CASE STUDY

Submitted by:
BSN 3y3-13A
Agoyaoy, Leah G.
Aler, Riza F.
Andres, Kimberly Joy C.
Balatbat, Kasselyn
Bautista, Jesaren
Bautista, Dan Leonard

Submitted to:
Mr. Marshal Espiritu
OBJECTIVES OF THE STUDY

The significance of the study is for us third year students to apply the
principles and concepts that we have learned in the NCM 103 (Medical and
Surgical Nursing) in our rotation at Bulacan Provincial Hospital , with the
following learning objectives:

1. Cognitive
 To be able to review concepts and theories in medical and surgical
nursing.

 To be able to describe the development, pathophysiology, medical-

surgical
management, and nursing care of a client who have undergone a surgery.

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

 To be able to provide information and heath teachings to the patient in the

postoperative 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, intraoperative and postoperative stages
INTRODUCTION

Nursing Process is a patient centered, goal oriented method of caring that

provides a framework 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 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.

Caesarean Section

A Caesarean section (US: Cesarean section), also C-section, Caesarian section,

Cesarian section, Caesar, etc., is a surgical procedure in which one or more
incisions are made through a mother's abdomen (laparotomy) and uterus
(hysterotomy) to deliver one or more babies, or, rarely, to remove a dead fetus. A
late-term abortion using Caesarean section procedures is termed a hysterotomy
abortion and is very rarely performed.

A Caesarean section 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.

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 labour, 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
extraperitoneal 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.

In many hospitals, the mother's birth partner is encouraged to attend the surgery
to support the mother and share the experience. The anaesthetist will usually
lower the drape temporarily as the child is delivered so the parents can see their
newborn.

Caesarean section is recommended when vaginal delivery might pose a risk to

the mother or baby. Not all of the listed conditions represent a mandatory
indication, and in many cases the obstetrician must use discretion to decide
whether a caesarean is necessary. Some indications for caesarean delivery are:

Complications of labor and factors impeding vaginal delivery such as:

• prolonged labor or a failure to progress (dystocia)

• fetal distress
• cord prolapse
 • uterine rupture
• increased blood pressure (hypertension) in the mother or baby after
amniotic rupture
• increased heart rate (tachycardia) in the mother or baby after amniotic
rupture
• placental problems (placenta praevia, placental abruption or placenta
accreta)
• abnormal presentation (breech or transverse positions)
• failed labor induction
• 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.
• overly large baby (macrosomia)
• umbilical cord abnormalities (vasa previa, multi-lobate including bi-lobate
and succenturiate-lobed placentas, velamentous insertion)
• contracted pelvis

Other complications of pregnancy, preexisting conditions and concomitant

disease such as

• pre-eclampsia
• hypertension
• multiple births
• precious (High Risk) Fetus
• HIV infection of the mother
• 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)
• previous Caesarean section (though this is controversial – see discussion
below)
 • prior problems with the healing of the perineum (from previous childbirth or
Crohn's Disease)

Other

• 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])
• Improper Use of Technology (Electric Fetal Monitoring [EFM])

Risks for the mother:

As with all types of abdominal surgery, a Caesarean section is associated

with risks of post-operative adhesions, incisional hernias (which may require
surgical correction) and wound infections.[18] If a Caesarean is performed under
emergency situations, the risk of the surgery may be increased due to a number
of factors. The patient's stomach may not be empty, increasing the anaesthesia
risk. Other risks include severe blood loss (which may require a blood
transfusion) and post spinal headaches.

A study published in the June 2006 issue of the journal Obstetrics and
Gynecology found that women who had multiple Caesarean sections were more
likely to have problems with later pregnancies, and recommended that women
who want larger families should not seek Caesarean section as an elective. The
risk of placenta accreta, a potentially life-threatening condition, is only 0.13%
after two Caesarean sections but increases to 2.13% after four and then to
6.74% after six or more surgeries. Along with this is a similar rise in the risk of
emergency hysterectomies at delivery. The findings were based on outcomes
from 30,132 caesarean deliveries.
 It is difficult to study the effects of caesarean sections because it can be
difficult to separate out issues caused by the procedure itself versus issues
caused by the conditions that require it. For example, a study published in the
February 2007 issue of the journal Obstetrics and Gynecology found that women
who had just one previous caesarean section were more likely to have problems
with their second birth. Women who delivered their first child by Caesarean
delivery had increased risks for malpresentation, placenta previa, antepartum
hemorrhage, placenta accreta, prolonged labor, uterine rupture, preterm birth,
low birth weight, and stillbirth in their second delivery. However, the authors
conclude that some risks may be due to confounding factors related to the
indication for the first caesarean, rather than due to the procedure itself.

