CASE ABSTRACT

This is a case of patient D.C 33 year’s old, female residing at Muntinlupa City.
With the chief complain of Labor Pain and Watery vaginal discharge . The initial vital
signs T: 36.5 ,RR: 24 cpm, PR: 110 bpm BP: 110/60. Seen and by attending physician
Dr. Valino.

LEARNING OBJECTIVES
GENERAL OBJECTIVE
• After this case study, we will be able to know what Caesarian Section (CS) is,
causes of caesarian, and its treatment.

SPECIFIC OBJECTIVE
After the completion of this study, we will able to:

• Define what is Caesarian Section (CS).

• Trace the patho physiology of Caesarian Section (CS)

• Identify and understand different types of Caesarian Section (CS)

• Formulate and apply nursing care plans utilizing the nursing process

NURSING CASE STUDY: CAESARIAN SECTION

I. DEMOGRAPHIC DATA

Name: A.G.M
Gender: Female
Civil Status: Married
Address: Bacoor, Cavite
Age: 40 years old
Birthdate: September 26, 1969
Birthplace: Imus, Cavite
Religion: Roman Catholic
Occupation: Housewife
Diagnosis: Elderly Gravida, PU 39-40 wks AOG
(Low Lying Placenta Frank Breech)
Operation Performed: Low Transverse Caesarian Section

II. HEALTH HISTORY

Patient A.G.M is a 40 year old female, who is preganant for 40 weeks,

married and a mother of two. She is a catholic with fair complexion, stands 153 cm
and weighs 76 kgs. She was born at Dasmarinas, Cavite and second among three
siblings.
 Her AOG is 40 weeks. Patient had a previous CS delivery because she had
difficulty on delivering her child. Patient had no history of asthma, no seizure, no
diabetes mellitus and no hypertension. Patient had complete immunization and had
no allergies to either food or medications.

III. LABORATORY / DIAGNOSTICS

Procedure / Actual Normal Nursing

Implications
Date Findings Findings Responsibilities
1. CBC Pre:
Hemoglobin 116 120 – 140 Decrease  Check Doctor’s
g/dL - Indicates Order.
occurrence of  Inform client and
anemia explain the
procedure.
Hematocrit 0.35 Increase  No need for NPO.
0.30 - Indicates
hypercoagulatio Intra:
n  Perform blood
WBC 8.0 extraction
Segmenters 0.60 5 - 10 Normal (venipuncture
0.36 - 0.66 Normal technique) using
Lymphocytes 0.14 aseptic
0.22 - 0.40 Decrease technique.
- Indicates high
 Put extracted
risk for acquiring
blood in
infection
ethyldiamino-
Eosinophils 0.02
tetracetate
Stab Cells 0.04 0.01 - 0.04 Normal
(EDTA) or the
Platelets 320 0.02 - 0.05 Normal
lavender top
150 – Normal
vacuum tube.
400x9/L

Post:
 Label the
container
properly and
correctly.
 Procedure / Actual Normal Nursing
Implications
Date Findings Findings Responsibilities
 Send specimen
to the lab
immediately.
 Document the
result to the
chart and inform
physician that
the result is out.

URINE ANALYSIS

Microscopic Exam Chemical Exam

Color: Yellow Albumin: Negative

Transparency: Hazel Sugar: Negative
pH: 6.0 (7.35 – 7.45)
Specific Gravity: 1.010 (1.010 – 1.025)
Epithelial Cells: Moderate

IV. INDICATIONS FOR THE PROCEDURE

INTRODUCTION:

A C-section delivery is performed when a vaginal birth is not possible or is not

safe for the mother or child. 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.

DEFINITION:
Cesarean section (also called a c-section) is the most common major surgery
done today. It is performed about 1 million times a year in the United States. In most
cases, a cesarean section is a safe method of delivering a baby. There are different
reasons why a woman may have a cesarean section. When the procedure is
scheduled ahead of time rather than performed in an emergency situation, it is
similar to having a scheduled surgery. Usually, this procedure is scheduled around
the time you are 39 weeks pregnant, or when the baby is ready for life outside the
womb. It may be done earlier if you have a scar on the upper part of your uterus from
a previous c-section.

