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INTRODUCTION

Vaginal delivery is the most common way to give birth, but in certain situations, Caesarean section is often
advised. Cesarean section refers to the delivery of the infant through an incision made on the abdominal and uterine
wall.

A Caesarean may be classified as:


-Elective surgery
An elective or planned Caesarean section is performed one to two weeks before the baby's due date. This ensures the
baby is mature before delivery.
-Emergency surgery
An emergency Caesarian section can be performed at a short notice, particularly if there are complications or difficulty
in labor.

Indications:
-Fetal malposition
-Fetal distress
-Previous cesarean section
-Abruptio placenta previa
-Cord prolapse
-Prolonged labor, uterine inertia
-Failed trial and induction of labor, failed forceps and vacuum extraction
-Multiple gestation
-Herpes genetalis in active stage
-Other maternal conditions: preeclampsia and eclampsia, heart disease, Rh and ABO Incompatibility

Types of CS:
1. Low Segment / Low-Transverse / Low-Cervical – Incision is made transversely on the lower segment of the
uterus.

Advantages:
Involves less blood loss
Less possibility of rupture of CS scar during subsequent pregnancy
Incision is easier to repair
Less incidence of postoperative complications: infection, adhesion
Less possibility of bowel to the incisional line, Intestinal obstruction

Disadvantages:
Difficult and longer to perform than the classical type
Not recommended with anterior placenta previa
Possibility of incision to extend to the uterine vessels laterally

2. Classical Type / Sanger – A vertical incision is made directly into the walls of corpus, the body of uterine which is
the most contractile portion.
Advantages:
Easiest and quickest incision to perform
Rapid extraction of fetus can be done

Disadvantages:
Involves more blood loss because incision is made on the thick vascular portion of the uterine
Higher incidence of postoperative complications
Rupture of CS scar on subsequent pregnancy and labor is more likely
Involves more healing discomfort and a wider CS scar

3. Extra peritoneal Cesarean Section – Incision is made around the bladder and into the lower uterine segment
without entering the peritoneal cavity.

Advantages:
Useful after prolonged labor
Operation recommended in the presence of amnionitis because spilling of amniotic fluid into the peritoneal cavity is
avoided
Disadvantages:
Operation is difficult to perform
Possibility of uterine bleeding and postoperative infection is high

Types of Abdominal Incision:

1. Infraumbilical Vertical Incision – Quickest incision to make which involves performing a 2cm vertical incision at
the level of the anterior rectus sheath. The incision should be long enough to allow delivery of the infant without
difficulty. This incision is made in obese women and in those requiring immediate delivery.

2. Modified Pfannensteil Incision –Lower transverse slightly curvilinear incision is made at the level of the pubic
hairline and extended a little beyond the lateral borders of the rectus muscles. This kind of incision is stronger with
less possibility of dehiscence of hernia formation. This type of incision is made on thin women. Repeat cesarean
section takes longer to perform after this type of incision because if scarring.

PATIENT’S PROFILE:
Name: Mrs. JB Age: 18 y/o Birthday: May 24, 1991 Husband’s age: 23 y/o
Address: Labong, Sta. Lucia, Ilocos Sur
Socio Economic:
Mrs. JB is a housewife. Her husband is an Auto Mechanic worker. He earns P150/day from his job.

Present Medical History:


Mrs. JB was admitted at Tagudin General Hospital and Capillariasis Center on August 7, 2009 at around 9:00
AM. She was admitted to give birth and she does it through cesarean section.

