Andres Bonifacio College

School of Nursing

College Park, Dipolog City

CARE OF PATIENT WITH PREGNANCY UTERINE

DELIVERED BY PRIMARY CS SECONDARY TO CEPHALOPELVIC DISPROPORTION

SUBMITTED BY: SUBMITTED TO:

Liza Marie Nayre Mrs. Julyn Marie A. Gallardo RN, MN.

Thrizsa Cathlyn Ashley M. Legados Clinical Instructor

Regene Balancar

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Learning Objectives:
General Objectives:
At the end of the Case Presentation, the Learners shall improve their understanding, enhance their knowledge and manifest desirable attitude in
providing immediate and holistic care to patients with pregnancy uterine delivered by primary cs secondary to cephalopelvic disproportion.

Specific Objectives:
Within 1 hour of discussion, the listeners will be able to:

1. Identify what is cesarean section and cephalopelvic disproportion

2. Identify why might anyone need a c-section.
3. Identify risks of c-section.
4. Identify ways on how to gert ready for c-section.
5. Discuss what to expect before, during and after the procedure.
6. Discuss the disease process and its Pathophysiology effectively.
7. Identify and discuss its appropriate management effectively.

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 Table of Contents

I. Learning Objectives --------------------------------------------------------- 2

II. Introduction --------------------------------------------------------- 4 -5
III. Anatomy and Physiology --------------------------------------------------------- 6-9
IV. Patient’s Profile --------------------------------------------------------- 10
V. Laboratory result --------------------------------------------------------- 11-13
VI. Gordon’s 11 Functional Health Pattern --------------------------------------------------------- 14 - 17
VII. Physical Assessment --------------------------------------------------------- 18 - 20
VIII.Pathophysiology --------------------------------------------------------- 21
IX. Nursing care plan --------------------------------------------------------- 22 - 27
X. Drug Study --------------------------------------------------------- 28 - 36
XI. References ---------------------------------------------------- 37

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 INTRODUCTION
Caesarean section, also known as C-section, or caesarean delivery, is the surgical procedure by
which one or more babies are delivered through an incision in the mother's abdomen, often performed
because vaginal delivery would put the baby or mother at risk. Reasons for the operation
include obstructed labor, twin pregnancy, high blood pressure in the mother, breech birth, and
problems with the placenta or umbilical cord. A caesarean delivery may be performed based upon the
shape of the mother's pelvis or history of a previous C-section. A trial of vaginal birth after C-
section may be possible. The World Health Organization recommends that caesarean section be
performed only when medically necessary. Some C-sections are performed without a medical reason,
upon request by someone, usually the mother.

A C-section typically takes 45 minutes to an hour. It may be done with a spinal block, where the woman is awake, or under general anesthesia.
A urinary catheter is used to drain the bladder, and the skin of the abdomen is then cleaned with an antiseptic. An incision of about 15 cm (6 inches) is
then typically made through the mother's lower abdomen. The uterus is then opened with a second incision and the baby delivered. The incisions are
then stitched closed. A woman can typically begin breastfeeding as soon as she is out of the operating room and awake. Often, several days are required
in the hospital to recover sufficiently to return home.

Cephalopelvic disproportion (CPD) is a condition where the baby’s head or body is too large to fit through the
mother’s pelvis. This can happen when the baby is too big, the pelvis is too small, the baby is in a wrong position,
or the relationship between the baby and the pelvis is incorrect even though the baby is not too big and the pelvis is
not too small. Cephalopelvic disproportion is rare, but often diagnosed when a women’s  labor fails to progress, the

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cervix has stopped dilating, or the baby does not descend through the pelvis. When an accurate diagnosis of CPD has been made, the safest type of
delivery for mother and baby is a cesarean.

WHY IT’S DONE

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).
 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.
 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.

RISK FACTORS

Like other types of major surgery, C-sections also carry risks.

Risks to your baby include:

 Breathing problems. Babies born by scheduled C-section are more likely to develop transient tachypnea — a breathing problem marked by
abnormally fast breathing during the first few days after birth.
 Surgical injury. Although rare, accidental nicks to the baby's skin can occur during surgery.

Risks to you include:

 Infection. After a C-section, you might be at risk of developing an infection of the lining of the uterus (endometritis).
 Postpartum hemorrhage. A C-section might cause heavy bleeding during and after delivery.

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  Reactions to anesthesia. Adverse reactions to any type of anesthesia are possible.
 Blood clots. A C-section might increase your risk of developing a blood clot inside a deep vein, especially in the legs or pelvic organs (deep vein
thrombosis). If a blood clot travels to your lungs and blocks blood flow (pulmonary embolism), the damage can be life-threatening.
 Wound infection. Depending on your risk factors and whether you needed an emergency C-section, you might be at increased risk of an incision
infection.
 Surgical injury. Although rare, surgical injuries to the bladder or bowel can occur during a C-section. If there is a surgical injury during your C-
section, additional surgery might be needed.
 Increased risks during future pregnancies. After a C-section, you face a higher risk of potentially serious complications in a subsequent
pregnancy than you would after a vaginal delivery. The more C-sections you have, the higher your risks of placenta previa and a condition in which
the placenta becomes abnormally attached to the wall of the uterus (placenta accreta). The risk of your uterus tearing open along the scar line from a
prior C-section (uterine rupture) is also higher if you attempt a VBAC.

