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Nursing Program
A CASE STUDY
ON
CESAREAN DELIVERY
In partial fulfillment
of the requirements for
Related Learning Experience
Submitted by:
Cuevas, Reynaldo
Parungao, April Dianne
Rabe, Reyna
Raz, Jerickson
Resumadero, Mary Ross
Revilla, Byron
Submitted to:
Mrs. Maribelle Paglinawan RN -
MAN
Clinical Instructor
INTRODUCTION
A C-section delivery is performed when a vaginal birth is not possible or is
not safe for the mother or child. Cesarean deliveries were initially performed
to separate the mother and the fetus in an attempt to save the fetus of a
moribund patient. This operation subsequently developed into a surgical
procedure to resolve maternal or fetal complications not amenable to vaginal
delivery, either for mechanical limitations or to temporize delivery for
maternal or fetal benefit.
Surgery is usually done while the woman is awake but numbed from the
chest to the feet. This is done by giving her epidural or spinal anesthesia.
The surgeon make a cut across the belly just above the pubic area. The
uterus and amniotic sac are opened, and the baby is delivered.The health
care team clears the baby's mouth and nose of fluids, and the umbilical cord
is clamped and cut. The pediatrician or nurse makes sure that the infant's
breathing is normal and that the baby is stable.
The mother is awake and she can hear and see her baby. The father or
another support person is often able to be with the mother during the
delivery. The decision to have a C-section delivery can depend on the
obstetrician, the delivery location, and the woman's past deliveries or
medical history.
Some reasons for having C-section instead of vaginal delivery are:
Reasons related to the baby: Abnormal heart rate in the baby, abnormal
position of the baby in the uterus such as crosswise (transverse) or feet-first
(breech), developmental problems such as hydrocephalus or spina bifida,
multiple babies in the uterus (triplet and some twin pregnancies)
Reasons related to the mother: Active genital herpes infection, large uterine
fibroids low in the uterus near the cervix, HIV infection in the mother,
previous uterine surgery, including myomectomy and previous C-sections,
severe illness in the mother, including heart disease, toxemia, preeclampsia
or eclampsia
Problems with labor or delivery: Baby's head is too large to pass through
mother's pelvis (cephalopelvic disproportion), prolonged or arrested labor,
very large baby (macrosomia)
Problems with the placenta or umbilical cord: placenta attaches in abnormal
location (placenta previa), placenta prematurely separated from uterine wall
(placenta abruptio), umbilical cord comes through the cervix before the baby
(umbilical cord prolapse).
Typically the recovery time depends on the patient and their pain/
inflammation levels. Doctors do recommend no strenuous work i.e. lifting
objects over 10 lbs., running, walking up stairs, or athletics for up to two
weeks.
NURSING HEALTH HISTORY
Patient’s Profile:
This the case of Mrs, Vicky Cabael, a 36 yrs old mother with an OB
score of G6P5 and a TPAL of 5005. The age of gestation is 39 weeks by LMP.
Her LMP was 2nd week of October 2008, exact date unrecalled. Her EDC was
supposed to be July 21 2009. She mentioned having all 5 elderly children
delivered in a lying-in near close to their neighborhood. She was brought
there and was assessed by a midwife and went through the course of labor.
Unfortunately even with a fully dilated cervix, the fetus won’t descend. She
was on second stage of labor when admitted to Tondo Medical Hospital OB
Ward. Mrs. Cabael was also examined for vulvar edema and the amniotic
discharge was thickly meconium stained which is an indication of fetal
distress. Upon admission, she had the following VS:
T = 37.2°C
P = 96 bpm
R = 20 bpm
BP=130/100 mmHg
Dr. N. Ramos, her surgeon gave her the following orders: July 13, 2009
o > NPO
o IVF: D5LRS 1L x 20 gtts/min
PN55 1L x 20 gtts/min
o For CBC, U/A
o For abdominoperineal prep
o Secure 2 U FWB, PTAC
o Therapeutic: Cefazolin 2g IV LD then 500mg IV q6h ANST
An Elective Low Transverse Cesarean Section was opted and performed by
Dr. N. Ramos (Surgeon) and Dr. Gomez(Anesthesiologist) assisted by
surgical Nurse L. Contiling. Mrs. Cabael had bilateral tubal ligation right after
the successful delivery to a live baby boy at 10:34pm (AS: 7,9).
• Childhood illness
• Chickenpox and Measles
Immunization
• None
Previous Hospitalization/Operation
• Normal vaginal delivery to 5 children and 1 miscarriage (D&C
performed)
Medications
• None
Allergies
• None
PHYSICAL ASSESSMENT
Neurological assessment
Behavior – Patient is silent but is conscious and coherent upon interaction.
