CAESARIAN

SECTION
Case Presentation

Prepared By:
Group 165- A&B
BSN 3D2-6

Ms. Led Erika R. Paez, RN

NCOR 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. 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:
1. Repeat cesarean delivery:
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 dangerous to the fetus even if delivery is accomplished

immediately after a uterine rupture.

Factors that Impede vaginal birth

1. prolonged labor or a failure to progress (dystocia)fetal distress
2. cord prolapse
3. uterine rupture
4.placental problems (placenta praevia, placental abruption or placenta accreta)
5. abnormal presentation (breech or transverse positions)
6. failed labor induction
7. 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 pelvis
10. pre-eclampsia
11. hypertension
12.multiple births
13.precious (High Risk) Fetus
14.HIV infection of the mother
15. 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 commenced
4. 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.

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

Women 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 Anesthesia
1. 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 decision
Fetal mortality and morbidity
Newborn health
VBAC
Cost
Pelvic floor damage
Maternal mortality
Cultural factors
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- Patient goes to the Patient is concern Patient cannot
Health Management health center once about her second function normally
upon when she got cesarean section anymore like before
pregnant. All in all, thinking that it may be because of her
she thinks she is in a detrimental to her hospital confinement
healthy state. health. and condition. Her
body image changed
after the surgical
procedure done.
2. Nutritional- Prior to confinement, During hospitalization, Patient’s nutritional
Metabolic patient loves eating the patient is on diet and metabolic status
Management instant foods and fatty as tolerated. She eats has been changed
foods like fries and fruits like apples and due to her
burgers. She also oranges. She eats confinement.
loves condiments like bread instead of rice.
“patis”, vinegar, and She said she loss her
soy sauce. She appetite since her
basically loves eating onset of labor.
whatever she likes.
3.Elimination Pattern Bowel: Bowel: Bowel:
Patient defecates 1-2 Patient defecates There was a change
times a day, usually once a day but not on in the frequency and
morning and in the a regular basis. Stool amount.
afternoon. Stool is is soft, minimal in
brown in color and amount and brown in
well-formed. color.

Bladder:
Patient voids usually Bladder: Bladder:
6-8 times a day. Urine Patient voids 3-4 There was a change
is yellow in color. No times a day without in the frequency and
pain when voiding. pain and discomfort. amount.
4.Activity, Leisure, Patient is a housewife Patient’s activities in During patient’s
and Recreation so she is always in the hospital are confinement in the
Pattern charge of the ambulation, deep hospital, there is a
household chores. breathing and limitation in her
Her leisure time would coughing exercise, activities of daily living
include playing with taking a bath or and a disruption in her
her firstborn and personal hygiene. leisure and recreation
watching television. pattern.
5.Sleep and Rest Patient puts herself to Due to her Patient’s sleep and
Pattern sleep by watching uncomfortable rest pattern changed
television programs. condition and pain, when she was
She usually sleeps at patient complains of admitted. She cannot
around 11pm to 6am. difficulty of sleeping put himself to sleep
She feels rested when and short period of anymore due to
sleeping and thinks sleeps. present condition and
that her energy is pain plays a big factor
sufficient for her for her sleep
activities. disturbances.
6.Cognitive – Patient is a high Patient’s present No changes/
Perceptual Pattern school graduate. She condition is not a alterations.
can read and write. hindrance to her
She can speak and cognitive- perceptual
be understood by pattern.
others.
7. Self-Perception / Patient is a friendly During the times of There is a slight
Self-Concept Pattern person; she loves to her confinement, she change in her self-
socialize with his doesn’t think that she perception due to
friends in their is a holistic person present condition.
neighborhoods. She anymore. However,
considers himself as she is positive that
holistic human being she will be ok after
as long as she is confinement.
healthy, complete,
and his family is
always there.
8. Role Relationship Patient can The patient’s family is Normal/ No
understand English, supportive to the alterations.
Tagalog, and patient. She is happy
Kapampangan. She with their presence
has 5 siblings. She is and support.
married with 1 child.
9. Sexuality/ Patient has been Patient reserved her Patient reserved her
Reproductive Pattern married for 3 years. right to privacy. right to privacy.
10.Coping and Stress When patient is The recent Patient accepts
Tolerance stressed, she sings in hospitalization of the present condition with
the karaoke and eats patient was stressful a positive attitude.
comfort foods like and source of anxiety.
burgers, fries, and her However, she is
favorite sizzling sisig. positive that she will
When it comes to be able to cope up
problems, she lets with current condition.
herself think
immediately for a
solution.
11.Values- Belief Patient is a Roman She follows a Due to her
Pattern Catholic. She has a therapeutic regimen confinement, patient
strong faith to God and her strong faith to is trusting God that
and goes to mass God accounts for her she will be discharge
 every Sunday with her fast recovery. soon and will recover
family. 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. skin
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.
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 by
the anterior pituitary gland