The most common reason that a cesarean section is performed (in 35% of all
cases, according to the United States Public Health Service) is the woman has had a
previous c-section. The "once a cesarean, always a cesarean" rule originated when
the uterine incision was made vertically (termed a "classical incision"); the resulting
scar was weak and had a risk of rupturing in subsequent deliveries. Today, the
incision is almost always made horizontally across the lower end of the uterus (called
a low transverse incision), resulting in reduced blood loss and a decreased chance of
rupture. This kind of incision allows many women to have a vaginal birth after a
cesarean (VBAC).

A Caesarian section is a form of childbirth in which a surgical incision is made

through a mother’s abdomen and uterus 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 requests for births
that would otherwise have been normal.

Caesarian section (CS) is recommended when vaginal delivery might pose a

risk to the mother or baby. Reasons for CS include:

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)

V. PREPARATION

• POSITIONING

Patient that would undergo caesarian delivery should be required to be in

SUPINE POSITION in the entire course of delivery. This position provides access to the
internal organs needed to be repaired in a certain operation. This position is used for
procedures of the anterior body such as: abdominal, thoracic, facial and anterior
upper and lower extremity procedures.
 • CATHETER INSERTION

The patient is placed in a lithotomy position. The nurse must wear sterile
gloves when performing this procedure. The genital area is exposed. The area is
cleansed with the use of antiseptic solution (3 times). Cleaning of the genital area
starts at the top of the genitalia to the bottom using a pattern-7 motion on both
sides. Then, the catheter is inserted. To facilitate the insertion, the catheter is
lubricated. Urine will flow when the catheter passed the bladder. Then, the catheter
is secured by injecting 10ml of sterile water on the Y-port. The urune bag is then
attached to the catheter.

• APPLICATION OF DRAPES

Draping includes the use of towels, eye sheets and laparatomy sheet to
maintain the accessibility and maximize the area to be examined and repaired and
also provide a continuous sterile field.

• ANESTHESIA

Spinal and epidural anesthesia are ways to numb surgical patienst from the
chest on down the legs. Both spinal and epidural anesthesia involve placing
medications directly into the spinal area. The patient may be given an injection of
local anesthetic diretly over the spot where the spinal or epidural anesthetic will be
given, to decrease pain from the needle. Epidural anesthesia may be given as a
single injection just outside of the sac of fluid that surrounds the spinal cod. When
more than one dose of epidural anesthesia might be required, the anesthetist will
leave a tiny, flexible tube or catheter in place outside of the fluid sac surrounding the
spinal cord. More anesthetic can be given easily if the operation takes longer than
expected.

• INDUCTION OF ANESTHETIC AGENT

The patient is placed on a lateral position with back exposed. The nurse must
wear sterile gloves before performing the procedure. The area where the anesthesia
is to be inducted is cleansed with alcohol and followed by antiseptic solution (3
times). The cleaning starts on the insertion site with circular motion using firm
strokes.

• INCISION SITE

The patient is placed on a supine position exposing the abdominal area.

Sterile gloves are donned using the open glove method before performing the
procedure. The operative site is cleansed with the use of cleanser (3 times), wet OS
(3 times) and then changed the gloves before applying the antiseptic (3 times).
Beginning at the incision site, the area will include posterior breast as the upper
margin, the axillary line as lateral margins and to the anterior two thirds of the legs
as posterior margin. Cleaning would always include use of firm circular motion
leaving no spaces unwiped.