CAUSES OF CPD

With true CPD, there is a mismatch in size between the mother’s pelvis and the baby’s head. This is either due to the baby being especially large or
the mother’s pelvis being especially small.

The medical term for when the fetus is overly large is fetal macrosomia. Macrosomia is defined as over 8lbs 13 oz. About 10% of pregnancies, and
50% of pregnancies with gestational diabetes, are affected by macrosomia. But how does a baby grow too big to be born vaginally? Babies can be large
for a number of reasons, including:

 Physically large or obese parents (hereditary factors)

 Mothers with diabetes or gestational diabetes

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 Having a male vs. a female baby

 Post-term pregnancy (baby still hasn’t been born past due date)

It is also possible for mothers to have small or abnormally shaped pelvises. This occurs because of a prior injury to the pelvis or genetic factors.
Adolescents and shorter women are more likely to experience this problem. An injury or malformation of the pelvis can also affect childbirth. The pelvis
may be misshapen, have bony growths, or have a bone out of place.

Other risk-factors include polyhydramnios (excess amniotic fluid) and multiparity (having given birth previously, either vaginally or by c-section).

HOW IS CPD DIAGNOSED AND TREATED

Obstetricians can use radiologic pelvimetry, a type of imaging technology that measures the dimensions of the mother’s pelvis, to predict or confirm
CPD. Ultrasounds can be used to estimate the size of the baby’s head. However, studies have found a poor correlation between the use of imaging
technologies and labor outcomes.

This is because the bones in the baby’s head are meant to change shape in order to pass through the birth canal. Many petite mothers carrying babies
with heads that appear large are still able to successfully deliver vaginally. Additionally, imaging technologies are not as precise as obstetricians would
like. They can only estimate the baby’s size, not measure it exactly.

Given these circumstances, doctors do not necessarily schedule a c-section in advance just because a baby looks large or a mother’s pelvis seems
small. A c-section may not be indicated unless it is obvious that the baby will be too big for the mother to deliver vaginally or there is some other
complication with the pregnancy such as a prior pelvic injury. What this means is that CPD is often diagnosed during labor, not before.

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 During labor, doctors monitor the position of the baby in the birth canal, uterine contractions, and the dilation of the cervix. When doctors see that the
baby is not moving through the birth canal as expected, they may administer a drug such as oxytocin to stimulate labor. If the labor is still slow or if labor
becomes completely obstructed, doctors will perform an emergency c-section to deliver the baby. If they don’t promptly perform a c-section, the baby
may suffer from oxygen deprivation, which can cause a number of birth injuries, including cerebral palsy.

How to prepare for C-Section

 Your healthcare provider will explain the procedure to you and you can ask question.

 You will be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is
unclear.

 You will be asked when you last had anything to eat or drink. If your C-section is planned and requires general, spinal, or epidural anesthesia, you
will be asked to not eat or drink anything for 8 hours before the procedure.

 Tell your healthcare provider if you are sensitive to or are allergic to any medicine, latex, iodine, tape, or anesthesia.

 Tell your healthcare provider of all medicine (prescription and over-the-counter), vitamins, herbs, and supplements that you are taking.

 Tell your healthcare provider if you have a history of bleeding disorders or if you are taking any blood-thinning medicines (anticoagulants), aspirin, or
other medicines that affect blood clotting. You may be told to stop these medicines before the procedure.

 You may be given medicine to decrease the acid in your stomach. These also help dry the secretions in your mouth and breathing passages.

 Plan to have someone stay with you after a C-section. You may have pain in the first few days and will need help with the baby.

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 Follow any other instructions your provider gives you to get ready

PATIENT’S PROFILE
Name: Patient X
Age: 30 years old Allergies:
Gender: Female
 Plaster
Civil status: Married Past health History
Address: Punta, Dipolog City, Zamboanga del Norte
 None
Date of birth: February 7, 1991 Chief of Complaint:
Place of Birth: Dipolog City
“Sakit kaayo ang part sakong tiyan, likod ug balakang ug naa koy
Religion: Catholic nabatiang contactions.” as verbalized by the patient.
Nationality: Filipino
Family health history
Ward: OB- Gyne Ward
 Cardiovascular disease (Father side)
Education: 2nd year College (HRM)
Present health history
 Watery vaginal discharge 1 hour PTA
 Labor pains

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11
12
13
14
 GORDON’S 11 TYPOLOGY OF HEALTH PATTERNS

USUAL INITIAL ONGOING

I. HEALTH PERCEPTION /  Received patient sitting on chair awake, and  Patient still stting on chair awake and
HEALTH PATTERN oriented to time. Verbalized “Isa ra ka oras responsive
 Haven’t been hospitalized before. akong tulog kay nag akatar ko sakong anak”  Verbalized “kulang gihapon ko’g tulog.”
 Patient has an allergy to plaster.
 Patient seek medical help Vital signs
Vital Signs 8:00 AM 12:00
 Patient’s does not smoke and Vital Signs 8:00 AM 12:00
drink’s occassionally. PM
PM (November 9, 2021)
(November 9, 2021)
Temperature 37. 3◦c 36. 7◦c
Temperature 36. 5 ◦c 36.3 ◦c
Respiration 19 cpm 20 cpm
Respiration 20 cpm 21 cpm
Pulse Rate 89 bpm 95 bpm
Pulse Rate 85 bpm 90 bpm
BP 120/80 120/80
BP 110/80 120/80
mmHg mmHg
mmHg mmHg

