C-Section Overview

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Introduction   

When hearing the phrase Cesarean section, what comes to mind? If you’re a nurse, you’ve definitely heard about Cesarean sections (C sections) at some point in your nursing studies and nursing career. Maybe even before nursing school, conversations about giving birth and being a parent most certainly existed. Presently, patients seek guidance and information on various health topics from nurses, including information on a C-section and the recovery process. The information in this course will serve as a valuable resource for nurses of all specialties, education levels, and backgrounds to learn more about C-sections and C-section recovery.  

Defining Cesarean Section 

What is a C-section? How prevalent is it? 

A C-section is a medical, surgical procedure that is done to remove a fetus from the uterus of a pregnant person. C-sections are the most common surgeries in the United States and among the most common surgeries in the world. A C-section is the only surgical procedure in which the patient leaves the hospital with another person to take care of. C-sections typically account for a third of all U.S. births with exact rates varying by state, race, income, insurance status, and more. While C-sections are increasingly more common in the U.S. and globally, C-sections have existed for centuries. Advanced practice registered nurses (APRNs) can be involved in C-sections as first-assistant surgical specialists if they complete additional training and if it is within their scope of work in their practicing state. APRNs can see patients after a C-section during their postpartum inpatient and outpatient visits. Registered nurses (RNs) who work in antepartum care and newborn care often play a major role in maternal and infant health during C-sections as well. Particularly, the past few decades in the U.S. have seen tremendous growth in C-section incision techniques, C-section recovery options, and C-section patient safety profiles (1,2,3,4).  

That said, a C-section is a major surgical procedure that involves a surgical incision through several layers of tissue, collaboration with an anesthesiologist for pain management options, and substantial recovery post-operatively. For some patients, C-sections can often be life-altering with very little ease of returning to a life prior to a C-section if there were surgical complications, maternal complications, or fetal complications. With adequate medication, treatment, therapy, and intervention, many people who have experienced a C-section can resume activities done prior to a C-section and pregnancy. However, it is important to note that a life in C-section recovery and postpartum is going to be a new normal for the person who experienced a C-section, their loved ones, their families, and for possible caregivers (1,2,3,4,5,6).  

What if C-section complications are not addressed? 

If C-section complications are left untreated, severe health complications can arise, such as postpartum hemorrhage (PPH), placental retention, surgical site infection, infant developmental malformation, maternal hypertension, inadequate pain management, organ damage, nerve damage, impaired blood perfusion, maternal mental health complications, maternal death, or infant heath. Given the importance of the pelvis for walking, sitting, and performing other activities of daily living (ADLs), proper care for a C-section is essential to minimize C-section complications. Follow-up with health care services postpartum is essential for C-section recovery (1,2,3,4,6). 

What causes C-sections? 

C-sections can be performed for many different reasons. Some patients prefer to have a C-section instead of a vaginal birth for personal reasons, also known as an elective C-section. Some patients choose a C-section because of a history of sexual trauma, lack of desire to labor, or personal preference. Some maternal causes for C-sections often include the health of the pregnant person, such as maternal hypertension (HTN), pre-eclampsia, gestational diabetes, multiple gestation, placental complications, uterine complications, and more.  

Some fetal causes for C-sections often include fetal distress, lack of fetal heart tones, blunt trauma to the pregnant person, and more. While there are several causes for C-sections, it is also important to know that patients can give birth vaginally if they have conditions such as pre-eclampsia or gestational diabetes. Because of the wide range of clinical presentations of health conditions and health complications that can arise during pregnancy and labor, it is important to keep patient health in mind. Health assessment, health history, patient preference, and collaborative clinical judgment is essential for performing a C-section, as this is a permanent medical procedure that will affect the patient forever (1,2,3,4).  

What are C-section risk factors? 

Risk factors for C-section include anyone who is pregnant! Anyone who is pregnant can have a C-section, including people who are pregnant with intrauterine fetal demises (IUFD), multiple gestations, fetal complications, maternal complications, blunt force trauma, placental complications, uterine complications, or maternal preference. C-section risk factors are similar to causes for C-section, but it is important to note that risks for C-sections can also vary significantly depending on patient health and clinical presentation (1,2,3,4).  

