CESARIAN SECTION CASE PRESENTATION

CAESARIAN SECTION Case Presentation Prepared By:

Group 165- A&B BSN 3D2-6

Ms. Led Erika R. Paez, RN NCOR Instructor

I.

INTRODUCTION

Nursing process is a patient centered, goal oriented method of caring that provides a frame work to the nursing care. The nursing process exists for every problem that the patient has, and for every element of patient care, rather than once for each patient. The nurse's evaluation of care will lead to changes in the implementation of the care and the patient's needs are likely to change during their stay in hospital as their health either improves or deteriorates. Nursing process was used in this case study for a more systematic to care for a client who have undergone a cesarean section birth. Cesarean delivery, also known as cesarean section, is a major abdominal surgery involving 2 incisions (cuts), One is an incision through the abdominal wall (laparotomy) and the second is an incision involving the uterus (hysteretomy) to deliver the baby. History : Legend has it that the Roman leader Julius Caesar was delivered by this operation, and the procedure was named after him. 3 Theories about Origin of the Name: 1. The name for the procedure is said to derive from a Roman legal code called "Lex Caesarea", which allegedly contained a law prescribing that the baby be cut out of its mother's womb in the case that she dies before giving birth.The Merriam-Webster dictionary is unable to trace any such law; but "Lex Caesarea" might mean simply "imperial law" rather than a specific statute of Julius Caesar.)

1. 2. The derivation of the name is also often attributed to an ancient story, told in the first century A.D. by Pliny the Elder, which claims that an ancestor of Caesar was delivered in this manner.

2. 3. An alternative etymology

suggests that the procedure's name derives from the Latin

verb caedere (supine stem caesum), "to cut," in which case the term "Caesarean section" is redundant. Proponents of this view consider the traditional derivation to be a false etymology, though the supposed link with Julius Caesar has clearly influenced the spelling. (A corollary suggesting that Julius Caesar himself derived his name from the operation is refuted by the fact that the cognomen "Caesar" had been used in the Julii family for centuries before his birth, and the Historia Augusta cites three possible sources for the name Caesar, none of which have to do with Caesarean sections or the root word caedere.)

CAUSES: 1. Repeat cesarean delivery: There are 2 types of uterine incisions—a low transverse incision and a vertical uterine incision.

1a) A low transverse uterine incision is the approach of choice. 1b) A vertical incision on the uterus (low or high) may be used for delivering preterm babies, abnormally positioned placentas, pregnancies with more than one fetus, and in extreme emergencies. 1a In the last 20 years, studies have shown that women who have had a prior cesarean section with a low transverse incision may safely and successfully go through labor and have a vaginal delivery in later pregnancies. (VBAC) Uterine rupture can be dangerous to the fetus even if delivery is accomplished immediately after a uterine rupture. Factors that Impede vaginal birth 1. prolonged labor or a failure to progress (dystocia)fetal distress 2. cord prolapse 3. uterine rupture 4.placental problems (placenta praevia, placental abruption or placenta accreta) 5. abnormal presentation (breech or transverse positions) 6. failed labor induction 7. failed instrumental delivery (by forceps or ventouse. Sometimes a 'trial of forceps/ventouse' is tried out - This means a forceps/ventouse delivery is attempted, and if the forceps/ventouse delivery is unsuccessful, it will be switched to a caesarean section. 8. overly large baby (macrosomia) umbilical cord abnormalities (vasa previa, multi-lobate including bi-lobate and succenturiate-lobed placentas, filamentous insertion) 9. contracted pelvis 10. pre-eclampsia 11. hypertension 12.multiple births 13.precious (High Risk) Fetus 14.HIV infection of the mother 15. Sexually transmitted infections such as genital herpes (which can be passed on to the baby if the baby is born vaginally, but can usually be treated in with medication and do not require a Caesarean section) 16. previous Caesarean section prior problems with the healing of the perineum (from previous childbirth or Crohn's Disease) 17. Lack of Obstetric Skill (Obstetricians not being skilled in performing breech births, multiple births, etc. [In most situations women can birth under these circumstances naturally. However, obstetricians are not always trained in proper procedures]) 18. Improper Use of Technology (Electric Fetal Monitoring [EFM])

