In my opinion electrocardiograph (ECG) monitoring is absolutely required for all women after cesarean birth. Cesarean birth, while increasingly more common, is a surgical procedure and, therefore, is subject to the same standards of care that currently exist for all postoperative/postanesthesia patients. The normal hemodynamic changes in the postpartum period are accentuated in the woman having a cesarean birth, and the physiology of the postsurgical patient must be considered if we are to render excellent nursing care to these women. Why should our patients be denied care designed to protect them from harm and prevent maternal morbidity and mortality? While it is true that maternal morbidity and mortality rates have declined as obstetrical advances have increased over past decades, maternal deaths still occur. New mothers can experience complications from surgery, or even worse, they can die.

In most instances, nurses tend to be most concerned about women with identified high-risk pregnancies. However, nurses need to realize that women who have cesarean births have become "high risk" due to the surgical procedure they undergo. This is sometimes difficult to remember, especially when the women insist on being treated as if they had given birth vaginally (sometimes their healthcare providers act as if cesarean birth was the norm as well). Cesarean birth cannot be treated as "normal." A cesarean birth requires surgical intervention through the abdomen, with disruption and then repair of the skin, muscles, blood vessels, fascia, peritoneum, and uterus. Women who give birth through cesarean are surgical patients.

Treating the woman who has a cesarean birth as a surgical patient does not mean that bonding, breastfeeding, family time, and various other wonderful postbirth moments cannot occur. This is especially true if the patient has a continuous epidural. Because the mother should have the electrodes in place from the operating suite, the ECG monitor can be easily resumed in the postanesthesia care unit (PACU) or labor/delivery room designated for patients recovering from a cesarean birth. Pulse oximetry can be accomplished by placing the electrode on the mother's toe instead of using a finger (which might keep her from holding, touching, and stroking her newborn). Breastfeeding can be easily accomplished in the PACU by arranging the wires leading to the electrode to suitable positions and placing a small piece of tape if needed to keep them in place.

I suspect that nurses who are opposed to ECG monitoring for all women after a cesarean birth are also nurses who are not comfortable interpreting the ECG tracing. "Obstetric nurses have traditionally been infrequent assessors of electrocardiogram (ECG) tracings" (Burke, 1991, p. 25). However, if obstetric nurses are going to provide postanesthesia care, they should be educated and competent to interpret a basic ECG tracing. This is another excellent reason for labor/delivery nurses to complete an ACLS course. The ACLS course increases the skill level of nurses in recognizing abnormal rates and rhythms, which are often warning signs of maternal complications. For example, although tachycardia is abnormal, there are many reasons a postoperative mother may have tachycardia. Each potential reason needs to be investigated and abnormal reasons ruled out to increase the likelihood of preventing complications such as infection or hemorrhage. A new mother who is hemorrhaging internally may have an abnormal rhythm on the ECG as her circulating volume decreases. The ECG monitor provides an additional assessment tool for the nurse to provide the highest level of care to the postoperative new mother.

A final argument to be made for the routine use of the ECG monitor in the care of women having a cesarean birth is one that is pragmatic. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2002) requires that patients having a cesarean birth be provided a comparable level of care to what they would receive in the main hospital PACU. In my opinion, there are multiple reasons why ECG monitoring during the postanesthesia period should be standard of care for all women who have a cesarean birth. Nurses working with obstetric postanesthesia patients should be competent to provide this important nursing care.

References