Roque, Abie Jewel Joy R.

August 31, 2018

BSN301| NCM 103D (Pain and Surgery) Prof. Cambe

CASE STUDY

DEFINITION

Caesarean section, also known as C-section or caesarean delivery, is the use of

surgery to deliver babies. A caesarean section is often necessary when a vaginal
delivery would put the baby or mother at risk. This may include obstructed labour, twin
pregnancy, high blood pressure in the mother, breech birth, or problems with the
placenta or umbilical cord. A caesarean delivery may be performed based upon the
shape of the mother's pelvis or history of a previous C-section. A trial of vaginal birth
after C-section may be possible. The World Health Organization recommends that
Caesarean section be performed only when medically necessary. Some C-sections are
performed without a medical reason, upon request by someone, usually the mother

A C-section typically takes 45 minutes to an hour. It may be done with a spinal

block, where the woman is awake or under general anesthesia. A urinary catheter is
used to drain the bladder and the skin of the abdomen is then cleaned with an
antiseptic. An incision of about 15 cm (6 inches) is then typically made through the
mother's lower abdomen. The uterus is then opened with a second incision and the
baby delivered. The incisions are then stitched closed. A woman can typically begin
breastfeeding as soon as she is awake and out of the operating room. Often, several
days are required in the hospital to recover sufficiently to return home

C-sections result in a small overall increase in poor outcomes in low-risk

pregnancies. They also typically take longer to heal from, about six weeks, than vaginal
birth. The increased risks include breathing problems in the baby and amniotic fluid
embolism and postpartum bleeding in the mother. Established guidelines recommend
that caesarean sections not be used before 39 weeks of pregnancy without a medical
reason. The method of delivery does not appear to have an effect on subsequent sexual
function.

INDICATION OF C-SECTION

Some indications are controversial and some are accepted as the standard.

 Fetal indications
1. Abnormal fetal heart rate patterns (nonreassuring fetal status) (Figure 4A)
 Figure 4a - Non-reassuring fetal status - Printout
showing slowing of fetal heart rate with uterine
contractions, which led to cesarean section.

2. Breech presentation of the fetus ( bottom down instead of head down)

(Figure 4B)
1. Very low birth weight (<1500grams or 3.3 pounds)
2. Active genital herpes lesions
3. Idiopathic thrombocytopenia purpura - disease in which there are
low platelets in the blood and easy bleeding
4. Major malformations in the fetus making passage through the birth
canal difficult or impossible

Figure 4b - Breech presentation. Fetus

presents bottom side down

 Maternal indications
1. Tumor obstructing the birth canal
2. Large genital warts (condyloma)
3. Cervical cerclage- a suture is placed in the cervix to prevent preterm
delivery. Cerclage may be permanent or temporary to allow for vaginal
delivery
4. Certain vaginal surgeries (vaginal repair can break down)
 5. Conjoined twins (Siamese twins)
6. Prior surgery in which an incision was made in the uterus (myomectomy -
removal of fibroid tumor)
7. HIV - The American College of Obstetricians and Gynecologists
recommends that HIV+ mothers should deliver the fetus by C-section at
38 weeks of pregnancy to reduce the chance of transmitting the virus to
the fetus
 Maternal-Fetal Indications
1. Cephalopelvic disproportion- either the baby is too large or the pelvis is
too small to allow passage
2. Failure of the cervix to dilate or failure of the fetus to pass down the birth
canal
3. Abruption - when the tears away from the uterus. This is an emergency
situation
4. Previa - this is when the implants over all or part of the cervix. (Figure 4C)

Figure 4C - previa. The is

implanted over the opening of the
cervix thus preventing a vaginal
delivery.

ANATOMY AND PHYSIOLOGY OF ORGANS INVOLVED

 The uterus or womb is a pear shaped organ that is found in the pelvis at the top
of the vagina. The uterus in a woman that is not pregnant does not extend above
the pubic bone (Figures 1, 2 and 3)
 Figure 1 - Anatomy of the uterus Figure 2 - Uterus as seen from in
and surrounding organs as seen in front.
a section through the middle of the
body.