Types and Indications

1. Classical Caesarean Section-Here the upper portion of the uterus is opened by an incision and the baby is then extracted. This is not practiced anymore due to a higher incidence of complications. -involves a midline longitudinal incision which allows a larger space to deliver the baby. 2. Lower Segment Caesarean Section– In this case, the uterus is opened in the lower segment and the baby’s head or breech as the case may be is delivered. -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. 3. Emergency C SectionWhen there is suspected danger to the mother's or baby’s condition an emergency section is resorted to. -done once labor has commenced 4. Elective Caesarean Section (Planned C-Section)The caesarean is planned and done on a specific date chosen by the patient and the doctor after assessing the maturity of the baby. 5. A crash Caesarean section is a Caesarean performed in an obstetric emergency, where complications of pregnancy onset suddenly during the process of labour, and swift action is required to prevent the deaths of mother, child(ren) or both. 6. 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. 7. Traditionally other forms of Caesarean section have been used, such as extraperitoneal Caesarean section or Porro Caesarean section. 8. a repeat Caesarean section is done when a patient had a previous Caesarean section. Typically it is performed through the old scar.

In a normal pregnancy, the baby is positioned head down in the uterus.

4. Abnormal position of the fetus & Placental causes : i) Breech delivery ii) Oblique lie iii) Persistent Occipitoposterior position iv) Deflexed Head (cord round the neck) v) Abruptio placenta

vi) Placenta praevia 6. Emergency situations: If the woman is severely ill or has a life-threatening injury or illness with interruption of the normal heart or lung function, she may be a candidate for an emergency cesarean section.

Maternal Complications: * Urinary function and bladder injury: Urinary retention after Cesarean due to bladder atony could be relieved by urethral catheter for 24 hours. Bladder injury during Cesarean can occur inadvertently. * Bowel function and bowel injury: Typically, bowel function after a cesarean section returns quickly. Unrecognized bowel injury may occur occasionally and should be managed appropriately. Complications for the infant Injury during the delivery. Need for special care in the neonatal intensive care unit (NICU). Lung immaturity, if the due date has been miscalculated or the infant is delivered before 39 weeks of gestation. Long Term Complications Women who have a uterine cesarean scar have slightly increased long-term risks. These risks, which increase further with each additional cesarean delivery, include: Breaking open of the incision scar during a later pregnancy or labor (uterine rupture). For more information, see the topic Vaginal Birth After Cesarean (VBAC). Placenta previa, the growth of the placenta low in the uterus, blocking the cervix. Placenta accreta, placenta increta, placenta percreta (least to most severe), the growth of the placenta deeper into the uterine wall than normal, which can lead to severe bleeding after childbirth, sometimes requiring a hysterectomy. Risks for the mother Three times higher mortality rate than that of vaginal delivery. *However, it is misleading to directly compare the mortality rates of vaginal and caesarean deliveries. Women with severe medical conditions, or higher-risk pregnancies, often require a caesarean section which can distort the mortality figures. Possible problems in later pregnncies -malpresentation, placenta previa, antepartum hemorrhage, placenta accreta, prolonged labor, uterine rupture, preterm birth, low birth weight, and stillbirth in their second delivery. Emergency hysterectomy at delivery Increased risks for placenta accreta Risks for incisional hernias and wound infections

Increased anesthesia risks and post spinal headaches Risks for the child: Neonatal depression: babies may have an adverse reaction to the anesthesia given to the mother, causing a period of inactivity or sluggishness after delivery. Fetal injury: injury may occur to the baby during uterine incision and extraction.