She sits and walks if she wants to.
Labia Majora – two folds of skin with fat underneath; contain Bartholin’s
glands (believed to secrete a yellowish mucus which acts as a lubricant
during sexual intercourse. The openings of the Bartholin’s glands are
located posteriorly on either side of the vagina orifice.
Labia Minora – two thin folds of delicate tissues; form an upper fold encircling
the clitoris (called the prepuce) and unite posteriorly (called the fourchetes,
which is highly sensitive to manipulation and trauma that is why it is often
torn during a woman’s delivery.)
Clitoris – small, erectile structure at the anterior junction of the labia minora,
which is comparable to the penis in its being extremely sensitive. Landmark
for catheterization
Vestibule – narrow space seen when the labia minora are separated.
Urethral Meatus – external opening of the urethra; slightly behind and to the
side are the openings of the Skene’s glands (which are often involved in
infections of the external genitalia).
Perineum – area from the lower border of the vaginal orifice to the anus;
contains the muscles (e.g., pubococcygeal and levator ani) which support the
pelvic organs, the arteries that supply blood and the pudendal nerves which
are important during delivery under anesthesia.
Vagina – a 3-4 inch long dilatable canal located between the bladder and the
rectum; contains rugae (which permit considerable stretching without
tearing); passageway for menstrual discharges, copulation and fetus.
In the reproductive process, the vagina functions as a two-way street,
accepting the penis and sperm during intercourse and roughly nine months
later, serving as the avenue of birth through which the new baby enters the
world .
Fallopian Tubes – 4 inches long from each side of the fundus; widest part
(called ampulla) spreads into fingerlike projections (called fimbriae).
Responsible for transport of mature ovum from ovary to uterus; fertilization
takes place in its outer third or outer half.
Ovaries – almond-shaped, dull white sex glands near the fimbriae, kept in
place by ligaments. Produce, mature and expel ova and manufacture
estrogen and progesterone.
The Cervix -The vagina ends at the cervix, the lower portion or neck of the
uterus. Like the vagina, the cervix has dual reproductive functions.
After intercourse, sperm ejaculated in the vagina pass through the
cervix, then proceed through the uterus to the fallopian tubes where,
if a sperm encounters an ovum (egg), conception occurs. The cervix is
lined with mucus, the quality and quantity of which is governed by
monthly fluctuations in the levels of the two principle sex hormones,
estrogen and progesterone.
When estrogen levels are low, the mucus tends to be thick and sparse,
which makes it difficult for sperm to reach the fallopian tubes. But when an
egg is ready for fertilization and estrogen levels are high the mucus then
becomes thin and slippery, offering a much more friendly environment to
sperm as they struggle towards their goal. (This phenomenon is employed by
birth control pills, shots and implants. One of the ways they prevent
conception is to render the cervical mucus thick, sparse, and hostile to
sperm.)
INTERNAL REPRODUCTIVE STRUCTURE
PATHOPHYSIOLOGY OF CESAREAN DELIVERY
Release of FSH by
of the endometrium)
to the uterus
Implantation
head into the pelvis) >begin and remain irregular the cervix feels
softer like
dilatation
TRUE LABOR
tation
cervical atrophy)
1000-1500 mL)
LABORATORY RESULTS
Urinalysis
Hematology
DIFFERENTIAL COUNTING
DISCHARGE PLANNING
NURSING PRIORITIES
1. Promote family unity and bonding.
2. Enhance comfort and general well-being.
3. Prevent/minimize postoperative complications.
4. Promote a positive emotional response to birth experience and parenting
role.
5. Provide information regarding postpartal needs.
DISCHARGE GOALS
1. Family bonding initiated
2. Pain/discomfort easing
3. Physical/psychological needs being met
4. Complications prevented/resolving
5. Positive self-appraisal regarding birth and parenting roles expressed
6. Postpartal care understood and plan in place to meet needs after
discharge
M – Medication
Take home medication as prescribed by the Physician.
Instruct patient and relative about the proper way of taking medications.
Explain the proper drug dosage and time of intake and as much as
possible comply with drug regimen especially with antibiotics.
Daily intake of vitamins and iron supplements for 4 to 6 weeks is
recommended for breastfeeding mothers to ensure nutritious milk supply
to the infant.
E – Environment / Exercise
Instructed patient to stay in calm and clean environment, if possible.
Home environment must be free from slipping or accident hazards.
Encourage the patient to exercise (walking and post-partum exercises
such as abdominal breathing, kegel, Chin to chest and arm raising).
T – Treatment
Stressed the importance of perineal cleaning to prevent infection, to ease
the woman and eliminate odor. Flush perineum with warm water after
each voiding, wipe it dry from front to back. Apply perineal pad from front
to back as well.
