CAESARIAN

SECTIONCase Presentation

Prepared By:Group 165- A&B

BSN 3D2-6

Ms. Led Erika R. Paez, RNNCOR Instructor

I. INTRODUCTION

Nursing process is a patient centered, goal oriented method of caring that provides a frame

work to the nursing care. The nursing process exists for every problem that the patient has, and

for every element of patient care, rather than once for each patient. The nurse's evaluation of

care will lead to changes in the implementation of the care and the patient's needs are likely to

change during their stay in hospital as their health either improves or deteriorates. Nursing

process was used in this case study for a more systematic to care for a client who have

undergone a cesarean section birth.

Cesarean delivery, also known as cesarean section, is a major abdominal surgery involving 2 incisions (cuts), One is an incision through the abdominal wall (laparotomy) and the second is an incision involving the uterus (hysteretomy) to deliver the baby. History : Legend has it that the Roman leader Julius Caesar was delivered by this operation, and the procedure was named after him.

3 Theories about Origin of the Name:1. The name for the procedure is said to derive from a Roman legal code called "Lex

Caesarea", which allegedly contained a law prescribing that the baby be cut out of its

mother's womb in the case that she dies before giving birth.The Merriam-Webster dictionary

is unable to trace any such law; but "Lex Caesarea" might mean simply "imperial law" rather

than a specific statute of Julius Caesar.)

1. 2. The derivation of the name is also often attributed to an ancient story, told in the first

century A.D. by Pliny the Elder, which claims that an ancestor of Caesar was delivered in

this manner.

2.2. 3. An alternative etymology suggests that the procedure's name derives from the Latin

verb caedere (supine stem caesum), "to cut," in which case the term "Caesarean section" is

redundant. Proponents of this view consider the traditional derivation to be a false

etymology, though the supposed link with Julius Caesar has clearly influenced the spelling.

(A corollary suggesting that Julius Caesar himself derived his name from the operation is

refuted by the fact that the cognomen "Caesar" had been used in the Julii family for

centuries before his birth, and the Historia Augusta cites three possible sources for the

name Caesar, none of which have to do with Caesarean sections or the root word caedere.)

CAUSES:CAUSES:

1. Repeat cesarean delivery:1. Repeat cesarean delivery:

There are 2 types of uterine incisions—a low transverse incision and a vertical uterine incision. There are 2 types of uterine incisions—a low transverse incision and a vertical uterine incision.

1a) A low transverse uterine incision is the approach of choice.1b) A vertical incision on the uterus (low or high) may be used for delivering preterm

babies, abnormally positioned placentas, pregnancies with more than one fetus, and in extreme emergencies.

1a In the last 20 years, studies have shown that women who have had a prior cesarean section with a low transverse incision may safely and successfully go through labor and have a vaginal delivery in later pregnancies. (VBAC)

Uterine rupture can be Uterine rupture can be dangerous to the fetus even if delivery is accomplished even if delivery is accomplished immediately after a uterine rupture. immediately after a uterine rupture.

Factors that Impede vaginal birth1. prolonged labor or a failure to progress (dystocia)fetal distress2. cord prolapse3. uterine rupture4.placental problems (placenta praevia, placental abruption or placenta accreta)5. abnormal presentation (breech or transverse positions)6. failed labor induction7. failed instrumental delivery (by forceps or ventouse. Sometimes a 'trial of forceps/ventouse' is tried out - This means a forceps/ventouse delivery is attempted, and if the forceps/ventouse delivery is unsuccessful, it will be switched to a caesarean section.8. overly large baby (macrosomia)umbilical cord abnormalities (vasa previa, multi-lobate including bi-lobate and succenturiate-lobed placentas, filamentous insertion)9. contracted pelvis10. pre-eclampsia11. hypertension12.multiple births13.precious (High Risk) Fetus14.HIV infection of the mother15. Sexually transmitted infections such as genital herpes (which can be passed on to the baby if the baby is born vaginally, but can usually be treated in with medication and do not require a Caesarean section)16. previous Caesarean section prior problems with the healing of the perineum (from previous childbirth or Crohn's Disease)17. Lack of Obstetric Skill (Obstetricians not being skilled in performing breech births, multiple births, etc. [In most situations women can birth under these circumstances naturally. However, obstetricians are not always trained in proper procedures])18. Improper Use of Technology (Electric Fetal Monitoring [EFM])

