REPUBLIC OF THE PHILIPPINES

University of Northern Philippines

Tamag, Vigan City
2700 Ilocos Sur
Website: www.unp.edu.ph
College of Nursing

In Partial Fulfillment
of the Requirements for
Related Learning Experiences (RLE)

----------------------------------

A CASE STUDY ON

ELECTIVE CESAREAN SECTION

---------------------------------

Presented to:
LUIGI RAY T. NAVARRO, RN, MAN
Clinical Instructor
‘
Presented by:
MARJORIE M. UMIPIG
BSN III-C

November
S.Y. 2021-2022
 INTRODUCTION

Cesarean section or C-section is an alternative way of delivering a fetus through an

open abdominal incision and an incision in the uterus; therefore, it allows the fetus to be
delivered surgically. According to legend, the first documented cesarean section took place
around 1020 AD, with the birth of Julius Cesar. Since then, the operation has changed
immensely.
The procedure may be scheduled as a form of birth plan (elective), or may be done in
emergency situations during labor. Indications for C-sections is are classified into 3
categories: (1) maternal factors, (2) fetal factors, (3) co-existing fetomaternal factors.
Maternal factors include: preferences, multiple pregnancies, previous C-section, dystocia due
to maternal health problems (e.g. cardiopulmonary disorders, obstructive lesions/tumor in the
lower genital tract, non-progressive labor, threatened rupture or obstructed labor, HIV
infection or STD’s, pre-eclampsia/eclampsia, placental problems, pelvic problems, etc.).
Example of fetal factors are abnormal fetal position (breech), macrosomia, fetal distress,
certain congenital malformations, or skeletal disorders (osteogenesis imperfect). Other factors
are also likely to have increased the chance of a C-section: an increased in mother’s age
during pregnancy, obesity and gestational diabetes prevalence. Contraindications include the
absence of an appropriate indication, when maternal condition may be adversely affected, if
the fetus has a known congenital abnormality that may result in death (anencephaly),
pyogenic infection of the abdominal wall, and so on.
The direction of the incision in the abdomen distinguishes the types of C-sections:
lower segment cesarean section (LSCS), lower segment vertical incision, classical cut,
extraperitoneal cesarean and cesarean hysterectomy. LSCS is the most commonly utilized in
the OR; it involves lower segment transverse incision above the attachment of the urinary
bladder to the uterus which is used in more than 90% of CS due to reduced blood loss and
easier repair. Lower segment vertical incision is indicated to certain situations. In contrast to
LSCS, this is more difficult to repair as it is associated with severe bleeding and more
incidence of rupture in subsequent pregnancies. Classical CS’ incision is done at the upper
portion of the uterus because lower segment is not approachable (may be related to
obstructive adhesions/myomas, cervical cancer, placenta previa, conjoined twins), thus, fetal
foot is grasped and baby is delivered as breech. However, it is no longer practiced because of
the increased risk for a wide range of complications. Extraperitoneal caesarean section is a
special surgical technique and not needing to open up the peritoneal cavity. It is ultimately
less invasive on tissue and therefore less painful. Finally, cesarean hysterectomy consists of
C-section followed by the removal of the uterus –it is a life saving measure for severe atonic
post-partum hemorrhage. Indications include: severe atonic PPH, placenta
previa/accreta/increta, severe sepsis, multiple large myomas, and carcinoma in situ of the
cervix.
Regional anesthesia, such as epidural or spinal anesthesia is used for 95% of planned
cesarean section --it numbs the body from the waist down. In most circumstances, this is
preferred because it allows the woman to remain awake during the operation and has fewer
risks than general anesthesia, though it may be utilized in extreme cases such as fetal distress.
A review by Afolabi et. al. found that patients undergoing local anesthetic techniques were
found to have a significantly lower difference between preoperative and postoperative
hematocrit levels when compared with patients undergoing general anesthesia. Women
having either an epidural anesthesia or spinal have a lower estimated maternal blood loss.
Major complications connected with C-sections include cardiac arrests, heavy
bleeding, blood clots, anesthesia reaction, and an increased probability of infection, which
causes a woman to suffer three times more than with regular spontaneous deliveries. Apart
from the intraoperative risks, numbers of side effects can occur on post-partum, for example:
thromboembolic complications (e.g. ischemic stroke, acute myocardial infarction, venous
thromboembolism during the first 6 weeks postpartum).
This procedure is now one of the most common operations performed worldwide, and
the number of cases has increased substantially in the recent decades. According to World
Health Organization (WHO), rates of caesarean section in many countries have increased
beyond the recommended level of 15%, almost doubling in the last decade especially in high
income areas like Australia, France, Germany, Italy, North America and United Kingdom.
Similar trend is also seen in low resource countries like China, Brazil and India, especially
due to births in private hospitals. Scientific advances, social and cultural changes, and medico
legal considerations seem to be the main reasons for the increased acceptability of cesarean
sections.

OBJECTIVES

General objective:
 This case study aims to describe, understand, and gain extensive knowledge about
cesarean section. Furthermore, it is presented to highlight and understand evidence-based
guidelines for caring for women after a cesarean section, and prevent possible complications.

Specific objectives:

 To define what C-section is and its indications,

 To understand associated risks and associated complications,
 To describe the diagnostic tests used,
 To identify the anatomical structures involved,
 To be able to plan appropriate nursing interventions and treatment course,
 To be able to provide information and heath teachings to the patient in the postpartum
period, and
 To learn about the management and rehabilitation factors of women who have had C-
sections.
 PATIENT’S PROFILE

Name: Connie Lingus

Birthdate: August 24, 1994
Birthplace: Tamag, Vigan City, Ilocos sur
Age: 27
Sex: Female
Occupation: Housewife
Educational attainment: College Graduate
Civil Status: Married
Nationality: Filipino
Address: Tamag, Vigan City, Ilocos sur
Religion: Roman Catholic
Chief Complaint:
Date Admitted: October 19, 2021
Admitting Diagnosis: G3P2, Pregnancy Uterine (PU), 37 weeks and 5 days AOG, Previous
CS II
Attending Physician: Dr. Arizona Robbins
Source of Information: Connie Lingus (patient)

HISTORY OF PRESENT ILLNESS

Patient CL, a 27-year old female, presented to the primary health care institution
accompanied by significant other on October 19, 2021, 5 PM. Patient is at 37 weeks and 5
days, admitted at OB-Ward on for elective cesarean section the following day at 7AM.

PAST HEALTH HISTORY

Patient CL has an obstetric history of G3P2. Her first born is a term 2-year-old
female. Previous C-section. Negative uterine contraction, negative vaginal discharge. No
history of hypertension.
 PEARSON ASSESSMENT
Phase 1
(October 19, 2021 5 pm-
ASSESSMENT
Admission, Day 1)
PSYCHOSOCIAL Patient CL, admitted to
OB-ward for scheduled
cesarean section the
following day. Patient
looks neat and well-
groomed, and dressed
appropriately. She has a
sense of reality and oriented
with time, date, and place.
Upon assessment, there is
negative uterine
contractions and no vaginal
discharge present.
Initial vital signs are as
follows:
Temp: 36.7℃ ,
PR: 80 bpm,
RR: 18 cpm,
BP 120/80 mmHg,
02 sat.: 96%.,
FHT: 110 bpm
ELIMINATION Patient urinates about 5
times during the day and 3
times at night with normal
urinary output. Her bowel
movement varies, but the
pattern alternates for 1
day. Bowel sounds are
present upon auscultation.
ACTIVITY Patient spends a typical
day doing light household
chores, preparing meals
for the family, taking a
walk or stretch every now
and then, rests in between
and taking long naps in the
afternoon. Patient can still
perform ADL’s but with
extra care and assistance
from SO.
REST Patient gets tired after
Phase 2
(October 20, 2021 –
Day 2)
Post-Op
Upon assessment,
patient appears weak
while lying on supine
position. Facial grimace
noted. Rates pain as
10/10 (10 being the
highest possible pain).
Guarding behavior on
operative site.
Responds to questions
with a weak voice while
maintaining eye
contact.
Vital signs are as
follows:
T: 36.7℃
PR: 79 bpm
RR: 17 cpm
BP: 110/70 mmHg
O2 sat.: 96%
Intermittent Foley
catheter is still inserted,
urine output of 30
ml/hr. Patient reported
that she hasn’t had
bowel elimination prior
to surgery. Bladder is
neither palpable nor
tender. Patient hasn’t
passed gas (fart) yet.
Patient remains lying on
bed for 6-8 hours and
requires assistance with
feeding, grooming,
dressing and other
activities. Limited range
of motion. Patient
requires assistance
during ambulation (after
anesthesia wears off).
Patient reports that she
Phase 3
(October 21 2021 –
Day 3)
Patient appears
relaxed and well-
rested while on bed in
a semi-fowler’s
position. Rates pain as
7/10. Vital signs are
within normal limits.
Alert and oriented to
person, place, time,
and events. Patient is
cooperative, expresses
appropriate feelings
upon her situation,
and expressing
readiness to go home.
Patient needs
assistance in using the
toilet. Urinary output
is normal. Bowel
sounds are present
upon auscultation.
Patient reports she had
her bowel movement
in the morning.
Patient is ambulatory
but still needs
assistance in grooming,
dressing and other
activities.
Patient has been able
 doing activities that
requires effort or standing
over a long period of time.
Patient reports that she
usually sleeps 6-10 hours
every night and feels well-
rested after naps in the
afternoon.
SAFETY & Patient has no known
SECURITY allergies, no family history
of hypertension, etc.
Patient is assisted by SO,
and is being monitored
closely for any indications
of possible problems or
fetal distress.
is unable to rest due to to rest by taking long
pain at the incision site. naps in the afternoon
Interrupted sleep and is now looking
pattern. Appears weak more rested than the
and restless. previous day. She
slept at least 8 hours,
is interrupted at
midnight with the
need to void.
Raised side rails of the Patient is assisted by
bed for safety. IV site significant other; has a
intact and patent. goof range of motion
Patient’s vital signs are and patient’s
being monitored q15 condition is generally
minutes for 2 hours, improved. No signs of
then hourly until stable. allergies, adverse
No signs of allergies, reactions from
adverse reactions from treatment and
treatment and medications. No signs
medications. No signs of bleeding in the
of bleeding in the operative site.
operative site.

