BY: BJCV

Patients Profile
Name: Mrs. Go, Ma. Glenda Address: Brgy. 2, Hernani E. Samar Age: 31 Years Old Sex: female Race: Filipino Marital Status: Married Occupation: Teacher Mother: Corazon Colico Father: Gaudinsio Candido Religion: Roman Catholic Admitting Dx: PU 39 wks G1 P1 Low-lying Placenta Admitting Physician: Dra. Domingo

History of Present Illness

The patient is reactive of Hepatitis B. She was admitted on October 10, diagnose of low lying placenta for Cesarean procedure. She reported painless vaginal bleeding recently. Low lying placenta was confirmed through ultrasound.

History of Past Illness

Patient has not been admitted for the past few years, although she experienced fever, cough and colds but she managed it at their home by using herbal medicines and she has not experienced any injury before. She has no known allergies to drugs and food. She said she is complete in immunizations.

Family History
The family history of illnesses of the patient is HPN and asthma.

Laboratory

ULTRASOUND FINDINGS 1. 2. 3. 4. Lie:---------------- Longitudinal Fetal No.:-------- Single Presentation:--- Cephalic AFV:--------------- Normal a. AFI (Amniotic Fluid Index)--- 14.0 cm 5. Placenta a. Grade III b. Previae------Low lying 38 weeks and 4 days AOG Impression: Single, live intrauterine pregnancy, cephalic, 38 weeks sonological age, with good fetal cardiac and motor activity, posterior low-lying placenta of grade III maturity index adequate amniotic fluid volume.

HEMATOLOGY HbsAg determination: Reactive Parameters Leukocytes number cone Differential Cell Count: Segmenters Lymphocytes Hematocrit Results 6.2 X 10 9/L 0.81 0.19 0.33 Normal Values 5-10 x 10 9/L 0.65-0.85 0.15-0.35 0.37-0.47

Blood Type: A+

Anatomy and Physiology

The female reproductive system contains two main parts: the uterus, which hosts the developing fetus, produces vaginal and uterine secretions, and passes the male's sperm through to the fallopian tubes; and the ovaries, which produce the female's egg cells. These parts are internal; the vagina meets the external organs at the vulva, which includes the labia, clitoris and urethra. The vagina is attached to the uterus through the cervix, while the uterus is attached to the ovaries via the Fallopian tubes. At certain intervals, the ovaries release an ovum, which passes through the Fallopian tube into the uterus. If, in this transit, it meets with sperm, the sperm penetrate and merge with the egg, fertilizing it. The fertilization usually occurs in the oviducts, but can happen in the uterus itself. The zygote then implants itself in the wall of the uterus, where it begins the processes of embryogenesis and morphogenesis. When developed enough to survive outside the womb, the cervix dilates and contractions of the uterus propel the fetus through the birth canal, which is the vagina. The ova are larger than sperm and are generally all created by birth. Approximately every month, a process of oogenesis matures one ovum to be sent down the Fallopian tube attached to its ovary in anticipation of fertilization. If not fertilized, this egg is flushed out of the system.

Internal Structures Vagina The vagina is a fibromuscular tubular tract leading from the uterus to the exterior of the body in female. The vagina is the place where semen from the male is deposited into the female's body at the climax of sexual intercourse, commonly known as ejaculation. Around the vagina, pubic hair protects the vagina from infection and is a sign of puberty. The vagina is mostly used for sexual intercourse. Cervix The cervix is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. Approximately half its length is visible; the remainder lies above the vagina beyond view. Uterus The uterus or womb is the major female reproductive organ of humans. One end, the cervix, opens into the vagina; the other is connected on both sides to the fallopian tubes. The uterus is a pear-shaped muscular organ. Its major function is to accept a fertilized ovum which becomes implanted into the endometrium, and derives nourishment from blood vessels which develop exclusively for this purpose. The fertilized ovum becomes an embryo, develops into a fetus and gestates until childbirth. If the egg does not embed in the wall of the uterus, a woman begins menstruation and the egg is flushed away.