Type 1 diabetes: A 2008 study found that babies delivered by Caesarean section are 20% more likely to develop Type 1 diabetes in their lifetimes than babies delivered vaginally. While the correlation was established, the reason for it is not entirely clear. It has been suggested that the infant's first exposure to hospital-originating bacteria rather than to maternal bacteria during C-section may be the cause. Breathing problems: babies born by c-section, even at full term, are more likely to have breathing problems than are babies who are delivered vaginally. Breastfeeding problems: babies born by c-section are less likely to successfully breastfeed than those delivered vaginally. Potential for early delivery and complications: One study found an increased risk of complications if a repeat elective Caesarean section is performed even a few days before the recommended 39 weeks Risks for both mother and child Risk for developing hospital borne infection because of prolonged hospital stays Longer time before good mother-child interactions can be achieved.

Effects of Anesthesia 1. Regional anesthesia -(spinal, epidural or combined spinal and epidural anaesthesia) -is preferred as it allows the mother to be awake and interact immediately with her baby -the absence of typical risks of general anesthesia: *pulmonary aspiration (which has a relatively high incidence in patients undergoing anesthesia in late pregnancy) of gastric contents and *Oesophageal intubation 2. General Anesthesia -may be necessary because of specific risks to mother or child. Patients with heavy, uncontrolled bleeding may not tolerate the hemodynamic effects of regional anesthesia -is also preferred in very urgent cases, such as severe fetal distress, when there is no time to perform a regional anesthesia.

Factors involved in decision Fetal mortality and morbidity Newborn health VBAC Cost Pelvic floor damage Maternal mortality Cultural factors Autonomy - C-section on demand?

II. OBJECTIVES The significance of the study is for us third year students to apply the principles and concepts that we have learned in the NCM 102 (Operating Room Nursing) in our successive clinical rotations, with the following learning objectives: 1.

Cognitive



To be able to review concepts and theories in Oerating Room Nursing.



To be able to describe the development, pathophysiology, medicalsurgical management, and nursing care of a client who have undergone a cesarean section birth.



To be able to design a Nursing Care Plan for the patient who have undergone cesarean birth.



To be able to provide information and heath teachings to the patient in the postpartum period.

2. 

Psychomotor To be able carry-out hospital routines and the treatment prescribed to the patient.



To be able to perform nursing procedures and nursing considerations for a client in the preoperative and postoperative stages

 3. 

To be able to implement the nursing care plan. Affective To be able to establish a good working relationship with the patient and hospital staff.

III. NURSING ASSESSMENT Patient’s Profile: Name

: Asa Cana Sy

Age

: 18 years old

Birthday

: February 29, 1991

Address

: 15-B Hollywood St Brgy. Saguin, CSFP

Name of Spouse

: Aliv Sy

Name of Father

: Muh Cana

Name of Mother

: Malah Cana

Nationality

: Filipino

Occupation

: Housewife

Educational Attainment: High School Graduate Admission Date

: April 22, 2009

Discharge Date

: April 24, 2009

Surgery Performed

: LTCS II

IV. FAMILY HISTORY Unremarkable. V. HISTORY OF PAST AND PRESENT ILLNESS The patient stands 153 centimeters and weighs about 83 kilograms. Her AOG is 43 weeks, LMP was last November 1, 2008, and her EDC was on April 8, 2009. Her OB score is G2P1 (2,0,0,2). She was already married at the age of 16 years old. She was only 17 years old when she gave birth to her first child through Cesarean Section (Low Segment Transverse), because she had a difficulty in delivering the child due to her age and the lack of knowledge. It was on April 22, 2008 at around 8:00am when Patient Asa Cana Sy was admitted at the Ob-ward of Porac District Hospital and was sent to the OR/DR for an internal examination

and was told that her pregnancy was already over due. The patient opted for another cesarean section for this pregnancy. VI. PHYSICAL ASSESSMENT Gordon’s Level of Functioning Pattern Before 1.Health Perception- Patient goes to the Health Management health center once upon when she got pregnant. All in all, she thinks she is in a healthy state.

Present Patient is concern about her second cesarean section thinking that it may be detrimental to her health.

2. NutritionalMetabolic Management

During hospitalization, the patient is on diet as tolerated. She eats fruits like apples and oranges. She eats bread instead of rice. She said she loss her appetite since her onset of labor.