OXYGENATION Oxygen saturation of 96% Oxygen saturation of Oxygen saturation of

room air, within the 96% room air. 98% room air.
normal range. Patient has Respiratory rate (18 Respiratory rate (17
normal breath sounds and cpm), pulse (74 bpm) cpm), pulse (76 bpm)
displayed no signs of and blood pressure and blood pressure
respiratory distress. (120/80 mmHg) are (120/80 mmHg) are
within normal limits. within normal limits.
Normal breath sounds, Patient has normal
no difficulty of breath sounds; no
breathing, no chest chest pain, wheezing,
pains noted. or shortness of breath.
NUTRITION Patient eats small, frequent Patient’s input and Patient’s input and
meals within the day. output is closely output is closely
Drinks adequate amount of balanced over 24 hrs. balanced over 24-
water, approximately 1000 Good skin turgor. hours. Skin is soft and
mL per day. Good skin Patient is in clear liquid warm to touch. Good
turgor. diet and is given skin turgor. Patient is
Patient is on NPO 12 intravenous fluids to advanced from
hours prior to C-section, maintain fluid balance general liquid diet to
clear liquid diet (ice in the body. soft diet and IV fluids
chips/water), as ordered by are continued.
physician.
 DIAGNOSTIC PROCEDURES
IDEAL

a) Obstetric History

Gynecological history taking involves a series of methodical questioning of a

gynecological patient relevant to a patient’s current and previous pregnancies with the
aim of developing a diagnosis or a differential diagnosis on which further
management of the patient can be arranged. This further treatment may involve
examination of the patient, further investigative testing or treatment of a diagnosed
condition. It also includes gravidity, number of term pregnancies, pre-term,
miscarriages, abortion, mode of delivery, sex of infants, number of living children,
and also the complications before, during and after delivery.

b) Genetic screening (during pregnancy)

Genetic testing is a type of medical test that identifies changes in genes,

chromosomes, or proteins. The results of a genetic test can confirm or rule out a
suspected genetic condition or help determine a person's chance of developing or
passing on a genetic disorder.

c) Chorionic Villi Sampling (CVS)

This may be offered to women with an increased risk of chromosomal

abnormalities or who have a family history of a genetic defect that is testable from the
placental tissue. Chorionic villus sampling is a procedure performed to biopsy
placental tissue between 10 to 13 weeks’ gestation for prenatal genetic testing (to test
for chromosomal abnormalities and certain other genetic problems). The primary
advantage of chorionic villus sampling is earlier genetic results in pregnancy. This
knowledge provides patients with the opportunity to seek counseling for obstetric
management and recommendations, early referral to pediatric subspecialists, or earlier
and safer methods of pregnancy termination if results are abnormal.

d) Alpha-fetoprotein Screening (AFP)

Alpha-fetoprotein (AFP) is a plasma protein produced by the embryonic yolk

sac and the fetal liver. AFP levels in serum, amniotic fluid, and urine functions as a
screening test for congenital disabilities (neural tube defects), chromosomal
 abnormalities (Trisomy 21), as well as some other adult occurring tumors and
pathologies.

e) Ultrasound

An abdominal ultrasound is an imaging test that uses sound waves to create a

picture of how a baby is developing in the womb. These ultrasound images are a
useful way of examining organs, tissues, blood vessels, and other structures within the
abdomen. It is also used to check the female pelvic organs during pregnancy.

f) Leopold’s Maneuver

Leopold’s maneuvers are a method for determining the presentation, position,

and lie of the fetus through the use of four specific steps. This method involves
inspection and palpation of the maternal abdomen as a screening assessment for
malpresentation.

g) Vaginal examination/internal exam

It is done during labor to assess and check how many centimeters dilated the
woman is, the consistency and position of the cervix, to estimate how far the baby’s
head has come down into the pelvis, the position of the baby by determining the
presenting part, and checking for cervical effacement. It is key in indicating whether
labor has progressed or has stopped.

h) Fetal monitoring

Using a fetoscope (a type of stethoscope) to listen to the fetal heartbeat is the

most basic type of fetal heart rate monitoring. Another type of monitoring is
performed with a hand-held Doppler device. During labor, continuous electronic fetal
monitoring is often used as it helps monitor for fetal distress.

ACTUAL

a) Complete Blood Count (CBC)

The complete blood count (CBC) is one of the most commonly ordered blood
tests. The complete blood count is the calculation of the cellular (formed elements) of
blood.
b) Crossmatching-Blood Typing

Blood cross-matching is a series of tests that are done before a blood

transfusion is performed. These tests ensure that the blood is compatible between the
person giving it and the person that is receiving it.

c) Prothrombin Time (PT) & Partial Thromboplastin Time (PTT)

Result Normal Range

PT (s) 11.8 12-14
PTT (s) 30.5 20-40 seconds

Two laboratory tests are used commonly to evaluate coagulation disorders:

Prothrombin Time (PT) which measures the integrity of the extrinsic system as well
as factors common to both systems and Partial Thromboplastin Time (PTT), which
measures the integrity of the intrinsic system and the common components.

A prothrombin time (PT) blood test measures the time it takes for your plasma
to clot. The PT test is used to monitor patients taking certain medications as well as to
help diagnose clotting disorders. PTT or the activated partial thromboplastin time
(aPTT) is a test performed to investigate bleeding disorders and to monitor patients
taking an anticlotting drug such as heparin which inhibits factors X and thrombin,
while activating anti-thrombin.

d) Urinalysis
 Urinalysis is a screening/examination of the physical and chemical properties
of urine and its microscopic appearance to aid in medical diagnosis. It involves the
assessment of color and clarity; chemical analysis using a urine test strip; and
microscopic examination. This test provides a preoperative assessment of patient’s
renal function prior to undergoing surgery. It also monitors for pregnancy
abnormalities, including bladder or kidney infection, dehydration, etc.
 ANATOMY AND PHYSIOLOGY OF THE ORGAN INVOLVED

FEMALE REPRODUCTIVE SYTEM

The female reproductive system consists of the ovaries, the fallopian tubes, the uterus,
the vagina, and the external genitalia. The organs of the female reproductive system produce
and sustain the female sex cells (egg cells or ova), transport these cells to a site where they
may be fertilized by sperm, provide a favorable environment for the developing fetus, move
the fetus to the outside at the end of the development period, and produce the female sex

hormones.

Figure 1 depicts anterior view of the uterus, uterine tubes, and associated ligaments.
The uterus and uterine tubes are cut in section (on the left side), and the vagina is cut to show
the internal anatomy. The inset shows the relationships among the ovary, the fallopian tubes,
and the ligament that suspend them in the cavity.

OVARIES
The primary female reproductive organs, or gonads, are the two ovaries. It is the site
where oocyte formation begins. Each ovary is a small, solid, ovoid structure about the size
and shape of an almond, about 3.5 cm in length, 2 cm wide, and 1 cm thick, suspended in the
pelvic cavity by two ligaments. Each of the ovarian follicles contains an oocyte, or the female
cell. The ovaries are located in shallow depressions, called ovarian fossae, one on each side
of the uterus, in the lateral walls of the pelvic cavity.