Oviducts The Fallopian tubes or oviducts are two very fine tubes leading from the ovaries of females into the uterus. On maturity of an ovum, the follicle and the ovary's wall rupture, allowing the ovum to escape and enter the Fallopian tube. There it travels toward the uterus, pushed along by movements of cilia on the inner lining of the tubes. This trip takes hours or days. If the ovum is fertilized while in the Fallopian tube, then it normally implants in the endometrium when it reaches the uterus, which signals the beginning of pregnancy. Ovaries The ovaries are the place inside the female body where ova or eggs are produced. The process by which the ovum is released is called ovulation. The speed of ovulation is periodic and impacts directly to the length of a menstrual cycle. After ovulation, the ovum is captured by the oviduct, after traveling down the oviduct to the uterus, occasionally being fertilized on its way by an incoming sperm, leading to pregnancy and the eventual birth of a new human being. The Fallopian tubes are often called the oviducts and they have small hairs (cilia) to help the egg cell travel

External Structures The function of the external female reproductive structures (the genital) is twofold: To enable sperm to enter the body and to protect the internal genital organs from infectious organisms. The main external structures of the female reproductive system include: Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally translated as "large lips," the labia majora are relatively large and fleshy, and are comparable to the scrotum in males. The labia majora contain sweat and oil-secreting glands. After puberty, the labia majora are covered with hair. Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just inside the labia majora, and surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body) and urethra (the tube that carries urine from the bladder to the outside of the body). Bartholins glands: These glands are located next to the vaginal opening and produce a fluid (mucus) secretion. Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The clitoris is covered by a fold of skin, called the prepuce, which is similar to

the foreskin at the end of the penis. Like the penis, the clitoris is very sensitive to stimulation and can become erect.

Indications for the procedure

Cesarean section A Cesarean section, also known as C-section, is a surgical procedure in which incisions are made through a mothers abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies. It is usually performed when a vaginal delivery would put the baby's or mother's life or health at risk, although in recent times it has been also performed upon request for childbirths that could otherwise have been natural. The World Health Organization(WHO) recommends that the rate of Caesarean sections should not exceed 15% in any country. There are several types of Caesarean section (CS). An important distinction lies in the type of incision (longitudinal or latitudinal) made on the uterus, apart from the incision on the skin. The classical Caesarean section involves a midline longitudinal incision which allows a larger space to deliver the baby. However, it is rarely performed today as it is more prone to complications. The lower uterine segment section is the procedure most commonly used today; it involves a transverse cut just above the edge of the bladder and results in less blood loss and is easier to repair. An emergency Caesarean section is a Caesarean performed once labour has commenced. A crash Caesarean section is a Caesarean performed in an obstetric emergency, where complications of pregnancy onset suddenly during the process of labor, and swift action is required to prevent the deaths of mother, child(ren) or both. A Caesarean hysterectomy consists of a Caesarean section followed by the removal of the uterus. This may be done in cases of intractable bleeding or when the placenta cannot be separated from the uterus. Traditionally other forms of Caesarean section have been used, such as extra peritoneal Caesarean section or Porro Caesarean section. A repeat Caesarean section is done when a patient had a previous Caesarean section. Typically it is performed through the old scar.