Figure 3 - View of the uterus, ovaries, Fallopian

tubes, and round ligament through a laproscope.

 In the pregnant woman at the end of pregnancy, the uterus enlarges to

approximately 40 centimeters (16 inches) above the pubic bone
 The cervix is found at the lowermost portion of the uterus and is the opening
through which the fetus passes during delivery. Normally, this opening is closed
until late in the pregnancy
 Fertilization occurs within the fallopian tubes. The fallopian tubes are found at the
top of the uterus, one on each side. The end of each fallopian tube has fingerlike
projections called fimbria which guide the egg from the ovary into the Fallopian
tube
 The fertilized egg then passes from the Fallopian tube into the cavity within the
uterus where the fertilized egg implants into the wall of the uterus. The site of
implantation becomes the
  As the egg develops into a fetus the remains attached to the fetus through the
umbilical cord. Thus the blood supply to the fetus originates in the uterine wall
 The umbilical cord extends from the to the fetus where it inserts at umbilicus
(belly button) of the fetus

PHATOPHYSIOLOGY OF C-SECTION

SIGNS AND SYMPTOMS

When it comes to giving birth, your doctor will likely try and keep things as procedure-
free as possible for you. Since a C-section is, after all, a surgery, most doctors try to
avoid. However, there are occasions when C-sections are preferred, and even
necessary. In fact, there are some early signs you may need a C-section that your
doctor may be on the lookout for, even during the early stages of your pregnancy.

Though some women end up having C-sections after labor has already started, others
schedule a C-section in advance. Both cases mean that your doctor has assessed the
options for delivery and decided that the C-section is the best and safest option for both
mom and baby, in order to avoid any complications that might occur during a vaginal
birth. Once labor has begun, the ideal delivery is vaginal, which is why the following
early signs you may need a C-section are important to not only pay attention to, but
discuss with your doctor. C-sections are considered a major abdominal surgery, and
often pose a longer recovery time than vaginal deliveries do. But if you fall under any of
the following categories, you and your doctor can determine the proper birthing plan to
suit both you and your baby.

You've Had A Previous C-Section

If you've had a previous C-section or other surgeries on your womb, there's a

good chance you'll be having another C-section. Though Parents noted that it's possible
for women who have had C-sections to safely undergo a vaginal birth, nearly 80 percent
of scheduled C-sections are repeats. Once you've delivered one baby by C-section,
you'll be offered the option for every pregnancy after.
You're Having Problems With The Placenta

If you're diagnosed with a placenta previa during your third trimester, chances
are high that you'll be having a C-section. According to WebMD, a placenta previa is
when the placenta lies low in your uterus and blocks the cervix. This can lead to
dangerous bleeding during vaginal birth. If a complete or even a partial placenta previa
has been detected by your doctor, a C-section is usually necessary.

You Have An Infection

If you have a sexually transmitted infection like HIV or herpes, your doctor will
likely recommend a C-section, as both infections can be transmitted to the fetus during
vaginal delivery, according to WebMD.

You're Having Multiples

WebMD noted that women expecting more than one baby may need a C-section. If
you're having twins (or triplets, or more) who are sharing one amniotic sac or are poorly
positioned, your doctor will probably recommend a C-section for the safety of both you
and your babies.

You Have A Health Condition

If you have a preexisting condition that could be made worse by the stress that
labor induces, your doctor may suggest a C-section delivery for your baby. Depending
on your doctor's assessment, Parents reported that some women with heart conditions
may still be able to give birth vaginally. According to Healthline, however, diabetes
poses a different risk for expecting mothers, as women with diabetes can experience an
impairment of uterine contractibility. In other words, you could push all day and get
nowhere.

Your Baby Is In The Wrong Position

 If your baby is in a breech position and has been for some time, your doctor may
choose to deliver the child via a C-section, according to the American Pregnancy
Association (APA). In fact, the APA noted that a C-section is sometimes the only option
for breech position babies who won't budge.

Your Baby Has Been Diagnosed With A Birth Defect

If your baby has been diagnosed with a birth defect in the womb, your doctor
may schedule a C-section in an attempt to reduce any further complications during your
delivery, according to the APA.