Types and Indications

1. Classical Caesarean Section--Here the upper portion of the uterus is opened by an incision and the baby is then extracted. This is not practiced anymore due to a higher incidence of complications.-involves a midline longitudinal incision which allows a larger space to deliver the baby. 2. Lower Segment Caesarean Section– In this case, the uterus is opened in the lower segment and the baby’s head or breech as the case may be is delivered. -is the procedure most commonly used today; it involves a transverse cut just above the edge of the bladder and results in less blood loss and is easier to repair.3. Emergency C Section- When there is suspected danger to the mother's or baby’s condition an emergency section is resorted to. -done once labor has commenced4. Elective Caesarean Section (Planned C-Section)- The caesarean is planned and done on a specific date chosen by the patient and the doctor after assessing the maturity of the baby. 5. A crash Caesarean section is a Caesarean performed in an obstetric emergency, where complications of pregnancy onset suddenly during the process of labour, and swift action is required to prevent the deaths of mother, child(ren) or both.6. A Caesarean hysterectomy consists of a Caesarean section followed by the removal of the uterus. This may be done in cases of intractable bleeding or when the placenta cannot be separated from the uterus.7. Traditionally other forms of Caesarean section have been used, such as extraperitoneal Caesarean section or Porro Caesarean section.8. a repeat Caesarean section is done when a patient had a previous Caesarean section. Typically it is performed through the

old scar.

In a normal pregnancy, the baby is positioned head down in the uterus. In a normal pregnancy, the baby is positioned head down in the uterus.

4. Abnormal position of the fetus & Placental causes :

i) Breech delivery

ii) Oblique lie

iii) Persistent Occipitoposterior position

iv) Deflexed Head (cord round the neck)

v) Abruptio placenta

vi) Placenta praevia

6. Emergency situations: If the woman is severely ill or has a life-threatening injury or illness with interruption of the normal heart or lung function, she may be a candidate for an emergency cesarean section.

Maternal Complications:Maternal Complications:

* Urinary function and bladder injury: Urinary retention after Cesarean due to bladder atony could be relieved by urethral catheter for 24 hours. Bladder injury during Cesarean can occur inadvertently.

* Bowel function and bowel injury: * Bowel function and bowel injury: Typically, bowel function after a cesarean section returnsTypically, bowel function after a cesarean section returns quickly. quickly. Unrecognized bowel injury may occur occasionally and should be managedUnrecognized bowel injury may occur occasionally and should be managed appropriately.appropriately.

Complications for the infant Injury during the delivery. Need for special care in the neonatal intensive care unit (NICU). Lung immaturity, if the due date has been miscalculated or the infant is delivered before 39

weeks of gestation.

Long Term ComplicationsWomen who have a uterine cesarean scar have slightly increased long-term risks. These risks, which increase further with each additional cesarean delivery, include:

Breaking open of the incision scar during a later pregnancy or labor (uterine rupture). For more information, see the topic Vaginal Birth After Cesarean (VBAC).

Placenta previa , the growth of the placenta low in the uterus, blocking the cervix. Placenta accreta , placenta increta, placenta percreta (least to most severe), the growth of the

placenta deeper into the uterine wall than normal, which can lead to severe bleeding after childbirth, sometimes requiring a hysterectomy.

Risks for the mother Three times higher mortality rate than that of vaginal delivery.

*However, it is misleading to directly compare the mortality rates of vaginal and caesarean deliveries. Women with severe medical conditions, or higher-risk pregnancies, often require a caesarean section which can distort the mortality figures. Possible problems in later pregnncies

-malpresentation, placenta previa, antepartum hemorrhage, placenta accreta, prolonged labor, uterine rupture, preterm birth, low birth weight, and stillbirth in their second delivery. Emergency hysterectomy at delivery Increased risks for placenta accreta

Risks for incisional hernias and wound infections Increased anesthesia risks and post spinal headaches

Risks for the child: Neonatal depression: babies may have an adverse reaction to the anesthesia given to the

mother, causing a period of inactivity or sluggishness after delivery. Fetal injury: injury may occur to the baby during uterine incision and extraction.

Type 1 diabetes: A 2008 study found that babies delivered by Caesarean section are 20% more likely to develop Type 1 diabetes in their lifetimes than babies delivered vaginally. While the correlation was established, the reason for it is not entirely clear. It has been suggested that the infant's first exposure to hospital-originating bacteria rather than to maternal bacteria during C-section may be the cause.

Breathing problems: babies born by c-section, even at full term, are more likely to have breathing problems than are babies who are delivered vaginally.

Breastfeeding problems: babies born by c-section are less likely to successfully breastfeed than those delivered vaginally.

Potential for early delivery and complications: One study found an increased risk of complications if a repeat elective Caesarean section is performed even a few days before the recommended 39 weeks

Risks for both mother and child Risk for developing hospital borne infection because of prolonged hospital stays Longer time before good mother-child interactions can be achieved.

Effects of Anesthesia1. Regional anesthesia

-(spinal, epidural or combined spinal and epidural anaesthesia) -is preferred as it allows the mother to be awake and interact immediately with her baby -the absence of typical risks of general anesthesia:

*pulmonary aspiration (which has a relatively high incidence in patients undergoing anesthesia in late pregnancy) of gastric contents and

*Oesophageal intubation 2. General Anesthesia

-may be necessary because of specific risks to mother or child. Patients with heavy, uncontrolled bleeding may not tolerate the hemodynamic effects of regional anesthesia -is also preferred in very urgent cases, such as severe fetal distress, when there is no time to perform a regional anesthesia.