Risks for the child:

This list covers the most commonly discussed risks to the child. Some risks are
rare, and as with most medical procedures the likelihood of any risk is highly
dependant on individual factors such as whether other pregnancy complications
exist, whether the operation is planned or done as an emergency measure, and
how and where it is performed.

• 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.

• Breathing problems: babies born by Caesarean section, even at full term,

are more likely to have breathing problems than are babies who are
delivered vaginally.
• Breastfeeding problems: babies born by Caesarean 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.

• Type 1 Diabetes: a 2008 study found that children born by Caesarean

section have a 20% higher likelihood of developing type 1 Diabetes in their
lifetimes than babies born vaginally.

Risks for both mother and child:

Due to extended hospital stays, both the mother and child are at risk for
developing a hospital-borne infection. Studies have shown that mothers who
have their babies by caesarean take longer to first interact with their child when
compared with mothers who had their babies vaginally.

Anesthesia:

Both general and regional anaesthesia (spinal, epidural or combined

spinal and epidural anaesthesia) are acceptable for use during caesarean
section. Regional anaesthesia is preferred as it allows the mother to be awake
and interact immediately with her baby. Other advantages of regional anesthesia
include 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.

Regional anaesthesia is used in 95% of deliveries, with spinal and

combined spinal and epidural anaesthesia being the most commonly used
regional techniques in scheduled caesarean section. Regional anaesthesia
during caesarean section is different to the analgesia (pain relief) used in labor
and vaginal delivery. The pain that is experienced because of surgery is greater
than that of labor and therefore requires a more intense nerve block. The
dermatomal level of anesthesia required for caesarean delivery is also higher
than that required for labor analgesia.
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. General anesthesia is also
preferred in very urgent cases, such as severe fetal distress, when there is no
time to perform a regional anesthesia.

Vaginal birth after caesarean:

While Vaginal birth after caesarean (VBAC) are not uncommon today,
their numbers are shrinking[50]. The medical practice until the late 1970s was
"once a caesarean, always a caesarean" but a consumer-driven movement
supporting VBAC changed the medical practice. Rates of VBAC in the 80s and
early 90s soared, but more recently the rates of VBAC have dramatically dropped
owing to medico-legal restrictions.

In the past, caesarean sections used a vertical incision which cut the
uterine muscle fibres in an up and down direction (a classical caesarean).
Modern caesareans typically involve a horizontal incision along the muscle fibres
in the lower portion of the uterus (hence the term lower uterine segment
caesarean section, LUSCS/LSCS). The uterus then better maintains its integrity
and can tolerate the strong contractions of future childbirth. Cosmetically the scar
for modern caesareans is below the "bikini line".

Obstetricians and other caregivers differ on the relative merits of vaginal

and caesarean section following a caesarean delivery; some still recommend a
caesarean routinely, others do not. What should be emphasized in modern
obstetric care is that the decision should be a mutual decision between the
obstetrician and the mother/birth partner after assessing the risks and benefits of
each type of delivery. As is the case for all surgical procedures a patient signed
form relating to informed consent must be obtained prior to surgery attesting the
completeness of patient information because of reasonable and viable
alternatives to maternal choice CS.
 Because uterine rupture may be catastrophic, VBAC should be attempted
in institutions equipped to respond to emergencies with physicians immediately
available to provide emergency care.

This recommendation has, in some cases, had a major impact on the

availability of VBACs to birthing mothers in the United States. For example, a
study of the change in frequency of VBAC deliveries in California after the
change in guidelines, published in 2006, found that the VBAC rate fell to 13.5%
after the change, compared with 24% VBAC rate before the change. The new
recommendation has been interpreted by many hospitals as indicating that a full
surgical team must be standing by to perform a caesarean section for the full
duration of a VBAC woman's labor. Hospitals that prohibit VBACs entirely are
said to have a 'VBAC ban'. In these situations, birthing mothers are forced to
choose between having a repeat caesarean section, finding an alternate hospital
in which to deliver their baby or attempting delivery outside the hospital setting.

