University of Baguio College of Nursing General Luna Road, Baguio City

An OR write-up Presented to the Faculty Of School of Nursing

In partial fulfillment For the requirement of the subject NCM104 (Related Learning Experience)

By: Segui, Dominick

Mrs. Concepcion

Patient Profile
Name: Jennifer dulawan Age: 34 Address: Caba la union Birthday: June 5, 1977 Time of admission: 6:15pm Diagnose: Placenta Previa

Preparation of the patient

Antiembolitic hose are put on the legs. The patient is supine with the right side slightly elevated to displace from the inferior vena cava. Arms may be extended on padded arm boards. A pillow may be placed under the lumbar spine and/ or undr the knees (to avoid straining back muscles). Pad all bony prominences and areas vulnerable to skin and neurovascular trauma or pressure. Very carefully insert Foley catheter and connect it to continuous drainage.

Skin preparation
Do not prep the vagina. Draping Folded towels and a laparotomy (or transverse) sheet Additional drap sheet to cover a second back table for care of the infant

Equipment
Suction ESU Heat lamps and bassinet with a warmer Identification bands

Ink pad (for infants footprint, single use) (optimal)

Instrumentation
Cesarian section tray Delivery forceps

Supplies
basin net Electro surgical pencil and cord with holder and scraper Suction tubing Blades, (2) #10 Needle magnet or counter Bulb syringe (to aspirate infants nose and mounth) Resuscitation equipment for infant Erythromycin ointment (0.5%) for infants eyes (conjuctival sacs) Oxytocin, usually 20 mg in a syringe (to the anesthesia provider) Medicine cup, paper labels, marking pen Test tubes (2) for cord blood Drain (e.g.,penrose), optimal

Bupivacaine is for the production of local or regional anesthesia or analgesia for surgery, for oral surgery procedures, for diagnostic and therapeutic procedures, and for obstetrical procedures. Bupivacaine is a widely used local anesthetic agent. Bupivacaine is often administered by spinal injection prior to total hip arthroplasty. It is also commonly injected into surgical wound sites to reduce pain for up to 20 hours after surgery. In comparison to other

local anesthetics it has a long duration of action. It is also the most toxic to the heart when administered in large doses. This problem has led to the use of other long-acting local anaesthetics: ropivacaine and levobupivacaine. Levobupivacaine is a derivative, specifically an enantiomer, of bupivacaine. Systemic absorption of local anesthetics produces effects on the cardiovascular and central nervous systems. At blood concentrations achieved with therapeutic doses, changes in cardiac conduction, excitability, refractoriness, contractility, and peripheral vascular resistance are minimal. However, toxic blood concentrations depress cardiac conduction and excitability, which may lead to atrioventricular block, ventricular arrhythmias and to cardiac arrest, sometimes resulting in fatalities. In addition, myocardial contractility is depressed and peripheral vasodilation occurs, leading to decreased cardiac output and arterial blood pressure. Following systemic absorption, local anesthetics can produce central nervous system stimulation, depression or both.

DISCUSSION
there are numerous indications for cesarean section of surgical delivery, including mechanical, fetal distress, malrotation, malpresentation, toxemia, multiple pregnancy, placenta previa, and prolapsed cord. When performed as an emergency, the goal is to deliver the infant promptly, while avoiding injury to both mother and infant. Additional reason for this type of surgical delivery might be cervical dystocia, active herpes simplex in the birth canal, or metabolic disease, as diabetes. Previous cesarean section or other uterine surgery is no longer regarded as an absolute indication for the procedure.

PROCEDURE

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A low vertical incision consistent with the estimated size of the fetus is made The rectus muscle is separated and the peritoneum incised. Homeostasis is assured. The bladder is reflected from the uterine segment, and the uterus is incised. The amiotic sac is spontaneously entered, and fluid aspirated immediately by suction tubing without a tip to avoid injury. The fetal head is delivered using manual pressure and counter pressure on the fundus The deliver is complete. Oxytocin is administered intravenous to encourage the uterus to contract and to decrease blood loss.

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The umbilical cord is clam and cut The infant is received in a sheet and transferred to a gowned and gloved member of the neonatal team Resuscitative measures are provided to the neonatal under warming lamps. Vernix caseusa are wipe from the infant skin Ointment is applied to the conjunctiva sacs by a member of the neonatal team. The placenta is delivered. The uterus is massage to encourage it to contract.

Placenta previa
Placenta previa is a complication of pregnancy in which the placenta grows in the lowest part of the womb (uterus) and covers all or part of the opening to the cervix. The placenta is the organ that nourishes the developing baby in the womb.

Causes, incidence, and risk factors

During pregnancy, the placenta moves as the uterus stretches and grows. In early pregnancy, a low-lying placenta is very common. But as the pregnancy progresses, the growing uterus should "pull" the placenta toward the top of the womb. By the third trimester, the placenta should be near the top of the uterus, leaving the opening of the cervix clear for the delivery. Sometimes, though, the placenta remains in the lower portion of the uterus, partly or completely covering this opening. This is called a previa. There are different forms of placenta previa:
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Marginal: The placenta is against the cervix but does not cover the opening. Partial: The placenta covers part of the cervical opening. Complete: The placenta completely covers the cervical opening.