3.Elimination Pattern

4.Activity, Leisure, and Recreation Pattern

Prior to confinement, patient loves eating instant foods and fatty foods like fries and burgers. She also loves condiments like “patis”, vinegar, and soy sauce. She basically loves eating whatever she likes. Bowel: Patient defecates 1-2 times a day, usually morning and in the afternoon. Stool is brown in color and well-formed. Bladder: Patient voids usually 6-8 times a day. Urine is yellow in color. No pain when voiding. Patient is a housewife so she is always in charge of the household chores. Her leisure time would include playing with her firstborn and watching television.

Interpretation Patient cannot function normally anymore like before because of her hospital confinement and condition. Her body image changed after the surgical procedure done. Patient’s nutritional and metabolic status has been changed due to her confinement.

Bowel: Patient defecates once a day but not on a regular basis. Stool is soft, minimal in amount and brown in color.

Bowel: There was a change in the frequency and amount.

Bladder: Patient voids 3-4 times a day without pain and discomfort. Patient’s activities in the hospital are ambulation, deep breathing and coughing exercise, taking a bath or personal hygiene.

Bladder: There was a change in the frequency and amount. During patient’s confinement in the hospital, there is a limitation in her activities of daily living and a disruption in her leisure and recreation pattern.

5.Sleep and Rest Pattern

6.Cognitive – Perceptual Pattern

7. Self-Perception / Self-Concept Pattern

8. Role Relationship

9. Sexuality/ Reproductive Pattern 10.Coping and Stress Tolerance

11.Values- Belief Pattern

Patient puts herself to sleep by watching television programs. She usually sleeps at around 11pm to 6am. She feels rested when sleeping and thinks that her energy is sufficient for her activities. Patient is a high school graduate. She can read and write. She can speak and be understood by others. Patient is a friendly person; she loves to socialize with his friends in their neighborhoods. She considers himself as holistic human being as long as she is healthy, complete, and his family is always there. Patient can understand English, Tagalog, and Kapampangan. She has 5 siblings. She is married with 1 child. Patient has been married for 3 years. When patient is stressed, she sings in the karaoke and eats comfort foods like burgers, fries, and her favorite sizzling sisig. When it comes to problems, she lets herself think immediately for a solution. Patient is a Roman Catholic. She has a strong faith to God and goes to mass

Due to her uncomfortable condition and pain, patient complains of difficulty of sleeping and short period of sleeps.

Patient’s present condition is not a hindrance to her cognitive- perceptual pattern.

Patient’s sleep and rest pattern changed when she was admitted. She cannot put himself to sleep anymore due to present condition and pain plays a big factor for her sleep disturbances. No changes/ alterations.

During the times of her confinement, she doesn’t think that she is a holistic person anymore. However, she is positive that she will be ok after confinement.

There is a slight change in her selfperception due to present condition.

The patient’s family is supportive to the patient. She is happy with their presence and support.

Normal/ No alterations.

Patient reserved her right to privacy. The recent hospitalization of the patient was stressful and source of anxiety. However, she is positive that she will be able to cope up with current condition.

Patient reserved her right to privacy. Patient accepts present condition with a positive attitude.

She follows a therapeutic regimen and her strong faith to God accounts for her

Due to her confinement, patient is trusting God that she will be discharge

every Sunday with her fast recovery. family.

soon and will recover without any complications.

VII. ANATOMY AND PHYSIOLOGY

Vagina The vagina is a muscular, hollow tube that extends from the vaginal opening to the cervix of the uterus. It is situated between the urinary bladder and the rectum. It is about three to five inches long in a grown woman. The muscular wall allows the vagina to expand and contract. The muscular walls are lined with mucous membranes, which keep it protected and moist. A thin sheet of tissue with one or more holes in it, called the hymen, partially covers the opening of the vagina. The vagina receives sperm during sexual intercourse from the penis. The sperm that survive the acidic condition of the vagina continue on through to the fallopian tubes where fertilization may occur. The vagina is made up of three layers, an inner mucosal layer, a middle muscularis layer, and an outer fibrous layer. The inner layer is made of vaginal rugae that stretch and allow penetration to occur. These also help with stimulation of the penis. The middle layer has glands that secrete an acidic mucus (pH of around 4.0.) that keeps bacterial growth down. The outer muscular layer is especially important with delivery of a fetus and placenta. Purposes of the Vagina •

Receives a males erect penis and semen during sexual intercourse.