Development of the graafian follicle

Production of estrogen (thickening

of the endometrium)

Release of the luteinizing hormone

Ovulation (release of mature ovum from

the graafian follicle)

Ovum travels into the fallopian tube

Fertilization (union of the ovum

and sperm in the ampulla)

Zygote travels from the fallopian tube

to 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 wherein
head 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 duration
and intensity
>do not achieve cervical
dilatation

TRUE LABOR

Uterine Contractions SHOW Rupture of

Membranes
>increase in duration (pink-tinge of blood, (rupture of the
and 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 PROCEDURES

Urine 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

Normal Interpretatio
Result Significance
Values n

4.5 – 6.0 x
RBC 5.4 Normal
10/L

Indicates
WBC 10.1 5 – 10 x 10/L Increase presence of
infection

Indicates
120 – 140
HgB 116 Decrease occurrence of
g/dl
anemia

Indicates
Hct 0.35 0.30 Increase hyper
coagulation

150 – 400 x
Platelet 320 Normal
09/L

DIFFERENTIAL COUNTING
 Indicates
Neutrophils 0.86 0.05 – 0.70 Increase infection or
inflammation

Indicates
high risk for
Lymphocytes 0.14 0.20 – 0.40 Decrease
acquiring
infection

X. OPERATING ROOM- Surgery

PREOPERATIVE
1. Preop checklist
2. starting an IV line
3. shaving the pubic hair
4. inserting a bladder catheter
INTRAOPERATIVE
1. Supine on bed
2. Induction of anesthesia-
Epidural
General
-IV/Inhalation
-ET tube
3. Skin preparation
4. 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. PACU
2. 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

Oxytocin infusion, max 40 units/1000 ml.

Postpartum haemorrhage
Adult: 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
Incompatibility: When admixed: fibrinolysin
(human), norepinephrine, prochlorperazine
edisylate, warfarin; variable compatibility
with phytonadione.
Overdosage
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.
Contraindications
Cephalopelvic 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 Precautions
CV 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 Reactions
Foetus 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 haemorrhage
Drug Interactions
Possible 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.
Antibiotics
cefuroxime
- 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.
Dosage
Tab 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 hrly
Severe infection ≥0.1 g/kg/day but not >1.5
g.
Administration
Should be taken with food
Contraindications
Hypersensitivity. GI absorption difficulties.
Childn <5 yr.
Special Precautions
Hypersensitivity to β-lactam antibiotics,
renal insufficiency, pseudomembranous
colitis. Pregnancy & lactation, neonates <3
mth.
Adverse Drug Reactions
Thrombophlebitis, GI disturbances. Skin
rash, itching, urticaria.
Drug Interactions
Aminoglycosides.
 Methylgonometrine
Methylergometrine maleate
Indications
Postpartum hemorrhage. Routine
management after delivery of the placenta,
postpartum atony, hemorrhage, uterine
subinvolution; used after caesarian &
hemorrhage after abortion.
Dosage
Tab 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.
Administration
May be taken with or without food
Contraindications
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 Acid
Contents
Mefenamic acid
Indications
traumatic pain; post-op, & postpartum pain;
Dosage
250mg 1 tab q4 hrs
Administration
Should be taken with food (Take
immediately after meals.).
Contraindications
CVA, 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.
Warnings
For additional cautionary notes to warn of
the potential risk of using the medicine...
Special Precautions
Patients 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
Contents
Fe sulfate 300 mg, folic acid 250 mcg
Indications
Prevention & treatment of Fe-deficiency
anemia; prenatal hematinic.
Dosage
1 tab daily.
Administration
Should 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