure to do more c-sections in the delivery room. We revised our original plan and began taking one evening shift and one night shift nurse in each orientation class. Most of the day shift nurses were prepared by this time. This has worked out well. We had originally hoped to be doing all c-sections in the obstetrical unit by early this fall; probably it will be late in the season before this is possible. Much like the OR, it takes many months to orient new nurses completely to the department. When c-sections were done in the operating room, labor and delivery room nurses were present to assist in caring for the baby and to transfer the baby to the nursery. When c-sections were done in the delivery room, this put a great stress on staffing. The care of the other labor patients was being compromised. We began a program to orient special care nursery nurses to take care of the c-section babies in the delivery room. This has taken some time, but the nurses and neonatologists like it. It has not solved all staffing problems, but it has given us time to create more permanent solutions. The strongest reasons for doing c-sections in the delivery room, I believe, are proximity to the nursery and

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family-centered care. Family-centeredcare means that the mother is awake and participating in the birth, and the father is in the delivery room. While this is not always possible, it has become quite common in our hospital. This has changed the anesthesia method from general to spinal or epidural. The fathers are brought into the delivery room just as draping of the mother is completed. They are seated next to the anesthesiologist on the side nearest the baby warmer. Most fathers watch only the actual birth, with their wives peeking over the top of the drapes to see their new son or daughter arrive. When the baby is stabilized, and footprints have been taken, the nursery nurse brings the baby to the new mother to hold for a few minutes. Baby and the father go to the nursery, with the father usually carrying the child. The mother usually is drowsy at this point, and the father is encouraged to change clothes so he can go to the recovery room to meet his wife there. Before Christmas 1981, we will be doing all c-sections in the obstetrical unit. The project is discussed in parent classes, so most of our patients are aware of it. Some even call asking where c-sections are done in our hospital. Consumers are becoming more knowledgeable, and we believe we serve them well.

Barbara C Doll, RN, CNOR Mequon, Wis

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Larkin reported t h a t preoperative teaching resulted in less patient anxiety, and the patient was more cooperative and required less medication.” After the patient has participated in the group interview and teaching, the nurse uses the SOAPE system to record her observations in the chart and to document the preoperative preparation. The SOAPE system provides the basis for continuity of patient care by describing the physical and psychological profile of the patient and her attitude toward the cesarean section. In this way, other health team members can continue to give the patient support and guidance when she needs it. SOAPE stands for 0 Subjective responses of the patient 0 Objective observations of the nurse Analysis of these two types of information 0 Plan for patient care 0 Evaluation of the outcomes. The SOAPE system allows the preoperative nurse to establish regular communication with the labor and delivery nurses a s well a s t h e postpartum nurses. In our program, the SOAPE format is used as a means to fulfilling patient goals and as a starting place for fulfilling future needs. An example is: Mother tells the nurse that she believes having a baby on the OR table is nothing like a “normal” vaginal delivery. Mother says she feels “cheated” out of a real birth experience. Mother says she has tried to convince her physician to allow her to have a trial labor. The patient appears angry and depressed. She openly discusses her feelings of failure because she must have a cesarean delivery. The chart shows that the patient had a previous emergency cesarean due to fetal distress and that her infant had respiratory complications and a protracted stay in the hospital.

A Patient needs support, encouragement, and understanding from all health team members. P a t i e n t needs formal teaching to relieve apprehensions concerning surgery and infant care. Patient needs extra time t o vent her feelings and frustrations. Determine if the attitude of the patient’s spouse is supportive or nonsupportive. P Carry out preoperative teaching with emphasis on patient support and understanding. The patient may accept information more readily if she understands the nurse’s purpose is that there be “no surprises” for the patient during the surgery. Let the patient talk about her feelings. Remain open and trusting so the patient feels she has support. Include family or husband if appropriate. Plan for extra time. Look for possible problems. E Evaluation is completed postoperatively and combined with the written patient evaluation of the preoperative program. Patient’s postoperative condition is assessed by the nurse using the chart and observing patient recovery. In our program, the cesarean patient evaluates the success of achieving the goal of positive birth experience and how well health team members fulfilled her needs. During the third or fourth postoperative day, the patient is given a voluntary evaluation form, and her remarks remain anonymous. The multiple-choice questions are directed at the subjects covered during the preoperative interview. By completing this form, the patient provides the nurse with the opportunity to improve and update information. It also allows the nurse to see the positive results of preoperative teaching. These evaluations are a way of interacting with the patient so the nurse can improve patient care. The best motivation