•

Pathway through a woman's body for the baby to take during childbirth.

•

Provides the route for the menstrual blood (menses) from the uterus, to leave the body.

•

May hold forms of birth control, such as a diaphragm, FemCap, Nuva Ring, or female condom.

The cervix (from Latin "neck") is the lower, narrow portion of the uterus where it joins with the top end of the vagina. Where they join together forms an almost 90 degree curve. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. Approximately half its length is visible with appropriate medical equipment; the remainder lies above the vagina beyond view. It is occasionally called "cervix uteri", or "neck of the uterus". During menstruation, the cervix stretches open slightly to allow the endometrium to be shed. This stretching is believed to be part of the cramping pain that many women experience. Evidence for this is given by the fact that some women's cramps subside or disappear after their first vaginal birth because the cervical opening has widened. The portion projecting into the vagina is referred to as the portio vaginalis or ectocervix. On average, the ectocervix is three cm long and two and a half cm wide. It has a convex, elliptical surface and is divided into anterior and posterior lips. The ectocervix's opening is called the external os. The size and shape of the external os and the ectocervix varies widely with age, hormonal state, and whether the woman has had a vaginal birth. In women who have not had a vaginal birth the external os appears as a small, circular opening. In women who have had a vaginal birth, the ectocervix appears bulkier and the external os appears wider, more slit-like and gaping. The passageway between the external os and the uterine cavity is referred to as the endocervical canal. It varies widely in length and width, along with the cervix overall. Flattened anterior to posterior, the endocervical canal measures seven to eight mm at its widest in reproductive-aged women. The endocervical canal terminates at the internal os which is the opening of the cervix inside the uterine cavity. During childbirth, contractions of the uterus will dilate the cervix up to 10 cm in diameter to allow the child to pass through. During orgasm, the cervix convulses and the external os dilates. The uterus is shaped like an upside-down pear, with a thick lining and muscular walls. Located near the floor of the pelvic cavity, it is hollow to allow a blastocyte, or fertilized egg, to

implant and grow. It also allows for the inner lining of the uterus to build up until a fertilized egg is implanted, or it is sloughed off during menses. The uterus contains some of the strongest muscles in the female body. These muscles are able to expand and contract to accommodate a growing fetus and then help push the baby out during labor. These muscles also contract rhythmically during an orgasm in a wave like action. It is thought that this is to help push or guide the sperm up the uterus to the fallopian tubes where fertilization may be possible. The uterus is only about three inches long and two inches wide, but during pregnancy it changes rapidly and dramatically. The top rim of the uterus is called the fundus and is a landmark for many doctors to track the progress of a pregnancy. The uterine cavity refers to the fundus of the uterus and the body of the uterus. Helping support the uterus are ligaments that attach from the body of the uterus to the pelvic wall and abdominal wall. During pregnancy the ligaments prolapse due to the growing uterus, but retract after childbirth. In some cases after menopause, they may lose elasticity and uterine prolapse may occur. This can be fixed with surgery. Some problems of the uterus include uterine fibroids, pelvic pain (including endometriosis, adenomyosis), pelvic relaxation (or prolapse), heavy or abnormal menstrual bleeding, and cancer. It is only after all alternative options have been considered that surgery is recommended in these cases. This surgery is called hysterectomy. Hysterectomy is the removal of the uterus, and may include the removal of one or both of the ovaries. Once performed it is irreversible. After a hysterectomy, many women begin a form of alternate hormone therapy due to the lack of ovaries and hormone production. At the upper corners of the uterus are the fallopian tubes. There are two fallopian tubes, also called the uterine tubes or the oviducts. Each fallopian tube attaches to a side of the uterus and connects to an ovary. They are positioned between the ligaments that support the uterus. The fallopian tubes are about four inches long and about as wide as a piece of spaghetti. Within each tube is a tiny passageway no wider than a sewing needle. At the other end of each fallopian tube is a fringed area that looks like a funnel. This fringed area, called the infundibulum, lies close to the ovary, but is not attached. The ovaries alternately release an egg.