VI. INSTRUMENTS (C/S set)

  Small kellies (6)
 Towel clips (4)
 Straight kellies (2)
 Needle holder (2)
 Mayo Collins (2)
 Tissue forceps (2)
 Ovum forcep (1)
 Metzenbaum (1)
 Ochsners
 Richarson retractor
 Medium Kellies (6)
 Allises (8)
 Bobcock (2)
 Army navy (2)
 Thumb forceps (2)
 Blade handle #3 and #4
 Mayo scissor (1)
 Bladder retractor
 Deaver
 Self-retaining retractor

VII. PROCEDURES

• Client was place in supine position with contraptions noted and

checked by anesthesiologist.
• Skin preparation of the induction site of anesthetic agents
• Induction of anesthesia, either spinal or epidural and sometimes
general anesthesia
• Abdominal skin preparation to be done
• Application of drapes, eye sheet, laparotomy sheet
• Sequential incision begins: the skin, subcutaneous, peritoneum
penetrating to the uterus
• Delivery of the baby
• Delivery of the placenta
• Sequential closing using appropriate absorbable sutures
• Hemostasis secured, peritoneal wash done
• Initials OS, instruments and needles completed

ANATOMY AND PHYSIOLOGY OF THE REPRODUCTIVE SYSTEM

 EXTERNAL GENITALIA

Our overview of the reproductive system begins at the external genital

area— or vulva—which runs from the pubic area downward to the rectum.
Two folds of fatty, fleshy tissue surround the entrance to the vagina and the
urinary opening: the labia majora, or outer folds, and the labia minora, or
inner folds, located under the labia majora. The clitoris, is a relatively short
organ (less than one inch long), shielded by a hood of flesh. When stimulated
sexually, the clitoris can become erect like a man's penis. The hymen, a thin
membrane protecting the entrance of the vagina, stretches when you insert a
tampon or have intercourse.

INTERNAL REPRODUCTIVE STRUCTURE

The Vagina

The vagina is a muscular, ridged sheath connecting the external genitals to

the uterus, where the embryo grows into a fetus during pregnancy. 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 .

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.

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 mostly consists of muscle, known as
myometrium. 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.

Oviducts
The Fallopian tubes or oviducts are two very fine tubes leading from
the ovaries of female mammals 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, where it travelled down
the oviduct to the uterus, occasionally being fertilised 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.

• The ovary is the organ that produces ova (singular, ovum), or eggs. The two
ovaries present in each female are held in place by the following ligaments:
o The mesovarium is a fold of peritoneum that holds the ovary in place.
o The suspensory ligament anchors the upper region of the ovary to the
pelvic wall. Attached to this ligament are blood vessels and nerves,
which enter the ovary at the hilus.
o The broad ligament is a section of the peritoneum that drapes over the
ovaries and uterus. It includes both the mesovarium and suspensory
ligament.
o The ovarian ligament anchors the lower end of the ovary to the uterus.

The following two tissues cover the outside of the ovary:

• The germinal epithelium is an outer layer of simple epithelium.

• The tunica albuginea is a fibrous layer inside the germinal epithelium.

The inside of the ovary, or stroma, is divided into two indistinct regions, the outer
cortex and the inner medulla. Embedded in the cortex are saclike bodies called
ovarian follicles. Each ovarian follicle consists of an immature oocyte (egg)
surrounded by one or more layers of cells that nourish the oocyte as it matures. The
surrounding cells are called follicular cells, if they make up a single layer, or
granulosa cells, if more than one layer is present.