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  Water consumption 6 glasses a day
 Takes vitamins C or multivitamins,
ferrous and calcium

 Water consumption 8 glasses a day

 Has good appetite

II. NUTRITIONAL-
METABOLIC PATTERN
 Patient has no difficulty
swallowing and drinking.
 Patient eats rice, meat and
vegetables
 Patient does not smoke but  Defecates for only once a day
occassionally drinks alcohol  Urinates 4 times a day, yellowish urine color
 Water consumption 8-10 glasses
a day
 No food restrictions and allergies
 Takes vitamins C or
multivitamins

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  Patient was admitted in the hospital for  Defecates for only once a day
recovery thus her daily activities were  Urinates 4 times a day, yellowish urine color
III. ELIMINATION PATTERN altered
 Defecates once a day
 Urinates 5 times a day, yellowish
urine color
 No blood, fats or pus noted in the
feces

IV. ACTIVITY-EXERCISE
PATTERN
 Patient likes to walk every
morning
 Plays volleyball  Lack of sleep due to parent-infant
 Likes to decorate interaction.  Patient was admitted in the hospital for
recovery thus her daily activities were altered

V. SLEEP- REST PATTERN

 Wakes up early at 6:00 am and
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 sleep at 10:00 pm or 11:00 pm  Married Lack of sleep due to parent-infant interaction.
 Does not use any sleeping aids

VI. ROLE/RELATIONSHIP

 Does not use pills

 She lives with her family
 Married

 Married
VII. SEXUALITY AND
REPRODUCTIE

 Does not use pills

 Does not use pills

VIII. COGNITIVE-PERCEPTUAL
PATTERN
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  Oriented to time, place, date and
previous events.
 Able to understand and express
his feelings well.
 No problem with senses
 Oriented with previous events
 Alert and responsive
 GCS: 15

VIII. SELF-PERCEPTION-SELF
CONCEPTUAL PATTERN

 The patient describes herself as a

happy person.

X. COPING – STRESS
TOLERANCE PATTERN  Doesn’t have any problems about her
 Verbalization of feelings perception about her self
 No problem with senses
 Oriented with previous events
 Alert and responsive

XI..VALUES-BELIEFS PATTERN
 Religion: Catholic
 Sometimes go to church  Share his concerns to her sister

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  Doesn’t have any problems about her
perception about her self
 Religion: Catholic
 Sometimes go to church

 Share his concerns to her sister

 Religion: Catholic
 Sometimes go to church


PHYSICAL ASSESSMENT  Admitted at Ob-gyne ward, 30 years old, sitting on chair awake,
and oriented to time. Verbalized “Isa ra ka oras akong tulog kay
nag akatar ko sakong anak”
GENERAL APPEARANCE  Post-op cesarean section
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 Inspection
1. VITAL SIGNS  Black in color and distributed well
Vital Signs 8:00 AM 12:00  Hair is straight
(November 9, 2021) PM
Temperature 38. 5 ◦c 36.3 ◦c  NAILS
Respiration 20 cpm 21 cpm Inspection
Pulse Rate 85 bpm 90 bpm  Short nails
BP 110/80 120/80  clean in appearance
mmHg mmHg  No clubbing of fingers
Palpation
1. INTEGUMENTARY SYSTEM  Return to usual color after 2 seconds (Blanch Test)
 SKIN
Inspection
 Generally brown skin color
2. HEAD AND NECK
 Skin appears dry.
 HEAD
 Has 2 moles on face.
Inspection
 Erythema and redness noted in the IV site.
 Symmetrical to facial features
 Head is still and upright in position
Palpation  Eyelids and eyebrows are symmetrical
 Skin is warm to touch
 Cranial Nerve Assessment (Facial)
 No pain upon palpation
Inspection
 Good skin turgor
 Facial features are round
 No lesions, edema, lumps, and masses when palpated
 Eye brows are symmetrical
 Skin is slightly dry
 Eyelids are symmetrical
 HAIR
Palpation
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 No pain noted on the upon palpation  MOUTH
Inspection
 EYES  Lips are symmetric, dry
Inspection
 Eyes are aligned to each other and sclera is white  NECK
 Each pupil constricts when looking or reflected by a light Inspection
 Eyeballs are aligned normally in the sockets  Neck is symmetrical without bulging masses
 Eyelids are symmetrical  Neck movement is smooth
 Dark circles under eyes.  Comfortably moves the neck