Factors involved in decisionFactors involved in decision

Fetal mortality and morbidityFetal mortality and morbidity Newborn healthNewborn health VBACVBAC Cost Cost Pelvic floor damage Pelvic floor damage Maternal mortalityMaternal mortality Cultural factorsCultural factors Autonomy - C-section on demand?Autonomy - C-section on demand?

II. OBJECTIVES

The significance of the study is for us third year students to apply the principles and

concepts that we have learned in the NCM 102 (Operating Room Nursing) in our successive

clinical rotations, with the following learning objectives:

1. Cognitive

To be able to review concepts and theories in Oerating Room Nursing.

To be able to describe the development, pathophysiology, medical-

surgical management, and nursing care of a client who have undergone a

cesarean section birth.

To be able to design a Nursing Care Plan for the patient who have

undergone cesarean birth.

To be able to provide information and heath teachings to the patient in the

postpartum period.

2. Psychomotor

To be able carry-out hospital routines and the treatment prescribed to the

patient.

To be able to perform nursing procedures and nursing considerations for a

client in the preoperative and postoperative stages

To be able to implement the nursing care plan.

3. Affective

To be able to establish a good working relationship with the patient and

hospital staff.

III. NURSING ASSESSMENT

Patient’s Profile:

Name : Asa Cana Sy

Age : 18 years old

Birthday : February 29, 1991

Address : 15-B Hollywood St Brgy. Saguin, CSFP

Name of Spouse : Aliv Sy

Name of Father : Muh Cana

Name of Mother : Malah Cana

Nationality : Filipino

Occupation : Housewife

Educational Attainment: High School Graduate

Admission Date : April 22, 2009

Discharge Date : April 24, 2009

Surgery Performed : LTCS II

IV. FAMILY HISTORY

Unremarkable.

V. HISTORY OF PAST AND PRESENT ILLNESS

The patient stands 153 centimeters and weighs about 83 kilograms. Her AOG is 43

weeks, LMP was last November 1, 2008, and her EDC was on April 8, 2009. Her OB score is

G2P1 (2,0,0,2). She was already married at the age of 16 years old. She was only 17 years old

when she gave birth to her first child through Cesarean Section (Low Segment Transverse),

because she had a difficulty in delivering the child due to her age and the lack of knowledge.

It was on April 22, 2008 at around 8:00am when Patient Asa Cana Sy was admitted at

the Ob-ward of Porac District Hospital and was sent to the OR/DR for an internal examination

and was told that her pregnancy was already over due. The patient opted for another cesarean

section for this pregnancy.

VI. PHYSICAL ASSESSMENT

Gordon’s Level of Functioning

Pattern Before Present Interpretation

1.Health Perception-Health Management

Patient goes to the health center once upon when she got pregnant. All in all, she thinks she is in a healthy state.

Patient is concern about her second cesarean section thinking that it may be detrimental to her health.

Patient cannot function normally anymore like before because of her hospital confinement and condition. Her body image changed after the surgical procedure done.

2. Nutritional- Metabolic Management

Prior to confinement, patient loves eating instant foods and fatty foods like fries and burgers. She also loves condiments like “patis”, vinegar, and soy sauce. She basically loves eating whatever she likes.

During hospitalization, the patient is on diet as tolerated. She eats fruits like apples and oranges. She eats bread instead of rice. She said she loss her appetite since her onset of labor.

Patient’s nutritional and metabolic status has been changed due to her confinement.

3.Elimination Pattern Bowel:Patient defecates 1-2 times a day, usually morning and in the afternoon. Stool is brown in color and well-formed.

Bladder:Patient voids usually 6-8 times a day. Urine is yellow in color. No pain when voiding.

Bowel: Patient defecates once a day but not on a regular basis. Stool is soft, minimal in amount and brown in color.

Bladder:Patient voids 3-4 times a day without pain and discomfort.

Bowel:There was a change in the frequency and amount.

Bladder:There was a change in the frequency and amount.

4.Activity, Leisure, and Recreation Pattern

Patient is a housewife so she is always in charge of the household chores. Her leisure time would include playing with her firstborn and watching television.

Patient’s activities in the hospital are ambulation, deep breathing and coughing exercise, taking a bath or personal hygiene.

During patient’s confinement in the hospital, there is a limitation in her activities of daily living and a disruption in her leisure and recreation pattern.

5.Sleep and Rest Pattern

Patient puts herself to sleep by watching television programs. She usually sleeps at

Due to her uncomfortable condition and pain, patient complains of

Patient’s sleep and rest pattern changed when she was admitted. She cannot

around 11pm to 6am. She feels rested when sleeping and thinks that her energy is sufficient for her activities.

difficulty of sleeping and short period of sleeps.

put himself to sleep anymore due to present condition and pain plays a big factor for her sleep disturbances.