Recovery Period:

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.
ANATOMY OF FEMALE REPRODUCTIVE SYSTEM

The female reproductive system (or female genital 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 have formed by the time a female is born.
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 through menstruation.
A female's internal reproductive organs are the vagina, uterus, fallopian tubes,
cervix and ovary.

Vagina

The vagina is a fibro muscular tubular tract leading from the uterus to the
exterior of the body in female mammals, or to the cloaca in female birds
and some reptiles. Female insects and other invertebrates also have a
vagina, which is the terminal part of the oviduct.

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 mainly 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. The vagina has a thick layer outside and it is
the opening where baby comes out during delivery. The cervix is also called the
neck of the uterus.

Uterus

The uterus or womb is the major female reproductive organ of humans. The
uterus provides mechanical protection, nutritional support, and waste removal for
the developing embryo (weeks1-8) and fetus (from week 9-delivery). In addition,
contractions in the muscular wall of the uterus are important in ejecting the fetus
at the time of birth.

The uterus contains three suspensory ligaments that help stabilize the position of
the uterus and limits it's range of movement. The uterosacral ligaments, keep the
body from moving inferiorly and anteriorly. The round ligaments, restrict posterior
movement of the uterus. The cardinal ligaments, also prevent the inferior
movement of the uterus.

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 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 small, paired organs that are located near the lateral walls of the
pelvic cavity. These organs are responsible for the production of the ova
and the secretion of hormones. 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.
 PHYSIOLOGY OF FEMALE REPRODUCTIVE SYSTEM

Female Reproductive System

• Produces eggs (ova)

• Secretes sex hormones
• Receives the male spermatazoa during
• Protects and nourishes the fertilized egg until it is fully developed
• Delivers fetus through birth canal
• Provides nourishment to the baby through milk secreted by mammary
glands in the breast

External Genitals

Vulva

The external female genitals are collectively referred to as The Vulva. This
consists of the labia majora and labia minora (while these names translate as
"large" and "small" lips, often the "minora" can be larger, and protrude outside the
"majora"), mons pubis, clitoris, opening of the urethra (meatus), vaginal vestibule,
vestibular bulbs, vestibular glands.

The term "vagina" is often improperly used as a generic term to refer to the vulva
or female genitals, even though - strictly speaking - the vagina is a specific
internal structure and the vulva is the exterior genitalia only. Calling the vulva the
vagina is akin to calling the mouth the throat.

Mons Veneris

The mons veneris, Latin for "mound of Venus" (Roman Goddess of love) is the
soft mound at the front of the vulva (fatty tissue covering the pubic bone). It is
also referred to as the mons pubis. The mons veneris is sexually sensitive in
some women and protects the pubic bone and vulva from the impact of sexual
intercourse. After puberty it is covered with pubic hair, usually in a triangular
shape. Heredity can play a role in the amount of pubic hair an individual grows.

Labia Majora

The labia majora are the outer "lips" of the vulva. They are pads of loose
connective and adipose tissue, as well as some smooth muscle. The labia
majora wrap around the vulva from the mons pubis to the perineum. The labia
majora generally hides, partially or entirely, the other parts of the vulva. There is
also a longitudinal separation called the pudendal cleft. These labia are usually
covered with pubic hair. The color of the outside skin of the labia majora is
usually close to the overall color of the individual, although there may be some
variation. The inside skin is usually pink to light brown. They contain numerous
sweat and oil glands. It has been suggested that the scent from these oils are
sexually arousing.

Labia Minora
Medial to the labia majora are the labia minora. The labia minora are the inner
lips of the vulva. They are thin stretches of tissue within the labia majora that fold
and protect the vagina, urethra, and clitoris. The appearance of labia minora can
vary widely, from tiny lips that hide between the labia majora to large lips that
protrude. There is no pubic hair on the labia minora, but there are sebaceous
glands. The two smaller lips of the labia minora come together longitudinally to
form the prepuce, a fold that covers part of the clitoris. The labia minora protect
the vaginal and urethral openings. Both the inner and outer labia are quite
sensitive to touch and pressure.