 ABDOMEN
 Uterine contraction noted
 EARS
Inspection
MUSCULOSKELETAL SYSTEM
 Symmetrical, aligned at the outer canthus of the eye Inspection
 Ears are equal in size  Only lies or sits in bed
 Few cerumen noted in both left and right ear  Posture is erect and comfortable for age
 Movements are coordinated
 Muscle weakness
 NOSES AND SINUSES
Inspection NEUROLOGICAL SYSTEM
 Color of the external nose is same as the rest of the face Inspection
 Nasal structure is smooth and symmetric  cooperates on assessment
 Color is the same as the facial skin
 Nasal septum positioned at the center GENITOURINARY SYSTEM
 Output: Urine: 4 Stool: 1
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 PATHOPHYSIOLOGY

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE DATA: Acute pain After 8 hours of INDEPENDENT: After 8 hours of
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  “sakit nalang gamay ang  related to nursing 1. Asses the patient’s  Assist in nursing intervention
tinahian sa akong tiyan agi kay surgical interventions, there pain, including the differentiating goals were:
incision as
gi cesarean ko” as verbalized will be relief of pain location, cause of pain and
manifested by 1. Met, patient reports
by the patient. slightly as evidenced by: characteristics, provides
satisfactory pain
 Rated pain as 6/10 on a pain weakness and a precipitating information
control at a level of
scale of 0 as no pain and 10 as pain rating 1. Patient will factors, onset, about disease
scale of 6 out of 2 to 4 on a scale of
the most painful. report duration, progression,
10. 0-10
satisfactory frequency, quality, development of
  2. Met, Patient uses
OBJECTIVE DATA: pain control intensity and complication and
pharmacological
 Slight weaknesss noted at a level of 2 severity effectiveness of
and non-
Vital Signs 8:00 AM 12:00 to 4 on a scale (COLDSPA) intervention.
pharmacological
(November 9, 2021) PM of 0-10
pain relief
Temperature 39. 5 ◦c 36.3 ◦c 2. Patient uses
measures.
Respiration 20 cpm 21 cpm pharmacologi  When you’re
Pulse Rate 85 bpm 90 bpm cal and non- properly rested,
BP 110/80 120/80 pharmacologi 2. Promote bed rest you’re more alert
cal pain relief and in low fowler’s
mmHg mmHg and able to
measures. position.
properly care for
your baby and
yourself. Energy
is allocated
towards healing
your body.

3. Encourage the use

of relaxation
technique such as  May enhance
breathing coping
exercises.

4. Note location of
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 surgical procedure.  This can
influence the
amount of
postoperative
pain experienced.

 Alleviate
5. Encourage anxiety.
verbalization of
feelings about the
pain.

DEPENDENT:  Used to relieve

 Administer pain.
celecoxib as
prescribed by the
physician.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE DATA: Impaired skin After 8 hours of INDEPENDENT: After 8 hours of
 “Murag nanghubag ug nag pula integrity nursing nursing intervention
 related to
akong kamot agi sa pag taod interventions, the goals were:
contact with 1. Acknowledge
nilag IV naa man diay koy allergens as patient will be able  AssAllow  Patient reported
allergy sa plaster.” as manifested by to display patient’s feeling. patient to increased comfort
verbalized by the patient. itchiness and improvement of verbalize feelings level and skin
erythema wound healing as regarding skin remains intact
OBJECTIVE DATA:   evidenced by: condition.  Patient remained
2. Encourage proper
 erythema noted hygiene. free of secondary
 Itchiness noted 1. Patient reports  Encourage infection.
increased patient to keep
Vital Signs 8:00 AM 12:00 comfort level skin clean, dry
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(November 9, 2021) PM and skin and well
Temperature 40. 5 ◦c 36.3 ◦c remains intact. lubricated to
Respiration 20 cpm 21 cpm 2. Patient remains reduce skni
Pulse Rate 85 bpm 90 bpm free of trauma and risk
BP 110/80 120/80 secondary for infection.
mmHg mmHg infection. 3. Encourage the
patient to bathe in
warm water using  Long bathing or
mild soap, the air showering causes
dry the skin and drying and can
gently pat to dry. aggreviate
itching through
vasodilation.
Rubbing the skin
with a towel can
irritate the skin.

 Reduce
4. Use topical inflammation and
application. Usual promte healing
application of of the skin.
topical steroids
creams or
oitnments twice a  Some change in
day, spread thinly lifestyle may be
and sparingly. indicated to
reduce triggers.
5. Encourage the  A broad
patient to avoid spectrum
aggravating antibiotic, which
factors. means that it is
active against a
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 wide variety of
DEPENDENT: bacteria. It is
 Administer used to treat
cefuroxime as bacterial
prescribed by the infections such
physician. as skin
infections.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE DATA: Disturbed After 8 hours of INDEPENDENT: After 8 hours of
 “Isa ra ka oras akong tulog kay sleep pattern nursing nursing intervention
 related to
nag akatar ko sakong anak.” as interventions, there 1. Observe parent-infant goals were:
parent-infant
verbalized by the patient. will be relief of pain interactions/provisions  Lack of
interaction as  Identified
manifested by as evidenced by: of emotional support. knowledge of
Note mother’s sleep- individually
OBJECTIVE DATA: frequent infant
yawning, dark wake pattern. appropriate
 Yawning 1. Identify cues/problem
circles under interventions to
 Dark circles under eyes individually relationship may
eyes. promote sleep.
appropriate create tension
   Reported
Vital Signs 8:00 AM 12:00 interventions to interfeing with
improvement in
(November 9, 2021) PM promote sleep. 2. Suggest an sleep.
sleep/rest
Temperature 41. 5 ◦c 36.3 ◦c 2. Report environment
pattern.
Respiration 20 cpm 21 cpm improvement in conducive to rest or  A lot of people  Reported
Pulse Rate 85 bpm 90 bpm sleep/rest sleep. slpeep better in increased sense
BP 110/80 120/80 pattern. cool, dark, quiet of well-being
mmHg mmHg 3. Report increased environment. and feeling
sense of well-
rested.
being and 3. Explore other sleep
feeling rested. aids (warm bath/milk
before bed time. )

