ACKNOWLEDGEMENT

Bismillahirrahmanirrahim. Alhamdullilah, all praises to Allah SWT for enabling

me to complete my assignment on time. Firstly, I would like to thank to my

family for non-stop giving me support to complete this clinical year. I also would

like to thank my Clinical Instructor, Miss Nur Asikin Binti Abd Razak and Miss

Nurul Khairul Anisa Binti Mahmud for the valuable guidance and advice to me

during my practical at Medical Ward of Sultan Haji Ahmad Shah Hospital

(HOSHAS). They inspired me greatly to complete this case study. I also would

like to thank them for showing me some example that related to the topic of my

assignment. Furthermore, I also appreciate the opportunity that has been given

by Sultan Haji Ahmad Shah Hospital (HOSHAS) for me to complete my clinical

year. Millions of thanks to HOSHAS staffs for teaching me and give me

guidance throughout the posting. In addition, special thanks to the patient that

willingly gave cooperation for me to complete this case study.

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 DEFINITION

According to Brian Kans on Healthline website “Cesarean Section”

updated on 17 July 2018, a cesarean delivery also known as a C-section or
cesarean section. It is the surgical delivery of a baby. It involves one incision in
the mother’s abdomen and another in the uterus.

It’s a common procedure that’s used to deliver nearly one-third of

babies in the United States, according to the Centers for Disease Control and
Prevention.

Cesarean deliveries are generally avoided before 39 weeks of

pregnancy so the child has proper time to develop in the womb. Sometimes,
however, complications arise and a cesarean delivery must be performed prior
to 39 weeks.

According to the author of “Cesarean Section” on Medicinenet website,

cesarean delivery, also called c-section, is surgery to deliver a baby. The baby
is taken out through the mother's abdomen. Most cesarean births result in
healthy babies and mothers. But c-section is major surgery and carries risks.
Healing also takes longer than with vaginal birth.

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 Most healthy pregnant women with no risk factors for problems during
labor or delivery have their babies vaginally. Still, the cesarean birth rate in the
United States has risen greatly in recent decades.

Public heath experts think that many c-sections are unnecessary, so it

is important for pregnant women to get the facts about c-sections before they
deliver. Women should find out what c-sections are, why they are performed,
and the pros and cons of this surgery.

Figure 1 Example of Cesarean Section

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 ETIOLOGY
According to the author of “Cesarean Section” on Medicinenet
website,your doctor might recommend a c-section if she or he thinks it is safer
for you or your baby than vaginal birth. Some c-sections are planned, but most
c-sections are done when unexpected problems happen during delivery. Even
so, there are risks of delivering by c-section. Limited studies show that the
benefits of having a c-section may outweigh the risks when:

 The mother is carrying more than one baby (twins, triplets, etc.)
 The mother has health problem including HIV infection, herpesinfection,
and heart disease

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  The mother has dangerously high blood pressure
 The mother has problems with the shape of her pelvis
 There are problems with the placenta
 There are problems with the umbilical cord
 There are problems with the position of the baby, such as breech
 The baby shows signs of distress, such as a slowed heart rate
 The mother has had a previous c-section

According to the author on Mayoclinic website “Cesarean Section”

updated on 09 June 2018,Sometimes a C-section is safer for you or your baby
than is a vaginal delivery. Your health care provider might recommend a
C-section if:

 Your labor isn't progressing. Stalled labor is one of the most common
reasons for a C-section. Stalled labor might occur if your cervix isn't
opening enough despite strong contractions over several hours.

 Your baby is in distress. If your health care provider is concerned

about changes in your baby's heartbeat, a C-section might be the best
option.

 Your baby or babies are in an abnormal position. A C-section might

be the safest way to deliver the baby if his or her feet or buttocks enter the
birth canal first (breech) or the baby is positioned side or shoulder first
(transverse).

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 Figure 2 Breech presentation. Fetus presents bottom side down

 You're carrying multiples. A C-section might be needed if you're

carrying twins and the leading baby is in an abnormal position or if you
have triplets or more babies.