While C-sections are life-saving medical procedures, C-sections also have many risks to be considered as well. C-sections have a higher rate of blood loss compared to vaginal births, possibility of anesthesia complications, uterine complications, need for recurrent C-sections with subsequent births, and scar tissue infection concerns (1).  

What are the most common types of C-section incisions? 

The most common types of C-section incisions are classical incisions and low transverse incisions. Classical incisions are incisions that go through the mid-line of the abdomen and remove the tissues in order to reach the fetus. Low transverse incisions are incisions that are typically near the lower hips and move the tissues in order to reach the fetus. Low transverse incisions have gained more popularity for the past few decades with advances in medical equipment and ultrasound technology. Classical incisions are still performed and are often performed on patients who are obese or those who are having multiple fetuses given the skin presentation and fetal presentation. Both types of incisions need extensive surgical preparation and a full team of nurses and medical staff prior. The anesthesiology team must be consulted, and anesthesia given prior to the procedure. In addition, C-section protocols typically only allow one other person other than the birthing parent in the operating room (OR). A C-section protocol is similar to a surgical protocol and must be followed by your local facility’s guidelines and scope of practice guidelines (1,2,3). 

What are options for C-section recovery? 

There are several options for C-section recovery, including physical therapy, medication for pain management, psychotherapy, and more. C-section recovery can vary significantly from person to person, as everyone’s return to fitness and ADLs can vary significantly. For instance, athletes who perform a more vigorous fitness regime might have a different recovery than someone who was not physically fit prior to pregnancy. For example, a birthing parent who had given birth to triplets at 37 weeks via C-section will have a different recovery path than a birthing parent who had a C-section for fetal demise at 34 weeks. C-section recovery is personal, so understanding the patient’s needs is crucial. C-section recovery options can vary depending on the severity of C-section complications, patient’s location, patient preference, cost, and more (1,2,3,4,5,6). 

What are the clinical criteria for undergoing a C-section? 

Clinical criteria for undergoing a C-section includes anyone who is pregnant and needs a C-section. C-sections can be elective procedures, but they are also lifesaving for both the birthing parent and fetus. With the rise in medical advances and advances in prenatal care, C-sections can be scheduled, performed after a trial of labor, can be an emergency procedure, or an elective procedure. While it is ideal for a patient to be hemodynamically stable and avoid consuming anything by mouth beforehand, C-sections can be done if a patient has eaten something by mouth within the past few hours or is not hemodynamically stable. Effective health care staff collaboration, clear protocols within your facility, and medical training are essential for healthy C-sections and recoveries (1,2,3,4).  

What is the average cost for C-sections and recovery? 

Cost for C-sections can significantly vary depending on the type of medications used, insurance, dosage, length of stay in the hospital afterwards, and other factors. Cost is among the leading reasons why many patients are unable to maintain their treatment regime (5). If cost is a concern for your patient regarding a C-section or recovery, consider reaching out to your local pharmacies or patient care teams to find cost effective solutions for your patients. In addition, many patients recovering from C-sections may require medical intervention outside of medication, such as physical therapy, so the cost for that is also something to consider as well (1,2,3,4,5,6).  

Common C-Section Medications  

C-Section Medications Overview and Side Effects: Procedure 

Health care provider professional discretion and patient condition should guide therapy. Consider reviewing a patient’s medication history, clinical presentation, and health history prior to prescribing medications during a C-section. Consider consulting with an obstetrician, anesthesiologist, and other relevant clinical staff regarding C-section medication options. It is important to assess the patient prior to medication administration, including checking for a history of allergies or documentation of refusal for blood products.  

During preparations for a C-section, the patient will receive spinal anesthesia administered by an anesthesiologist. Then, depending on facility protocol, anesthesia and pain management during the procedure may be monitored by the anesthesiologist, certified registered nurse anesthetist (CRNA), other medical staff, or a combination of all three. Pain medication during a C-section is typically bupivacaine, but other pain medications can be considered as well. Possible side effects of pain medications include altered consciousness, pain at the insertion site, allergic reaction, delayed analgesic effect, and more (1,2,3).  