4. Provide for child’s  L-tryptophan is a

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 sleeptime safety. milk which
( infant placed on promotes sleep.
back, bedrails/ bed in
low position,
nonplastic sheets.)
5. Instruct the patient to  To ensure safety
follow a consistent of the baby.
daily schedule for
sleep and rest.

 Consistent
schedules
facilitate
regulation of the
circadian rhythm
and decrease the
energy needed
for adaptation to
changes.

CEFTRIAXONE/Rocephin
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Third Generation Cephalosporin Frequent: Discomfort with IM administration, oral candidiasis
(thrush), mild diarrhea, mild abdominal cramping, vaginal candidiasis.
ACTION Occasional: Nausea, serum sickness-like reaction (fever, joint pain;
Binds to bacterial cell membranes, inhibits cell wall synthesis. usually occurs after second course of therapy and resolves after drug is
Therapeutic Effect: Bactericidal discontinued). Rare: Allergic reaction (rash, pruritus, urticaria),
thrombophlebitis (pain, redness, swelling at injection site).

USES
Treatment of susceptible infections due to gram-negative aerobic
organisms, some gram-positive organisms including respiratory tract, GU tract,
skin and skin structure, bone and joint, intra-abdominal, pelvic inflammatory
disease (PID), biliary tract/urinary tract infections; bacterial septicemia,
meningitis, perioperative prophylaxis, acute bacterial otitis media.
ADVERSE EFFECTS/ TOXIC REACTIONS
Antibiotic-associated colitis, other superinfections (abdominal cramps,
severe watery diarrhea, fever) may result from altered bacterial balance.
Nephrotoxicity may occur, esp. in pts with preexisting renal disease. Pts with
history of penicillin allergy are at increased risk for developing a severe
hypersensitivity reaction (severe pruritus, angioedema, bronchospasm,
anaphylaxis).

CONTRAINDICATIONS

History of hypersensitivity/anaphylactic reaction to NURSING CONSIDERATIONS BASELINE ASSESSMENT Obtain CBC,

cephalosporins. Hyperbilirubinemic neonates, esp. premature infants, renal function tests. Question for history of allergies, particularly
should not be treated with ceftriaxone (can displace bilirubin from its cephalosporins, penicillins.
binding to serum albumin, causing bilirubin encephalopathy).

INTERVENTION/EVALUATION
PHARMACOKINETICS
Widely distributed including to CSF. Protein binding: 83%–96%.
Primarily excreted unchanged in urine. Not removed by hemodialysis.
Half-life: IV: 4.3–4.6 hrs; IM: 5.8–8.7 hrs (increased in renal impairment).
SIDE EFFECTS
Assess oral cavity for white patches on mucous membranes,
tongue (thrush). Monitor daily pattern of bowel activity, stool
consistency. Mild GI effects may be tolerable (increasing severity may
indicate onset of antibiotic-associated colitis). Monitor I&O, renal
function tests for nephrotoxicity, CBC. Be alert for superinfection: fever,
vomiting, diarrhea, anal/ genital pruritus, oral mucosal changes
(ulceration, pain, erythema)

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CELECOXIB/Celebrex
NSAID

ACTION

Inhibits cyclooxygenase-2, the enzyme responsible for prostaglandin synthesis.

Therapeutic Effect: Reduces inflammation, relieves pain.

USES

Relief of signs/symptoms of osteoarthritis, rheumatoid arthritis ADVERSE EFFECTS/ TOXIC REACTIONS

(RA) in adults. Treatment of acute pain, primary dysmenorrhea. Relief of
signs/symptoms associated with ankylosing spondylitis. Treatment of Increased risk of cardiovascular events, (MI, CVA), serious,
juvenile rheumatoid arthritis (JRA). potentially lifethreatening GI bleeding.

CONTRAINDICATIONS

Hypersensitivity to aspirin, NSAIDs, sulfonamides. Treatment of
perioperative pain in coronary artery bypass graft (CABG) surgery.
Cautions: History of GI disease (bleeding/ ulcers); concurrent use with
aspirin, anticoagulants; smoking, alcohol, elderly, debilitated pts,
asthma, renal/hepatic impairment.
PHARMACOKINETICS
Rapidly absorbed from GI tract. Widely distributed. Protein
binding: 97%. Metabolized in liver. Primarily eliminated in feces. Half-
life: 11.2 hrs.
NURSING CONSIDERATIONS BASELINE ASSESSMENT Assess onset,
type, location, duration of pain/inflammation. Inspect appearance of affected
joints for immobility, deformity, skin condition. Assess for allergy to sulfa,
aspirin, or NSAIDs (contraindicated). cephalexin 237 Canadian trade name
Non-Crushable Drug High Alert drug C INTERVENTION/EVALUATION Assess
for therapeutic response: pain relief; decreased stiffness, swelling; increased
joint mobility; reduced joint tenderness; improved grip strength. Observe for
bleeding, bruising, weight gain.