 There's a problem with your placenta. If the placenta covers the

opening of your cervix (placenta previa), a C-section is recommended for
delivery.

Figure 3 Previa. The is implanted over the opening of the cervix thus
preventing a vaginal delivery.

 Prolapsed umbilical cord. A C-section might be recommended if a

loop of umbilical cord slips through your cervix ahead of your baby.

 You have a health concern. A C-section might be recommended if you

have a severe health problem, such as a heart or brain condition. A
C-section is also recommended if you have an active genital herpes
infection at the time of labor.

 Mechanical obstruction. You might need a C-section if you have a

large fibroid obstructing the birth canal, a severely displaced pelvic
fracture or your baby has a condition that can cause the head to be
unusually large (severe hydrocephalus).

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  You've had a previous C-section. Depending on the type of uterine
incision and other factors, it's often possible to attempt a VBAC. In some
cases, however, your health care provider might recommend a repeat
C-section.

Some women request C-sections with their first babies — to avoid labor or the
possible complications of vaginal birth or to take advantage of the convenience
of a planned delivery. However, this is discouraged if you plan on having
several children. Women who have multiple C-sections are at increased risk of
placental problems as well as heavy bleeding, which might require surgical
removal of the uterus (hysterectomy). If you're considering a planned
C-section for your first delivery, work with your health care provider to make
the best decision for you and your baby.

CLINICAL MANIFESTATIONS

According to Brian Kans on Healthline website “Infection of

PostCesarean Section” updated on 17 July 2018 ,If you’ve had a cesarean
delivery, it’s important to monitor the appearance of your wound and follow
your doctor’s postoperative instructions closely. If you’re unable to see the
wound, have a loved one check the wound every other day to watch for

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warning signs of a wound infection. Having a cesarean delivery can also put
you at risk for other problems, such as blood clots.

Call your doctor for advice or seek medical care if you have any of these
symptoms after your release from the hospital:

 severe abdominal pain

 redness at the incision site

 swelling of the incision site

 pus discharge from the incision site

 pain at the incision site that doesn’t go away or gets worse

 fever higher than 100.4ºF (38ºC)

 painful urination

 foul-smelling vaginal discharge

 bleeding that soaks a feminine pad within an hour

 bleeding that contains large clots

 leg pain or swelling

According to Mahak Arora on Parenting Firstcry website “Infection of

PostCesarean Section” updated on 19 June 2018, understanding that the
wound has been infected can only be surmised by observing the area of the
incision. In case you cannot see the wound for yourself, the area should be
inspected by somebody else. More often than not, certain symptoms are a
strong indicator of an infection being present in the body. These are:

 The area of the incision having redness or swelling, accompanied by

some pain.

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  The abdominal pain after delivery begins to increase instead of
decreasing.
 The wound begins to drain out pus or leaks out any other liquid.
 The actual wound begins to sting a lot and does not improve over time.
 The onset of a fever with a temperature above 100.5 degrees
Fahrenheit.
 Unable to pass urine or intense burning sensation accompanied by
pain.
 Discharge emitting from the vagina that has a bad odour to it.
 Vaginal bleeding increases, causing you to change pads within the
same hour.
 Vaginal bleeding consists of blobs or clot-like structures.
 The legs begin to swell again and start to hurt.

DISCUSSION
Both researches have its own similarities.The similarities of clinical
manifestation are abdominal pain , redness at the incision site , swelling
incision site , pus and other infected sign and symptoms at the incision site.
Other then that, patients should check by themself the incision site and the
vaginal and also the hygiene is important to prevent the infection. If they’re

infected, should to the check immediately.

INVESTIGATIONS

According to Brian Kans on Healthline website “Cesarean Section”

updated on 17 July 2018, to diagnosis of cesarean section begins with a
thorough history and physical examination. If you and your doctor decide that a
cesarean delivery is the best option for delivery, your doctor will give you

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complete instructions about what you can do to lower your risk of
complications and have a successful cesarean delivery.

