INTRODUCTION Vaginal delivery is the most common way to give birth, but in certain situations, Caesarean section is often advised. Cesarean section refers to the delivery of the infant through an incision made on the abdominal and uterine wall. A Caesarean may be classified as: -Elective surgery An elective or planned Caesarean section is performed one to two weeks before the baby's due date. This ensures the baby is mature before delivery. -Emergency surgery An emergency Caesarian section can be performed at a short notice, particularly if there are complications or difficulty in labor. Indications: -Fetal malposition -Fetal distress -Previous cesarean section -Abruptio placenta previa -Cord prolapse -Prolonged labor, uterine inertia -Failed trial and induction of labor, failed forceps and vacuum extraction -Multiple gestation -Herpes genetalis in active stage -Other maternal conditions: preeclampsia and eclampsia, heart disease, Rh and ABO Incompatibility Types of CS: 1. Low Segment / Low-Transverse / Low-Cervical – Incision is made transversely on the lower segment of the uterus. Advantages: Involves less blood loss Less possibility of rupture of CS scar during subsequent pregnancy Incision is easier to repair Less incidence of postoperative complications: infection, adhesion Less possibility of bowel to the incisional line, Intestinal obstruction
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INTRODUCTION
Vaginal delivery is the most common way to give birth, but in certain situations, Caesarean section is often advised. Cesarean section refers to the delivery of the infant through an incision made on the abdominal and uterine wall.
A Caesarean may be classified as:-Elective surgery An elective or planned Caesarean section is performed one to two weeks before the baby's due date. This ensures the baby is mature before delivery.-Emergency surgeryAn emergency Caesarian section can be performed at a short notice, particularly if there are complications or difficulty in labor.
Indications:-Fetal malposition-Fetal distress-Previous cesarean section-Abruptio placenta previa-Cord prolapse-Prolonged labor, uterine inertia-Failed trial and induction of labor, failed forceps and vacuum extraction-Multiple gestation-Herpes genetalis in active stage-Other maternal conditions: preeclampsia and eclampsia, heart disease, Rh and ABO Incompatibility
Types of CS:1. Low Segment / Low-Transverse / Low-Cervical – Incision is made transversely on the lower segment of the uterus.
Advantages: Involves less blood loss Less possibility of rupture of CS scar during subsequent pregnancy Incision is easier to repair Less incidence of postoperative complications: infection, adhesion Less possibility of bowel to the incisional line, Intestinal obstruction
Disadvantages: Difficult and longer to perform than the classical type Not recommended with anterior placenta previa Possibility of incision to extend to the uterine vessels laterally
2. Classical Type / Sanger – A vertical incision is made directly into the walls of corpus, the body of uterine which is the most contractile portion.
Advantages: Easiest and quickest incision to perform Rapid extraction of fetus can be done
Disadvantages: Involves more blood loss because incision is made on the thick vascular portion of the uterine Higher incidence of postoperative complications Rupture of CS scar on subsequent pregnancy and labor is more likely Involves more healing discomfort and a wider CS scar
3. Extra peritoneal Cesarean Section – Incision is made around the bladder and into the lower uterine segment without entering the peritoneal cavity.
Advantages: Useful after prolonged labor Operation recommended in the presence of amnionitis because spilling of amniotic fluid into the peritoneal cavity is avoidedDisadvantages: Operation is difficult to perform Possibility of uterine bleeding and postoperative infection is high
Types of Abdominal Incision:
1. Infraumbilical Vertical Incision – Quickest incision to make which involves performing a 2cm vertical incision at the level of the anterior rectus sheath. The incision should be long enough to allow delivery of the infant without difficulty. This incision is made in obese women and in those requiring immediate delivery.
2. Modified Pfannensteil Incision –Lower transverse slightly curvilinear incision is made at the level of the pubic hairline and extended a little beyond the lateral borders of the rectus muscles. This kind of incision is stronger with less possibility of dehiscence of hernia formation. This type of incision is made on thin women. Repeat cesarean section takes longer to perform after this type of incision because if scarring.