C-Section Medications Overview and Side Effects: Recovery 

Every medication has the possibility of side effects, and medications for C-section recovery are no exception. In fact, depending on the complications from the C-sections, patients themselves might not be able to perceive possible side effects in the way health care professionals can. As a result, it is important to educate caregivers on possible side effects of all medications to be administered and to monitor for any critical symptoms. For instance, a patient recovering from a C-section might be prescribed opioids, which have common side effects of respiratory complications and constipation. Pain medication options, such as non-steroidal anti-inflammatory drugs (NSAIDs) or opioids, are possible options for patients recovering from C-sections. Dosages, frequencies, types of these medications, and administration routes can vary significantly depending on the severity of the C-section, patient health, breastfeeding status, and more.  

It is also important to note that, depending on the type of C-section someone has experienced, pain sensation and perception can be altered. From a nurses’ point of view, pain assessment is critical. Opioids, such as morphine, can be transmitted via breastmilk, whereas NSAIDs like ibuprofen are not known to be transmitted via breastmilk. In addition, it is also important to listen to the patient regarding pain management needs (1,2,3,4,6). 

Other medications, such as antipsychotics and antidepressants, can also have their own set of possible side effects. Because of several medication options, dosages, frequencies, administration routes, and more regarding medications for C-section recovery, consistent education and review of medication side effects are essential. In general, it is important to monitor patient side effects to determine if risks outweigh the benefits and to adjust the medication regime as needed (1,2,3).    

What are some C-section recovery medication alternatives? 

Given the nature of C-section recovery, medications are rarely, if ever, enough to manage immediate or long-term recovery outcomes. C-section recovery medication alternatives often include changes to diet, changes to sleep, outpatient vital signs monitoring (especially if the patient had health conditions during pregnancy or antepartum), ice packs, various therapy options, and more. Patients can try lifestyle modifications, such as abdominal wraps, stress reduction techniques, and acupuncture, but these methods are often in conjunction with medication therapies. Because of the wide range of C-section recovery medications and adjunct recovery options, appropriate patient education is essential prior to patient discharge (1,2,3).  

How can family and caregivers be involved in medication administration? 

Because there are several routes and several medication options for C-section recovery, medication education, including medication administration education, is essential for all family and caregivers involved in the care of a patient recovering from a C-section. A wide variety of care professionals, such as obstetricians, midwives, nurses, therapists, lactation consultants, and doulas may be involved. Making sure everyone is aware of each medication’s administration route is essential. It is important to provide culturally appropriate, evidence-based, and realistic education on medication administration for everyone involved in C-section recovery care for the patient. Family and caregivers should be aware of general side effects of all medications administered and aware of red flags to report (1,2,3,4,6).   

Common C-Section Recovery Non-Pharmacological Management: Physical Therapy and Psychotherapy 

Health care provider professional discretion and patient condition should guide therapy. Consider reviewing a patient’s medication history, clinical presentation, and health history prior to prescribing C-section recovery non-pharmacological management. Consider consulting with an obstetrician and other relevant clinical staff regarding C-section recovery options. 

What is physical therapy? How much does it cost? How accessible is physical therapy? 

Physical therapy (PT) is the treatment or management of a condition that involves the physical movements of body parts to restore their function and mobility to the best of a patient’s capabilities. PT is done by licensed physical therapists in PT offices, at the patient’s home, or remotely. PT can be done a few times a week to a few times a month depending on the severity of the patient’s needs. In general, PT for patients in C-section recovery can vary significantly depending on the type of postpartum complications experienced, such as diastasis recti (seperation of the abdominal muscles), pelvic pain, or pain with vaginal sex. It is always important to consider the patient’s finances, preference, health care access, and more when referring a patient to PT (1,2,3). 

Cost for C-section recovery PT can significantly vary as well. It is important to note that PT is not guaranteed to return the pelvis to its prior function as C-sections are permanent surgeries that change the body forever. Overall health outcomes and recovery are not guaranteed by PT alone. If a patient recovering from a C-section needs PT, discussing transportation, cost, and feasibility is also something to consider when speaking with the patient and their caregivers (1,2,3,4,6).  

What is psychotherapy? How much does it cost? How accessible is psychotherapy? 