When an ovary does ovulate, or release an egg, it is swept into the lumen of the fallopian tube by the frimbriae. Once the egg is in the fallopian tube, tiny hairs in the tube's lining help push it down the narrow passageway toward the uterus. The oocyte, or developing egg cell, takes four to five days to travel down the length of the fallopian tube. If enough sperm are ejaculated during sexual intercourse and there is an oocyte in the fallopian tube, fertilization will occur. After fertilization occurs, the zygote, or fertilized egg, will continue down to the uterus and implant itself in the uterine wall where it will grow and develop. If a zygote doesn't move down to the uterus and implants itself in the fallopian tube, it is called a ectopic or tubal pregnancy. If this occurs, the pregnancy will need to be terminated to prevent permanent damage to the fallopian tube, possible hemorrhage and possible death of the mother.

Mammary glands are the organs that produce milk for the sustenance of a baby. These exocrine glands are enlarged and modified sweat glands. The basic components of the mammary gland are the alveoli (hollow cavities, a few millimetres large) lined with milk-secreting epithelial cells and surrounded by myoepithelial cells. These alveoli join up to form groups known as lobules, and each lobule has a lactiferous duct that drains into openings in the nipple. The myoepithelial cells can contract, similar to muscle cells, and thereby push the milk from the alveoli through the lactiferous ducts towards the

nipple, where it collects in widenings (sinuses) of the ducts. A suckling baby essentially squeezes the milk out of these sinuses. The development of mammary glands is controlled by hormones. The mammary glands exist in both sexes, but they are rudimentary until puberty when - in response to ovarian hormones - they begin to develop in the female. Estrogen promotes formation, while testosterone inhibits it. At the time of birth, the baby has lactiferous ducts but no alveoli. Little branching occurs before puberty when ovarian estrogens stimulate branching differentiation of the ducts into spherical masses of cells that will become alveoli. True secretory alveoli only develop in pregnancy, where rising levels of estrogen and progesterone cause further branching and differentiation of the duct cells, together with an increase in adipose tissue and a richer blood flow. Colostrum is secreted in late pregnancy and for the first few days after giving birth. True milk secretion (lactation) begins a few days later due to a reduction in circulating progesterone and the presence of the hormone prolactin. The suckling of the baby causes the release of the hormone oxytocin which stimulates contraction of the myoepithelial cells. The cells of mammary glands can easily be induced to grow and multiply by hormones. If this growth runs out of control, cancer results. Almost all instances of breast cancer originate in the lobules or ducts of the mammary glands. ABDOMINAL LAYERS 1. skin The skin of the lower abdominal wall is incised in a transverse direction just above the pubic hairline in the majority of cases (side to side rather than up and down). A longitudinal (up and down) incision is infrequently employed. 2. subcutaneous tissue 3.fascia rectus fascia- a dense shiny white layer of fascia. This fascia layer is incised to expose the two rectus abdominal muscles which are big muscles running from the rib cage to the pubic bone. 4.muscle These are the main muscles employed to do sit-ups (rectus). The two muscles meet in the midline where they are sometimes fused but quite often, however, they are separated as the result of the stretching from the distended uterus. These muscles are now separated (without cutting them) and pulled to the sides to create a space between them.

5. peritoneum The peritoneal layer is a very thin membrane-like layer, which can be described as the lining of the abdominal cavity.

VIII.