Clitoris

The clitoris, visible as the small white oval between the top of the labia minora
and the clitoral hood, is a small body of spongy tissue that functions solely for
sexual pleasure. Only the tip or glans of the clitoris shows externally, but the
organ itself is elongated and branched into two forks, the crura, which extend
downward along the rim of the vaginal opening toward the perineum. Thus the
clitoris is much larger than most people think it is, about 4" long on average.

The clitoral glans or external tip of the clitoris is protected by the prepuce, or
clitoral hood, a covering of tissue similar to the foreskin of the male penis.
However, unlike the penis, the clitoris does not contain any part of the urethra.

During sexual excitement, the clitoris erects and extends, the hood retracts,
making the clitoral glans more accessible. The size of the clitoris is variable
between women. On some, the clitoral glans is very small; on others, it is large
and the hood does not completely cover it.

Urethra

The opening to the urethra is just below the clitoris. Although it is not related to
sex or reproduction, it is included in the vulva. The urethra is actually used for
the passage of urine. The urethra is connected to the bladder. In females the
urethra is 1.5 inches long, compared to males whose urethra is 8 inches long.
Because the urethra is so close to the anus, women should always wipe
themselves from front to back to avoid infecting the vagina and urethra with
bacteria. This location issue is the reason for bladder infections being more
common among females.

Hymen

The hymen is a thin fold of mucous membrane that separates the lumen of the
vagina from the urethral sinus. Sometimes it may partially cover the vaginal
orifice. The hymen is usually perforated during later fetal development.

Because of the belief that first vaginal penetration would usually tear this
membrane and cause bleeding, its "intactness" has been considered a guarantor
of virginity. However, the hymen is a poor indicator of whether a woman has
actually engaged in sexual intercourse because a normal hymen does not
completely block the vaginal opening. The normal hymen is never actually
"intact" since there is always an opening in it. Furthermore, there is not always
bleeding at first vaginal penetration. The blood that is sometimes, but not always,
observed after first penetration can be due to tearing of the hymen, but it can
also be from injury to nearby tissues.

A tear to the hymen, medically referred to as a "transection," can be seen in a

small percentage of women or girls after first penetration. A transection is caused
by penetrating trauma. Masturbation and tampon insertion can, but generally are
not forceful enough to cause penetrating trauma to the hymen. Therefore, the
appearance of the hymen is not a reliable indicator of virginity or chastity.

Perineum

The perineum is the short stretch of skin starting at the bottom of the vulva and
extending to the anus. It is a diamond shaped area between the symphysis pubis
and the coccyx. This area forms the floor of the pelvis and contains the external
sex organs and the anal opening. It can be further divided into the urogenital
triangle in front and the anal triangle in back.

The perineum in some women may tear during the birth of an infant and this is
apparently natural. Some physicians however, may cut the perineum
preemptively on the grounds that the "tearing" may be more harmful than a
precise cut by a scalpel. If a physician decides the cut is necessary, they will
perform it. The cut is called an episiotomy.

Internal Genitals

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. microscopically the vaginal rugae 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.

Cervix

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.

Uterus

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.
Fallopian Tubes

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 fimbriae.

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

Cross section of the breast of a human female.

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.
 PATHOPHYSIOLOGY

Release of FSH by the interior pituitary gland

Development of the graafian follide

Production of estrogen

(Thickening of the endometrium)

Release of the lutenizing hormone

Ovulation

(Release of the mature ovum from the graafian follicle)

Ovum travels to fallopian tube

Zygote travels from the fallopian tube to the uterus

Implantation

Development of the fetus /embryo and placental structure until full term

↓
 PRELIMINARY SIGN OF LABOR

↓ ↓ ↓

Lightening Braxton Hicks Contraction Goodles sign

(Descent of the fetal (false labor)

\______________________________________________________________/

TRUE LABOR

↓ ↓ ↓

Uterine contractions SHOW Rapture of members

-increase in duration and pink tinge of blood,

a mixture

And intensity of blood and fluid

-pain is not relieved no matter

What activity

-achieve cervical dilatation

\_______________________________________________________________/

Falled to progress labor

(due to previous cesarian birth ,cervical arrest, cervical atrophy)