SIDE EFFECTS

Frequent (16%–5%): Diarrhea, dyspepsia, headache, upper

respiratory tract infection. Occasional (less than 5%): Abdominal pain,
flatulence, nausea, back pain, peripheral edema, dizziness, insomnia,
rash.

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RANITIDINE/Zantac
Histamine H2 receptor antagonist.
ACTION
Inhibits histamine action at histamine 2 receptors of gastric
parietal cells. Therapeutic Effect: Inhibits gastric acid secretion.
Reduces gastric volume, hydrogen ion concentration of gastric juice.
USES
Short-term treatment of active duodenal ulcer. Prevention of
duodenal ulcer re currence. Treatment of active benign gastric ulcer,
pathologic GI hypersecretory conditions, acute gastroesophageal reflux
disease (GERD), including erosive esophagitis. Maintenance of healed
erosive esophagitis. Part of regimen for H. pylori eradication to reduce
risk of duodenal ulcer recurrence.
Contraindications:
None known. Cautions: Renal/hepatic impairment, elderly, history
of acute porphyria.
PHARMACOKINETICS
Rapidly absorbed from GI tract. Protein binding: 15%. Widely
distributed. Metabolized in liver. Primarily excreted in urine. Not
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removed by hemodialysis. Half-life: PO: 2.5 hrs; IV: 2–2.5 hrs (increased
with renal impairment).
SIDE EFFECTS
Occasional (2%): Diarrhea. Rare (1%): Constipation, headache
(may be severe). ADVERSE EFFECTS/ TOXIC REACTIONS
Reversible hepatitis, blood dyscrasias occur rarely.
NURSING CONSIDERATIONS BASELINE ASSESSMENT Obtain history
of epigastric/abdominal pain. Obtain baseline renal function, LFT.
INTERVENTION/EVALUATION
Monitor serum ALT, AST levels, BUN, creatinine. Assess mental
status in elderly. Question present abdominal pain, GI distress.
PATIENT/FAMILY TEACHING
• Smoking decreases effectiveness of medication.
• Do not take medicine ranolazine 1063 Canadian trade name Non-Crushable
Drug High Alert drug R within 1 hr of magnesium- or aluminumcontaining
antacids.
• Transient burning/ pruritus may occur with IV administration.
• Report headache.
• Avoid alcohol, aspirin.

CEFUROXIME/Ceftin

Secondgeneration cephalosporin SIDE EFFECTS

Frequent: Discomfort with IM administration, oral candidiasis

(thrush), mild diarrhea, mild abdominal cramping, vaginal candidiasis.
ACTION Occasional: Nausea, serum sickness–like reaction (fever, joint pain;
celecoxib 235 Canadian trade name Non-Crushable Drug High Alert
Binds to bacterial cell membranes, inhibits cell wall synthesis.
drug C usually occurs after second course of therapy and resolves after
Therapeutic Effect: Bactericidal.
drug is discontinued). Rare: Allergic reaction (rash, pruritus, urticaria),
USES thrombophlebitis (pain, redness, swelling at injection site)

Treatment of susceptible infections due to group B streptococci,
pneumococci, staphylococci, H. influenzae, E. coli, Enterobacter,
Klebsiella including acute/ chronic bronchitis, gonorrhea, impetigo, early
Lyme disease, otitis media, pharyngitis/tonsillitis, sinusitis, skin/skin
structure, UTI, perioperative prophylaxis.
Contraindications:
History of hypersen sitivity/anaphylactic reaction to
cephalosporins. Cautions: Severe renal impairment, history of penicillin
allergy.
PHARMACOKINETICS
Rapidly absorbed from GI tract. Protein binding: 33%–50%.
Widely distributed including to CSF. Primarily excreted unchanged in
urine. Moderately removed by hemodialysis. Half-life: 1.3 hrs (increased
in renal impairment).
ADVERSE EFFECTS/ TOXIC REACTIONS
Antibiotic-associated colitis, other superinfections (abdominal
cramps, severe watery diarrhea, fever) may result from altered bacterial
balance. Nephrotoxicity may occur, esp. in pts with preexisting renal
disease. Pts with history of penicillin allergy are at increased risk for
developing a severe hypersensitivity reaction (severe pruritus,
angioedema, bronchospasm anaphylaxis).
NURSING CONSIDERATIONS BASELINE ASSESSMENT Obtain CBC,
renal function tests. Question for history of allergies, particularly
cephalosporins, penicillins.
INTERVENTION/EVALUATION
Assess oral cavity for white patches on mucous membranes,
tongue (thrush). Monitor daily pattern of bowel activity, stool
consistency. Mild GI effects may be tolerable (increasing severity may