UTERINE TUBES

There are two uterine tubes, also known as fallopian tubes or oviducts, and is
associated with each ovary. It extends from the area of the ovaries to the uterus. The end of
the tube near the ovary expands to form a funnel-shaped infundibulum, which is surrounded
by fingerlike extensions called fimbriae. Fertilization usually occurs in the part of the uterine
tube near the ovary, called the ampulla. The fertilized oocyte then travels to the uterus, where
it embeds in the uterine wall in a process called implantation.

UTERUS

The uterus is a muscular organ that receives the fertilized oocyte and provides an
appropriate environment for the developing fetus, it is as big as a medium-sized pear. It is
oriented in the pelvic cavity with the larger, round part directed superiorly. The uterine wall
is composed of 3 layers: a serous layer (perimetrium), a muscular layer (myometrium), and
the endometrium.

VAGINA

The vagina is the female organ of copulation –a fibromuscular tube, about 10 cm

long, that extends from the cervix of the uterus to the outside.; it receives the penis during
intercourse, allows menstrual flow and childbirth, thus, the vagina can increase in size to
accommodate it, and can stretch greatly during childbirth. The superior portion of the vagina
is attached to the cervix, so that a part of the cervix extends into the vagina.

EXTERNAL GENITALIA

The external genitalia, also called the vulva or pudendum, consist of the vestibule and
its surrounding structures (i.e. labia majora, mons pubis, labia minora, clitoris, and glands
within the vestibule). The clitoris is an erectile organ, similar to the male penis, that responds
to sexual stimulation. Posterior to the clitoris, the urethra, vagina, paraurethral glands and
greater vestibular glands open into the vestibule. The vestibule is the space into which both
the vagina and the urethra open. The urethra opens into the vestibule just anterior to the
vagina. The vestibule bordered by a thin, longitudinal skin folds is the labia minora. The two
labia minora unite over the clitoris to form a fold of skin called the prepuce. Lateral to the
labia minora are two, prominent, rounded folds of skin called the labia majora which unite
anteriorly at an elevation of tissue over the pubic symphysis called the mons pubis. The
region between the vagina and the anus is the clinical perineum.

LAYERS OF THE ABDOMINAL WALL

There are 5 abdominal layers involved in the cesarean section delivery.

SKIN

The skin is made up of two major tissue layers: the epidermis and the dermis. The
epidermis is the most superficial layer of skin. It is a layer of epithelial tissue that rests on the
dermis. The second layer is the dermis, a layer of dense connective tissue.

SUBCUTANEOUS TISSUE

The subcutaneous tissue, also called as hypodermis, is where the skin rests, it attaches
the skin to underlying bone and muscle and supplies it with blood vessels and nerves. It is
made up of loose connective tissue, including adipose tissue that contains half the body’s
stored lipids.

Next to the subcutaneous tissue is the superficial fascia. The superficial layer of subcutaneous
tissue is known as Camper's fascia, whereas the deep membranous layer is known as Scarpa's
fascia.

MUSCLE

The anterior abdominal wall muscles involve various muscle layers including: the
external abdominal oblique muscle, internal abdominal oblique muscle and the transversus
abdominis muscle.

FASCIA (DEEP)

The transversalis fascia (or transverse fascia) is a thin aponeurotic membrane of the
abdomen which lies between the inner surface of the transverse abdominal muscle and the
parietal peritoneum.

PARIETAL PERITONEUM

The walls of the abdominal cavity and the abdominal organs are associated with a
serous membrane called the peritoneum. The Parietal peritoneum is a serous membrane that
lines the abdominal and pelvic cavities. The visceral peritoneum, or serosa, covers the
abdominal organs.
 PATHOPHYSIOLOGY ALGORITHM AND EXPLANATION

Release of FSH by the anterior pituitary gland

Development of the graafian follicle

Production of estrogen (thickening of the

endometrium)

Release of the luteinizing hormone

Ovulation (release of mature ovum from the
graafian follicle)

Ovum travels into the fallopian tube

Fertilization (union of the ovuma and sperm in

the ampulla)

Zygote travels from the fallopian tube to the

uterus

Implantation

Development of the fetus/embryo & placental

structure until full term.

TRUE LABOR

Uterine contractions SHOW Rupture of membranes

 FAILED TO PROGRESS LABOR
(Dystocia)

Abnormalities Abnormalities Abnormalities Psychological charac-

of power of the passenger of the passageway teristics of the mother

Increase risk for fetal distress

Emergent cesarean delivery

Expulsion of the fetus

Expulsion of the placenta

(accompanied by blood loss of 500ml-1000 mL)

PHYSIOLOGY OF FEMALE REPRODUCTION

The reproductive system in females is responsible for producing gametes (called eggs
or ova), certain sex hormones, and maintaining fertilized eggs as they develop into a mature
fetus and become ready for delivery. female’s reproductive years are between menarche (the
first menstrual cycle) and menopause (cessation of menses for 12 consecutive months).
During this period, cyclical expulsion of ova from the ovary occurs, with the potential to
become fertilized by male gametes (sperm). This cyclic expulsion of eggs is a normal part of
the menstrual cycle.
Female sex cells, or gametes, develop in the ovaries by a form of meiosis called
oogenesis. During ovulation, the ovary releases an oocyte. Just before the ovulation, the
primary oocyte completes the first meiotic division to produce secondary oocyte. After
ovulation, the secondary oocyte may be fertilized by a sperm cell. Fertilization occurs when a
sperm and an oocyte (egg) combine and their nuclei fuse, which takes place in the ampulla of
the fallopian tubes.
 Zygote is the end-product from the union of the egg and the sperm cell. This then
travels from the fallopian tube to the uterus for implantation. It takes about 6-7 days after
fertilization. A successful implantation leads in pregnancy, which allows the fetus/embryo
and placental structure to develop to full term.

ON LABOR AND DELIVERY

To define the abnormal process of delivery, it is important to understand the concept

of normal process of labor first. Normal labor is defined as uterine contractions that result in
progressive dilation and effacement of the cervix. Failure to meet these milestones defines
abnormal labor, which suggests an increased risk of an unfavorable outcome. Thus, abnormal
labor alerts the obstetrician to consider alternative methods for a successful delivery that
minimize risks to both the mother and the infant.

Dystocia may be the cause of labor that results in failure to progress. It is defined as
difficult labor or abnormally slow progress of labor. Other terms that are often used
interchangeably with dystocia are dysfunctional labor, failure to progress (lack of progressive
cervical dilatation or lack of descent), and cephalopelvic disproportion (CPD). It is the
consequence of four distinct abnormalities that may exist singly or in combination: (1)
Abnormalities of power in which frequent, painful, but poor-quality contractions fail to
accomplish effective cervical effacement and dilation; (2) Abnormalities in the passenger due
to fetal abnormalities such as macrosomia, abnormal presentation, position , and posture that
cannot be extruded through the birth canal; (3) Abnormalities of the passageway, or the birth
canal that form an obstacle to the descent of the fetus, including cephalopelvic disproportion
(CPD) as well as contracted pelvis; lastly, (4) psychological characteristics of the mother (e.g.
emotional factors, anxiety) also affects the outcome of the delivery.

These four abnormalities consequently lead to increased risk of fetal distress, thus,
requiring immediate medical-surgical intervention: C-section delivery –the delivery of a baby
through a surgical incision in the abdomen and uterus. This in turn results to another cesarean
section delivery once the woman gets pregnant again.
 MEDICAL-SURGICAL MANAGEMENT

ACTUAL

Medical Management

1. IV Fluids
 PNSS 1L x 12 hours
 IVF to follow: D5LR 1L x 8 hours
 IVF to follow afrer D5LR: PNSS 1L x 8 hours
2. IV Drugs
 Cefuroxime 1500 mg IV (ANST) Prior to OR
 Oxytocin 10 units
 Cefuroxime 750 mg IV q8 hrs
 Ketorolac 30 mg IV q6 hours x 24 hours
 Tramadol side drip: D5W 500 ml + 1amp. tramadol x 12 hours

Surgical Management

Cesarean birth step-by-step process:

Pre-operative Management:

 Pre-operative fasting time of at least 2 hours from clear liquids, 6 hours from a light
meal, and 8 hours from a regular meal. But on average, patients do not eat anything
for 12 hours prior to procedure.
 Laboratory testing: Cross Matching-Blood Typing, PT PTT, Urinalysis
 Placement of an intravenous (IV) line
 Infusion of IV fluids (e.g., lactated Ringer solution or saline with 5% dextrose).
 Placement of a Foley catheter (to drain the bladder and to monitor urine output).
 Placement of an external fetal monitor and monitors for the patient’s blood pressure,
pulse, and oxygen saturation.
 Pre-operative administration of prophylactic antibiotics (Cefuroxime) as per doctor’s
order.
 Evaluation by the surgeon and the anesthesiologist.
 Pre-operative checklist complete.