Increase risk for fetal distress

(meconium staining, hypoxia)

↓
 Emergent cesarian delivery

(the incision made on the lower part of the abdomen )

Expulsion of the fetus

 NURSING HEALTH HISTORY

Patient’s Profile

Name: Pagunuran, Digna Santiago

Age: 23 years old

Birthday: January 16, 1987

Address: San Pascual, Obando Bulacan

Name of Spouse: Ruel Pagunuran

Name of Father: Arthur Santiago

Name of Mother: Mel Santiago

Nationality: Filipino

Occupation: Housewife

Educational Attainment: High School

Admission Date: 08-25-2010 5:57:40pm

Discharge Date: 08-28-2010

Surgery Performed: LTS

History of Past and Present Illness

The patient stands 63cm and weighs about 50kg. Her AOG is 40 weeks,
LMP was last November 15, 2010 and her EDC was on August 22, 2010. She
was only 17 years old when she gave birth to her first child through Cesarean
Section (Low Transverse Segment), because she had a difficulty in delivering the
child due to her age and lack of knowledge.

It was on August 25, 2010 at around 6pm when patient Digna S.

Pagunuran admitted at the OB ward of Bulacan Medical Center and was sent to
the OR-DR for an internal examination and was told that pregnancy was already
over due. The patient opted for another Cesarean Section for this pregnancy.
 GORDON’S FUNCTIONAL HEALTH PATTERN

Pattern Before Present Interpretation

1. Health Patient goes to Patient is concern Patient cannot
Perception Health the health center about her second function normally
Management once when she cesarean section anymore like
got pregnant. All thinking that it before because of
in all, she thinks may be her hospitality
she is in a healthy detrimental to her confinement and
state. health. conscious to her
body image
changed after
surgical procedure
done.
2. Nutritional Prior to During Patient’s
Metabolic confinement, hospitalization, the nutritional and
Management patient loves patient is on diet metabolic status
eating instant as tolerated. She has been changed
foods and fatty eats fruits like due to her
foods like fries apples and confinement.
and burgers. She oranges. She eats
also loves bread instead of
condiments like rice. She said she
“patis”, vinegar, lost her appetite
and soy sauce. since her onset of
She basically eats labor.
whatever she
likes.
3. Elimination Bowel: Bowel: Bowel:
Pattern Patient defecates Patient defecates There was a
1-2 times a day, once a day but not change in the
 usually in the on a regular basis. frequency and
morning, and in Stool is soft, amount.
the afternoon. minimal in amount
Stool is brown in and brown in
color and well color.
formed.

Bladder: Bladder: Bladder:

Patient voids Patient voids 3-4 There was a
usually 6-8 times times a day change in the
a day. Urine without pain and frequency and
yellow in color. No discomfort. amount.
pain when voiding.
4. Activity, Patient is a Patient’s activities During patient’s
Leisure, and housewife so she in the hospital are confinement in the
Recreation is always in the ambulation, hospital, there is a
Pattern charge of the deep breathing limitation in her
household chores. and coughing activities of daily
Her leisure time exercise, taking a living and a
would include bath or personal disruption in her
watching hygiene. leisure and
television. recreation patter.
5. Sleep and Rest Patient puts Due to her Patient sleep and
Pattern herself to sleep by uncomfortable rest pattern
watching condition and changed when
television pain, patient she was admitted.
programs. She complains of She cannot put
usually sleeps at difficulty of herself to sleep
around 11pm to sleeping and short anymore due to
6am. She feels period of sleeps. present condition
rested when and pain plays a
sleeping and big factor for her
 thinks that her sleep
energy is sufficient disturbances.
for her activities.
6. Cognitive Patient is a high Patient’s present No changes/
Perceptual Pattern school graduate. condition is not a alterations.
She can read and hindrance to her
write. She can cognitive
speak and be perceptual
understood by pattern.
others.
7. Self Perception/ Patient is a During times of There is a slight
Self concept friendly person; her confinement, change in her self
Pattern she loves to she doesn’t thinks perception due to
socialize with her that she is a present condition.
friends in holistic person
neighborhoods. anymore.
She considers However she is
herself as holistic positive that she
human being as will be ok after
long as she is confinement.
healthy, complete
and her family is
always there.
8. Role Patient can The patient’s Normal/ No
Relationship understand family is alterations.
English, Tagalog supportive. She is
and happy with their
Kapampangan. presence.
She has 5
siblings.
9. Sexuality/ Patient has been Patient reserved Patient reserved
Reproductive with her partner her right to her right to
Pattern for 3years. privacy. privacy.
10. Coping and When patient is The recent Patient accepts
Stress Tolerance stressed, she hospitalization of present condition
sings in the the patient was with a positive
karaoke and eats stressful and attidude.
comfort foods like source of anxiety.
burgers and fries. However, she is
When it comes to positive that she
problems, she lets will be able to
herself think cope up with
immediately for a current condition.
solution.
11. Values- Belief Patient is a She follows a Due to her
Pattern Roman Catholic. therapeutic confinement,
She has a strong regimen and her patient is trusting
faith to God and strong faith to God God that she will
goes to mass accounts to her be discharge soon
every Sunday with fast recovery. and will recover
her family. without any
complications.