PLACENTA PREVIA The placenta is implanted in the lower uterine segment near or over the internal cervical os. The degree to which the internal cervical os is covered by the placenta has been used to classify four types of placenta previa; total, partial, marginal and lowlying. In total previa the internal os is entirely covered by the placenta. Partial placenta previa implies incomplete coverage of the internal os. Marginal placenta previa indicates that only an edge of the placenta extends to the margin of the internal os. And the last is the low lying placenta has been used when the placenta is implanted in the lower uterine segment but not reach the os. The more descriptive classification that includes placenta previa is in the third trimester. The incidence of placenta previa is approximately 0.5% of births. The most important risk factors are previous placenta previa, previous cesarean birth, and suction curettage for miscarriage or induced abortion, possible related to endometrial scarring. The risk also increases with multiple gestations because of the larger placental area, closely spaced pregnancies, advanced maternal age older than 30 years, African or Asian ethnicity, male fetal sex, smoking, cocaine use, multiparity, and tobacco use. Classification of Placenta Previa: 1. Total Previa- the placenta completely covers the internal cervical os. 2. Partial Previa- the placenta covers a part of the internal cervical os. 3. Marginal Previa- the edge of the placenta lies at the margin of the internal cervical os and may be exposed during dilatation. 4. Low-lying placenta- the placenta is implanted in the lower uterine segment but does not reach to the internal os of the cervix. Predisposing Factors: 1. Multiparity (80% of affected clients are multiparous) 2. Advanced maternal age (older than 30 years old in 33% of cases 3. Multiple gestation 4. Previous Cesarean birth 5. Uterine Incisions 6. Prior placenta previa ( incidence is 12 times greater in women with previous placenta previa) Complications for the baby include: Problems for the baby, secondary to acute blood loss Intrauterine growth retardation due to poor placental perfusion Increased incidence of congenital anomalies

Clinical Manifestations: Painless vaginal bleeding > occurs after 20 weeks of gestation, bright red in color associated with the stretching and thinning of the lower uterine segment that occurs in third trimester. Adequately contract and stop blood flow from open vessels. Decrease urinary output Normal Placenta during Childbirth Process of placental growth and uterine wall changes during pregnancy 1. The placenta grows with the placental site during pregnancy. 2. During pregnancy and early labor the area of the placental site probably changes little, even during uterine contractions. 3. The semirigid, noncontractile placenta cannot alter its surface area. Anatomy of the uterine/placental compartment at the time of birth 1. The cotyledons of the maternal surface of the placenta extend into the decidua basalis, which forms a natural cleavage plane between the placenta and the uterine wall. 2. There are interlacing uterine muscle bundles, consisting of tiny myofibrils, around the branches of the uterine arteries that run through the wall of the uterus to the placental area. 3. The placental site is usually located on either the anterior or the posterior uterine wall. 4. The amniotic membranes are adhered to the inner wall of the uterus except where the placenta is located

Pathophysiology
Painless Vaginal Bleeding

Risk Factor Advanced Maternal Age (>30 y.o.)

Decreased UO COMPLICATIONS: Congenital anomalies Intrauterine Growth Retardation Maternal Mortality

Low-lying placenta
Tachycardia

Bleeding Continues Maternal hemorrhage

Hypotension

Cesarean birth Physical Examination

V/S: Temp: PR: 64 RR: 22 BP: 100/70 Gen. Survey: Gen. Appearance: Good Level of Consciousness: Conscious Orientation: Oriented (time, place, and person) Development: Well developed Nutritional State: Well-nourished Emotional State: Calm Skin: Gen. Color: Pinkish Texture: Smooth Turgor: Good Temp: Warm Moisture: Dry Head: Configuration: normocephalic Facial Movements: Symmetrical Fontanels: Closed Hair: Even distribution Scalp: Clean Eyes: Lids: Symmetrical Conjunctiva: Pink Sclera: anicteric Pupils: Equal, reactive to light Reaction to light: Uniform constriction Visual acuity: grossly normal Peripheral vision: Intact Ears: External Pinnae: Symmetrical Tympanic Membrane: Intact Gross Hearing: Symmetrical Nose: Septum: Midline Mucosa: Pinkish Gross Smell: Symmetrical Mouth:

Lips: Dryness Mucosa: Pink Tongue: Midline Teeth: Complete Gums: Pinkish Speech: intact Pharynx: Uvula: midline Mucosa: Pinkish Tonsils: not inflamed Neck: Trachea: Midline Thyroids: Nonpalpable Chest and Lungs:

Breathing pattern: Regular Lung Expansion: Symmetrical Tactile Fremitus: symmetrical Breast: Size: Equal Shape: Symmetrical Color: Pink Surface: Smooth Back And Extremities: Peripheral Pulses: Regular Nail beds: Pink ROM: Full Spine: Midline