Intraoperative Management:
 Administration of anesthesia. The majority of Caesarean sections are performed under
regional anesthetic, however, a general anesthesia may be required if there are
presence of: maternal contraindication to regional anesthetic, failure of regional
anesthesia to achieve the required block, or more commonly because of concerns
about fetal wellbeing and the need to expedite delivery as soon as possible.
 Skin and abdominoperineal preparation. Shaving away abdominal hair and cleaning
the skin over the incision site using 3 skin preparation balls: 1) cleanser, 2) washer,
and 3) sterilizer/antiseptic reduces the bacteria on the skin, thus, minimizing infection.
 Draping. The patient would be covered by a sterile drape to block the flow of the
bacteria from her respiratory tract to the incision site and also block the woman’s and
support person’s lines of sight from the incision site.
 Operative Procedure. To minimize the risk of supine hypotension due to aortocaval
compression, the patient is positioned with a 15° left lateral tilt. An indwelling
Foley’s catheter is inserted when the anesthetic is ready, to drain the bladder and to
reduce the risk of bladder injury during the procedure. The skin is then prepared using
an antiseptic solution and antibiotics are administered just prior to the ‘knife to skin’
incision.

There are multiple ways to perform a Caesarean, but what follows is a standard
technique: (1) Skin incision is usually with either a Pfannenstiel or Joel-Cohen – these
are both transverse lower abdominal skin incisions; (2) next, sharp or blunt dissection
into the abdomen is made through several layers: the skin, subcutaneous tissue,
muscle, fascia, abdominal peritoneum, and revealing the ; (3) The visceral peritoneum
covering the lower segment of the uterus is then incised and pushed down to reflect
the bladder, which is retracted by the Doyen retractor; (4) Uterine incision
(hysteromy) is made on the lower uterine segment beneath the line of peritoneal
reflection. This is a transverse curvilinear incision which is digitally extended. The
baby is then delivered cephalic/breech with fundal pressure from the assistant.

 After the delivery of the baby, oxytocin 5iu is given intravenously by the
anesthesiologist to aid delivery of the placenta by controlled cord traction by the
surgeon.
 Delivery of the placenta.
 Abdominal lavage.
  Suturing. The uterine cavity is ensured empty, then closed with two layers. The rectus
sheath is then closed and then the skin (either with continuous/interrupted sutures or
staples).

Post-operative care (Nursing responsibilities)

The post-partal care period of a woman who has undergone emergent cesarean birth is
divided into two: immediate recovery period and extended post-partal period.

 Patient is transferred by stretcher to the PACU.

 Routine assessment: palpating the fundus to ensure that it is contracted.
 Monitor vital signs q15 minutes for 2 hours until stable, then hourly
 Intake and outputs are monitored on an hourly basis.
 Observations are recorded on an early warning score chart, and lochia (per vaginal
blood loss post-delivery) is monitored.
 Assess pain by using pain scale from 1-10 (10 being the highest). Patient may need
controlled analgesia.
 Supplement the analgesics with comfort measures such as change in position or
straightening of bed linen.
 Early mobilization, eating and drinking and removal of catheter is encouraged to
enhance recovery.
 Encourage rooming in with patient and initiate breastfeeding within a few hours after
delivery.
 Note carefully the woman’s first bowel movement after surgery because if no bowel
movement has been observed, the physician may order a stool softener, a suppository,
or an enema to facilitate stool evacuation.
 Activity:
o Bed rest
o Supine for 8 hours after spinal anesthetic
o Incentive Spirometry every 1 hour while awake
 Standard Diet
o Nothing by mouth (NPO) for 8 hours after cesarean section
o Sips of water after 8-hour window
o Advance to clear liquids as tolerated
o Advance to Regular diet when flatus or Bowel Movement
  Discontinue Foley catheter when no longer needed.

PROMOTIVE AND PREVENTIVE MANAGEMENT

Health teachings have been provided for Patient Connie Lingus, including her
significant other and family members. Health education is directed both at helping the patient
to decrease the risk of complications and promoting health behaviors to manage taking care
of themselves and ensure timely healing of wounds by reinforcing proper techniques of
wound care and maintenance of good hygiene.

Although in cases caused by chromosomal abnormalities or congenital defects,

promotive management includes a folate-rich diet, and folic acid and vitamin B12
supplementation, with dosage, depending on risk level to prevent neural tube defects.
Prenatal multivitamins or micronutrient supplements are prescribed for the mother to support
a healthy pregnancy. The benefit of folic acid oral supplementation or dietary folate intake
combined with a multivitamin/micronutrient supplement is associated with decrease in neural
tube defects and perhaps in other specific birth defects and obstetrical complications.

Cesarean section poses risks and serious complications as any other surgery. Common
complications related to cesarean delivery include infection, hemorrhage (excessive
bleeding), injury to pelvic organs, and blood clots. Preventive management mainly focuses on
the prevention of occurrence of these possible complications after C-section delivery.

Enhanced Recovery After Surgery (ERAS) pathways was developed with the goal of
maintaining normal physiology in the perioperative period, thus optimizing patient outcomes
without increasing postoperative complications or readmissions. The basic principles of
ERAS include attention to the following: preoperative counseling and nutritional strategies,
including avoidance of prolonged perioperative fasting; perioperative considerations,
including a focus on regional anesthetic and non-opioid analgesic approaches, fluid balance,
and maintenance of normothermia; and promotion of postoperative recovery strategies,
including early mobilization and appropriate thromboprophylaxis.

It is recommended that urinary catheters are removed within 24 hours in ERAS

protocols. There are few data on the timing of urinary catheter removal in women who have
cesarean delivery under spinal anesthesia. In a published audit of an ERAS protocol for
cesarean delivery, urinary catheters were removed 7 hours after the procedure to facilitate
early ambulation with no complications reported. According to studies, early mobilization
improves pulmonary function and tissue oxygenation, improves insulin resistance, reduces
risk of thromboembolism, and shortens length of stay. Effective postoperative analgesia is a
key factor in facilitating early postoperative mobilization. Pneumatic compression devices are
recommended for all women undergoing cesarean delivery and not already receiving
pharmacologic thromboprophylaxis. The compression devices should be continued until the
patient is fully ambulatory. In women with one or more additional risk factors,
pharmacological thromboprophylaxis is recommended

To illustrate ERAS in the context of nutrition, consider the following: Plan healthy,
balanced meals and snacks that include the right amount of foods from all the MyPlate food
groups — protein foods, fruits, vegetables, dairy and grains. Include also protein-rich foods
and increase fluid intake. Choose vegetables and fruits rich in vitamin C, such as broccoli or
strawberries. For adequate zinc, choose fortified grains and protein foods, such as beef,
chicken, seafood or beans. Some wounds may require a higher intake of certain vitamins and
minerals to support healing. Supplements may be prescribed by healthcare provider. Also,
one of the core principles of ERAS is the maintenance of a normal fluid balance. In the
general surgical population, goal-directed fluid therapy based on physiologic endpoints has
been shown to reduce perioperative complications and length of stay.

Benefits of ERAS pathways include shorter length of stay, decreased postoperative

pain and need for analgesia, more rapid return of bowel function, decreased complication and
readmission rates, and increased patient satisfaction. Implementation of ERAS protocols has
not been shown to increase readmission, mortality, or reoperation rates. These benefits have
been replicated across the spectrum of gynecologic surgeries, including open and minimally
invasive approaches and benign and oncologic surgeries. The implementation of the ERAS
program requires collaboration from all members of the surgical team. Enhanced Recovery
After Surgery is a comprehensive program, and data demonstrate success when multiple
components of the ERAS pathway are implemented together. Successful ERAS pathway
implementation across the spectrum of gynecologic care has the potential to improve patient
care and health care delivery systems.
 NURSING CARE PLANS (PRE-OP)
ASSESMENT DIAGNOSIS OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subjective: Anxiety After immediate Independent: After immediate

“Ma’am related to nursing Assess psychological The greater the nursing
agbutengak upcoming intervention, the response to event and patient interventions,
man toy Cesarean patient will: availability of perceives the
pannaka-CS delivery as  Discuss her support systems. threat, the GOAL MET.
kon ta evidenced feelings or greater the
adbutengak by concerns. level of her Patient appeared
matudokan expressed  Have anxiety. relaxed,
injection”, as concerns relaxed Remain with the comfortable and
verbalized by posture, patient, and stay Helps to able to show
the patient. facial calm. Speak in a slow reduce readiness for
expressions, manner. Convey interpersonal upcoming
Objective: gestures. empathy. transmission surgery as
Restlessness  Able to anxiety, and evidenced by
VS: show shows caring patient
T: 36.5℃ readiness for for the patient verbalization,
PR: 86 bpm upcoming or couple. “nakissayan
RR: 18 cpm C-section Support or bassit
BP: 120/80 delivery. encouraged patient to Promotes panpanunotek,
mmHg  Report other coping relaxation and ma’am.”
O2 Sat.: 97% absence of mechanisms feeling of
FHT: 114 or decrease (listening to music, well-being.
bpm in subjective guided imagery). Refocuses
distress. client’s
attention,
promotes
positive
attitude, and
enhances
comfort.
Provide therapeutic
touch and healing Provides relief
touch techniques (e.g. and soothes
back rubs, light feeling.
massage). Reduces
anxiety.