As with any pregnancy, prenatal appointments will involve many

checkups. This will include blood tests and other examinations to determine
your health for the possibility of a cesarean delivery.

Your doctor will make sure to record your blood type in case you need a
blood transfusion during the surgery. Blood transfusions are rarely needed
during a cesarean delivery, but your doctor will be prepared for any
complications. Other investigation:

 Cardiotocography (CTG)

CTG uses sound waves called ultrasound to detect the baby's heart rate.
Ultrasound is a high-frequency sound that you cannot hear but it can be
sent out (emitted) and detected by special machines.Ultrasound travels
freely through fluid and soft tissues. However, ultrasound bounces back
as 'echoes' (it is reflected back) when it hits a more solid (dense) surface.
For example, the ultrasound will travel freely through blood in a heart
chamber. But, when it hits a solid valve, a lot of the ultrasound echoes
back. Another example is that when ultrasound travels though bile in a
gallbladder it will echo back strongly if it hits a solid gallstone.So, as
ultrasound 'hits' different structures in the body, of different density, it
sends back echoes of varying strength.

Figure 4 CTG when contraction

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 According to the author on Mayoclinic website “Cesarean Section”
updated on 09 June 2018, if you and your doctor decide that a cesarean
delivery is the best option for delivery, your doctor will give you complete
instructions about what you can do to lower your risk of complications and
have a successful cesarean delivery. The doctor will do this below :

 Electronic fetal monitoring - monitoring of the fetus' heart tracing.

Repetitive decreases in heart rate may signal a decrease in oxygen to
the fetus (e.g. compression of the umbilical cord)
 Fetal scalp pH - monitors the acidity of the scalp tissue. An elevated
acidic reading (pH < 7.2) indicates a build up of carbon dioxide and
lactic acid in the blood, which occurs when the fetus is poorly
oxygenated
 Examination of the cervix -

1. Rule out prolapse of the umbilical cord

2. Rule out bleeding from the cervix (e.g. with l previa

 Abdominal Ultrasound - ultrasound images of the uterus and its

contents are obtained

1. Position of the fetus - head down or up

2. Position of the relative to the cervix
3. Size of the head (e.g. enlarged head due to hydrocephalus)

 Vaginal Ultrasound - similar to abdominal ultrasound but may be more

accurate in previa
 Test for HIV and MRI - can be used to determine the position of the
fetus
 Blood tests for Rh factor and bleeding tendency

DISCUSSION

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 Based on both researches have the point about the investigation of
Cesarean section. When the C section the doctor should do the blood test to
preparation if have any complication on the surgery like blood loss. Moreover,
the doctor will monitor the fetus heartbeat with CTG and if the heartbeat
decrease means that the oxygen of fetus decrease. Other investigation is
ultrasound to find out the position the fetus because have to C-section if the
position of the fetus is risk when normal delivery. Many others investigation
that can we use to diagnosis.

MANAGEMENTS AND TREATMENTS

According to author on BetterHealthvic website “Cesarean Section”
updated on 7/11/2018, Once a diagnosis of C-section is made, To prepare for
your caesarean section:

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  You will need to fast. That means no food or drink, including water, for
six hours before a planned caesarean. If you are having an emergency
caesarean, the doctor will ask you when you last had any food or drink
so they know how to proceed with your operation.

 You will have blood tests taken.

 You may have a support person with you, unless there are serious
complications or you need a general anaesthetic. It is generally
possible for someone to take photos of your baby being born, so ask
your support person to bring a camera if they have one.

 Don’t be afraid to ask questions or to tell the doctors or midwives if you

are feeling worried. If you have any special preferences, talk to your
doctor or midwife beforehand, so they can try to support your choices.

 If the doctor believes you are at increased risk of blood clots, you may
be measured for compression stockings to wear during the operation.

 The theatre team will clean your abdomen with antiseptic and cover it
with sterile cloths to reduce the risk of infection. In many hospitals, the
hair around the area to be cut is shaved so that it is easier to clean.
You will have a catheter (plastic tube) inserted into your bladder so
that it remains empty during the operation.