III. INTEGUMENTARYA. HAIR and SCALP-Black hair, No dandruff, No liceB. SKINBrown-skinned(-) rashes, (-) edema, (-) jaundice and (-) lesionC. NAILS-Evenly cut, convex surface-Capillary refill in 3 seconds
IV. THORAXA. POSTERIOR and ANTERIOR THORAX-Symmetrical chest expansion when breathing. Rhythmical normal depthB. LUNGS-No rales; no crackles sound
C. HEART-No murmur sound
V. EXTEMITIESA. LOWER EXTREMITIES-No deformitiesB. UPPER EXTREMITIES-No deformities
THE FEMALE REPRODUCTIVE SYSTEM-Group of organs with the function of production of ovum and sex hormones
The internal organsOVARY-Firm almond shaped organ covered by the peritoneum-Two parts: cortex and medulla-CORTEX- follicles are found-Medulla- connective tissue Fallopian tubes-Bilateral ducts extends laterally from the uterus4 parts1. Infundibulum- funnel shape, with fimbriae2. Ampulla- widest part; usual site of FERTILIZATION3. Isthmus- narrowest part4. Interstitial or Intramural- embedded in the uterine wallFUNCTION: Transport of ovum
The Uterus-Pear-shaped organ with a cavity3 main parts1. Fundus- upper dome-shape part2. Corpus or Body- broad part3. Cervix- narrow lower part-Isthmus- junction between the body and the cervixPOSITION: Anteverted and Anteflexed
The UterusThe uterine wall is made up of three layers1. Perimetrium- superficial part surrounded by the perimetrium2. Myometrium- thickest muscular part3. Endometrium- inner layerFUNCTION: Fetal development in pregnancy
Vaginal canal-Connects the cervix to the vestibule-Fibromuscular canal lined with mucus and covered with hymen-The remnant of hymen is called CARUNCULAE MYRTIFORMISFUNCTION: organ of copulation and passageway of baby
External genitalia1. Vestibule- space between the labia minora2. Pudendal cleft- space between the labia majora3. Clitoris- erectile tissue, homologue of penis4. Labia majora- thick fold of skin, homologue of scrotum5. Labia Minora- thin fold of skin devoid of hairs6. Mons pubis/veneris- elevated area above the labia
THE SURGICAL PROCEDURE
OPERATIVE REPORT
Surgeon: Dr Eugene DauzScrub Nurse: Ms. Imee EsquilonPost-Operative Diagnosis: Post CSProcedure: Vertical incision CSAnesthesia: SpinalCondition: Stable
For informed consent, the most common risks, the complications were thoroughly discussed with Mrs. JB and her family by DR.E.Dauz. An appropriate consent form was signed, indicating Mrs. JB understands the procedure and its possible complications.
This 18-year-old primigravida was brought to the operating room and placed on the surgical table in a supine position. Vital signs were stable prior to surgery. Blood pressure was 110/90. Pulse Rate: 84. Respiratory Rate:22. @9:26 Induction of Spinal anesthesia was induce to numb or desentized the lower part of the patient’s body, the patient is placed in a supine position and the surgical site was prepped by Betadine solution and drape while maintaining a strict sterile technique. @9:31 after the anesthesia takes effect, the surgeon makes an abdominal incision. The uterus is exposed through the abdominal wall incision, and an incision is made in the uterine covering. the muscles of the uterus are separated, producing a hole, the opening in the uterine wall is where the infant is delivered. After which, The surgeon reaches into the uterus and lifts the baby's head. A scrub nurse pushes down on the mother's upper uterus to help guide the baby out. @9:35 Baby was out the scrub nurse suction the baby and the surgeon clamp and cut the umbilical cord. @9:38 the placenta was out and the surgeon clean thoroughly the uterus, after which, the uterus is stitched closed as well as the incision made in the abdominal wall. Operation ended around 9:50. Sterile gauze was then placed in the suture line as a dressing. The patient was awakened and taken to the recovery room in good condition.