Explain all activities, Preoperative

procedures, and information
issues that involve reduced the
the client; use anxiety of
nonmedical terms clients
and calm, undergoing
slow speech. Do this surgery under
in advance of regional
procedures when anesthesia
possible, and validate
the client’s
understanding.
 NURSING CARE PLANS (PRE-OP)
ASSESME DIAGNO OBJECTIV INTERVENT RATIONAL EVALUATI
NT SIS E ION E ON
Subjective: Impaired Short-term: Independent: After 2
“Haan nak comfort After 2 hours Ask about Performing hours of
unay r/t of nursing clinet’s current accurate nursing
makarelax” upcoming interventions, level of comfort interventio
as surgery as the patient comfort. measurements n, the
verbalized evidenced will: is essential for patient:
by the by  Report providing
patient. feelings of improve evidence about GOAL
discomfor d which MET.
Objective: t, comfort strategies and
Restlessnes restlessne  Demonst interventions Patient
s ss and rate how are effective reports
Anxiety inability to use Assess several improved
episodes to relax coping factors Any of these comfort
(physical, factors may and appear
mechani
VS: mental, cause relaxed.
sms (e.g.
T: 36.5℃ socioeconomic, discomfort,
PR: 86 bpm deep spiritual) that especially
RR: 18 breathin may cause during
cpm g) discomfort and hospitalization.
BP: 120/80  Maintain obtain a Obtaining a
mmHg desirable baseline in baseline of the
O2 Sat.: level of each of them. patient’s
97% comfort concerns
FHT: 114 provides a great
bpm starting point
for healthcare
staff to use to
raise the
Obtain a patient’s level
detailed history of comfort.
about aspects
that might History of
affect comfort anxiety,
level and depression, past
evaluate how surgeries, and
these may comorbidities
affect the may contribute
patient’s to the current
comfort in the illness and
recovery decrease
process. patients’
comfort.
Enhance
feelings of
trust between Promoting open
the client and relationships
the health care with clients,
provider. To which helps to
attain the acknowledge
highest their
comfort level, individuality.
clients must be
able to trust
their nurse.

Manipulate the
environment as Addressing
necessary to clients’
improve environmental
comfort. preferences or
needs enhances
holistic
Encourage comfort.
early
mobilization Before hand
and provide massage,
routine positions of
position comfort were
changes. assured to
Range of maximize the
motion and effect of the
weight bearing intervention.
decrease
physical
discomforts
and disability
associated with
bed rest.
Inform the
Provide client of
healing touch, options for
which is well- control of
suited for discomfort such
clients who as meditation
cannot tolerate and guided
more imagery,
stimulating and provide
interventions. these
interventions if
appropriate
Keep a calm
attitude when An accurate
interacting empathic
with the response to a
patient. Use client’s
empathy as a expressions of
response to a negative
client’s emotions can
negative contribute to
emotions. comfort.
 NURSING CARE PLANS (PRE-OP)
ASSESMEN
DIAGNOSIS OBJECTIVE INTERVENTION RATIONALE EVALUATION
T
Subjective: Situational Short-term: Independent: After immediate
low Self- After immediate Ascertain patient’s Diagnosis of a nursing
Objective: Esteem r/t nursing unusual feelings shift in self- interventions,
VS: inability to interventions, the about self and concept is
T: 36.5℃ deliver child patient will, pregnancy. Note based on GOAL MET.
PR: 86 bpm vaginally  Identify cultural influences. knowledge of
RR: 18 cpm and past perceptions The patient was
BP: 120/80 discuss and able to verbalize
mmHg feelings experiences. her feelings, and
O2 Sat.: 97%  Verbalize Cesarean birth, build confidence
FHT: 114 bpm confidence even if planned towards her self.
in herself or not, has the .
and her potential to
change the way
abilities.
the patient feels
about herself.

Allow the patient Determines

to verbalize areas to be
feelings and discussed.
thoughts. Patients’
feedback varies
and may be
hard to
diagnose in the
preoperative
stage. Feelings
of negative
self-image
related to
disappointment
in the birth
experience may
interfere with
postpartal
activities

Encourage Improves
questions and give understanding
facts. Reinforce and clarifies
previous learning. misconceptions.

Provide verbal During the

communication of preoperative
assessment and period, patient
interventions. is focusing on
 the here and
now and may
not be ready to
read or deal
with additional
information.

Allow partner’s Provides

presence at the support for the
delivery as desired. patient,
encourages
parental
bonding, and
gives additional
input to the
patient’s recall
of the birth
experience
because
memory lapses
are more
common during
periods of
crisis.

Encourage the Provides

patient or couple to reinforcement
participate in room of the birth
bonding activities experience and
(e.g., breastfeeding deemphasizes
and holding the the surgical
infant) as able. nature of the
delivery.
 NURSING CARE PLANS (POST-OP)

ASSESMENT DIAGNOSIS OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subjective: Acute pain Short-term: Independent: Short term:
“Nagsakit related to After 2 hours of Assess pain Indicates need for,
ditoy ayan ti abdominal nursing reports, noting and effectiveness of, GOAL MET.
sugat ko nu incision intervention, location, intensity interventions and
aggaraw- from patient will frequency, and may After 2 hours of
garaw nak”, as cesarean report reduction time of onset. signal development nursing
verbalized by delivery as of pain as Note nonverbal or resolution of intervention,
the patient. evidenced by manifested by: cues, such as complications. patient reports
Rated pain as pain scale of  Pain scale restlessness, pain is reduced,
9/10 (highest). 10/10, facial of at least tachycardia, or now rates pain
grimace, and 5/10, grimacing. as 5/10; no
Objective: guarding  No facial To identify possible facial grimace.
Facial grimace behavior grimace Monitor VS q 15 changes in VS and
Guarding minutes for 2 monitor any Long term:
behavior Long term: hours until stable. fluctuations.
After 24 hours of GOAL
VS: nursing Efficacy of comfort PARTIALLY
T: 36.7℃ intervention, Encourage client measures and MET.
PR: 79 bpm patient will: to report pain as it medications is
RR: 17 cpm  Achieve develops rather improved Patient was able
BP: 110/70 timely than with timely to move
mmHg healing waiting until level intervention. without much
O2 sat.: 96% is severe. assistance from
of
Promotes relaxation others.
incision.
Instruct client in, and feeling of well- Continue goal.
and encourage use being. Refocuses
 Able to of, visualization, client’s attention,
move guided promotes positive
without imagery, attitude, and
much progressive enhances comfort. It
assistance relaxation, deep- may decrease the
from breathing need for opioid
others. techniques, analgesics.
meditation, and
mindfulness. To determine if those
actions were
Reassess pain effective, and the
after 30 minutes patient’s pain control
of intervention. goals have been met.

Analgesic drugs like

NSAIDS, opioids,
Dependent: and local anesthetics
Administer pain pharmacologically
medications as per reduce acute pain
doctor’s order. quickly and
effectively.
 NURSING CARE PLANS (POST-OP)

ASSESMENT DIAGNOSIS OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subjective: Readiness for Short-term: Independent: Short-term:
enhanced Assess client’s In some
Patient breastfeeding After 4 hours of nursingbeliefs and concerns cultures, After 4 hours of
expresses interventions, the about the women refuse nursing
desire to patient will: postpartum period. to bathe and interventions,
enhance ability Provide culturally wash their hair
to provide  Verbalize
breast milk for satisfaction with appropriate health after childbirth
breastfeeding & nutrition and during the GOAL MET.
child’s information & postpartum
nutritional process.
guidance on period. The
needs and the  State contemporary influence of Patient is able to
ability to understanding of postpartum beliefs offers understand
exclusively health teachings. practices and take health risks for health teachings
breastfeed. away common the postpartum and
 Breastfeeding
establishment misconceptions woman and implemented
with infant. about traditional newborn. In proper
dietary and health contrast, breastfeeding as
Objective: behaviors beliefs & evidenced by
taboos that do proper
VS: Long-term: alingnment,
not offer
After 12 hours of health risks correct sucking
T: 36.7℃ and tongue
nursing interventions, should not be
PR: 79 bpm patient will: countered placement of the
because they infant.
RR: 17 cpm  Maintain contribute to
effective the well-being
BP: 110/70 breastfeeding
mmHg of postpartum
without women.
O2 sat.: 96% supplementation Long-term:
formula. Encourage rooming- Mothers who After 12 hours
in and breastfeeding room-in with of nursing
on demand. their infants interventions,
have greater
percentages of
exclusive GOAL MET.
breastfeeding
when released Patient was able
from the to maintain
hospital. breastfeeding
without the use
Monitor the breast- While mothers of alternative
feeding process and and babies are formula milk.
identify in the hospital
opportunities to it is essential
enhance knowledge that hospital
and experience personnel
regarding support their
breastfeeding. effort to learn
to breastfeed.