NURSING RESPONSIBILITIES

Preoperative Assessment

A nursing assessment of a pregnant woman about to undergo cesarean birth is also

important to obtain health history that would become essential later on.

 Assess the woman about past surgeries, secondary illnesses, allergies to

foods or drugs, reaction to anesthesia, and medications that could increase
any surgical risk.
 The woman should be in the best possible physical and psychological state
before undergoing any surgery.
 An obese woman with poor nutritional status is at risk for a slow wound
healing.
 Tissue that contains extra fatty cells would be difficult to suture and the
incision will heal much slower and predispose the woman to infection and
dehiscence.
 An obese woman would also have difficulty in initiating ambulation and turning
after surgery as it will increase the risk for pneumonia or thrombophlebitis.
 A woman with protein or vitamin deficiency is also at risk for poorer healing
because these are needed for new cell formation at the incision site.
 Age can also affect surgical risk because it can cause decreased circulatory
and renal function.
  A woman who has secondary illness is also at greater surgical risk depending
on the extent of the disease because the secondary illness may affect the
woman’s ability to adapt to the demands of the surgery.
 The general medication history of the woman must also be assessed because
there are drugs that could increase the surgical risk by interfering with the
effects of anesthesia.
 A woman with lower than normal blood volume might feel the effects of
surgery more than a woman with normal blood volume.
 An example of this is a woman who began labor and was told later on that she
should undergo cesarean birth instead because she may not have had
anything to eat or drink for almost 24 hours.
 To prevent fluid and electrolyte imbalance, intravenous fluid replacement is
initiated preoperatively and postoperatively.
 There are women who are very worried about the procedure, so they need a
very detailed explanation of the procedure before they can enter surgery
without intense fear.
 A woman who is frightened is at greater risk for cardiac arrest during
anesthesia administration.
 Acknowledge that the woman’s fear of surgery is normal so that she can view
her feelings as expected which could increase her self-esteem.
 The newborn is also at greater risk than those newborn born through
vaginal delivery.
 Infants born through cesarean delivery develop a degree of respiratory
difficulty because when a fetus is pushed through the birth canal, pressure on
the chest helps to rid the newborn lungs of fluid.

Preoperative Measures

Preoperatively, there are measures that should be taken to ensure the woman’s safety
during surgery.

 The most important responsibility of the surgeon is securing the informed

consent from the patient.
  It is everyone’s responsibility to see to it that the consent is obtained, and
witnesses might be asked to witness the woman’s signature.
 The consent must be informed, and the risks and benefits of the procedure
must be explained in a language that the woman understands.
 Upon admission, the woman is provided with a clean hospital gown and
her hair is pulled into a ponytail.
 The woman’s nails should be free from nail polish or any acrylic fingernails
because nails are used to assess capillary refill.
 To decrease stomach secretions, a gastric emptying agent is used before
surgery, because the woman would be lying on her back during surgery which
makes esophageal reflux and aspiration highly possible.
 An indwelling catheter is prescribed before or after the surgery to
reduce bladder size and keep the bladder away from the surgical field.
 Make sure that you have good lighting when inserting a catheter on a
pregnant woman to clearly reveal the perineum.
 The urine should be draining freely, and the drainage bag should be kept
below the level of the bladder during transport to prevent backflow and the
introduction of microorganisms into the bladder.
 To ensure that the woman is fully hydrated, an intravenous solution such as
Ringer’s can be started as prescribed.
 Only a minimum of preoperative medications is given to prevent compromising
the fetal blood supply and make sure that the newborn is wide awake at birth
and respirations are initiated spontaneously.
 Documentation of nursing care up until the woman leaves the hospital must be
complete and factual.
 Upon transport to surgery, ensure that the woman is lying on her left side to
prevent supine hypotension.
 Ensure that the side rails are up, and the woman is covered with a blanket.
 A support person may be needed during cesarean birth, and they also need
encouragement to watch the birth live.