yellow slight turbidCellsPus Cells 1-2RBC 5-7Squamos fewBacteria few
NURSING INTERVENTIONS
A. Preoperative: Explain purpose of procedure to be done Clarify misconceptions Check maternal vital signs and FHT Remove nail polish Position woman in supine and drape properly. Advice the woman to ambulate on the first postpartum dayB. Postoperative: Ensure safety of the patient Maintain patent airway. Watch for signs of hemorrhages
DRUG STUDY:
Generic Name: CefuroximeBrand Name: Zinacef®Dosage: 750 mg IV every 8hr ANST (-)Classification: Cephalosporin, Anti-infective AgentsAction: inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall, thus inhibiting biosynthesis and arresting cell wall assembly resulting in bacterial cell death.Indication: Prophylaxis for surgical infection.Contraindications: Hypersensitivity to cephalosporins.Adverse Effect:-Skin: Pruritus, rash-GI: Abdominal cramps, diarrhea, nausea, vomiting, oral candidiasis-GU: Vaginal candidiasis
Generic Name: TramadolBrand Name: Ultram®Dosage: 50 mg IV every 8hrClassification: Non-narcotic AnalgesicsAction: Tramadol inhibits reuptake of norepinephrine, serotonin and enhances serotonin release. It alters perception and response to pain by binding to mu-opiate receptors in the CNS.Indication: Relief of moderate to moderately severe pain.Contraindications: Hypersensitivity to tramadol, opioids, or any component of the formulation; opioid-dependent patients; acute intoxication with alcohol, hypnotics, centrally-acting analgesics, opioids, or psychotropic drugs.Adverse Effect:-CV: Vasodilation-CNS: Agitation, anxiety, confusion, coordination impaired, emotional lability, euphoria, hallucinations, malaise, nervousness, sleep disorder, tremor-Skin: Pruritus, rash-Endocrine & metabolic: Menopausal symptoms
Generic Name: Diclofenac SodiumBrand Name: Lofenax® [amp]Dosage: 1 amp Intramuscular every 8hrClassification: Nonsteroidal Anti-inflammatory Drugs (NSAID’s)Action: Diclofenac has potent anti-inflammatory, analgesic and antipyretic actions. It inhibits the enzyme, cyclooxygenase, thus resulting in reduced synthesis of prostaglandin precursors. Indication: Acute treatment of mild to moderate pain.Adverse Effect:-CNS: Dizziness, nervousness, headache-Nervous System: Anxiety, asthenia, confusion, depression, dream abnormalities, drowsiness, insomnia, malaise, nervousness, paresthesia, somnolence, tremors, vertigo-Cardiovascular System: Congestive heart failure, hypertension, tachycardia, yncope-Respiratory System: Asthma, dyspnea
-Digestive System: Dry mouth, esophagitis, gastric/peptic ulcers, gastritis, gastrointestinal bleeding, glossitis, hematemesis, hepatitis, jaundice-Hemic and Lymphatic System: Ecchymosis, eosinophilia, leukopenia, melena, purpura, rectal bleeding, stomatitis, thrombocytopeniaContraindications: Hypersensitivity to diclofenac, any component, aspirin or other nonsteroidal anti inflammatory drugs (NSAID’s).
Generic Name: MethergineBrand Name: Methylergonovine maleate Dosage: 1 ml amp IV pushAction: Increases motor activity o the uterus by direct stimulation of the smooth muscle, shortening the third stage of labor and reducing blood loss.Adverse Effect: -CNS: dizziness, headache, seizures, hallucinations, CVA with I.V use -CV: hypertension, transient chest pain, palpitations, hypotention, thrombophebitis.-EENT: tinnitus, nasal congestion-G.I: nausea, Vomiting, diarrhea, foul taste-G.U: hematuria-Musculoskeletal: leg cramps-Respiratory: dyspnea-Skin: diaphoresisContraindication: Contraindicated in pregnant patients, in patients sensitive to ergot preparations, and in patients with hypertension or toxemia.
Generic name: Oxytocin Brand name: Pitocin Action: Antihemorrhagic (e.g uterine bleeding) ,to induce labor, strengthen labor contractions during childbirth, control bleeding after childbirth, or to induce an abortion, used for purposes other than those listed in this medication guide. Dosage: 20 units incorporated in 1l of D5LRSAdverse effect: -Respiratory: Pulmonary Arterial Pressure Increased-CV: Right Atrial Pressure Increased, Hypotension, Acute Right Ventricular Failur, Haemodynamic Instability Contraindication: Hypersensitivity to oxytocin or any component of the formulation; significant cephalopelvic disproportion; unfavorable fetal positions; fetal distress; hypertonic or hyperactive uterus; contraindicated vaginal delivery (invasive cervical cancer, active genital herpes, prolapse of the cord, cord presentation, total placenta previa, or vasa previa).Nursing consideration1. Use with extreme caution during first and second stages of labor because cervical laceration, uterine rupture and maternal and fetal death have been reported.2. Use with extreme caution, if at all, in patience with invasive cervical cancer and in those with previous cervical and uterine surgery (including cesarean section), grand multiparity, uterine sepsis, traumatic delivery, over distended uterus.3. Drug is not recommended for routine IM use. However, 10 units maybe given IM after delivery of placenta to control post partum uterine bleeding.
4. Never give oxytocin simultaneously by more than route.5. Monitor fluid intake and output. Antidiuretic effect may lead to fluid overload, seizures and coma from water intoxication.6. Monitor and record uterine contractions, heart rate, blood pressure, intrauterine pressure, fetal heart rate, and character of blood loss every 15 miinutes.Patient teaching:1. Explain use and administration of drug to patient and family.2. Instruct patient to report adverse reactions promptly.