Teach mother to Monitor and

observe for infant assess the
behavioral cues and mom and baby
responses to for several
breastfeeding breastfeeding
sessions.
Teaching
mother will
build her
confidence
and
knowledge
base, which
facilitates
successful
breastfeeding.

Discuss prevention Common

and treatment of problems
common experienced
breastfeeding by
problems, such as breastfeeding
nipple pain or breast women may
engorgement. be preventable
with
anticipatory
guidance, or
successfully
managed with
prompt
assistance
from a health
care provider.

Avoid supplemental A correlation

bottle feedings and exists between
do not provide hospital staff
samples of formula providing
on discharge. formula and/or
water
supplements
and failure to
succeed with
exclusive
breastfeeding.
Teach the client the Breastfeeding
importance of mothers
maternal nutrition should
consume 450
to 500
calories.
Collaborative:
Provide follow-up Systematic
contact; as available reviews
provide home visits support the use
and/or peer of
counseling. professionals
with special
skills in
breastfeeding
and peer
support
programs to
promote
continued
breastfeeding
 NURSING CARE PLANS (POST-OP)
ASSESMENT DIAGNOSIS OBJECTIVE INTERVENTION RATIONALE EVALUATION
Subjective: Risk for Short-term: Independent: Short-term:
infection After 4 hours of Assess signs and Change in
Objective: (Risk factor: nursing intervention, symptoms of mental status, GOAL MET.
abdominal patient will: infection (e.g., fever, shaking,
VS: incision)  Demonstrate redness, elevated chills, and After 4 hours of
T: 36.7℃ appropriate temperature, pulse, hypotension nursing
PR: 79 bpm hygienic WBC; abnormal are indicators intervention,
RR: 17 cpm measures (e.g. odor or color of of sepsis patient was able
BP: 110/70 handwashing vaginal discharge,) to demonstrate
mmHg and perineal and know the
O2 sat.: 96% care) within 24 Maintain sterile Meticulous importance of
hours of technique when infection good hygiene,
instruction. changing dressings, prevention remained
 Remain suctioning, and precautions afebrile, and
afebrile. providing site care. are required to maintained lab
 Maintain white Wear gloves and prevent health values within
blood cell gowns when caring care– normal range.
count and for open wounds or associated
differential anticipating direct infection, with Long term:
within normal contact with particular
secretions or
limits. attention to GOAL
excretions.
hand hygiene PARTIALLY
Long term: and standard MET.
After 24 hours of precautions.
nursing intervention, After 24 hours
patient will be: Prevent spread of nursing
Instruct and teach
 Free from of infection & intervention,
patient appropriate
symptoms of cross- patient is free
hygiene
infection contamination. from infection
techniques. Ensure
 Achieves until
the client’s
timely wound discharged.
appropriate
healing without Continue goal.
hygienic care with
complications.
handwashing,
bathing, oral care,
and hair, nail, and
perineal care
performed by
either the nurse or
the client.

Dependent:
Prophylactic
Give parenteral
antibiotic may
broad-spectrum
be requested
antibiotic
to prevent
preoperatively.
development
of an
 infectious
process, or as
treatment for
an identified
infection