During a caesarean section

 The actual operation usually takes between 30 and 60 minutes. It will

involve:

 The doctor will make a cut in your abdomen and your uterus (both about
10 cm long).

 Your baby will be lifted out through the cut. Sometimes the doctor may use
forceps to help lift out your baby’s head.

 Your baby will be carefully checked.

 You will be able to hold your baby soon afterwards. Skin-to-skin contact
can strengthen your early bond with your baby and make breastfeeding
easier.

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 If you cannot hold your baby in the operating theatre, your support person
will most likely be able to hold your baby instead.

 The umbilical cord will be cut and your placenta removed.

 An injection will usually be given to make your uterus contract and to

minimise bleeding.

 Antibiotics will be given to reduce the risk of infection.

 The layers of muscle, fat and skin will be stitched back together and a
dressing will be applied over the wound.

After a caesarean section

 A number of things will occur after you have a caesarean section,

including:

 You will be cared for in the recovery room until you are ready to go to
the ward.

 If you have had a general anaesthetic, you will most likely wake up in
the recovery room. You should be able to see your baby once you are
awake.

 You will be encouraged to breastfeed. The earlier you start to

breastfeed, the easier it is likely to be for both you and your baby.
Having a caesarean section can make breastfeeding harder to start,
so ask for all the support you need. Breastfeeding is the best possible
food to help your baby grow healthy and strong, and the midwives are
there to help you. Some hospitals encourage women to breastfeed
their baby in the recovery room if there is a midwife to assist.

 Tell your midwife or doctor when you are feeling pain so they can give
you something to ease it. Pain-relieving medication may make you a
little drowsy.

 You may have a drip for the first 24 hours or so, until you have
recovered from the anaesthetic.

 You can start to drink after any nausea has passed.

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  The midwife or doctor will tell you when you can eat again.

 Your catheter will stay in until the anaesthetic has worn off and you
have normal sensation in your legs to walk safely to the toilet. This
may not be until the next day.

 Walking around can help with recovery. It can also stop blood clots and
swelling in your legs. A midwife will help you the first time you get out
of bed.

 You may also have an injection to stop blood clots.

 You may need antibiotics after the operation.

 You may have trouble with bowel movements for a short time after the
operation. It should help to drink plenty of water and eat high-fibre food.
The doctor or midwife can give you more advice.

 When your dressing is taken off, you will be instructed to keep the
wound clean and dry. This will help it to heal faster and reduce the risk
of infection.

Special care for your baby after a caesarean section

 After a caesarean, your baby is more likely to have breathing problems

and be admitted to the special care nursery for a period of time
(although they are usually ready to go home when you are). About 35
in every 1,000 babies have breathing problems after a caesarean birth
(compared with five in 1,000 babies following a vaginal birth).

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  If your baby is premature or unwell, they may also need to go to the
special care nursery. Your partner or support person can usually go
with the baby. When you are well enough, and as soon as it is possible,
the midwife or nurse will help you to see your baby. The midwives or
nurses can help you with expressing breastmilk for your baby.

According to author on CSH website “Cesarean Section” updated on 30

November 2018, management is directed surgery If the C-section is :

 The skin is prepared with a solution that reduces the risk of wound
infection
 A catheter is placed in the bladder
 The hair near the incision may be shaved
 An incision is made in the skin and is carried through the abdominal wall
to enter the pelvis. The skin incision may be made vertical (up and down)
or transverse (from side-to-side). The decision is based on many factors
including speed of entry, exposure needed, anticipated weight of the
baby and risk of wound infection. A transverse skin incision is most
common and is usually made 2-3 centimeters (one inch) above the
pubic bone (Figure 5)

Figure 5

 The uterus is then identified. There is a layer of thin tissue, which

drapes over the anterior surface of the uterus and then onto the bladder

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 (the vesicouterine peritoneum). This layer is incised so that the bladder
can be retracted away form the uterus to allow for the uterine incision.
(Figure 6) The incision is then carried into the uterus to allow for delivery
of the baby