Family History:
Most of the member of the family had a difficulty in giving birth, and most often when they give birth it
is through cesarean section.
PHYSICAL ASSESSMENT
I.GENERAL SURVEY
A. GENERAL APPEARANCE
-Conscious and coherent
Trusting, cooperative
B. HEIGHT- 5 feet and 1 inch
WEIGHT- 4 kg
C. VITAL SIGNS
-BP – 110/90
-RR – 22
-PR – 84
-Temp. – 37.5

II. HEAD and NECK


HEAD No scar
EYES Symmetrical
Coordinated and can see clearly
NOSE No deformities
No discharge
EARS Symmetrical
No discharges and can hear clearly

NECK Vein engorgement negative


Lymph nodes negative

III. INTEGUMENTARY
A. HAIR and SCALP
-Black hair, No dandruff, No lice
B. SKIN
Brown-skinned
(-) rashes, (-) edema, (-) jaundice and (-) lesion
C. NAILS
-Evenly cut, convex surface
-Capillary refill in 3 seconds

IV. THORAX
A. POSTERIOR and ANTERIOR THORAX
-Symmetrical chest expansion when breathing. Rhythmical normal depth
B. LUNGS
-No rales; no crackles sound

C. HEART
-No murmur sound
V. EXTEMITIES
A. LOWER EXTREMITIES
-No deformities
B. UPPER EXTREMITIES
-No deformities

THE FEMALE REPRODUCTIVE SYSTEM


-Group of organs with the function of production of ovum and sex hormones

The internal organs


OVARY
-Firm almond shaped organ covered by the peritoneum
-Two parts: cortex and medulla
-CORTEX- follicles are found
-Medulla- connective tissue

Fallopian tubes
-Bilateral ducts extends laterally from the uterus
4 parts
1. Infundibulum- funnel shape, with fimbriae
2. Ampulla- widest part; usual site of FERTILIZATION
3. Isthmus- narrowest part
4. Interstitial or Intramural- embedded in the uterine wall
FUNCTION: Transport of ovum

The Uterus
-Pear-shaped organ with a cavity
3 main parts
1. Fundus- upper dome-shape part
2. Corpus or Body- broad part
3. Cervix- narrow lower part
-Isthmus- junction between the body and the cervix
POSITION: Anteverted and Anteflexed

The Uterus
The uterine wall is made up of three layers
1. Perimetrium- superficial part surrounded by the perimetrium
2. Myometrium- thickest muscular part
3. Endometrium- inner layer
FUNCTION: Fetal development in pregnancy

Vaginal canal
-Connects the cervix to the vestibule
-Fibromuscular canal lined with mucus and covered with hymen
-The remnant of hymen is called CARUNCULAE MYRTIFORMIS
FUNCTION: organ of copulation and passageway of baby
External genitalia
1. Vestibule- space between the labia minora
2. Pudendal cleft- space between the labia majora
3. Clitoris- erectile tissue, homologue of penis
4. Labia majora- thick fold of skin, homologue of scrotum
5. Labia Minora- thin fold of skin devoid of hairs
6. Mons pubis/veneris- elevated area above the labia

THE SURGICAL PROCEDURE


OPERATIVE REPORT

Surgeon: Dr Eugene Dauz


Scrub Nurse: Ms. Imee Esquilon
Post-Operative Diagnosis: Post CS
Procedure: Vertical incision CS
Anesthesia: Spinal
Condition: Stable

INSTRUMENT USED:

Sponges: 6, Allis:6, Bladder Retractor: 1 ,Richardson: 1 ,Straight Clamp: 2 ,Curve Clamp: 6 ,Tissue Forceps: 1
,Thumb Forceps: 1 ,Straight Mayo: 1 ,Army Navy: 1 ,Curve Mayo: 1 ,Metz: 1 ,Blade Holder: 1 ,Needle Holder:2
,Blade: 1 ,Towel Clip: 4 ,Needle- 6.

For informed consent, the most common risks, the complications were thoroughly discussed with Mrs. JB and her
family by DR.E.Dauz. An appropriate consent form was signed, indicating Mrs. JB understands the procedure and its
possible complications.