Collaborative:
Note and report Risk of post-
laboratory values delivery
(e.g., white blood infection and
cell count and poor healing is
differential, serum increased if
protein, serum Hb levels are
albumin, and low and blood
cultures) and loss is
estimated blood excessive.
loss during Note: Greater
surgical procedure. blood loss is
associated
with classic
incision than
with lower
uterine
segment
incision.
 DRUG STUDY
DOSAGE, MECHANIS NURSING
NAME OF ROUTE & CONTRAINDICATIO ADVERSE
M OF INDICATIONS RESPONSIBILIT
DRUG FREQUE NS EFFECTS
NCY ACTION Y
Cefuroxime 1500 Inhibits  Perioperati  Contraindicated CV: phlebitis,  Monitor
mg IV cell wall ve in patients thrombophlebiti patient for
Therapeutic synthesis, prophylaxis hypersensitive s signs and
class: promoting  Mild to to drug or other GI: diarrhea, symptoms of
Antibiotics osmotic moderate cephalosporins. pseudomembran superinfectio
instability; acute  Use cautiously ous colitis, n and
Pharmacologic usually bacterial nausea, diarrhea and
in patients
class: Second- bactericidal exacerbatio anorexia, treat
hypersensitive
generation . ns of vomiting. appropriately
chronic to penicillin Hematologic: .
cephalosporin because of
s bronchitis hemolytic  Drug may
 Uncomplic possibility of anemia, increase INR
ated skin cross- thrombocytopen and risk of
and skin- sensitivity with ia, transient bleeding.
structure other beta- neutropenia, Monitor
infection. lactam eosinophilia. patient.
 Serious antibiotics. Skin:  Advise
lower  Use cautiously maculopapular patient to
respiratory in patients with and continue
tract history of erythematous taking drug,
infection, colitis and in rashes, urticaria, even if
UTI, those with renal pain, induration, feeling
septicemia, insufficiency. sterile better.
meningitis, abscesses, temp.  Instruct
 Some
& elevation, tissue patient to
gonorrhea. cephalosporins sloughing at IM notify
have been injection site. prescriber
associated with Other: about rash,
seizures in anaphylaxis, loose stools,
patients with hypersensitivity diarrhea, or
renal reactions, serum evidence of
impairment sickness superinfectio
when dose n.
wasn’t reduced.  Advise
 There are no patient
adequate receiving
studies in drug IV to
pregnant report
women. Use discomfort at
IV injection
only when
site.
potential
benefit justifies
possible risk to
the fetus.
 Drug appears in
 milk. Use
cautiously in
breastfeeding
women
Oxytocin 10 Activates  Antepartu  Hypersensitivit MATERNAL  Assess
units receptors m y to oxytocin. CNS: baselines for
Therapeutic that trigger (induction  Contraindicated subarachnoid vital signs,
class: Oxytotic increase of labor in with adequate hemorrhage, B/P, fetal
agent in patients uterine activity seizures, coma heart rate.
Pharmacologic intracellula with that fails to CV: Determine
class: r calcium medical progress, arrhythmias, frequency,
Exogenous levels in indication cephalopelvic HTN, PVCs duration,
hormone uterine ) disproportion, \GI: nausea, strength of
myofibrils;  Postpartu fetal distress vomiting contractions.
increases m (to without GU: Abruptio  Monitor B/P,
prostagland produce imminent placenta, tetanicpulse,
in uterine delivery, grand uterine respirations,
production. contractio multiparity, contractions, fetal heart
Therapeuti ns during hyperactive or PPH, uterine rate,
c Effect: third stage hypertonic rupture, intrauterine
Stimulates of labor uterus, obstetric impaired uterine pressure,
uterine and to emergencies boood flow, contractions
contraction control that favor pelvic (duration,
s. postpartu surgical hematoma, strength,
m intervention, increased frequency)
bleeding/ prematurity, uterine motility.q15min.
hemorrha unengaged fetal Hematologic:  Notify
ge. head, afibronogemia physician of
unfavorable possibly related contractions
fetal position/ to PPG that last
presentation, Other: longer than 1
when vaginal anaphylaxis, min, occur
delivery is death from more
contraindicated oxytocin- frequently
(e.g., active induced water than every 2
genital herpes intoxification, min, or stop.
infection, hypersensitivity
 Maintain
invasive reactions. careful I&O;
cervical cancer, be alert to
placenta previa, FETAL: potential
cord CNS: infant water
presentation) brain damage, intoxication.
 Generally not seizures Check for
recommended CV: blood loss.
in fetal bradycardia,  Keep pt,
 distress, arrhythmias, family
hydramnios, PVCs informed of
partial placental EENT: neonatal labor
previa, retinal progress.
hemorrhage 
 predisposition Hepatic:
to uterine neonatal
rupture. jaundice
Other: low
APGAR scores
at 5 minutes,
death.
Ketorolac 30mg Inhibits  Short-term  Hypersensitivit CV: Headache  Assess onset,
IV Q6 COX-1 and manageme y to ketorolac, EENT: Nasal type,
Therapeutic x 24 COX-2 nt off aspirin, or discomfort, location,
class: NSAIDs hours enzymes, moderately other NSAIDs. rhinalgia, duration of
resulting severe,  Patients with increased, pain. Obtain
Pharmacologic in acute pain Intracranial lacrimation, baseline
class: decreased for single bleeding, throat irritation, renal/
Analgesic, prostagland dose hemorrhagic rhinitis. hepatic
intraocular in treatment/ diathesis, GI: dyspepsia, function
anti- synthesis; multiple- incomplete abdominal tests.
inflammatory. reduces dose- hemostasis, cramps/pain,  Monitor
prostagland treatment high risk of nausea, renal
in levels in  Allergic bleeding. diarrhea, function,
aqueous conjunctivit  Labor and flatulence, LFT, urinary
humor. is delivery peptic output.
 Cataract  Patients with ulceration,  Monitor
Therapeuti extraction advanced renal stomatitis, GI daily patter
c Effect: & corneal impairment or hemorrhage. of bowel
Produces refractive risk of renal GU: renal activity, &
analgesic, surgery failure, active failure stool
antipyretic, or history of Hematologic: consistency.
anti- peptic ulcer decreased  Assess for
inflammato disease, platelet therapeutic
ry effect; chronic adhesion, response:
reduces inflammation prolonged relief of
intraocular of GI tract, bleeding time, pain,
inflammati recent or purpura. stiffness,
on. history of GI Skin: swelling;
bleeding/ diaphoresis, increased
ulceration. pruritus, rash joint
 Perioperative mobility;
pain in setting reduced joint
of CABG tenderness;
surgery. improved
 Prophylaxis grip strength.
before major  Monitor for
surgery. bleeding.
 Avoid
aspirin,
alcohol.
 Advise
patient to
report any
 abdominal
pain, bloody
stools, or
hematemesis
.
 Take drug
with food or
milk.
Tramadol 1 Binds to  Immediate-  Hypersensitivit CNS: Dizziness,  Assess
ampul mu-opioid release: y to tramadol, somnolence, onset, type,
Therapeutic e receptors in Manageme opioids. vertigo, location,
class: trama CNS, nt of  Pediatric pts headache, duration of
Centrally dol x inhibiting moderate to under 12 drowsiness, pain. Assess
Acting 12 hrs ascending moderately  yrs. of age; seizures, drug history,
Synthetic pain severe pain. post-op confusion, esp.
Opioid pathway.  Extended- management in malaise, tremor, carbamazepi
Pharmacologic Inhibits release: pts under18 yrs. depression, ne,
: class: Opiate reuptake of around-the-  Patients with CNS analgesics,
(narcotic) norepineph clock severe stimulation. CNS
analgesic rine, manageme respiratory, GI: nausea, depressants,
serotonin, nt of acute bronchial vomiting, MAOIs.
inhibiting moderate to asthma in abdominal pain, Assess renal
descending severe pain absence of flatulence, dry function.
pain for appropriate mouth,  Monitor
pathways. extended monitoring, GI dyspepsia, pulse, B/P,
period. obstruction. constipation, renal/hepatic
Therapeuti  Contraindicated anorexia. function.
c Effect: with GU: urinary  Assist with
Reduces concomitant use retention/ ambulation
pain. with or within frequency, if dizziness,
14 days menopausal vertigo
following symptoms, occurs.
MAOI therapy. pelvic pain,  Advise pt to
UTI, prostate eat dry
disorder. crackers,
Respiratory: cola may
bronchitis, relieve
respiratory nausea. Sips
distress. of water may
Metabolic: to relieve
weight loss. dry mouth.
Musculosketal:  Palpate
hypertonia, bladder for
arthralgia, neck urinary
ain, myalgia. retention.
Skin: rash,  Monitor
pruritus, daily pattern
diaphoresis. of bowel
activity,
stool
 consistency.
 Assess for
clinical
improvemen
t, record
onset of
relief of
pain.
Monitor
closely for
misuse or
abuse.
Nalbuphine 0.5mg Agonist of  Analgesia  Contraindicated CNS: dizziness,  Obtain vital
IV q8 kappa (moderate in patients headache, signs before
Therapeutic PRN opioid to severe hypersensitive sedation, giving
class: Opioid receptors pain) to drug or its vertigo. medication.
analgesic. and  Adjunct to component. CV: If
Pharmacologic partial balanced  Use cautiously bradycardia respirations
class: Opioid antagonist anesthesia; in patients in EENT: dry are 12/min
partial agonist of mu pre- patients with mouth. or less
opioid operative history of drug GI: nausea (20/min or
receptors and post- abuse and in Respiratory: less in
within operative those with respiratory children),
CNS, analgesia; emotional depression. withhold
inhibiting obstetric instability, head Skin: medication,
ascending analgesia injury, clamminess, contact
pain during increased ICP, diaphoresis. physician.
pathways. labor and impaired  Assess
delivery. ventilation, MI onset, type,
Therapeut accompanied by location,
ic Effect: nausea and duration of
Alters vomiting, pain. Effect
pain upcoming of
perception, biliary surgery, medication
emotional or hepatic, is reduced if
response to renal, or adrenal full pain
pain. insufficiency. recurs
 Drug may cause before next
mood disorders dose.
and  Monitor for
osteoporosis. change in
 Use cautiously respirations,
in pregnant/ B/P,
lactating rate/quality
women as drug of pulse.
readily crosses  Monitor
the placenta and daily pattern
distributed in of bowel
breast milk. activity,
May cause fetal, stool
 neonatal consistency.
adverse effects  Initiate deep
during breathing,
labor/delivery coughing
(e.g., fetal exercises,
bradycardia). particularly
 Contraindicated in pts with
in children pulmonary
under 2 years impairment.
old.  Assess for
clinical
improvemen
t, record
onset of
relief of
pain.
 Consult
physician if
pain relief is
not
adequate.
 Advise
patient to
avoid
alcohol,
avoid tasks
that require
alertness,
motor skills
until
response to
drug is
established.
 DISCHARGE PLANNING/INSTRUCTION

Medicine o Take home medication as prescribed by the

physician.
o Laxative may be prescribed; check with your
healthcare provider before taking any over-the-
counter medicines.
Environment/Exercise o Maintain clean environment and free from accident
hazards as possible.
o Use incentive spirometer to practice deep
breathing/cough exercises.
o Activity as tolerated, do not do strenuous activities
or lift heavy weights.
o Have a lot of rest periods to gain strength.
o Increase activities little by little.
o Ask for assistance if needed.
Treatment o Staple removable on day 3-4 and placing steri-strips
for horizontal incision; staple removal on day 4-5
for vertical incision.
o Informed patient to have a follow-up checkup after
2 weeks.
o Post-partum visit at 6 weeks.
Health Education/Teaching o Practice good hygiene— Keep your hands clean. Be
sure to wash them every time you use the bathroom.
o Clean perineal area every time after voiding or
bowel elimination. Shower as needed.
o Pat the incision dry after washing. Keep incision
area clean and dry.
o Wear clean comfortable clothes.

o Instructed patient to increase intake of protein-rich

foods to promote faster wound healing and promote
adequate fluid intake.

o You will have some vaginal bleeding for a few

weeks after delivery. Wear sanitary pads for about 6
weeks after delivery.

o To relieve discomfort, press a pillow or your hand

against your abdomen when shifting your position
or with sudden movements such as sneezing or
coughing.
o Don’t have sexual intercourse until after you’ve had
a checkup with your healthcare provider and you
have decided on a birth control method.
o Instructed patient to report to physician any signs of
infection and any case of hemorrhage or abnormal
bleeding.
Out-patient o Call your primary healthcare provider if you have
any of these:
 Fever of 100.4°F (38°C) or higher
 Redness, pain, or drainage at your incision
site
 Bleeding that requires a new sanitary pad
every hour
 Severe pain in the abdomen
 Pain or urgency with urination
 Foul odor from vaginal discharge
 Trouble urinating or emptying your bladder
 No bowel movement within 1 week after the
birth of your baby
 Swollen, red, painful area in the leg
 Appearance of rash or hives
 Sore, red, painful area on the breasts
that may come with flu-like symptoms
 Feelings of anxiety, panic, and/or depression
Diet o Eat a well-balanced, healthy diet to help you
recover from childbirth. If you are breastfeeding,
you will need additional calories each day. You
may also be advised to avoid certain foods by your
doctor. Follow all recommendations.
o Encourage increase fluid intake.
o Eat food high in fiber such as whole grains, cereal,
bread, fruits, vegetables, beans, and lentils to avoid
constipation.
 UPDATES
Although it was introduced in clinical practice as a lifesaving intervention for both the
mother and the baby, the increasing trend of caesarean section in modern obstetrics is a
serious problem in health care systems all over the world. Over the past decades, the number
of women opting for C-section has increased exponentially, possibly due to increased
surgical safety and rising demands. This sparked the controversy regarding elective cesarean
delivery on maternal request or CDMR. The 2013 American College of Obstetricians and
Gynecologists (ACOG) Committee on Obstetric Practice and 2006 National Institutes of
Health (NIH) consensus committee determined that the evidence supporting this concept was
not conclusive and that more research is needed.