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for the nurse is positive feedback f r o m the patient. T h e patient's personal ideas and feelings, wh e th e r communicated orally or in t he evaluation form, describe 0 how w e l l h e r needs were fulfilled. Notes 1 . Joanne Sullivan Marut. Ramona T Mercer. "Comparison of primiparas' perceptions of vaginal and cesarean birth.'. Nursing Research 28 (September:October 1979) 260-266. 2. Jaynelle F Stichler. Dyanne Affonso, "Cesarean birth." American Journal of Nursing 80 (March 1980) 466-468. 3. T F Baskett. "Cesarean section: What is an acceptable rate?" editorial. Canadian Medical Journal 118 (May 1978) 1019-1020. 4. Ibid. 1019. 5. Lois Mevs, "The current status of cesarean section and today's maternity patients,"JOGN Nursing 6 (July/August 1977) 44-47. 6. Bonnie Donovan. Ruth M Allen, "The cesarean birth method.'' JOGN Nursing 6 (November; December 1977) 37-48. 7. Ibid, 38. 8. Ibid, 43. 9. Marut. Mercer. "Comparison of primiparas' perceptions," 260-266. 10. Stichler, Affonso. "Cesarean birth," 68. 11. Marcia M Dziurbejko, Judith Candib Larkin. "Including the family in preoperative teaching." American Journal of Nursing 78 (November 1978) 1892- 1894. Suggested reading Conklin. Mary. "Discussion groups as preparation for cesarean section." JOGN Nursing 6 (July! August 1977) 52-54. Hedahl, Kathleen. "Cesarean birth: A real family affair." American Journal of Nursing 80 (March 1980) 471 -472. Marut. Joanne S. "Special needs of the cesarean mother." MCN 3 (Ju1y:August 1978) 204-206. Reynolds, Cheryl. "Updating care of cesarean section patients." JOGN Nursing 6 (JulyiAugust 1977) 48-51. "Should fathers attend cesarean section deliveries?" AORN Journal 28 (September 1978) 434-454. Wright. JD. "Cesarean section." Nursing Mirror 144 (Jan 27, 1977) 51-53.

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Send in entries for new writers contest Applied Fiberoptics, Inc, and AORN are pleased to announce a new writers contest. Cash prizes of $500 (first prize), $300 (second prize), and $200 (third prize) will be awarded for papers relevant to any aspect of operating room nursing. The closing deadline is Dec 31. Judging will be by an independent panel, and prizes will be awarded at the 1982 AORN Congress in Anaheim, Calif. The contest is open to all members of AORN except Headquarters staff and members of the Board of Directors and Editorial Board. Papers must be typed and double-spaced. Only original work will be considered, and all papers become the property of AORN, Inc. All contest entries will be considered for publication in the AORN Journal. Entries should be sent to Writers Contest, AORN Journal, 10170 E Mississippi Ave, Denver, Colo 80231. In your cover letter or on the first page of the aflicle, please specify that this is a contest entry. DePuy, Inc, continues to sponsor its writers contest, as well, which applies to articles by members published in the AORN Journal during 1981. The DePuy prizes, also awarded at Congress, are $500 for first place and $200 for second place. Five finalists are selected by the Editorial Board from among articles published during theyear, and the final judging is done by an independent panel of nurses. Often it is difficult for nurses in clinical practice to find time to write about their innovative ideas for patient care. In the hospital, writing for publication is not part of the rewards structure. Through these writers contests, we hope that more OR nurses will be inspired to share their ideas with their colleagues.

AORN Journal. KoL.ernber 1981. Vol 34, N o 5