This 18-year-old primigravida was brought to the operating room and placed on the surgical table in a supine position.
Vital signs were stable prior to surgery. Blood pressure was 110/90. Pulse Rate: 84. Respiratory Rate:22. @9:26
Induction of Spinal anesthesia was induce to numb or desentized the lower part of the patient’s body, the patient is
placed in a supine position and the surgical site was prepped by Betadine solution and drape while maintaining a strict
sterile technique. @9:31 after the anesthesia takes effect, the surgeon makes an abdominal incision. The uterus is
exposed through the abdominal wall incision, and an incision is made in the uterine covering. the muscles of the uterus
are separated, producing a hole,
the opening in the uterine wall is where the infant is delivered. After which, The surgeon reaches into the uterus and
lifts the baby's head. A scrub nurse pushes down on the mother's upper uterus to help guide the baby out. @9:35 Baby
was out the scrub nurse suction the baby and the surgeon clamp and cut the umbilical cord. @9:38 the placenta was
out and the surgeon clean thoroughly the uterus, after which, the uterus is stitched closed as well as the incision made
in the abdominal wall. Operation ended around 9:50. Sterile gauze was then placed in the suture line as a dressing.
The patient was awakened and taken to the recovery room in good condition.
LABORATORY RESULTS
Hematology

Results Normal Value Significance


Hemoglobin 120 125-160 g/L Slightly decreased
RBC 4.2 4.5-5x10 12/L Slightly decreased
WBC 4.5 5-10 x10 9/L Slightly decreased
HbsAg = (-) negative
Differential Counts
Neutrophils 0.93
Lymphocytes 0.07

URINALYSIS
Color Character
yellow slight turbid
Cells
Pus Cells 1-2
RBC 5-7
Squamos few
Bacteria few

NURSING INTERVENTIONS

A. Preoperative:
Explain purpose of procedure to be done
Clarify misconceptions
Check maternal vital signs and FHT
Remove nail polish
Position woman in supine and drape properly.
 Advice the woman to ambulate on the first postpartum day
B. Postoperative:
Ensure safety of the patient
Maintain patent airway.
Watch for signs of hemorrhages
DRUG STUDY:
Generic Name: Cefuroxime
Brand Name: Zinacef®
Dosage: 750 mg IV every 8hr ANST (-)
Classification: Cephalosporin, Anti-infective Agents
Action: inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall, thus inhibiting
biosynthesis and arresting cell wall assembly resulting in bacterial cell death.
Indication: Prophylaxis for surgical infection.
Contraindications: Hypersensitivity to cephalosporins.
Adverse Effect:
-Skin: Pruritus, rash
-GI: Abdominal cramps, diarrhea, nausea, vomiting, oral candidiasis
-GU: Vaginal candidiasis

Generic Name: Tramadol


Brand Name: Ultram®
Dosage: 50 mg IV every 8hr
Classification: Non-narcotic Analgesics
Action: Tramadol inhibits reuptake of norepinephrine, serotonin and enhances serotonin release. It alters perception
and response to pain by binding to mu-opiate receptors in the CNS.
Indication: Relief of moderate to moderately severe pain.
Contraindications: Hypersensitivity to tramadol, opioids, or any component of the formulation; opioid-dependent
patients; acute intoxication with alcohol, hypnotics, centrally-acting analgesics, opioids, or psychotropic drugs.
Adverse Effect:
-CV: Vasodilation
-CNS: Agitation, anxiety, confusion, coordination impaired, emotional lability, euphoria, hallucinations, malaise,
nervousness, sleep disorder, tremor
-Skin: Pruritus, rash
-Endocrine & metabolic: Menopausal symptoms

Generic Name: Diclofenac Sodium


Brand Name: Lofenax® [amp]
Dosage: 1 amp Intramuscular every 8hr
Classification: Nonsteroidal Anti-inflammatory Drugs (NSAID’s)
Action: Diclofenac has potent anti-inflammatory, analgesic and antipyretic actions. It inhibits the enzyme,
cyclooxygenase, thus resulting in reduced synthesis of prostaglandin precursors.
Indication: Acute treatment of mild to moderate pain.
Adverse Effect:
-CNS: Dizziness, nervousness, headache
-Nervous System: Anxiety, asthenia, confusion, depression, dream abnormalities, drowsiness, insomnia, malaise,
nervousness, paresthesia, somnolence, tremors, vertigo
-Cardiovascular System: Congestive heart failure, hypertension, tachycardia, yncope
-Respiratory System: Asthma, dyspnea
-Digestive System: Dry mouth, esophagitis, gastric/peptic ulcers, gastritis, gastrointestinal bleeding, glossitis,
hematemesis, hepatitis, jaundice
-Hemic and Lymphatic System: Ecchymosis, eosinophilia, leukopenia, melena, purpura, rectal bleeding, stomatitis,
thrombocytopenia
Contraindications: Hypersensitivity to diclofenac, any component, aspirin or other nonsteroidal anti inflammatory
drugs (NSAID’s).

