Cesarean Section Final

INTRODUCTION Vaginal delivery is the most common way to give birth, but in certain situations, Caesarean section is often advised. Cesarean section refers to the delivery of the infant through an incision made on the abdominal and uterine wall. A Caesarean may be classified as: -Elective surgery An elective or planned Caesarean section is performed one to two weeks before the baby's due date. This ensures the baby is mature before delivery. -Emergency surgery An emergency Caesarian section can be performed at a short notice, particularly if there are complications or difficulty in labor. Indications: -Fetal malposition -Fetal distress -Previous cesarean section -Abruptio placenta previa -Cord prolapse -Prolonged labor, uterine inertia -Failed trial and induction of labor, failed forceps and vacuum extraction -Multiple gestation -Herpes genetalis in active stage -Other maternal conditions: preeclampsia and eclampsia, heart disease, Rh and ABO Incompatibility Types of CS: 1. Low Segment / Low-Transverse / Low-Cervical – Incision is made transversely on the lower segment of the uterus. Advantages: Involves less blood loss Less possibility of rupture of CS scar during subsequent pregnancy Incision is easier to repair Less incidence of postoperative complications: infection, adhesion Less possibility of bowel to the incisional line, Intestinal obstruction Disadvantages: Difficult and longer to perform than the classical type Not recommended with anterior placenta previa Possibility of incision to extend to the uterine vessels laterally 2. Classical Type / Sanger – A vertical incision is made directly into the walls of corpus, the body of uterine which is the most contractile portion.

Advantages: Easiest and quickest incision to perform Rapid extraction of fetus can be done Disadvantages: Involves more blood loss because incision is made on the thick vascular portion of the uterine Higher incidence of postoperative complications Rupture of CS scar on subsequent pregnancy and labor is more likely Involves more healing discomfort and a wider CS scar 3. Extra peritoneal Cesarean Section – Incision is made around the bladder and into the lower uterine segment without entering the peritoneal cavity. Advantages: Useful after prolonged labor Operation recommended in the presence of amnionitis because spilling of amniotic fluid into the peritoneal cavity is avoided Disadvantages: Operation is difficult to perform Possibility of uterine bleeding and postoperative infection is high Types of Abdominal Incision: 1. Infraumbilical Vertical Incision – Quickest incision to make which involves performing a 2cm vertical incision at the level of the anterior rectus sheath. The incision should be long enough to allow delivery of the infant without difficulty. This incision is made in obese women and in those requiring immediate delivery. 2. Modified Pfannensteil Incision –Lower transverse slightly curvilinear incision is made at the level of the pubic hairline and extended a little beyond the lateral borders of the rectus muscles. This kind of incision is stronger with less possibility of dehiscence of hernia formation. This type of incision is made on thin women. Repeat cesarean section takes longer to perform after this type of incision because if scarring.

PATIENT’S PROFILE: Name: Mrs. JB Age: 18 y/o Birthday: May 24, 1991 Husband’s age: 23 y/o Address: Labong, Sta. Lucia, Ilocos Sur Socio Economic: Mrs. JB is a housewife. Her husband is an Auto Mechanic worker. He earns P150/day from his job. Present Medical History: Mrs. JB was admitted at Tagudin General Hospital and Capillariasis Center on August 7, 2009 at around 9:00 AM. She was admitted to give birth and she does it through cesarean section. Family History: Most of the member of the family had a difficulty in giving birth, and most often when they give birth it is through cesarean section.

PHYSICAL ASSESSMENT I.GENERAL SURVEY A. GENERAL APPEARANCE -Conscious and coherent Trusting, cooperative B. HEIGHT- 5 feet and 1 inch WEIGHT- 4 kg C. VITAL SIGNS -BP – 110/90 -RR – 22 -PR – 84 -Temp. – 37.5 II. HEAD and NECK HEAD EYES NOSE EARS NECK

No scar Symmetrical Coordinated and can see clearly No deformities No discharge Symmetrical No discharges and can hear clearly Vein engorgement negative Lymph nodes negative

III. INTEGUMENTARY A. HAIR and SCALP -Black hair, No dandruff, No lice B. SKIN Brown-skinned (-) rashes, (-) edema, (-) jaundice and (-) lesion C. NAILS -Evenly cut, convex surface -Capillary refill in 3 seconds IV. THORAX A. POSTERIOR and ANTERIOR THORAX -Symmetrical chest expansion when breathing. Rhythmical normal depth B. LUNGS -No rales; no crackles sound C. HEART -No murmur sound