PHYSICAL ASSESSMENT

Skull · Generally round, with prominences in

the frontal and occipital area.
 (Normocephalic).
Scalp · Lighter in color than the complexion.
· Moist.
· No scars noted.
· No lesions should noted.
Hair ·Can be black, brown or burgundy
depending on the race.
· Evenly distributed covers the whole
scalp (No evidences of Alopecia)
CN VII (Facial) · Rounded in shape.
· Face is symmetrical.
· No involuntary muscle movements.
· Move facial muscles at will.
Eyebrows · Symmetrical and in line with each
other.
· Black in color.
· Evenly distributed.
Eyes · Evenly placed and inline with each
other.
· Non protruding.

Eyelashes · Color dependent on race.

· Evenly distributed.
· Turned outward.
Eyelids · Upper eyelids cover the small portion
of the iris, cornea, and sclera when
eyes are open.
· No PTOSIS noted. (drooping of upper
eyelids).
· Meets completely when eyes
Conjunctivae · Both conjunctivae are pinkish or red
in color.
· With presence of many minutes
capillaries.
 · Moist
· No ulcers
· No foreign objects

Sclerae · Sclerae is white in color (anicteric

sclera)
· No yellowish discoloration (icteric
sclera).
· Some capillaries are visible.
Cornea · There are no irregularities on the
surface.
· Looks smooth.
· The features of the iris should be
fully visible through the cornea.
· There is a positive corneal reflex.

Pupils · Equally round.

· Constrict sluggishly when light is
directed to the eye, both directly and
consensual.
· Pupils dilate when looking at distant
objects, and constrict when looking at
nearer objects.

Ears · The ear lobes are bean shaped,

parallel, and symmetrical.
· The upper connection of the ear lobe
is parallel with the outer canthus of the
eye.
· Skin is same in color as in the
complexion.
· No lesions noted on inspection.
 · No discharges or lesions noted at the
ear canal.

Nose and Paranasal Sinuses · Nose in the midline

· No Discharges.
· Both nares are patent.
· No bone and cartilage deviation noted
on palpation.
· The nasal mucosa is pinkish to red in
color.

Extremities • Both extremities are equal in

size.
• Have the same contour with
prominences of joints.
• No involuntary movements.
• Color is even.
• Temperature is warm and even.
• Has equal contraction and even.
• No crepitus noted on joints.

LABORATORY EXAMINATIONS

LAB LAB NORMAL SIGNIFICANCE

EXAMINATIONS RESULTS VALUE
Hgb 110 FEMALE: 120- The patient may be anemic
150 gm/ L because of the large amount
of blood that she loss during
 the CS delivery.
Hct .33 FEMALE: 0.37- The patient may be anemic
0.47 because of the large amount
of blood that she loss during
the CS delivery.
WBC count 10.5 5-10 x 10/L Increase in the number of
WBC may indicate presence
of infection in the body.
Rbc count 3.7 FEMALE: 4.0- This result may indicate that
5.5 x 10/L the patient has anemia
because of the blood loss,
and this is the reason why
Hgb and Hct is decrease in
amount.
Neutrophils 0.82 0.55-0.65 As one kind of a WBC,
increase in amount of
Neutrophils may indicate
presence of infection in the
patient’s body.
Lymphocytes 0.18 0.25-0.40 A low normal to low absolute
lymphocyte concentration is
associated with increased
rates of infection after
surgery or trauma.