Psychotherapy is the treatment or management of mental health conditions and mental health state. Psychotherapy, also commonly known as mental health therapy, can be done by licensed mental health professionals, such as licensed mental health counselors, psychiatrists, mental health nurse practitioners, social workers, and more. Psychotherapy can be done virtually or in person. Psychotherapy can be done weekly, monthly, or as needed depending on the severity of the patient’s needs. In general, psychotherapy for patients post C-section can vary significantly depending on the patient’s finances, patient preference, health care access, and more. Psychotherapy is often prescribed for patients who have had a C-section since C-sections can be traumatic on the body, especially if it was an emergent or unplanned C-section. Many people report feelings of obstetric violence or coercion, which can affect their mental health postpartum and in C-section recovery, making psychotherapy a good option for many patients after C-section (1,2,3,6).  

Cost for C-section recovery psychotherapy can significantly vary as well depending on types of insurances, types of psychotherapy, and mental health evaluations required. It is important to note that psychotherapy is not guaranteed to treat or cure mental health conditions. If a patient recovering from a C-section needs psychotherapy, discussing transportation, cost, telehealth needs, and feasibility is also something to consider when speaking with caregivers and family members (1,2,3).  

Common C-Section Recovery Non-Pharmacological Management: Cultural Practices 

Birth is very personal for some patients, and cultural considerations need to be taken into account when caring for patients post C-section.  

What are cultural practices in C-section recovery? How much does it cost? How can family and caregivers be involved in cultural practices? 

Cultural practices for C-sections can include abdominal binding with traditional cloth or wraps, specific diets, rest, or involvement of family members in the care of the patient and infant. Cultural practices post C-section can definitely influence C-section recovery, maternal health, infant health, and more. Since there are several cultures that have their own customs for C-section recovery, consider asking the patient about their specific cultural preferences or needs in C-section recovery. This can be applied to both inpatient and outpatient C-section settings, as C-section recovery can take at least six weeks, if not more, for many patients. Cost for cultural practices in C-section recovery can vary significantly, and the role of family and caregivers’ involvement in C-section recovery can also vary (1,4,6). 

Nursing Considerations 

What is the nurse’s role in C-section patient education and medication management? 

Nurses remain the most trusted profession for a reason, and nurses are often pillars of patient care in several health care settings. Patients turn to nurses for guidance, education, and support. While there is no specific guideline for the nurses’ role in C-section education and recovery, here are some suggestions to provide quality care for patients anticipating, having, or recovering from a C-section (1,2,7,8,9,10).  

1. Take a detailed health history of the patient. Often times, vital signs and history taking can be complex with pregnant or postpartum patients, especially in more complex cases. It is important for patients to be involved in the vital signs and history taking process to learn about the importance of reporting abnormalities or medical concerns. As nurses, we are aware that pregnancy and postpartum can lead to rapid fluctuations in vital signs, such as blood pressure and heart rate, but someone without medical knowledge might not be aware of this. If a patient is complaining of symptoms that could be related to their C-section, such as pelvic pain, increased vaginal bleeding, trouble breathing, or headaches, inquire more about that complaint. Ask about how long the symptoms have lasted, what treatments have been tried, if these symptoms interfere with their quality of life, and if anything alleviates any of these symptoms. If you feel like a patient’s complaint is not being taken seriously by other health care professionals, advocate for the patient to the best of your abilities.  
2. Review medication history at every encounter. Often times, in busy clinical settings, reviewing health records can be overwhelming, especially for patients recovering from C-section. Millions of people take medications for various reasons, and people’s medication histories can look similar over time. Ask each patient about how they are feeling on the medication, if their symptoms are improving, and if there are any changes to medication history. If a patient is complaining of their pain increasing or pain needs not being met, inquire more about the cause of the pain and other pain medication options.   
3. Be willing to answer questions about C-section recovery and medication options. There are many people who do not know about medication side effects, risk factors to be aware of, and lifestyle changes that can influence C-section recovery. Be willing to be honest with yourself about your comfort level discussing topics and providing education on various C-section recovery medications, therapy recovery options, and various steps involved in comprehensive C-section recovery.    
4. Communicate the care plan to other staff involved for continuity of care. For several patients, especially for patients with complex C-section recovery, care often involves a team of nurses, specialists, pharmacies, obstetricians, and more. Ensure that patients’ records are up to date for ease in record sharing and continuity of care. 
5. Stay up to date on continuing education related to medications and C-section recovery, as evidence-based information is always evolving and changing. You can then present your new learnings and findings to other health care professionals and educate your patients with the latest information. You can learn more about the latest research on C-section recovery by following updates from evidence-based organizations, such as the National Institutes of Health (NIH). You can also share any evidence-based information with caregivers.  