V. EXTEMITIES A. LOWER EXTREMITIES -No deformities B. UPPER EXTREMITIES -No deformities

THE FEMALE REPRODUCTIVE SYSTEM -Group of organs with the function of production of ovum and sex hormones The internal organs OVARY -Firm almond shaped organ covered by the peritoneum -Two parts: cortex and medulla -CORTEX- follicles are found -Medulla- connective tissue Fallopian tubes -Bilateral ducts extends laterally from the uterus 4 parts 1. Infundibulum- funnel shape, with fimbriae 2. Ampulla- widest part; usual site of FERTILIZATION 3. Isthmus- narrowest part 4. Interstitial or Intramural- embedded in the uterine wall FUNCTION: Transport of ovum The Uterus -Pear-shaped organ with a cavity 3 main parts 1. Fundus- upper dome-shape part 2. Corpus or Body- broad part 3. Cervix- narrow lower part -Isthmus- junction between the body and the cervix POSITION: Anteverted and Anteflexed The Uterus The uterine wall is made up of three layers 1. Perimetrium- superficial part surrounded by the perimetrium 2. Myometrium- thickest muscular part 3. Endometrium- inner layer FUNCTION: Fetal development in pregnancy Vaginal canal -Connects the cervix to the vestibule -Fibromuscular canal lined with mucus and covered with hymen -The remnant of hymen is called CARUNCULAE MYRTIFORMIS FUNCTION: organ of copulation and passageway of baby

External genitalia 1. Vestibule- space between the labia minora 2. Pudendal cleft- space between the labia majora 3. Clitoris- erectile tissue, homologue of penis 4. Labia majora- thick fold of skin, homologue of scrotum 5. Labia Minora- thin fold of skin devoid of hairs 6. Mons pubis/veneris- elevated area above the labia

THE SURGICAL PROCEDURE OPERATIVE REPORT Surgeon: Dr Eugene Dauz Scrub Nurse: Ms. Imee Esquilon Post-Operative Diagnosis: Post CS Procedure: Vertical incision CS Anesthesia: Spinal Condition: Stable INSTRUMENT USED: Sponges: 6, Allis:6, Bladder Retractor: 1 ,Richardson: 1 ,Straight Clamp: 2 ,Curve Clamp: 6 ,Tissue Forceps: 1 ,Thumb Forceps: 1 ,Straight Mayo: 1 ,Army Navy: 1 ,Curve Mayo: 1 ,Metz: 1 ,Blade Holder: 1 ,Needle Holder:2 ,Blade: 1 ,Towel Clip: 4 ,Needle- 6. For informed consent, the most common risks, the complications were thoroughly discussed with Mrs. JB and her family by DR.E.Dauz. An appropriate consent form was signed, indicating Mrs. JB understands the procedure and its possible complications. This 18-year-old primigravida was brought to the operating room and placed on the surgical table in a supine position. Vital signs were stable prior to surgery. Blood pressure was 110/90. Pulse Rate: 84. Respiratory Rate:22. @9:26 Induction of Spinal anesthesia was induce to numb or desentized the lower part of the patient’s body, the patient is placed in a supine position and the surgical site was prepped by Betadine solution and drape while maintaining a strict sterile technique. @9:31 after the anesthesia takes effect, the surgeon makes an abdominal incision. The uterus is exposed through the abdominal wall incision, and an incision is made in the uterine covering. the muscles of the uterus are separated, producing a hole, the opening in the uterine wall is where the infant is delivered. After which, The surgeon reaches into the uterus and lifts the baby's head. A scrub nurse pushes down on the mother's upper uterus to help guide the baby out. @9:35 Baby was out the scrub nurse suction the baby and the surgeon clamp and cut the umbilical cord. @9:38 the placenta was out and the surgeon clean thoroughly the uterus, after which, the uterus is stitched closed as well as the incision made in the abdominal wall. Operation ended around 9:50. Sterile gauze was then placed in the suture line as a dressing. The patient was awakened and taken to the recovery room in good condition.

LABORATORY RESULTS Hematology Results Hemoglobin RBC WBC Neutrophils Lymphocytes

Color yellow Cells Pus Cells RBC Squamos Bacteria

120 4.2 4.5

Normal Value

125-160 g/L 4.5-5x10 12/L 5-10 x10 9/L HbsAg = (-) negative Differential Counts 0.93 0.07

Significance Slightly decreased Slightly decreased Slightly decreased

URINALYSIS Character slight turbid 1-2 5-7 few few

NURSING INTERVENTIONS A. Preoperative: Explain purpose of procedure to be done Clarify misconceptions Check maternal vital signs and FHT Remove nail polish Position woman in supine and drape properly.  Advice the woman to ambulate on the first postpartum day B. Postoperative: Ensure safety of the patient Maintain patent airway. Watch for signs of hemorrhages