Demonstrate and observe incision site cleaning and watch for signs of
infection (redness, swelling, unusual discharge)
H – Health Teachings
Instructed mother to come back to the hospital for post-partum check-up/
clinic visit (4 to 6 weeks after delivery).
Advised mother to visit the hospital or their local Barangay office for the
infant’s immunization and check up.
Encourage and explain the importance of breastfeeding to the client.
Breastfeeding, especially the first milk, colostrum can reduce postpartum
bleeding/hemorrhage in the mother, and to pass immunities and other
benefits to the baby.
Advice client to let her child expose to mild sunlight in order to balance
and avoid excess bilirubin in the blood (jaundice).
Encouraged client to have hot sitz bath.
Post-partum diet should be rich in protein, iron and vitamins to promote
healing. Lactating women need an additional 500 – 800 calories per day.
Instructed to promote adequate fluid intake
Discouraged patient to participate in strenuous activities that might
precipitate stress and trauma to the wound and avoid lifting heavy objects
for 1-2 weeks. Light housekeeping chores may be resumed on the second
week and back to normal activities by 4 to 6 weeks.
Sexual intercourse is usually resumed after the first post-partum check
up. Usewater soluble lubricant to reduce painful intercourse.
D – Diet
Encouraged client to increase intake of high fiber foods to avoid
constipation
Instructed to increase fluid intake and eat nutritious foods such as fruits
and vegetables.
Malungay leaves and soups are highly recommended for breastfeeding
mothers.
S – Social Services
Advised patient to see the Social Services Department of the hospital or a
relative can check with the local municipal office if they can avail of
financial aid so they can settle their hospital bill.
NURSING INTERVENTION
ASSESSMENT PLANNING (I = Independent, D = Dependent, RATIONALE EVALUATION
DIAGNOSIS C = Collaborative)
Subjective: Risk for Short Term Goal: INDEPENDENT After 8º of
- Ang sakit ng constipation r/t Within 8º of INTERVENTIONS: nursing
tiyan ko, para post pregnancy nursing · Ascertain normal bowel · This is to determine the interventions,
akong may 2° cesarean interventions, functioning the patient, about normal bowel pattern. the patient was
kabag section the patient will how many times a day does able to identify
DRUG STUDY
DRUG PHARMACOLOGIC INDICATIONS AND ADVERSE EFFECTS DESIRED NURSING RESPONSIBILITIES/
ORDER ACTION OF DRUG CONTRAINDICATIONS OF THE DRUG ACTION PRECAUTIONS
Ketorolac Inhibits Indications: Edema. Less Analgesic Assess clients history of allergy to
30 mg IV prostaglandin Short-term management of frequently, NSAIDs,
then q6h synthesis, but has a pain, used to treat pain hypersensitivity
after greater analgesic following a procedure but reactions (such as Check VS and peripheral edema
ANST properties than may also be used for such anaphylaxis,
other anti- things as pain caused by bronchospasm, Educate client of the common side
inflammatory kidney stones, back pain or laryngeal edema, effect which may include nausea,
agents. cancer pain. tongue edema, vomiting, peripheral edema, GI
hypotension), upset, purpura or dizziness.
Contraindicated in: flushing, weight gain,
Patients with a previously or fever. Very
demonstrated infrequently,
hypersensitivity to ketorolac, asthenia.
and in patients with the
complete or partial
syndrome of nasal polyps,
angioedema, bronchospastic
reactivity or other allergic
manifestations to aspirin or
other non-steroidal anti-
inflammatory drugs (due to
possibility of severe
anaphylaxis). As with all
NSAIDs, ketorolac should be
avoided in patients with
renal (kidney) dysfunction.
(Prostaglandins are needed
to dilate the afferent
arteriole; NSAIDs effectively
reverse this.) The patients at
highest risk, especially in the
elderly, are those with fluid
imbalances or with
compromised renal function
(e.g., heart failure, diuretic
use, cirrhosis, dehydration).
DRUG PHARMACOLOGIC INDICATIONS AND ADVERSE EFFECTS DESIRED NURSING RESPONSIBILITIES/
ORDER ACTION OF DRUG CONTRAINDICATIONS OF THE DRUG ACTION PRECAUTIONS
Cefazolin Inhibits bacterial Indications: Superfinfections, Antibacterial Assess allergy to cefazolin, if
2g IV LD cell wall synthesis Surgical prophylaxis, treats urticaria, seizures (in allergic do not administer drug.
then and produce a respiratory, urinary ad skin high dozes)
500mg IV bactericidal action. infections, treats bone and Record VS and I and O, report
q6h ANST joint infections, genital abnormal findings which may
The onset of action infections and endocarditis include elevated body