6.Cognitive – Perceptual Pattern

Patient is a high school graduate. She can read and write. She can speak and be understood by others.

Patient’s present condition is not a hindrance to her cognitive- perceptual pattern.

No changes/ alterations.

7. Self-Perception / Self-Concept Pattern

Patient is a friendly person; she loves to socialize with his friends in their neighborhoods. She considers himself as holistic human being as long as she is healthy, complete, and his family is always there.

During the times of her confinement, she doesn’t think that she is a holistic person anymore. However, she is positive that she will be ok after confinement.

There is a slight change in her self-perception due to present condition.

8. Role Relationship Patient can understand English, Tagalog, and Kapampangan. She has 5 siblings. She is married with 1 child.

The patient’s family is supportive to the patient. She is happy with their presence and support.

Normal/ No alterations.

9. Sexuality/ Reproductive Pattern

Patient has been married for 3 years.

Patient reserved her right to privacy.

Patient reserved her right to privacy.

10.Coping and Stress Tolerance

When patient is stressed, she sings in the karaoke and eats comfort foods like burgers, fries, and her favorite sizzling sisig. When it comes to problems, she lets herself think immediately for a solution.

The recent hospitalization of the patient was stressful and source of anxiety. However, she is positive that she will be able to cope up with current condition.

Patient accepts present condition with a positive attitude.

11.Values- Belief Pattern

Patient is a Roman Catholic. She has a strong faith to God and goes to mass every Sunday with her family.

She follows a therapeutic regimen and her strong faith to God accounts for her fast recovery.

Due to her confinement, patient is trusting God that she will be discharge soon and will recover without any complications.

VII. ANATOMY AND PHYSIOLOGY

Vagina

The vagina is a muscular, hollow tube that extends from the vaginal opening to the

cervix of the uterus. It is situated between the urinary bladder and the rectum. It is about three to

five inches long in a grown woman. The muscular wall allows the vagina to expand and

contract. The muscular walls are lined with mucous membranes, which keep it protected and

moist. A thin sheet of tissue with one or more holes in it, called the hymen, partially covers the

opening of the vagina. The vagina receives sperm during sexual intercourse from the penis. The

sperm that survive the acidic condition of the vagina continue on through to the fallopian tubes

where fertilization may occur.

The vagina is made up of three layers, an inner mucosal layer, a middle muscularis

layer, and an outer fibrous layer. The inner layer is made of vaginal rugae that stretch and allow

penetration to occur. These also help with stimulation of the penis. The middle layer has glands

that secrete an acidic mucus (pH of around 4.0.) that keeps bacterial growth down. The outer

muscular layer is especially important with delivery of a fetus and placenta.

Purposes of the Vagina

Receives a males erect penis and semen during sexual intercourse.

Pathway through a woman's body for the baby to take during childbirth.

Provides the route for the menstrual blood (menses) from the uterus, to leave the body.

May hold forms of birth control, such as a diaphragm, FemCap, Nuva Ring, or female

condom.

The cervix (from Latin "neck") is the lower, narrow portion of the uterus where it joins with

the top end of the vagina. Where they join together forms an almost 90 degree curve. It is

cylindrical or conical in shape and protrudes through the upper anterior vaginal wall.

Approximately half its length is visible with appropriate medical equipment; the remainder lies

above the vagina beyond view. It is occasionally called "cervix uteri", or "neck of the uterus".

During menstruation, the cervix stretches open slightly to allow the endometrium to be shed.

This stretching is believed to be part of the cramping pain that many women experience.

Evidence for this is given by the fact that some women's cramps subside or disappear after their

first vaginal birth because the cervical opening has widened.

The portion projecting into the vagina is referred to as the portio vaginalis or ectocervix. On

average, the ectocervix is three cm long and two and a half cm wide. It has a convex, elliptical

surface and is divided into anterior and posterior lips. The ectocervix's opening is called the

external os. The size and shape of the external os and the ectocervix varies widely with age,

hormonal state, and whether the woman has had a vaginal birth. In women who have not had a

vaginal birth the external os appears as a small, circular opening. In women who have had a

vaginal birth, the ectocervix appears bulkier and the external os appears wider, more slit-like

and gaping.

The passageway between the external os and the uterine cavity is referred to as the

endocervical canal. It varies widely in length and width, along with the cervix overall. Flattened

anterior to posterior, the endocervical canal measures seven to eight mm at its widest in

reproductive-aged women. The endocervical canal terminates at the internal os which is the

opening of the cervix inside the uterine cavity.

During childbirth, contractions of the uterus will dilate the cervix up to 10 cm in diameter to

allow the child to pass through. During orgasm, the cervix convulses and the external os dilates.

The uterus is shaped like an upside-down pear, with a thick lining and muscular walls.