Generic Name: Methergine


Brand Name: Methylergonovine maleate
Dosage: 1 ml amp IV push
Action: Increases motor activity o the uterus by direct stimulation of the smooth muscle, shortening the third stage of
labor and reducing blood loss.
Adverse Effect:
-CNS: dizziness, headache, seizures, hallucinations, CVA with I.V use
-CV: hypertension, transient chest pain, palpitations, hypotention, thrombophebitis.
-EENT: tinnitus, nasal congestion
-G.I: nausea, Vomiting, diarrhea, foul taste
-G.U: hematuria
-Musculoskeletal: leg cramps
-Respiratory: dyspnea
-Skin: diaphoresis
Contraindication: Contraindicated in pregnant patients, in patients sensitive to ergot preparations, and in patients
with hypertension or toxemia.

Generic name: Oxytocin


Brand name: Pitocin
Action: Antihemorrhagic (e.g uterine bleeding) ,to induce labor, strengthen labor contractions during childbirth,
control bleeding after childbirth, or to induce an abortion, used for purposes other than those listed in this medication
guide.
Dosage: 20 units incorporated in 1l of D5LRS
Adverse effect:
-Respiratory: Pulmonary Arterial Pressure Increased
-CV: Right Atrial Pressure Increased, Hypotension, Acute Right Ventricular Failur, Haemodynamic Instability
Contraindication: Hypersensitivity to oxytocin or any component of the formulation; significant cephalopelvic
disproportion; unfavorable fetal positions; fetal distress; hypertonic or hyperactive uterus; contraindicated vaginal
delivery (invasive cervical cancer, active genital herpes, prolapse of the cord, cord presentation, total placenta previa,
or vasa previa).
Nursing consideration
1. Use with extreme caution during first and second stages of labor because cervical laceration, uterine rupture and
maternal and fetal death have been reported.
2. Use with extreme caution, if at all, in patience with invasive cervical cancer and in those with previous cervical and
uterine surgery (including cesarean section), grand multiparity, uterine sepsis, traumatic delivery, over distended
uterus.
3. Drug is not recommended for routine IM use. However, 10 units maybe given IM after delivery of placenta to
control post partum uterine bleeding.
4. Never give oxytocin simultaneously by more than route.
5. Monitor fluid intake and output. Antidiuretic effect may lead to fluid overload, seizures and coma from water
intoxication.
6. Monitor and record uterine contractions, heart rate, blood pressure, intrauterine pressure, fetal heart rate, and
character of blood loss every 15 miinutes.
Patient teaching:
1. Explain use and administration of drug to patient and family.
2. Instruct patient to report adverse reactions promptly.

Generic name: Ephedrine Sulfate


Brand name: Pretz – D
Action: Relaxes bronchial smooth muscle by stimulating Beta 2 Receptors; also, stimulates Alpha and Beta receptors
and is a direct – and indirect acting sympatho mimetic .
Dosage: 50 mg/ml IV 1ml amp
Adverse effect:
-CNS: Insomnia, nervousness, dizziness, headache, muscle weakness, euphoria, confusion, delirium, tremor, cerebral
hemorrhage,
-CV: Palpitations, tachycardia, hypertension, precordial pain, arrythmias.
-EENT: Dry nose and throat.
-GI: Nausea, vomiting, anorexia.
-GU: Urine retention, painful urination caused by visceral sphincter spasm.
-Skin: Diaphoresis
Contraindication: Contraindicated in patients hypersensitive to ephedrine and other sympatho mimetics and in those
with porphyria, severe coronary disease, arrhythmias, angle closure glaucoma, psychoneurosis, angina pectoris,
substantial organic heart disease or CV disease. Also, contraindicated in those receiving MAO Inhibitors or General
Anesthesia with cyclopropane or halothane.
Nursing consideration:
1. Use with extreme caution in elderly patients and in those with hypertension, hyperthyroidism, nervous are excitable
states, diabetes or prostatic hyperplasia.
2. To prevent insomnia, avoid giving drug during bedtime.
3. Alert, hypoxia, hypercapnea, and acidosis must be identified and corrected before or dring ephedrine therapy
because they may reduce effectiveness or increase adverse reacrtions.
Patient teaching:
1. Tell patient oral form of drug at home to take last dose of day at least two hours before bedtime.
2. Warn patient not to take OTC drugs or herbs that contain ephedrine without consulting prescriber.