Figure 6

 The uterine incision is then made down to the amniotic sack (fetal
membranes or bag of water). (Figure 7)

Figure 7

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 The uterine incision can be either transverse or vertical. Ninety percent
have a transverse uterine incision. Some indications for a vertical
incision in the uterus are a pre-term fetus, a fetus that is not head down
and with emergency C-sections. Even in these situations a transverse
incision may sometimes be used. A woman that has a prior C-section
with a vertical uterine incision is usually not a candidate for vaginal birth
 The fetal head or buttocks are then delivered through the uterine
incision followed by the rest of the body. (Figure 8) Then the is delivered

Figure 8

 Some obstetricians repair the uterus by first delivering the uterus

through the abdominal incision and some repair it while it is still in the
abdomen. The uterus is closed with one or two layers of suture (Figure
9)

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 Figure 9

 The layers of the abdominal wall are sutured and then the skin closed
with either suture or staples

Care After Surgery

 Walking is important to prevent pneumonia and blood clots

 Diet initiallly consists of ice chips on the day of surgery, fluids on the first
day after surgery, and a regular diet two days after surgery
 The catheter placed in the bladder at the time of surgery,is usually
removed the first day after surgery
 Fluids may be given in the vein up to and sometimes through the first
day after surgery
 Discharge to home may occur in two to five days depending on the
circumstances

DISCUSSION
Based on both management of website , they’re have mostly same
management at the labour room. Below is some of the management:

 Patient have been call in to OT for surgery. The Preoperative:

 Patients should fasting before OT

 Before going to OT , patients asked to change clothes and requested

to be remove of jewelery.

 Patients been given IVD HM and NS

 Must check the personal detail by asking the patients to makes sure
the right patient and give knowledge and the risk about the procedure
is C-section.

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  The family must sign the consent form for C-section

 Catheter with be insert

 After that patients been sending to OT and the surgery begin.

 After the surgery , the Postoperative:

 Patients must feeling nause and vomiting from the side effect of the
anesthetist.

 Monitor the vital sign

 Continue the IVD of normal saline

 Patients GCS check in 24 hours

 The medication:

 Iv tramal 50mg tds

 Iv maxolon 10mg tds

 After tha patients stable and recover , patient discharges with some
medication given.

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21
 CONCLUSION

In Conclusion, a caesarean section is a surgical procedure in which a

baby is born through a cut made in the mother’s abdominal wall and uterus.A
baby will need to be born by caesarean section if there are serious problems
that prevent the baby being born by a normal vaginal birth.Caesarean section
is a relatively safe operation; however, possible complications include infection,
damage to your internal organs, an increased risk of respiratory distress for
your baby and complications with future pregnancies.

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References

 According to Brian Kans on Healthline website “Cesarean Section”

updated on 17 July 2018

https://www.healthline.com/health/c-section

https://www.healthline.com/health/pregnancy/post-cesarean-wound-infecti
on

 According to the author of “Cesarean Section” on Medicinenet website

https://www.medicinenet.com/c-section_cesarean_birth/article.htm#c-secti
on_introduction

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 According to the author on Mayoclinic website “Cesarean Section”
updated on 09 June 2018.

https://www.mayoclinic.org/tests-procedures/c-section/about/pac-2039365
5

 According to Mahak Arora on Parenting Firstcry website “Infection of

PostCesarean Section” updated on 19 June 2018

http://parenting.firstcry.com/articles/c-section-scar-infection-symptomscau
sestypestreatment-and-prevention/

 According to author on BetterHealthvic website “Cesarean Section”

updated on 7/11/2018

https://www.betterhealth.vic.gov.au/health/healthyliving/caesarean-secti
on

 According to author on CSH website “Cesarean Section” updated on 30

November 2018

http://www.csh.org.tw/dr.tcj/educartion/teaching/CS/index.htm

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