PATHOPHYSIOLOGY 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 ovum 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 PRELIMINARY SIGNS OF LABOR

Lightening (descent of the fetal head into the pelvis)

Braxton Hicks Contraction (false labor) >begin and remain irregular >1st felt abdominally >pain disappears with ambulation >do not increase in duration and intensity >do not achieve cervical dilatation

Ripening of the cervix (Goodell’s Sign wherein the cervix feels softer like consistency of the earlobe

TRUE LABOR

Uterine Contractions

SHOW

>increase in duration and intensity >1st felt at the back & radiates to the abdomen >pain is not relieved no matter what the activity >achieve cervical dilatation

(pink-tinge of blood, a mixture of blood and fluid)

Rupture of Membranes (rupture of the amniotic sac)

Failed to progress labor (due to previous cesarean birth, cervical arrest, cervical atrophy) increase risk for fetal distress (meconium staining, hypoxia) Increase risk of fetal death Emergent cesarean delivery (the incision made on the lower part of the abdomen) Expulsion of the fetus

Expulsion of the placenta (accompanied by blood approximately 500-1000 mL) IX. LABORATORY PROCEDURES Urine Analysis Date Ordered: April 22, 2009 Date Performed: April 22, 2009 Microscopic Exam

Chemical Exam

Color: Yellow

Albumin: Negative

Transparency: Hazel

Sugar: Negative

Rection pH: 6.0 (Normal: 7.35-7.45) Specific Gravity: 1.010 (Normal: 1.010-1.025) Pus Cells: 0.2 Epithelial Cells: Moderate Result

Normal Values

Interpretatio n

RBC

5.4

4.5 – 6.0 x 10/L

Normal

WBC

10.1

5 – 10 x 10/L

Increase

Indicates presence of infection

HgB

116

120 – 140 g/dl

Decrease

Indicates occurrence of anemia

Hct

0.35

0.30

Increase

Indicates hyper coagulation

Platelet

320

150 – 400 x 09/L

Normal

DIFFERENTIAL COUNTING

Significance

Neutrophils

Lymphocytes

0.86

0.14

0.05 – 0.70

0.20 – 0.40

Increase

Indicates infection or inflammation

Decrease

Indicates high risk for acquiring infection

X. OPERATING ROOM- Surgery PREOPERATIVE 1. Preop checklist 2. starting an IV line 3. shaving the pubic hair 4. inserting a bladder catheter INTRAOPERATIVE 1. Supine on bed 2. Induction of anesthesiaEpidural General -IV/Inhalation -ET tube 3. Skin preparation 4. draping 5. INCISION- longitudinal/Bikini-Obstetrician *skin *subcutaneous *fascia *muscle *Peritoneum *uterus *amniotic sac The skin of the lower abdominal wall is incised in a transverse direction just above the pubic hairline in the majority of cases (side to side rather than up and down). A longitudinal (up and down) incision is infrequently employed. Just under the skin, a layer of fat is found which is easily separated to reach the next layer. The reader will recognize this next type of layer since it is a dense shiny white layer of fascia called the rectus fascia. Like the pelvic fascia this is a connective tissue layer, which surrounds the rectus abdominal muscles and offers support, attachment and strength. This fascia layer is incised to expose the two rectus abdominal muscles which are big muscles running from the rib cage to the pubic bone. These are the main muscles employed to do sit-ups. The two muscles meet in the midline where they are sometimes fused but quite often, however, they are separated as the result of the stretching from the distended uterus. These muscles are now separated (without cutting them) and pulled to the sides to create a space between them.

After this space has been created, the only layers covering the uterus are thin fascia and the peritoneum. The peritoneal layer is a very thin membrane-like layer, which can be described as the lining of the abdominal cavity. After this layer is penetrated the uterus will lie directly in view. A second layer of peritoneum, which is also incised and pushed out of the way, usually covers the so-called lower segment of the uterus where the incision will be made. This simple, but essential part of a cesarean section, helps to prevent injuries to the bladder, which lies on top of the lowest part of the uterus and the immediate vagina. After the bladder has been pushed to safety the next step is to incise the uterus. The incision in the uterine wall is also made transversely and it is made in the lower segment of the uterus, just above the cervix, which is the thinnest part. The incision is usually started with a scalpel but usually completed by manual stretching. This is done to prevent injury to the immediately underlying infant. 6. Delivery of the infant - delivered by guiding its head into the opening with one hand while the assistant exerts pressure on the uterine fundus (top of the uterus). -handed to pediatrician 7. Delivery of the Placenta 8. Abdominal Lavage 9. Suturing- absorbable and nonabsorbable The final two layers that need closing are the rectus sheath and of course the skin. The rectus sheath is the most important layer (not surprisingly - it’s fascia!) and needs to be sutured with strong material. The skin can be closed with sutures, staples or various other methods, none of which have significant advantages over the other. POSTOPERATIVE 1. PACU 2. Removal of suction drain It is sometimes necessary, especially in subsequent cesarean births, to place a suction drain underneath the rectus sheath. This is to prevent the collection of serum or blood in this area, which could then become a site for infection. These drains would typically stay in for 12 to 24 hours. 3. The urinary catheter and IV are usually also removed at the same time. XII. DRUG STUDY