Intraoperative Measures
 While anesthesia is being administered, a surgical nurse will assist the woman
first to move from the transport stretcher to the operating table.
 The anesthesia of choice is usually a regional block.
 Encourage the woman to remain on her side or insert a pillow under her right
hip to keep her body slightly tilted to the side to prevent supine hypotension.
 In emergency cases, a spinal anesthesia is administered while the woman is
sitting up.
 It would be difficult for a woman in labor to remain in a curved position during
administration of the anesthetic, so talk to her gently and let her lean on you
while you gently restrain her.
 Epidural anesthesia is administered while the woman is lying on her side, and
it has an effect that lasts for 24 hours, so continuous pulse oximetry must be
used 24 hours post surgery to detect respiratory depression.
 For the skin preparation, shaving away abdominal hair and washing the skin
over the incision site with soap and water could reduce the bacteria on the
skin.
 The woman is then positioned with a towel under her right hip to move
abdominal contents away from the surgical field and lift her uterus away from
the vena cava.
 The woman would be covered by a sterile drape to block the flow of the
bacteria from her respiratory tract to the incision site and also block the
woman’s and support person’s lines of sight from the incision site.
 The incision area is scrubbed by an antiseptic, and additional drapes are
placed around the area so that only a small area of the skin is exposed.
 Prepare the woman and the support person for the sights they might see.
 A classic incision is made vertically through both the abdominal skin and the
uterus.
 A disadvantage of this type of incision is that it leaves a wide skin scar and
also runs through the active contractile portion of the uterus.
 The woman would not be able to have a subsequent vaginal birth because
this type of scar could rupture during labor.
  A low segment incision or low transverse incision is made horizontally across
the abdomen just over the symphysis pubis and also horizontally across the
uterus just over the cervix.
 This is the most common type of incision and is also referred to as “bikini”
incision.
 It is less likely that this type of incision would rupture during labor, so it is
possible for the woman to have VBAC in the future.
 It results in less blood loss, easier to suture, decreases puerperal infections
and less likely to cause postpartum gastrointestinal complications.
 The disadvantage of this incision is that it takes longer to perform, making it
inappropriate for an emergent cesarean birth.

Postpartal Care

 The postpartal care period of a woman who has undergone emergent

cesarean birth is divided into two: immediate recovery period and extended
postpartal period.
 After surgery, the woman would be transferred by stretcher to the
postanesthesia care unit.
 If spinal anesthesia was used, the woman’s legs are fully anesthetized so she
cannot move them.
 Pain control is a major problem after birth because it was so intense that it
interfered with the woman’s ability to move and deep breathe.
 This may lead to complications such as pneumonia or thrombophlebitis.
 Use a pain rating scale to allow a woman to rate her pain.
 Some women may need patient controlled analgesia or continued epidural
injections to relieve the pain.
 Supplement the analgesics with comfort measures such as change in position
or straightening of bed linen.
 Instruct the woman to ambulate because this is the most effective method to
relieve gas pain.
 Inform the woman that she should not take acetylsalicylic acid
or aspirin because this can interfere with blood clotting and healing.
  Instruct the woman to place a pillow on her lap as she feeds the infant to
deflect the weight of the infant from the suture line and lessen the pain.
 Football hold for breast feeding is a way to keep the infant’s weight off the
mother’s incision.
 During the extended postpartal period, the woman most commonly
experiences gastrointestinal function interference.
 Note carefully the woman’s first bowel movement after surgery because if no
bowel movement has been observed, the physician may order a stool
softener, a suppository, or an enema to facilitate stool evacuation.
 Teach the woman to eat a diet high in roughage and fluid and to attempt to
move her bowels at least every other day to avoid constipation.
 Incisional pain may interfere with the woman’s ability to use her abdominal
muscles effectively, so the physician may prescribe a stool softener.
 Caution the woman not to strain to pass stools because this puts pressure on
their incision.
 Advice the woman to keep their water pitcher full as a reminder for her to drink
fluids.
 Reassure the woman that it is normal not to have bowel movements for 3 to 4
days postoperatively, especially if there is enema administered before
surgery.

CLIENT AND FAMILY TEACHING

Home Care

Giving birth and major surgery is tiring, especially in the first few weeks postpartum.
Rest when you can to regain your energy. Try sleeping when the baby sleeps and ask
family or friends for help.

To help prevent infection:

Keep the incision area clean and dry.