Located near the floor of the pelvic cavity, it is hollow to allow a blastocyte, or fertilized egg, to

implant and grow. It also allows for the inner lining of the uterus to build up until a fertilized egg

is implanted, or it is sloughed off during menses.

The uterus contains some of the strongest muscles in the female body. These muscles are

able to expand and contract to accommodate a growing fetus and then help push the baby out

during labor. These muscles also contract rhythmically during an orgasm in a wave like action. It

is thought that this is to help push or guide the sperm up the uterus to the fallopian tubes where

fertilization may be possible.

The uterus is only about three inches long and two inches wide, but during pregnancy it

changes rapidly and dramatically. The top rim of the uterus is called the fundus and is a

landmark for many doctors to track the progress of a pregnancy. The uterine cavity refers to the

fundus of the uterus and the body of the uterus.

Helping support the uterus are ligaments that attach from the body of the uterus to the pelvic

wall and abdominal wall. During pregnancy the ligaments prolapse due to the growing uterus,

but retract after childbirth. In some cases after menopause, they may lose elasticity and uterine

prolapse may occur. This can be fixed with surgery.

Some problems of the uterus include uterine fibroids, pelvic pain (including endometriosis,

adenomyosis), pelvic relaxation (or prolapse), heavy or abnormal menstrual bleeding, and

cancer. It is only after all alternative options have been considered that surgery is recommended

in these cases. This surgery is called hysterectomy. Hysterectomy is the removal of the uterus,

and may include the removal of one or both of the ovaries. Once performed it is irreversible.

After a hysterectomy, many women begin a form of alternate hormone therapy due to the lack of

ovaries and hormone production.

At the upper corners of the uterus are the fallopian tubes. There are two fallopian tubes,

also called the uterine tubes or the oviducts. Each fallopian tube attaches to a side of the uterus

and connects to an ovary. They are positioned between the ligaments that support the uterus.

The fallopian tubes are about four inches long and about as wide as a piece of spaghetti. Within

each tube is a tiny passageway no wider than a sewing needle. At the other end of each

fallopian tube is a fringed area that looks like a funnel. This fringed area, called the

infundibulum, lies close to the ovary, but is not attached. The ovaries alternately release an egg.

When an ovary does ovulate, or release an egg, it is swept into the lumen of the fallopian tube

by the frimbriae.

Once the egg is in the fallopian tube, tiny hairs in the tube's lining help push it down the

narrow passageway toward the uterus. The oocyte, or developing egg cell, takes four to five

days to travel down the length of the fallopian tube. If enough sperm are ejaculated during

sexual intercourse and there is an oocyte in the fallopian tube, fertilization will occur. After

fertilization occurs, the zygote, or fertilized egg, will continue down to the uterus and implant

itself in the uterine wall where it will grow and develop.

If a zygote doesn't move down to the uterus and implants itself in the fallopian tube, it is

called a ectopic or tubal pregnancy. If this occurs, the pregnancy will need to be terminated to

prevent permanent damage to the fallopian tube, possible hemorrhage and possible death of

the mother.

Mammary glands are the organs that produce milk for the sustenance of a baby. These

exocrine glands are enlarged and modified sweat glands.

The basic components of the mammary gland are the alveoli (hollow cavities, a few

millimetres large) lined with milk-secreting epithelial cells and surrounded by myoepithelial cells.

These alveoli join up to form groups known as lobules, and each lobule has a lactiferous duct

that drains into openings in the nipple. The myoepithelial cells can contract, similar to muscle

cells, and thereby push the milk from the alveoli through the lactiferous ducts towards the

nipple, where it collects in widenings (sinuses) of the ducts. A suckling baby essentially

squeezes the milk out of these sinuses.

The development of mammary glands is controlled by hormones. The mammary glands

exist in both sexes, but they are rudimentary until puberty when - in response to ovarian

hormones - they begin to develop in the female. Estrogen promotes formation, while

testosterone inhibits it.

At the time of birth, the baby has lactiferous ducts but no alveoli. Little branching occurs

before puberty when ovarian estrogens stimulate branching differentiation of the ducts into

spherical masses of cells that will become alveoli. True secretory alveoli only develop in

pregnancy, where rising levels of estrogen and progesterone cause further branching and

differentiation of the duct cells, together with an increase in adipose tissue and a richer blood

flow.

Colostrum is secreted in late pregnancy and for the first few days after giving birth. True

milk secretion (lactation) begins a few days later due to a reduction in circulating progesterone

and the presence of the hormone prolactin. The suckling of the baby causes the release of the

hormone oxytocin which stimulates contraction of the myoepithelial cells.

The cells of mammary glands can easily be induced to grow and multiply by hormones. If

this growth runs out of control, cancer results. Almost all instances of breast cancer originate in

the lobules or ducts of the mammary glands.