Generic Name: Nalbuphine


Brand Name: Nubain
Action: Treating and preventing moderate to severe pain. It can also be used for pain relief before and after surgery
and during childbirth. It may also be used for other conditions as determined by your doctor.
Dosage: 10 mg/ml1ml amp
Adverse Reaction:
Skin: rash; hives;
Respiratory: difficulty breathing; tightness in the chest
Face: swelling of the mouth, face, lips, or tongue
GU: difficulty urinating
CNS: fainting; numbness of an arm or leg; seizures; severe headache, dizziness
CV: slow heartbeat
Contraindication:
1. allergic to any ingredient in Nubain or to another opioid analgesic (eg, morphine or hydromorphone)
2. diarrhea due to poisoning, a certain type of bowel problem (pseudomembranous colitis), or are dependent on any
medicine or substance
3. taking sodium oxybate (GHB)

Generic Name: Midazolam


Brand Name: Midazolam HCl
Action: intravenously for induction of general anesthesia, before administration of other anesthetic agents. With the
use of narcotic premedication, induction of anesthesia can be attained within a relatively narrow dose range and in a
short period of time. Intravenous midazolam can also be used as a component of intravenous supplementation of
nitrous oxide and oxygen (balanced anesthesia);
Dosage: 5 mg/ml1ml amp IV
Adverse Reaction:
Body as a Whole: Throat and chest pain.
-CNS: Drowsiness, fatigue, ataxia, confusion, paradoxic rage, dizziness, vertigo, amnesia, vivid dreams, headache,
slurred speech, tremor; EEG changes, tardive dyskinesia.
-CV: Hypotension, tachycardia, edema, cardiovascular collapse.
Special Senses: Blurred vision, diplopia, nystagmus.
-GI: Xerostomia, nausea, constipation, hepatic dysfunction. GU: Incontinence, urinary retention, gynecomastia
(prolonged use), menstrual irregularities, ovulation failure.
-Respiratory: Hiccups, coughing, laryngospasm.
Other: Pain, venous thrombosis, phlebitis at injection site.
Contraindication:
Injectable form: Shock, coma, acute alcohol intoxication, depressed vital signs, obstetrical patients, infants <30 d of
age.
Tablet form: Infants <6 mo of age, acute narrow-angle glaucoma, untreated open-angle glaucoma; during or within 14
d of MAO inhibitor therapy. Safe use during pregnancy (category D) and lactation is not established.

Nursing Intervention: Monitor for adverse reactions. Most are dose related. Observe patient closely and monitor vital
signs when Midazolam is given parenterally; hypotension, muscular weakness, tachycardia, and respiratory depression
may occur. Monitor I&O ratio, including urinary and bowel elimination.

EVALUATION:
After the surgery, there are no untoward situations that took place. The final BP taken is 120/80 and
there are no difficulties of breathing. Mother is transferred to OB ward via stretcher.
CASE STUDY

ON

CAESAREAN
SECTION

SUBMITTED BY:
ALUSEN, Abner
AMORIN, Ria Joy
CAIREL, Grace Ann Kelly
CASAMIS, Bernard James
DANAO Angelito
GALINO, Eduard
MEANA, Priscila
MONTEMAYOR, Jinky
NAVARRO, Jemarie Grace A.
RIMORIN, Jannil
RUNATAY, Jobert
SAGUN, Jefferson

Clinical Instructor:
MR. Gar-re Garcia RN