Oxytocin Postpartum haemorrhage Adult: 10-40 units by infusion in 1000 mL of IV fluid at a rate sufficient to control uterine atony. Reconstitution: Postpartum uterine bleeding: oxytocin 10-40 units to running IV

infusion, max 40 units/1000 ml. Incompatibility: When admixed: fibrinolysin (human), norepinephrine, prochlorperazine edisylate, warfarin; variable compatibility with phytonadione. Overdosage

Tetanic uterine contractions, impaired uterine blood flow, amniotic fluid embolism, uterine rupture, syndrome of inappropriate antidiuretic hormone secretion and seizures. Treatment: Supportive and symptom specific. Contraindications Cephalopelvic disproportion; abnormal presentation of the foetus; hydraminios; multiparae; previous caesarian section or other uterine surgery; hyperactive or hypertonic uterus, uterine rupture; contraindicated vaginal delivery (invasive cervical cancer, active genital herpes, prolapse of the cord, cord presentation, total placenta previa or vasa previa); foetal distress where delivery is not imminent; severe pre-eclamptic toxaemia. Special Precautions CV disorders; >35 yr; lactation. Monitor foetal and maternal heart rate, maternal BP and uterine motility. Monitor fluid intake and output during treatment. Discontinute immediately if the uterus is hypertonic or hyperactive or if there is foetal distress. Use of nasal spray may produce maternal dependence on its effects. IM admin not regularly used due to unpredictable effects of oxytocin. Not to be used for prolonged periods in resistant uterine inertia, severe pre-eclampsia, or severe CV disorders. Risk of water intoxication when used at high doses for prolonged periods. Adverse Drug Reactions Foetus or neonate: Jaundice; arrhythmias, bradycardia; brain, CNS damage; seizure; retinal haemorrhage; low Apgar score. Mother: transient hypotension, reflex tachycardia; nasal irritation, rhinorrhoea, lachrymation (following nasal admin); uterine bleeding, violent contractions, hypertonicity; spasm; nausea, vomiting. Potentially Fatal: Maternal water intoxication (especially with slow infusion over 24 hr); prolonged uterine contractions causing foetal hypoxia and death; rupture of gravid uterus; afibrinogenaemia; subarachnoid haemorrhage Drug Interactions

Possible severe hypertension if given within 3-4 hr of vasoconstrictor in association with a caudal block anaesthesia. Cyclopropane anaesthesia may increase risk of hypotension and maternal sinus bradycardia with abnormal AV rhythms. Dinoprostone and misoprostol may increase uterotonic effect of oxytocin, thus oxytocin should not be used within 6 hr after admin of vaginal prostaglandins. Concurrent use may increase the vasopressor effect of sympathomimetics. Potentially Fatal: Concomitant use with prostaglandins increases risk of uterine rupture and cervical lacerations. Antibiotics cefuroxime - it should be inexpensive, safe, and not reserved only for serious infections.. "The nice thing with cephalosporins is, it is not a drug of choice for any particular serious infection. Dosage Tab Adults 0.5 g/day. Max: 1g. Inj Adult 0.75-1.5 g 8 hrly for 5-10 days. Life-threatening infection 1.5 g 6 hrly. . Pre-op prophylaxis 1.5 g IV. Long operation 0.75 g IV/IM 8 hrly Severe infection ≥0.1 g/kg/day but not >1.5 g. Administration Should be taken with food Contraindications Hypersensitivity. GI absorption difficulties. Childn