ABDOMINAL LAYERS

1. skinThe skin of the lower abdominal wall is incised in a transverse direction just above the

pubic hairline in the majority of cases (side to side rather than up and down). A longitudinal (up and down) incision is infrequently employed. 2. subcutaneous tissue 3.fascia

rectus fascia- a dense shiny white layer of fascia. This fascia layer is incised to expose the two rectus abdominal muscles which are big muscles running from the rib cage to the pubic bone. 4.muscle

These are the main muscles employed to do sit-ups (rectus). The two muscles meet in the midline where they are sometimes fused but quite often, however, they are separated as the result of the stretching from the distended uterus. These muscles are now separated (without cutting them) and pulled to the sides to create a space between them. 5. peritoneum

The peritoneal layer is a very thin membrane-like layer, which can be described as the lining of the abdominal cavity.

VIII. PATHOPHYSIOLOGY

Release of FSH bythe anterior pituitary gland

Development of the graafian follicle

Production of estrogen (thickeningof the endometrium)

Release of the luteinizing hormone

Ovulation (release of mature ovum fromthe graafian follicle)

Ovum travels into the fallopian tube

Fertilization (union of the ovumand sperm in the ampulla)

Zygote travels from the fallopian tubeto the uterus

Implantation

Development of the fetus/embryo &placental structure until full term

PRELIMINARY SIGNS OF LABOR

Lightening Braxton Hicks Contraction Ripening of the cervix(descent of the fetal (false labor) (Goodell’s Sign whereinhead into the pelvis) >begin and remain irregular the cervix feels softer like

>1st felt abdominally consistency of the earlobe >pain disappears with

ambulation

>do not increase in durationand intensity

>do not achieve cervicaldilatation

TRUE LABOR

Uterine Contractions SHOW Rupture of Membranes

>increase in duration (pink-tinge of blood, (rupture of theand intensity a mixture of blood and fluid) amniotic sac) >1st felt at the back & radiates to the abdomen>pain is not relieved no matter what the activity>achieve cervical dila- tation

Failed to progress labor(due to previous cesarean birth, cervical arrest,

cervical atrophy)

increase risk for fetal distress(meconium staining, hypoxia)

Increase risk of fetal death

Emergent cesarean delivery(the incision made on the lower part of the abdomen)

Expulsion of the fetus

Expulsion of the placenta(accompanied by blood approximately

500-1000 mL)

IX. LABORATORY PROCEDURESUrine Analysis

Date Ordered: April 22, 2009

Date Performed: April 22, 2009

Microscopic Exam Chemical Exam

Color: Yellow Albumin: Negative

Transparency: Hazel Sugar: Negative

Rection pH: 6.0 (Normal: 7.35-7.45)

Specific Gravity: 1.010 (Normal: 1.010-1.025)

Pus Cells: 0.2

Epithelial Cells: Moderate

ResultNormal Values

Interpretation Significance

RBC 5.44.5 – 6.0 x

10/LNormal

WBC 10.1 5 – 10 x 10/L IncreaseIndicates

presence of infection

HgB 116120 – 140

g/dlDecrease

Indicates occurrence of

anemia

Hct 0.35 0.30 IncreaseIndicates

hyper coagulation

Platelet 320150 – 400 x

09/LNormal

DIFFERENTIAL COUNTING

Neutrophils 0.86 0.05 – 0.70 IncreaseIndicates

infection or inflammation

Lymphocytes 0.14 0.20 – 0.40 Decrease Indicates high risk for

acquiring

infection

X. OPERATING ROOM- Surgery

PREOPERATIVE1. Preop checklist2. starting an IV line 3. shaving the pubic hair 4. inserting a bladder catheterINTRAOPERATIVE1. Supine on bed2. Induction of anesthesia-

EpiduralGeneral-IV/Inhalation-ET tube

3. Skin preparation4. draping 5. INCISION- longitudinal/Bikini-Obstetrician

*skin*subcutaneous*fascia*muscle*Peritoneum*uterus*amniotic sac

The skin of the lower abdominal wall is incised in a transverse direction just above the pubic hairline in the majority of cases (side to side rather than up and down). A longitudinal (up and down) incision is infrequently employed. Just under the skin, a layer of fat is found which is easily separated to reach the next layer. The reader will recognize this next type of layer since it is a dense shiny white layer of fascia called the rectus fascia. Like the pelvic fascia this is a connective tissue layer, which surrounds the rectus abdominal muscles and offers support, attachment and strength. This fascia layer is incised to expose the two rectus abdominal muscles which are big muscles running from the rib cage to the pubic bone. These are the main muscles employed to do sit-ups. The two muscles meet in the midline where they are sometimes fused but quite often, however, they are separated as the result of the stretching from the distended uterus. These muscles are now separated (without cutting them) and pulled to the sides to create a space between them.