Generic name: Ephedrine Sulfate Brand name: Pretz – D Action: Relaxes bronchial smooth muscle by stimulating Beta 2 Receptors; also, stimulates Alpha and Beta receptors and is a direct – and indirect acting sympatho mimetic . Dosage: 50 mg/ml IV 1ml ampAdverse effect: -CNS: Insomnia, nervousness, dizziness, headache, muscle weakness, euphoria, confusion, delirium, tremor, cerebral hemorrhage, -CV: Palpitations, tachycardia, hypertension, precordial pain, arrythmias.-EENT: Dry nose and throat.-GI: Nausea, vomiting, anorexia.-GU: Urine retention, painful urination caused by visceral sphincter spasm.-Skin: DiaphoresisContraindication: Contraindicated in patients hypersensitive to ephedrine and other sympatho mimetics and in those with porphyria, severe coronary disease, arrhythmias, angle closure glaucoma, psychoneurosis, angina pectoris, substantial organic heart disease or CV disease. Also, contraindicated in those receiving MAO Inhibitors or General Anesthesia with cyclopropane or halothane. Nursing consideration:1. Use with extreme caution in elderly patients and in those with hypertension, hyperthyroidism, nervous are excitable states, diabetes or prostatic hyperplasia. 2. To prevent insomnia, avoid giving drug during bedtime.3. Alert, hypoxia, hypercapnea, and acidosis must be identified and corrected before or dring ephedrine therapy because they may reduce effectiveness or increase adverse reacrtions. Patient teaching:1. Tell patient oral form of drug at home to take last dose of day at least two hours before bedtime.2. Warn patient not to take OTC drugs or herbs that contain ephedrine without consulting prescriber.
Generic Name: Nalbuphine Brand Name: NubainAction: Treating and preventing moderate to severe pain. It can also be used for pain relief before and after surgery and during childbirth. It may also be used for other conditions as determined by your doctor.Dosage: 10 mg/ml1ml amp Adverse Reaction: Skin: rash; hives; Respiratory: difficulty breathing; tightness in the chest
Face: swelling of the mouth, face, lips, or tongue GU: difficulty urinating CNS: fainting; numbness of an arm or leg; seizures; severe headache, dizzinessCV: slow heartbeatContraindication: 1. allergic to any ingredient in Nubain or to another opioid analgesic (eg, morphine or hydromorphone) 2. diarrhea due to poisoning, a certain type of bowel problem (pseudomembranous colitis), or are dependent on any medicine or substance 3. taking sodium oxybate (GHB)
Generic Name: Midazolam Brand Name: Midazolam HClAction: intravenously for induction of general anesthesia, before administration of other anesthetic agents. With the use of narcotic premedication, induction of anesthesia can be attained within a relatively narrow dose range and in a short period of time. Intravenous midazolam can also be used as a component of intravenous supplementation of nitrous oxide and oxygen (balanced anesthesia);Dosage: 5 mg/ml1ml amp IVAdverse Reaction: Body as a Whole: Throat and chest pain. -CNS: Drowsiness, fatigue, ataxia, confusion, paradoxic rage, dizziness, vertigo, amnesia, vivid dreams, headache, slurred speech, tremor; EEG changes, tardive dyskinesia. -CV: Hypotension, tachycardia, edema, cardiovascular collapse. Special Senses: Blurred vision, diplopia, nystagmus. -GI: Xerostomia, nausea, constipation, hepatic dysfunction. GU: Incontinence, urinary retention, gynecomastia (prolonged use), menstrual irregularities, ovulation failure. -Respiratory: Hiccups, coughing, laryngospasm. Other: Pain, venous thrombosis, phlebitis at injection site.Contraindication: Injectable form: Shock, coma, acute alcohol intoxication, depressed vital signs, obstetrical patients, infants <30 d of age. Tablet form: Infants <6 mo of age, acute narrow-angle glaucoma, untreated open-angle glaucoma; during or within 14 d of MAO inhibitor therapy. Safe use during pregnancy (category D) and lactation is not established.
Nursing Intervention: Monitor for adverse reactions. Most are dose related. Observe patient closely and monitor vital signs when Midazolam is given parenterally; hypotension, muscular weakness, tachycardia, and respiratory depression may occur. Monitor I&O ratio, including urinary and bowel elimination.
EVALUATION:After the surgery, there are no untoward situations that took place. The final BP taken is 120/80 and
there are no difficulties of breathing. Mother is transferred to OB ward via stretcher.