How can nurses identify if someone is struggling with their C-section recovery? How can nurses identify if a patient is at imminent risk for a C-section? 

Unfortunately, it is not possible to look at someone with the naked eye and determine if they are struggling with their C-section recovery, as recovery can look different in every patient case. While some people might have notable C-section recovery complications, such as trouble breathing, increasing bleeding, or an infected incision site, for many people, C-section recovery varies widely. In addition, nurses can answer questions and concerns regarding the C-section recovery process. Nurses can also provide information on C-section recovery timelines, therapy options, medication options, and more. Nurses can provide quality care by completing a health history, listening to patients’ concerns, addressing caregivers’ concerns, and offering medication and lifestyle management (1,2,3,7,8,9).  

What should families and caregivers know about C-section recovery? 

Patients should know that anyone who is pregnant has the possibility of experiencing a C-section. That said, recovery after a C-section can range significantly depending on the type of C-section incision, a patient’s health prior to a C-section, finances, and access to care. Patients should be aware that if they notice any changes in their vision, trouble breathing, increased vaginal bleeding, or feel like something is a concern, they should seek medical care. Nurses should also teach patients to advocate for their own health in order to avoid untreated or undetected C-section recovery complications. Here are important tips for patient education in the inpatient or outpatient setting (1,2,3,7,8,9,10).  

• Tell the health care provider of any existing medical conditions or concerns (need to identify risk factors) 

• Tell the health care provider of any existing lifestyle concerns, such as drug use, sleeping habits, diet, stress levels, incision site changes, or vaginal bleeding changes (need to identify lifestyle factors that can influence C-section recovery medication use and therapy interventions) 

• Tell the health care provider if you have any changes to your body, such as trouble with urination, GI complications, pain with movement, or increased fatigue (potential systemic or pelvic floor C-section complication symptoms) 

• Tell the nurse or health care provider if you experience any pain that increasingly becomes more severe or interferes with your quality of life 

• Keep track of your health, medication use, and health concerns via an app, diary, or journal (self-monitoring for any changes) 

• Tell the health care provider right away if you are having thoughts of hurting yourself or others (possible increased risk of suicidality with C-section and postpartum complications) 

• Take all prescribed medications as indicated and ask questions about medications and possible other treatment options, such as non-pharmacological options 

• Tell the health care provider if you notice any changes while taking medications or on other treatments to manage C-section recovery (potential worsening or improving health situation) 

• Track your blood pressure and heart rate with an at-home blood pressure cuff, keep track of your readings, and report any changes to your health care provider (self-monitoring for any changes, especially for patients who had hypertension during pregnancy or delivery) 

Research Findings 

What research on C-section recovery education for caregivers exist presently? 

There is extensive publicly available literature on C-section recovery options and C-section recovery education for caregivers via the National Institutes of Health (NIH) and other evidence-based journals.  

What are some ways for people who are recovering from a C-section to become a part of research? 

If a patient is interested in participating in clinical trial research, they can seek more information on clinical trials from local universities and health care organizations. 

Case Study 

Beth is a 36-year-old woman working as an accountant. She arrives to the OB/GYN office because she thinks she is pregnant for the first time. She reports that she took a pregnancy test at home, and it was positive. She reports that she wants to maintain the pregnancy and establish prenatal care. After examination, an ultrasound shows that Beth is 11 weeks pregnant. Beth’s vitals are unremarkable: 80 bpm, 110/70 mmHg, afebrile, with fetal heart tones detected on the ultrasound. Beth tells you that she has a history of sexual trauma and distrusts health care because of negative experiences in the past, and she would like to opt for an elective C-section. 