After this space has been created, the only layers covering the uterus are thin fascia and the peritoneum. The peritoneal layer is a very thin membrane-like layer, which can be described as the lining of the abdominal cavity. After this layer is penetrated the uterus will lie directly in view. A second layer of peritoneum, which is also incised and pushed out of the way, usually covers the so-called lower segment of the uterus where the incision will be made. This simple, but essential part of a cesarean section, helps to prevent injuries to the bladder, which lies on top of the lowest part of the uterus and the immediate vagina.

After the bladder has been pushed to safety the next step is to incise the uterus. The incision in the uterine wall is also made transversely and it is made in the lower segment of the uterus, just above the cervix, which is the thinnest part. The incision is usually started with a scalpel but usually completed by manual stretching. This is done to prevent injury to the immediately underlying infant.

6. Delivery of the infant- delivered by guiding its head into the opening with one hand while the assistant exerts

pressure on the uterine fundus (top of the uterus).-handed to pediatrician

7. Delivery of the Placenta

8. Abdominal Lavage

9. Suturing- absorbable and nonabsorbable

The final two layers that need closing are the rectus sheath and of course the skin. The rectus sheath is the most important layer (not surprisingly - it’s fascia!) and needs to be sutured with strong material. The skin can be closed with sutures, staples or various other methods, none of which have significant advantages over the other.

POSTOPERATIVE

1. PACU2. Removal of suction drain

It is sometimes necessary, especially in subsequent cesarean births, to place a suction drain underneath the rectus sheath. This is to prevent the collection of serum or blood in this area, which could then become a site for infection. These drains would typically stay in for 12 to 24 hours.

3. The urinary catheter and IV are usually also removed at the same time.

XII. DRUG STUDY

OxytocinPostpartum haemorrhageAdult: 10-40 units by infusion in 1000 mL of IV fluid at a rate sufficient to control uterine atony.Reconstitution: Postpartum uterine bleeding: oxytocin 10-40 units to running IV infusion, max 40 units/1000 ml.Incompatibility: When admixed: fibrinolysin (human), norepinephrine, prochlorperazine edisylate, warfarin; variable compatibility with phytonadione.Overdosag e

Tetanic uterine contractions, impaired uterine blood flow, amniotic fluid embolism, uterine rupture, syndrome of inappropriate antidiuretic hormone secretion and seizures. Treatment: Supportive and symptom specific.ContraindicationsCephalopelvic disproportion; abnormal presentation of the foetus; hydraminios; multiparae; previous caesarian section or other uterine surgery; hyperactive or hypertonic uterus, uterine rupture; contraindicated vaginal delivery (invasive cervical cancer, active genital herpes, prolapse of the cord, cord presentation,

total placenta previa or vasa previa); foetal distress where delivery is not imminent; severe pre-eclamptic toxaemia.Special PrecautionsCV disorders; >35 yr; lactation. Monitor foetal and maternal heart rate, maternal BP and uterine motility. Monitor fluid intake and output during treatment. Discontinute immediately if the uterus is hypertonic or hyperactive or if there is foetal distress. Use of nasal spray may produce maternal dependence on its effects. IM admin not regularly used due to unpredictable effects of oxytocin. Not to be used for prolonged periods in resistant uterine inertia, severe pre-eclampsia, or severe CV disorders. Risk of water intoxication when used at high doses for prolonged periods.Adverse Drug ReactionsFoetus or neonate: Jaundice; arrhythmias, bradycardia; brain, CNS damage; seizure; retinal haemorrhage; low Apgar score. Mother: transient hypotension, reflex tachycardia; nasal irritation, rhinorrhoea, lachrymation (following nasal admin); uterine bleeding, violent contractions, hypertonicity; spasm; nausea, vomiting.Potentially Fatal: Maternal water intoxication (especially with slow infusion over 24 hr); prolonged uterine contractions causing foetal hypoxia and death; rupture of gravid uterus; afibrinogenaemia; subarachnoid haemorrhageDrug InteractionsPossible severe hypertension if given within 3-4 hr of vasoconstrictor in association with a caudal block anaesthesia. Cyclopropane anaesthesia may increase risk of hypotension and maternal sinus bradycardia with abnormal AV rhythms. Dinoprostone and misoprostol may increase uterotonic effect of oxytocin, thus oxytocin should not be used within 6 hr after admin of vaginal prostaglandins. Concurrent use may increase the vasopressor effect of sympathomimetics.Potentially Fatal: Concomitant use with prostaglandins increases risk of uterine rupture and cervical lacerations.

Antibioticscefuroxime

- it should be inexpensive, safe, and not reserved only for serious infections.. "The nice thing with cephalosporins is, it is not a drug of choice for any particular serious infection.DosageTab Adults 0.5 g/day.Max: 1g. Inj Adult 0.75-1.5 g 8 hrly for 5-10 days.Life-threatening infection 1.5 g 6 hrly.. Pre-op prophylaxis 1.5 g IV. Long operation 0.75 g IV/IM 8 hrlySevere infection ≥0.1 g/kg/day but not >1.5 g.AdministrationShould be taken with foodContraindicationsHypersensitivity. GI absorption difficulties. Childn <5 yr.Special PrecautionsHypersensitivity to β-lactam antibiotics, renal insufficiency, pseudomembranous colitis. Pregnancy & lactation, neonates <3 mth.Adverse Drug Reactions

Thrombophlebitis, GI disturbances. Skin rash, itching, urticaria.Drug InteractionsAminoglycosides.