DRUG STUDY: Generic Name: Cefuroxime Brand Name: Zinacef® Dosage: 750 mg IV every 8hr ANST (-) Classification: Cephalosporin, Anti-infective Agents Action: inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall, thus inhibiting biosynthesis and arresting cell wall assembly resulting in bacterial cell death. Indication: Prophylaxis for surgical infection. Contraindications: Hypersensitivity to cephalosporins. Adverse Effect: -Skin: Pruritus, rash -GI: Abdominal cramps, diarrhea, nausea, vomiting, oral candidiasis -GU: Vaginal candidiasis Generic Name: Tramadol Brand Name: Ultram® Dosage: 50 mg IV every 8hr Classification: Non-narcotic Analgesics Action: Tramadol inhibits reuptake of norepinephrine, serotonin and enhances serotonin release. It alters perception and response to pain by binding to mu-opiate receptors in the CNS. Indication: Relief of moderate to moderately severe pain. Contraindications: Hypersensitivity to tramadol, opioids, or any component of the formulation; opioid-dependent patients; acute intoxication with alcohol, hypnotics, centrally-acting analgesics, opioids, or psychotropic drugs. Adverse Effect: -CV: Vasodilation -CNS: Agitation, anxiety, confusion, coordination impaired, emotional lability, euphoria, hallucinations, malaise, nervousness, sleep disorder, tremor -Skin: Pruritus, rash -Endocrine & metabolic: Menopausal symptoms Generic Name: Diclofenac Sodium Brand Name: Lofenax® [amp] Dosage: 1 amp Intramuscular every 8hr Classification: Nonsteroidal Anti-inflammatory Drugs (NSAID’s) Action: Diclofenac has potent anti-inflammatory, analgesic and antipyretic actions. It inhibits the enzyme, cyclooxygenase, thus resulting in reduced synthesis of prostaglandin precursors. Indication: Acute treatment of mild to moderate pain. Adverse Effect: -CNS: Dizziness, nervousness, headache -Nervous System: Anxiety, asthenia, confusion, depression, dream abnormalities, drowsiness, insomnia, malaise, nervousness, paresthesia, somnolence, tremors, vertigo -Cardiovascular System: Congestive heart failure, hypertension, tachycardia, yncope -Respiratory System: Asthma, dyspnea

-Digestive System: Dry mouth, esophagitis, gastric/peptic ulcers, gastritis, gastrointestinal bleeding, glossitis, hematemesis, hepatitis, jaundice -Hemic and Lymphatic System: Ecchymosis, eosinophilia, leukopenia, melena, purpura, rectal bleeding, stomatitis, thrombocytopenia Contraindications: Hypersensitivity to diclofenac, any component, aspirin or other nonsteroidal anti inflammatory drugs (NSAID’s). Generic Name: Methergine Brand Name: Methylergonovine maleate Dosage: 1 ml amp IV push Action: Increases motor activity o the uterus by direct stimulation of the smooth muscle, shortening the third stage of labor and reducing blood loss. Adverse Effect: -CNS: dizziness, headache, seizures, hallucinations, CVA with I.V use -CV: hypertension, transient chest pain, palpitations, hypotention, thrombophebitis. -EENT: tinnitus, nasal congestion -G.I: nausea, Vomiting, diarrhea, foul taste -G.U: hematuria -Musculoskeletal: leg cramps -Respiratory: dyspnea -Skin: diaphoresis Contraindication: Contraindicated in pregnant patients, in patients sensitive to ergot preparations, and in patients with hypertension or toxemia. Generic name: Oxytocin Brand name: Pitocin Action: Antihemorrhagic (e.g uterine bleeding) ,to induce labor, strengthen labor contractions during childbirth, control bleeding after childbirth, or to induce an abortion, used for purposes other than those listed in this medication guide. Dosage: 20 units incorporated in 1l of D5LRS Adverse effect: -Respiratory: Pulmonary Arterial Pressure Increased -CV: Right Atrial Pressure Increased, Hypotension, Acute Right Ventricular Failur, Haemodynamic Instability Contraindication: Hypersensitivity to oxytocin or any component of the formulation; significant cephalopelvic disproportion; unfavorable fetal positions; fetal distress; hypertonic or hyperactive uterus; contraindicated vaginal delivery (invasive cervical cancer, active genital herpes, prolapse of the cord, cord presentation, total placenta previa, or vasa previa). Nursing consideration 1. Use with extreme caution during first and second stages of labor because cervical laceration, uterine rupture and maternal and fetal death have been reported. 2. Use with extreme caution, if at all, in patience with invasive cervical cancer and in those with previous cervical and uterine surgery (including cesarean section), grand multiparity, uterine sepsis, traumatic delivery, over distended uterus. 3. Drug is not recommended for routine IM use. However, 10 units maybe given IM after delivery of placenta to control post partum uterine bleeding.