Although CS is a safe method, in the absence of a clear medical indication, there is

always an excess risk connected with the procedure itself, which needs to be considered.
Especially when it is performed without medical need because it puts mothers and their
babies at risk of short- and long-term health problems (WHO, 2008). However, the
consensus around the indications for cesarean section has changed in many countries which
now includes psychosocial factors such as anxiety about the delivery, or even the mother’s
wish to have a cesarean section in the absence of any medical indication.

The National Institutes of Health (NIH) and American College of Obstetricians

(ACOG) agree that a doctor's decision to perform a C-section at the request of a patient
should be made on a case-by-case basis and be consistent with ethical principles. Concerns
about the rising rate have prompted medical organizations to suggest potential interventions
to reduce the rate of unnecessary procedures, such as education, standardization, better
childbirth preparation, second opinion before/peer review after a cesarean, broader
midwifery-led care, more trials of labor after a cesarean, continuous labor support,
multifaceted toolkits, changes in current financial incentives/disincentives, and process
measures with rapid feedback. Health experts believe that the C-section rates will continue to
rise. Though there are continuing efforts to reduce the rate of cesarean sections, experts do
not anticipate a significant drop for at least a decade or two.

In 2014, 32.2% of women who gave birth in the United States did so by cesarean
delivery. The rapid increase in cesarean birth rates from 1996 to 2014 without clear evidence
of concomitant decreases in maternal or neonatal morbidity or mortality raises significant
concern that cesarean delivery is overused. The most common indications for primary
cesarean delivery include labor dystocia, abnormal or indeterminate fetal heart rate tracing,
fetal malpresentation, multiple gestation, and suspected fetal macrosomia. External cephalic
version for breech presentation and a trial of labor for women with twin gestations when the
first twin is in cephalic presentation are examples of interventions that can help to safely
lower the primary cesarean delivery rate. A practice bulletin from the American College of
Obstetricians and Gynecologists (ACOG) recommends that all eligible women with breech
presentations who are near term should be offered external cephalic version (ECV) to
decrease the overall rate of cesarean delivery.

On Vaginal Birth After Caesarean Section (VBAC)

Obstetricians recommended that all women who had a cesarean delivery have the
same for all future deliveries. In women who have had one caesarean section, any subsequent
pregnancies should be counselled regarding the risks of vaginal birth:

 A planned VBAC is associated with a one in 200 (0.5%) risk of uterine scar rupture.
 The risk of perinatal death is low and comparable to the risk of women laboring with
their first child.
 There is a small increased risk of placenta praevia +/- accreta in future pregnancies,
and of pelvic adhesions.
 The success rate of planned VBAC is 72–75%, however this is as high as 85-90% in
women who have had a previous vaginal delivery.
 All women undergoing VBAC should have continuous electronic fetal monitoring in
labor as a change in fetal heart rate can be the first sign of impending scar rupture.
 Risks of scar rupture is higher in labors that are augmented or induced with
prostaglandins or oxytocin.

Overall, patients attempting a vaginal birth after a prior cesarean delivery can expect
success approximately 70% of the time. If the cesarean delivery was performed because of an
abnormal fetal heart pattern or for a malpresentation, then expectations for a successful
vaginal birth can be higher than 70%. If the uterine incision was vertical, the risk of uterine
rupture is increased above the approximate 1% risk associated with a low transverse incision.
If the incision was confined to the lower segment, many physicians allow patients to attempt
a vaginal birth in subsequent pregnancies. However, if the incision extended into the upper
contractile portion, the risk of uterine rupture can approach 10%, with 50% of these occurring
prior to the onset of labor. Between 60 and 80% of women who try to deliver vaginally after
a C-section are successful in delivering vaginally. However, women who have a vaginal birth
after cesarean (VBAC) have a less than 1 percent chance that the uterus will rupture during
delivery, which could affect the baby's health. A previous cesarean delivery can increase the
risk of developing placenta accreta if placenta previa is present in any subsequent
pregnancies. The risk of placenta accreta in a patient with previa is approximately 4% with no
prior cesarean deliveries; the risk increases to approximately 25% with 1 prior cesarean
delivery and to 40% with 2 prior cesarean deliveries.

Another type of C-section delivery is the modified extraperitoneal caesarean section is

an innovative caesarean section technique developed by the French obstetric surgeon, Dr.
Denis FAUCK, in the 2000s. It is done through the space of Retzius beneath the bladder. A
urinary catheter after surgery is not essential as the mother is able to get up and walk a few
hours after the operation. She can eat normally and shower the same day. The mother finds
her independence quickly and this means she is ready to take care of her baby. This progress
is due to a special surgical technique and not needing to open up the peritoneal cavity. It is
ultimately less invasive on tissue and therefore less painful. However, extraperitoneal
caesarean sections remain complex and require specialist training. It is still only practiced by
a few obstetricians. Dr. Velemir’s patients can benefit from his specialist training in
performing the Dr. Fauck’s extraperitoneal caesarean section.

On Complications

When compared to vaginal birth, cesarean delivery increases maternal mortality and
morbidity to approximately twice the rate after vaginal delivery. The overall maternal
mortality rate is 6-22 deaths per 100,000 live births, with approximately one third to one half
of maternal deaths after cesarean delivery being directly attributable to the operative
procedure itself. Major sources of morbidity and mortality can be related to sequelae of
infection, thromboembolic disease, anesthetic complications, and surgical injury.

One study indicated that despite clinical pressure to delay delivery until 39 weeks’
gestation, waiting to reach this benchmark before performing a repeat cesarean delivery may
increase maternal risk. According to the study, optimal time of delivery is 38 weeks for
women with 2 previous cesarean deliveries and 37 weeks for those with 3 or more. However,
this must be balanced with recent findings that infants delivered between 37 and 38 weeks
and 6 days have higher morbidity and mortality then infants delivered after 39 weeks. In
2013, ACOG and SMFM made the joint recommendation to reconsider the old gestational
age classification given those findings and replaced them with the following definitions of
gestational age: early term (37 0/7 weeks to 38 6/7 weeks), full term (39 0/7 weeks to 40 6/7
weeks), late term (41 0/7 weeks to 41 6/7 weeks) and post term (42 weeks and above).

RECOMMENDATIONS

Safe reduction of the primary cesarean delivery rate will require different approaches
for these indications, as well as others. Increasing women's access to nonmedical
interventions during labor has also been shown to reduce cesarean birth rates.

Not all of the associated complications can be prevented. Infections can be prevented
by using strict sterile technique, providing intravenous (IV) antibiotics within 60 minutes
prior to incision, and using a chlorhexidine-alcohol scrub before the surgery.4 A vaginal
cleanse should also be performed if the woman has labored prior to the c-section. If hair
removal is needed, this should be done by clipping, not shaving. For all women undergoing
cesarean delivery, mechanical thromboprophylaxis is recommended. For women with a high
risk of venous thromboembolism (VTE), mechanical thromboprophylaxis and pharmacologic
thromboprophylaxis (Lovenox, Heparin) are recommended. Pharmacologic prophylaxis
should begin at 6 to 12 hours postoperatively. Mechanical and pharmacologic prophylaxis
should be continued until the woman is fully ambulating. Multimodal pain relief options
should be used to help the woman to move easier and care for her baby while preventing the
overuse of narcotics. Early ambulation and oral intake have both been shown to promote
recovery.

In conclusion, a C-section is not the appropriate method of delivery for every woman
as it present risks to both the mom and fetus, however, it is necessary to prevent maternal or
fetal risks or death on certain circumstances. On the other hand, enhanced recovery program
for cesarean delivery should consist of the best evidence in perioperative care of the
parturient. There is wide variability in components of published ERAS protocols for cesarean
delivery that should be incorporated in the nursing care plans. Future studies on developing
and evaluating the impact of various components are needed.
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