Methylgonometrine

Methylergometrine maleateIndicationsPostpartum hemorrhage. Routine management after delivery of the placenta, postpartum atony, hemorrhage, uterine subinvolution; used after caesarian & hemorrhage after abortion.DosageTab Secondary postpartum hemorrhage 125 mcg tid for 3 days. Amp Prevention & treatment of postpartum hemorrhage 200

mcg IM repeated if necessary at intervals of 2-4 hr. In emergency 200 mcg slow IV inj over at least 60 sec.AdministrationMay be taken with or without foodContraindications Induction of labor or 1st stage of labor. Patients w/ eclampsia.Special Precautions Before delivery of the uterine shoulder. Hypertension & toxemia of pregnancy. Hypersensitivity to ergot alkaloids. Heart disease, hepatic or renal disease & sepsis. Monitor BP when used w/ anesth & hypertensors. Avoid injecting on the nerve track area & on to the same site. Pregnancy.Adverse Drug Reactions GI, CV, psychoneurotic disturbances. Chest pressure sensation.

Mefenamic AcidContentsMefenamic acidIndicationstraumatic pain; post-op, & postpartum pain; Dosage250mg 1 tab q4 hrs AdministrationShould be taken with food (Take immediately after meals.).ContraindicationsCVA, uncontrolled HTN, MI, treatment of peri-operative pain in the setting of coronary artery bypass graft surgery. Patients w/ severe renal & hepatic failure, CHF. Lactation. Active ulceration/chronic inflammation of upper/lower GIT & patient w/ preexisting renal disease.WarningsFor additional cautionary notes to warn of the potential risk of using the medicine... Special PrecautionsPatients w/ compromised cardiac function. Elderly. Pregnancy. Concomitant use w/ NSAIDs including COX-2 inhitors.Adverse Drug Reactions

GI bleeding & ulceration. Abdominal pain, nausea w/ or w/o vomiting. Agranulocytosis, aplastic anemia, autoimmune hemolytic anemia, bone marrow hyperplasia, decreased hematocrit, eosinophilia, leukopenia, pancytopenia & thrombocytopenic purpura. Glucose intolerance in diabetic patients, hyponatremia. Nervousness. Aseptic meningitis, blurred vision, convulsions, dizziness, headache & insomnia. Eye irritation, reversible loss of color vision. Ear pain, palpitation, hypotension, asthma, dyspnea. Angioedema, edema of the larynx, erythema multiforme, facial edema, Lyell's syndrome, perspiration, pruritus, rash, Stevens-Johnson syndrome & urticaria. Dysuria, hematuria, renal failure including papillary necrosis.

Ferrous sulfate

ContentsFe sulfate 300 mg, folic acid 250 mcgIndicationsPrevention & treatment of Fe-deficiency anemia; prenatal hematinic.Dosage1 tab daily.AdministrationShould be taken on an empty stomach (Best taken on an empty stomach. May be taken w/ meals to reduce GI discomfort.).Contraindications Patients receiving blood transfusion, w/ anemias not produced by Fe deficiency.Special Precautions Patients w/ Fe-shortage or Fe-absorption disease, hemoglobinopathies, GI disease. Folate-dependent tumors.Adverse Drug Reactions GI irritation & abdominal pain w/ nausea, vomiting, diarrhea or constipation.

Drug

Interactions Tetracycline, antacids

XIV. DISCHARGE PLANNING

M – Medication

Methylgonometrine 1 tab TID

Mefenamic Acid 250mg 1 tab q4 hrs

Ferrous sulfate 1 tab once a day

E – Environment

Instructed patient to stay in calm, quiet environment

Home environment must be free from slipping or accident hazards

T – Treatment

Informed patient to have a follow-up check up after 1- 2 weeks

H – Health Teachings

Informed patient to avoid lifting heavy objects for 1-2 weeks

Stressed the importance of perineal cleanliness

Encouraged client to have hot sitz bath

Instructed patient to increase intake of protein-rich foods to promote faster wound

healing

Instructed to promote adequate fluid intake

Discouraged patient to participate in strenuous activities that might precipitate

stress and trauma to the wound

Instructed patient to promote breastfeeding

O – Observable Signs and Symptoms

Observe for dehiscence and evisceration

Instructed patient to report to physician any signs of infection

Instructed patient to report any case of hemorrhage or abnormal bleeding

D – Diet

Encouraged client to increase intake of fiber to avoid constipation

Instructed to increase fluid intake

Instructed to increase intake of nutritious foods such as fruits and vegetables