• The uterine tubes (fallopian tubes, or oviducts) transport the

secondary oocytes away from the ovary and toward the uterus. The
following regions characterize each of the two uterine tubes (one for
each ovary):
o The infundibulum is a funnel-shaped region of the uterine tube that
bears fingerlike projections called fimbriae. Pulsating cilia on the
fimbriae draw the secondary oocyte into the uterine tube.
o The ampulla is the widest and longest region of the uterine tube.
Fertilization of the oocyte by a sperm usually occurs here.
o The isthmus is a narrow region of the uterine tube whose terminus
enters the uterus.
• The wall of the uterine tube consists of the following three layers:
o The serosa, a serous membrane, lines the outside of the uterine tube.
o The middle muscularis consists of two layers of smooth muscle that
generate peristaltic contractions that help propel the oocyte forward.
o The inner mucosa consists of ciliated columnar epithelial cells that help
propel the oocyte forward and secretory cells that lubricate the tube
and nourish the oocyte.
• The uterus (womb) is a hollow organ within which fetal development
occurs. The uterus is characterized by the following regions:
o The fundus is the upper region where the uterine ducts join the uterus.
o The body is the major, central portion of the uterus.
o The isthmus is the lower, narrow portion of the uterus.
 o The cervix is a narrow region at the bottom of ht uterus that leads to
the vagina. The inside of the cervix, or cervical canal, opens to the
uterus above through the internal os and to the vagina below through
the external os. Cervical mucus secreted by the mucosa layer of the
cervical canal serves to protect against bacteria entering the uterus
from the vagina. If an oocyte is available for fertilization, the mucus is
thin and slightly alkaline, attributes that promote the passage of
sperm. At other times, the mucus is viscous and impedes the passage
of sperm.
• The uterus is held in place by the following ligaments:
o The broad ligaments
o The uterosacral ligaments
o The round ligaments
o The cardinal (lateral cervical) ligaments
• The wall of the uterus consists of the following three layers:
o The perimetrium is a serous membrane that lines the outside of the
uterus.
o The myometrium consists of several layers of smooth muscle and
imparts the bulk of the uterine wall. Contractions of these muscles
during childbirth help force the fetus out of the uterus.
o The endometrium is the highly vascularized mucosa that lines the
inside of the uterus. If an oocyte has been fertilized by a sperm, the
zygote (the fertilized egg) implants on this tissue. The endometrium
itself consists of two layers. The stratum functionalis (functional layer)
is the innermost layer (facing the uterine lumen) and is shed during
menstruation. The outermost stratum basalis (basal layer) is
permanent and generates each new stratum functionalis
• The vagina (birth canal) serves both as the passageway for a
newborn infant and as a depository for semen during sexual
intercourse. The upper region of the vagina surrounds the protruding
cervix, creating a recess called the fornix. The lower region of the
vagina opens to the outside at the vaginal orifice. A thin membrane
called the hymen may cover the orifice. The vaginal wall consists of
the following layers:
o The outer adventitia holds the vagina in position.
o The middle muscularis consists of two layers of smooth muscle that
permit expansion of the vagina during childbirth and when the penis is
inserted.
o The inner mucosa has no glands. But bacterial action on glycogen
stored in these cells produces an acid solution that lubricates the
vagina and protects it against microbial infection. The acidic
environment is also inhospitable to sperm. The mucosa bears
transverse ridges called rugae.
• The vulvae (pudendum) make up the external genitalia. The following
structures are included:
o The mons pubis is a region of adipose tissue above the vagina that is
covered with hair.
o The labia majora are two folds of adipose tissue that border each side
of the vagina. Hair and sebaceous and sudoriferous glands are present.
Developmentally, the labia majora are analogous to the male scrotum.
o The labia minora are smaller folds of skin that lie inside the labia
majora.
 o The vestibule is the recess formed by the labia minora. It encloses the
vaginal orifice, the urethral opening, and ducts from the greater
vestibular glands whose mucus secretions lubricate the vestibule.
o The clitoris is a small mass of erectile and nervous tissue located
above the vestibule. Extensions of the labia minora join to form the
prepuce of the clitoris, a fold of skin covering the clitoris.

PATHOPYSIOLOGY OF CAESARIAN SECTION

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 Braxton Hicks Contraction Ripening of the cervix

(descent of the fetal (false labor) (Goodell’s Sign wherein
head into the pelvis) >begin and remain irregular the cervix feels softer like
>1st felt abdominally consistency of the earlobe
>pain disappears with
ambulation
>do not increase in duration
and intensity
>do not achieve cervical
dilatation

TRUE LABOR

Uterine Contractions SHOW Rupture of Membranes

>increase in duration (pink-tinge of blood, (rupture of the

and intensity a mixture of blood and fluid) amniotic sac)
>1st felt at the back &
radiates to the abdomen
>pain is not relieved no
matter what the activity
>achieve cervical dila-
tation

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)
(Low Lying Placenta Frank Breech)

Expulsion of the fetus

 Expulsion of the placenta
(accompanied by blood approximately 500-1000 mL)