URINALYSIS RESULTS

LAB LAB NORMAL SIGNIFICANCE

EXAMINATIONS RESULTS
(Characteristics)
Macroscopic:
Color Yellow Yellow >Yellow is the natural color
 for urine

Transparency Turbid Clear >Turbid urine may indicates

that the patient is suffering
from a UTI or other infection

Specific Gravity 1.015 1.003–1.035 > The patient’s urine S.

−3
(g·cm ) Gravity is normal because its
in the range of 1.003-1.035

Reaction (pH) 6.0 Close to neutral > Patient’s urine is in a

(7) but can normal pH, but it is slightly
normally vary acidic
between 4.4
and 8
Chemical test:
Sugar Negative None > it means that absence of
sugar in the urine is normal

Albumin Trace None > There is a positive

proteinuria, this may indicate
increase in GFR
Microscopic: none
RBC 0-12 None > RBC in the urine or
Hematuria is abnormal.
> Red blood cells in urine
can be due an inflammation,
disease, or injury to the
urinary tract system.

WBC 14-18 None or up to 5 > Greater numbers (pyuria)

WBC/HPF generally indicate the
 generally are presence of an inflammatory
considered process somewhere along
acceptable as the course of the urinary tract
"normal". (or urogenital tract in voided
specimens).
Epithelial cells Moderate Normal if it is
not so many > Amount of epithelial cells
can be increased in
infections and inflammations.
> Amount of epithelial cells is
also increased in
malignancies, but this
absolutely is not the only sign
Mucus Threads None None of cancer.

> presence of mucus threads

can either mean that the
collection was not clean
catch and the urine has been
contaminated by contact with
mucus membranes, or a
Yeast cells None None possible infection.

Bacteria Few None > If these are present, it can

mean you have an infection.

> Indicates infection, this also

related why there is presence
of WBC in the urine and
increase amount of urine in
 the blood.
Crystals:
A. Urates few None > Urate is a kind of kidney
stones, and this is abnormal.
Other Test:
Leukocyte +1 None > This indicates UTI of
infection in the urinary
system

CONCLUSION

This case study adds to growing scientific body that exercise during and
after caesarian delivery helps maintain physiologic function that may be
otherwise devastated during treatment. The case study provided the basis for our
assessment procedures and outlined the specific nursing interventions intensities
used in our nursing plan of care to the patient. Additionally, this case study also
helps to improved not only our capabilities but as well as the patient too.

Our client was a highly motivated mother who possessed a strong desire
to contribute to her health and rehabilitation during her treatment. She is capable
and many times would like to participate in nursing interventions during and after
their health teachings to take an active role for the development of her health yet
get imprecise direction on how much and how hard safe is.

Participation in plan of care and should be considered as part of a

therapeutic modality for a mother like her.

DISCHARGE PLANNING

 M – Medication
 Methylgonometrine 1 tab TID
 Mefenamic Acid 250mg 1 tab q4 hrs
 Ferrous sulfate 1 tab once a day
 E – Environment
 Instructed the patient to stay calm, quiet environment
 Home environment must be free from slipping or accident hazards.

T – Treatment
  Informed patient to have a follow-up check-up after 1-2 weeks.

 H – Health Teachings
 Informed patient to avoid lifting heavy objects for 1-2 week
 Stressed the importance of perineal cleanliness
 Encouraged client to have hot sitz bath
 Instructed patient to increase intake of protein-rich foods to promote
faster wound healing
 Instructed to promote adequate fluid intake
 Discouraged patient to participate in strenuous activities that might
precipitate stress and trauma to the wound.
 Instructed patient to promote breastfeeding

O – Observable Signs and Symptoms

 Observe for dehiscence and evisceration

 Instructed patient to report to physician any signs of infection
 Instructed patient to report any case of hemorrhage or abnormal bleeding.

D – Diet

 Encouraged client to increase intake of fiber to avoid constipation

 Instructed to increase fluid intake
 Instructed to increase intake of nutritious foods such as fruits and
vegetables.