Ask your doctor about when it is safe to shower, bathe, or soak in water.

You will have some vaginal bleeding for a few weeks after delivery. Wear sanitary pads
for about 6 weeks after

delivery.
The C-section incision can make everyday movements uncomfortable while it is healing.
To relieve discomfort, press a

pillow or your hand against your abdomen when shifting your position or with sudden
movements such as sneezing

or coughing.

Diet

Eat a well-balanced, healthy diet to help you recover from childbirth. If you are
breastfeeding, you will need additional calories each day. You may also be advised to
avoid certain foods by your doctor. Follow all recommendations.

Some women experience constipation after childbirth. To avoid this problem:

Drink plenty of fluids.

Eat food high in fiber such as whole grains, cereal, bread, fruits, vegetables, beans,
and lentils.

Physical Activity

Try to move around each day. Light physical activity will help with your recovery. During
recovery:

Do not lift anything heavier than your baby. Avoid heavy lifting until your doctor gives
you permission to do so.

Get up slowly. This will help you to avoid feeling lightheaded.

Ask your doctor when you will be able to go back to work and drive.

Avoid sexual activity until your doctor says it is safe to do so. Talk to your doctor
about family planning options before resuming sexual activity.

Medications

Your doctor may advise:

Over-the-counter pain medication such as ibuprofen or acetaminophen

Prescription pain medication

Stool softeners

If you are taking medications, follow these general guidelines:

 Take your medication as directed. Do not change the amount or the schedule.

Do not stop taking prescription medication without talking to your doctor.

Do not share prescription medication.

Ask what results and side effects to expect. Report them to your doctor.

Some medications can be dangerous when mixed. Talk to a doctor or pharmacist if

you are taking more than one

medication. This includes over-the-counter medication and herb or dietary supplements.

Follow-up

Your doctor will need to check on your progress. It is important to go to any

recommended appointments.

Call Your Doctor If Any of the Following Occur

Contact your doctor if your recovery is not progressing as expected or you develop
complications such as:

Signs of infection, including fever and chills

Heavy vaginal bleeding

Foul-smelling vaginal discharge

Excessive bleeding, redness, swelling, increasing pain or discharge from the incision
site

Pain that you cannot control with the medication you have been given

Lightheadedness or fainting

Swelling and/or pain in one or both legs

Cough, shortness of breath, or chest pain

Joint pain, fatigue, stiffness, rash, or other new symptoms

OPERATIVE TECHNIQUE /PROCEDURE

 The skin is prepared with a solution that reduces the risk of wound
infection
 A catheter is placed in the bladder
 The hair near the incision may be shaved
 An incision is made in the skin and is carried through the abdominal wall to enter
the pelvis. The skin incision may be made vertical (up and down) or transverse
(from side-to-side). The decision is based on many factors including speed of
entry, exposure needed, anticipated weight of the baby and risk of wound
infection. A transverse skin incision is most common and is usually made 2-3
centimeters (one inch) above the pubic bone (Figure A)
 The uterus is then identified. There is a layer of thin tissue, which drapes over the
anterior surface of the uterus and then onto the bladder (the vesicouterine
peritoneum). This layer is incised so that the bladder can be retracted away form
the uterus to allow for the uterine incision. (Figure B) The incision is then carried
into the uterus to allow for delivery of the baby
 The uterine incision is then made down to the amniotic sack (fetal membranes or
bag of water). (Figure C)
 The uterine incision can be either transverse or vertical. Ninety percent have a
transverse uterine incision. Some indications for a vertical incision in the uterus
are a pre-term fetus, a fetus that is not head down and with emergency C-
sections. Even in these situations a transverse incision may sometimes be used.
A woman that has a prior C-section with a vertical uterine incision is usually not a
candidate for vaginal birth
 The fetal head or buttocks are then delivered through the uterine incision
followed by the rest of the body. (Figure D) Then the is delivered
 Some obstetricians repair the uterus by first delivering the uterus through the
abdominal incision and some repair it while it is still in the abdomen. The uterus
is closed with one or two layers of suture (Figure E)
 The layers of the abdominal wall are sutured and then the skin closed with either
suture or staples