32
 indicate onset of antibiotic-associated colitis). Monitor I&O, renal
function tests for nephrotoxicity. Be alert for superinfection: fever,
vomiting, diarrhea, anal/ genital pruritus, oral mucosal changes
(ulceration, pain, erythema)
METOCLOPRAMIDE/Reglan
Dopamine receptor antagonist
ACTION
Stimulates motility of upper GI tract. Blocks dopamine/serotonin
receptors in chemoreceptor trigger zone. Enhances acetylcholine
response in upper GI tract; increases lower esophageal sphincter tone.
USES ORAL:
Symptomatic treatment of diabetic gastroparesis,
gastroesophageal reflux. IV/IM: Symptomatic treatment of diabetic
gastroparesis, placement of enteral feeding tubes, prevent/treat
nausea/vomiting with chemotherapy or after surgery
Contraindications:
Concurrent use of medications likely to produce extrapyramidal
reactions, GI hemorrhage, GI obstruction/perforation, history of seizure
disorder, pheochromocytoma. Cautions: Renal impairment, HF,
cirrhosis, hypertension, depression, Parkinson’s disease, elderly.
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PHARMACOKINETICS
SIDE EFFECTS 
ALERT Doses of 2 mg/kg or greater, or increased length of
therapy, may result in a greater incidence of side effects. Frequent
(10%): Drowsiness, restlessness, fatigue, lethargy. Occasional (3%):
Dizziness, anxiety, headache, insomnia, breast tenderness, altered
menstruation, constipation, rash, dry mouth, galactorrhea,
gynecomastia. Rare (less than 3%): Hypotension, hypertension,
tachycardia.
ADVERSE EFFECTS/ TOXIC REACTIONS
Extrapyramidal reactions occur most frequently in children,
young adults (18–30 yrs) receiving large doses (2 mg/kg) during
chemotherapy and usually are limited to akathisia (involuntary limb
movement, facial grimacing, motor restlessness). Neuroleptic malignant
syndrome (diaphoresis, fever, unstable B/P, muscular rigidity) has been
reported.
NURSING CONSIDERATIONS BASELINE ASSESSMENT Antiemetic:
Assess for dehydration (poor skin turgor, dry mucous membranes, longitudinal
furrows in tongue). Assess for nausea, vomiting, abdominal distention, bowel
sounds.
INTERVENTION/EVALUATION

Monitor for anxiety, restlessness, extrapyramidal symptoms

(EPS) during IV administration. Monitor daily pattern of bowel activity,
stool consistency. Assess skin for rash. Evaluate for therapeutic
response from gastroparesis (nausea, vomiting, bloating). Monitor renal
function, B/P, heart rate.

TRAMADOL/Ultram SIDE EFFECTS

Centrally acting synthetic opioid analgesic Frequent (25%–15%): Dizziness, vertigo, nausea, constipation,
headache, drowsiness. Occasional (10%–5%): Vomiting, pruritus, CNS
ACTION stimulation (e.g., nervousness, anxiety, agitation, tremor, euphoria,
mood swings, hallucinations), asthenia, diaphoresis, dyspepsia, dry
Binds to mu-opioid receptors, inhibits reuptake of norepinephrine,
mouth, diarrhea. Rare (less than 5%): Malaise, vasodilation, anorexia,
serotonin, inhibiting ascending and descending pain pathways.
flatulence, rash, 1240 trametinib underlined – top prescribed drug T
Therapeutic Effect: Reduces pain.
blurred vision, urinary retention/ frequency, menopausal symptoms.
USES

Management of moderate to moderately severe pain. Extended-

Release: Around-the-clock management of moderate to moderately
severe pain for extended period.
Contraindications:
Ultram, Ultram ER: Acute alcohol intoxication, concurrent use of
centrally acting analgesics, hypnotics, opioids, psychotropic drugs,
hypersensitivity to opioids. ConZip, Severe/ acute bronchial asthma,
hypercapnia, significant respiratory depression.
PHARMACOKINETICS
ADVERSE EFFECTS/ TOXIC REACTIONS
Seizures reported in pts receiving tramadol within recommended
dosage range. May have prolonged duration of action, cumulative effect
in pts with hepatic/renal impairment, serotonin syndrome (agitation,
hallucinations, tachycardia, hyperreflexia).
NURSING CONSIDERATIONS BASELINE ASSESSMENT Assess onset,
type, location, duration of pain. Assess drug history, esp. carbamazepine,
analgesics, CNS depressants, MAOIs. Review past medical history, esp.
epilepsy, seizures. Assess renal function, LFT.