Placenta previa occurs in 1 out of 200 pregnancies. It is more common in women who have:
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Abnormally developed uterus Many previous pregnancies Multiple pregnancy (twins, triplets, etc.) Scarring of the uterine wall caused by previous pregnancies, cesareans, uterine surgery, or abortions

Women who smoke or have their children at an older age may also have an increased risk. Possible causes of placenta previa include:
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Abnormal formation of the placenta Abnormal uterus Large placenta Scarred lining of the uterus (endometrium)

Symptoms
The main symptom of placenta previa is sudden, painless vaginal bleeding that often occurs near the end of the second trimester or beginning of the third trimester. In some cases, there is severe bleeding, or hemorrhage. The bleeding may stop on its own but can start again days or weeks later. There may be uterine cramping with the bleeding. Labor sometimes starts within several days after heavy vaginal bleeding. However, in some cases, bleeding may not occur until after labor starts.

Stages of Labor
There are three stages of labor. The first stage occurs from the time true labor begins until the cervix is completely dilated and effaced. During the second stage the baby is delivered. The third stage follows the birth of the baby through the birth of the placenta.
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First Stage Second Stage Third Stage

Labor and Delivery Checklist

First Stage
The first stage of labor is the longest. There are three phases within the first stage;
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Early or latent phase Active phase Transition phase

At the end of the first stage, the cervix is dilated to 10 centimeters. In mothers having their first child, this stage usually lasts 12 to 16 hours. For women having second or subsequent children, the first stage lasts around 6-7 hours.

Early Labor
During the early or latent phase, the cervix dilates to 4 centimeters. The duration of the first phase is the longest, averaging around 8 hours. Your contractions may be irregular, progressing to rhythmic and methodical. The pain felt at this early stage may be similar to menstrual pain: aching, fullness, cramping and backache. You will still be able to walk. Walking is usually more comfortable than sitting. Most women spend these hours at home, or they may be checked at the hospital and sent home until labor becomes more active. You may feel eager, excited and social. It is important that you conserve your energy for the work of labor.

Active Labor
Active labor is marked by regular contractions that become longer, stronger and closer together over time. Most providers recommend that you go to the hospital when your contractions are five minutes apart, lasting more then 60 seconds for at least an hour. Measure your contractions from the start of one contraction to the beginning of the next. Your physician will want to know:
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How far apart are the contractions? How long they are lasting, and how intense? Are you using breathing techniques to manage the pain?

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Has your "bag of water" broken? Your provider will want to know the time this occurred, and any color or odor. Has there been any discharge, such as a bloody show?

If you have had previous deliveries, the active phase of labor can proceed more quickly. Your physician may want to be contacted sooner. When you are in active labor, you will be concentrating on the task at hand, and will not feel like doing anything else. Your labor partner's support is important at this phase. Contractions are growing stronger, longer and closer together. Contractions will be about 3-4 minutes apart, lasting 40 to 60 seconds. You may have a tightening feeling in your pubic area and increasing pressure in your back. If you have learned breathing techniques, begin using them now, if you haven't already. Pain medication is often given at this stage. If you have chosen to have an epidural anesthetic, it is usually given at this stage. Please see pain management for more information.

Transition
Transition is the most difficult phase of labor, and fortunately, the shortest, lasting from 30 minutes to two hours. The cervix is opening the last few centimeters, from 7 to 10 centimeters. The pain may be intense, as the cervix stretches and the baby descends into the birth canal. All of your energy is concentrated on doing the work of labor. Try to remain calm and focused as your uterus works. At the end of transition, you may feel a strong urge to push the baby out. The baby is ready to be born.

Second Stage
During the second stage the baby is born. This stage of labor lasts anywhere from one contraction to up to two hours. The baby's head stretches your vagina and perineum (the skin between the vagina and rectum). This may cause a burning sensation. Some women may feel as if they are having a bowel movement, and feel the urge to push, or bear down. The labor nurse or physician will tell you when it is time to push. It is important that you not push until instructed. Pushing too early will cause the cervix to become edematous, or swollen. "Crowning" occurs as the widest part of the head appears at the vaginal opening. In the next few pushes, the baby is born. Mucous and amniotic fluid will be removed from the baby's mouth and nose with a bulb syringe. The baby will take its first breath, and may begin to cry. Immediately after birth, the baby is still connected to the placenta by the umbilical cord. The cord is clamped and cut.

Third Stage
The third stage begins with the birth of the baby and ends with the delivery of the placenta. It is the shortest stage, lasting from 5 to 15 minutes. Your contractions may stop for awhile, then resume to deliver the placenta. You will be observed closely for the next few hours to make certain that your uterus is contracting and bleeding is not excessive. The nurse will massage your uterus, or your lower abdomen to check that the uterus is contracting. Take this time to rest and get acquainted with your new baby.

Mechanisms of Labor

The Mechanisms of Labor occur to the fetus during delivery. Knowledge of these mechanisms enables the nurse to proceed with normal delivery and detect if any abnormalities are occurring during delivery that can enable the health care team to perform measures that could prevent possible complications. You can be guided by the acronym EDFIERERE.
E = Engagement

It is the mechanism wherein the fetus engages to the pelvis. It is also called lightening or dropping.
D = Descent

Descent is the mechanism where the fetal head begins its journey through the pelvis. Assessment measurement is termed as station.
F = Flexion

Is the mechanism where the fetal head is nodding or flexing forward toward its chest.
IR = Internal Rotation

This occurs from the occiput transverse position to the occiput anterior position while descending.
E = Extension

This enables the head to emerge when the fetus is in cephalic position. This begins when the head is crowning.
R = Restitution

It is the realignment of the head of the fetus with the body as the fetus head emerges.

ER = External Rotation

This mechanism is where the shoulders rotate externally once the head emerges and restitution occurs so that the shoulders would be in the anteroposterior diameter of the mothers pelvis.
E = Expulsion

It is the birth of the entire body of the fetus.