• What are some specific questions you’d want to ask about her health? 

• What are some health history questions you’d want to highlight? 

• What would be your initial education on C-sections and prenatal care for a first-time pregnant person?  

After speaking with Beth, she understands that she can change her mind at any time and that it is still very early in the pregnancy. She continues her routine prenatal care appointments and is maintaining a healthy pregnancy with no complaints or complications so far. At her 36-week visit, her vital signs show that she is hypertensive at 150/90 mmHg. Her other vital signs are unremarkable, but she said that she has been feeling more tired lately. Beth denies any additional symptoms. You recommend that she self-monitor her blood pressure for a week and call the office if she has any concerns. At the 37-week visit, her blood pressure is 170/90 mmHg. Given her increasing blood pressure, you will start her on blood pressure medication. She wants to know if she can still have a C-section with high blood pressure and if she is taking high blood pressure medications.  

• How would you explain causes for hypertension in pregnancy to Beth? 

• What questions would you ask Beth regarding her hypertension?  

• How might hypertension and antihypertensive medication affect a C-section? 

• What antihypertensive medications are safe during the third trimester of pregnancy?  

At 38 weeks, Beth is continuing to take her blood pressure medication and monitor her blood pressure at home. Beth reports that her blood pressures at home were between 110-140/50-80 mmHg. She arrives to the office today with a blood pressure of 160/80 mmHg and tells you she was having some vaginal bleeding earlier this morning that stopped, but she wanted to discuss the bleeding with you. You are aware that Beth planned a C-section for two weeks from today. However, given her hypertension and vaginal bleeding concerns, you recommend her to go to the local OB emergency room (ER) for monitoring. Beth’s husband, Josh, drives them to the local OB-ER, tells them the situation, and tells the staff that she would like a C-section and to not perform a trial of labor.  

• What are some tasks that nurses might do to monitor Beth and the pregnancy before the C-section occurs?   

• What sort of concerns do you have about Beth and the infant’s health?  

• What would be your pharmacological and non-pharmacological recommendations presently? 

At the hospital, Beth’s blood pressure is still elevated, and her vaginal bleeding has resumed. Fetal testing has shown that there are no fetal complications presently, but maternal hypertension remains a concern. After discussions with the health care team, Beth’s blood pressure is stabilized. After a few hours of admittance, Beth delivers a healthy baby girl via C-section with no known surgical complications to her or the baby. After two hours of the C-section, Beth is transferred to the postpartum unit. After two hours in the postpartum unit, the nurse performs another routine assessment. Beth tells the nurse that she is having some sharp pelvic pains and a headache that is only getting worse. The nurse checks her vital signs. They are: 150/90 mmHg, 120 bpm, 20 respirations, 101.4F temperature, and 9/10 pain.   

• What are some possible complications that can emerge with a C-section? 

• What would be some reasons why Beth’s blood pressure is elevated? 

• What are some reasons why Beth has a high self-reported pain score? 

• How would you handle Beth’s care from here?  

After examination in the hospital, it was determined that Beth had experienced postpartum hypertension caused by pre-eclampsia. Beth remained in the hospital for a few more days to manage her pain, bleeding, and hypertension. She was given specific instructions to monitor her incision site, breastfeed when possible, take her antihypertensive medications, and return to her OB/GYN with any issues and for her routine postpartum visit. Beth arrives at the 6 week postpartum visit and reports that the medication is working for her hypertension. She reports no high blood pressures at home, and her BP in the office is 100/60 mmHg with other vital signs unremarkable; however, Beth is concerned about her pelvic pain, as she reports having pain when urinating and defecating. Beth would also like to know when she can start working out again. 

• What are some possible reasons why Beth is having pelvic pain?  

• What are some ways to assess for pelvic pain in a patient post C-section?  

• How would you manage C-section exercise and fitness education?  

Conclusion

C-section recovery is a complex process for parents, especially when they are caring for a new infant as well! C-section recovery is often a process that involves physical therapy, exercises, medications, social support, and health care professionals. Often times, clinical presentation and symptom management for C-section recovery can vary widely. Education and awareness of different management options and different clinical presentations of C-section recoveries can influence the lives of many people in a healthy way. 

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