4. Never give oxytocin simultaneously by more than route. 5. Monitor fluid intake and output. Antidiuretic effect may lead to fluid overload, seizures and coma from water intoxication. 6. Monitor and record uterine contractions, heart rate, blood pressure, intrauterine pressure, fetal heart rate, and character of blood loss every 15 miinutes. Patient teaching: 1. Explain use and administration of drug to patient and family. 2. Instruct patient to report adverse reactions promptly. Generic name: Ephedrine Sulfate Brand name: Pretz – D Action: Relaxes bronchial smooth muscle by stimulating Beta 2 Receptors; also, stimulates Alpha and Beta receptors and is a direct – and indirect acting sympatho mimetic . Dosage: 50 mg/ml IV 1ml amp Adverse effect: -CNS: Insomnia, nervousness, dizziness, headache, muscle weakness, euphoria, confusion, delirium, tremor, cerebral hemorrhage, -CV: Palpitations, tachycardia, hypertension, precordial pain, arrythmias. -EENT: Dry nose and throat. -GI: Nausea, vomiting, anorexia. -GU: Urine retention, painful urination caused by visceral sphincter spasm. -Skin: Diaphoresis Contraindication: Contraindicated in patients hypersensitive to ephedrine and other sympatho mimetics and in those with porphyria, severe coronary disease, arrhythmias, angle closure glaucoma, psychoneurosis, angina pectoris, substantial organic heart disease or CV disease. Also, contraindicated in those receiving MAO Inhibitors or General Anesthesia with cyclopropane or halothane. Nursing consideration: 1. Use with extreme caution in elderly patients and in those with hypertension, hyperthyroidism, nervous are excitable states, diabetes or prostatic hyperplasia. 2. To prevent insomnia, avoid giving drug during bedtime. 3. Alert, hypoxia, hypercapnea, and acidosis must be identified and corrected before or dring ephedrine therapy because they may reduce effectiveness or increase adverse reacrtions. Patient teaching: 1. Tell patient oral form of drug at home to take last dose of day at least two hours before bedtime. 2. Warn patient not to take OTC drugs or herbs that contain ephedrine without consulting prescriber. Generic Name: Nalbuphine Brand Name: Nubain Action: Treating and preventing moderate to severe pain. It can also be used for pain relief before and after surgery and during childbirth. It may also be used for other conditions as determined by your doctor. Dosage: 10 mg/ml1ml amp Adverse Reaction: Skin: rash; hives; Respiratory: difficulty breathing; tightness in the chest

Face: swelling of the mouth, face, lips, or tongue GU: difficulty urinating CNS: fainting; numbness of an arm or leg; seizures; severe headache, dizziness CV: slow heartbeat Contraindication: 1. allergic to any ingredient in Nubain or to another opioid analgesic (eg, morphine or hydromorphone) 2. diarrhea due to poisoning, a certain type of bowel problem (pseudomembranous colitis), or are dependent on any medicine or substance 3. taking sodium oxybate (GHB) Generic Name: Midazolam Brand Name: Midazolam HCl Action: intravenously for induction of general anesthesia, before administration of other anesthetic agents. With the use of narcotic premedication, induction of anesthesia can be attained within a relatively narrow dose range and in a short period of time. Intravenous midazolam can also be used as a component of intravenous supplementation of nitrous oxide and oxygen (balanced anesthesia); Dosage: 5 mg/ml1ml amp IV Adverse Reaction: Body as a Whole: Throat and chest pain. -CNS: Drowsiness, fatigue, ataxia, confusion, paradoxic rage, dizziness, vertigo, amnesia, vivid dreams, headache, slurred speech, tremor; EEG changes, tardive dyskinesia. -CV: Hypotension, tachycardia, edema, cardiovascular collapse. Special Senses: Blurred vision, diplopia, nystagmus. -GI: Xerostomia, nausea, constipation, hepatic dysfunction. GU: Incontinence, urinary retention, gynecomastia (prolonged use), menstrual irregularities, ovulation failure. -Respiratory: Hiccups, coughing, laryngospasm. Other: Pain, venous thrombosis, phlebitis at injection site. Contraindication: Injectable form: Shock, coma, acute alcohol intoxication, depressed vital signs, obstetrical patients, infants <30 d of age. Tablet form: Infants <6 mo of age, acute narrow-angle glaucoma, untreated open-angle glaucoma; during or within 14 d of MAO inhibitor therapy. Safe use during pregnancy (category D) and lactation is not established. Nursing Intervention: Monitor for adverse reactions. Most are dose related. Observe patient closely and monitor vital signs when Midazolam is given parenterally; hypotension, muscular weakness, tachycardia, and respiratory depression may occur. Monitor I&O ratio, including urinary and bowel elimination.

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

CASE STUDY

ON

CAESAREAN SECTION

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