34
INTERVENTION/EVALUATION Hypersensitivity to other proton pump inhibitors. Cautions: May
increase risk of fractures, gastrointestinal infections. Hepatic
Monitor pulse, B/P, renal/hepatic function. Assist with ambulation impairment, pts of Asian descent.
if dizziness, vertigo occurs. Dry crackers, cola may relieve nausea.
Palpate bladder for urinary retention. Monitor daily pattern of bowel
activity, stool consistency. Sips of water may relieve dry mouth. Assess
for clinical improvement, record onset of relief of pain. PHARMACOKINETICS

OMEPRAZOLE/Prilosec

Benzimidazole. Proton pump inhibitor

SIDE EFFECTS
ACTION
Frequent (7%): Headache. Occasional (3%–2%): Diarrhea,
Inhibits hydrogen-potassium adenosine triphosphatase (H1/K1
abdominal pain, nausea. Rare (2%): Dizziness, asthenia (loss of
ATP pump), an enzyme on the surface of gastric parietal cells.
strength, energy), vomiting, constipation, upper respiratory tract
Therapeutic Effect: Increases gastric pH, reduces gastric acid
infection, back pain, rash, cough.
production.

USES
ADVERSE EFFECTS/ TOXIC REACTIONS
Short-term treatment (4–8 wks) of erosive esophagitis (diagnosed
by endoscopy), symptomatic gastroesophageal reflux disease (GERD) Pancreatitis, hepatotoxicity, interstitial nephritis occur rarely
poorly responsive to other treatment. H. pylori–associated duodenal
ulcer (with amoxicillin and clarithromycin). Long-term treatment of
pathologic hypersecretory conditions, treatment of active duodenal ulcer
NURSING CONSIDERATION INTERVENTION/EVALUATION
or active benign gastric ulcer.
Evaluate for therapeutic response (relief of GI symptoms).
Question if GI discomfort, nausea, diarrhea occurs.
Contraindications:

35
PATIENT/FAMILY TEACHING
•  Report headache, onset of black, tarry stools, diarrhea,
abdominal pain. •  Avoid alcohol.  •  Swallow capsules whole; do not
chew, crush, dissolve, or divide.  •  Take before eating.
Contraindications: Abdominal pain, appendicitis, intestinal
obstruction, nausea, undiagnosed rectal bleeding, vomiting, pregnancy,
lactation. Cautions: Long-term use may lead to laxative dependence,
loss of normal bowel function.

PHARMACOKINETICS

BISACODYL/Dulcolax
Gi Stimulant/ Laxative

SIDE EFFECTS
ACTION Frequent: Some degree of abdominal discomfort, nausea, mild
Direct effect on colonic smooth musculature by stimulating intramural nerve cramps, faintness. Occasional: Rectal administration: burning of rectal
plexi. Therapeutic Effect: Promotes fluid and electrolyte accumulation in colon, mucosa, mild proctitis.
increasing peristalsis, producing laxative effect.

ADVERSE EFFECTS/ TOXIC REACTIONS

USES
Treatment of constipation,
examinations or procedures.
Long-term use may result in laxative dependence, chronic
colonic evacuation before constipation, loss of normal bowel function. Overdose may result in
electrolyte or metabolic disturbances (hypokalemia, hypocalcemia,
metabolic acidosis, alkalosis), persistent diarrhea, vomiting, muscle
weakness, malabsorption, weight loss

PRECAUTIONS

36
NURSING CONSIDERATIONS BASELINE ASSESSMENT Observe
evidence of constipation. Assess pattern of bowel activity, stool consistency.
INTERVENTION/EVALUATION
Encourage adequate fluid intake. Assess bowel sounds for
peristalsis. Monitor daily pattern of bowel activity, stool consistency;
record time of evacuation. Assess for abdominal disturbances. Monitor
serum electrolytes in those exposed to prolonged, frequent, or
excessive use of medication.
RELATED ARTICLE
A Case of Vaginal Birth after Cesarean Delivery in a Patient with Uterine
Didelphys
Received05 Sep 2019
for A 32-year-old gravida-2 para-1 female at 12 1/7 weeks of gestation presented
to the office to establish prenatal care. The patient had a history of known
uterine didelphys, with confirmation of two uteri, two cervixes, a vertical vaginal
septum, and a normal renal system on magnetic resonance imaging. Her
obstetrical history was significant for a prior low-transverse CD at 35 1/7 weeks
for preterm labor with a fetus in the breech presentation in the left uterine horn
three years prior. The current pregnancy was also located in the left horn. The
patient declined cervical length screening and 17-alpha hydroxyprogesterone
caproate for her history of preterm labor. She had an otherwise uncomplicated
pregnancy, and at 32 0/7 weeks of gestation, a growth ultrasound showed that
the fetus was growing well at the 51st percentile for weight. She was
extensively counseled throughout her pregnancy on TOLAC versus repeat CD,
and the patient decided to proceed with TOLAC.
At 38 3/7 weeks of gestation, the patient presented to labor and delivery for
early labor with spontaneous rupture of membranes. An epidural was received
for analgesia. Labor was augmented with intravenous oxytocin and progressed
well. During the second stage of labor, the patient’s vaginal septum was
manually displaced while pushing, and less than one hour later, the patient had
a spontaneous vaginal delivery of a healthy female infant. The vaginal septum
was noted to have torn during delivery, so the remainder of the septum was
transected, and the incised edge was closed with polyglycolic acid suture in a
running fashion for hemostasis. Estimated blood loss was 300 mL. The
patient’s postpartum course was uncomplicated, and she was discharged
home on postpartum day 2.

Accepted10 Dec 2019

Published24 Dec 2019

Jennifer W. H. Wong

 Case Presentation
37

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