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An OR write-up onCESAREAN SECTION

Presented toThe Faculty of the School of NursingUniversity of Baguio

In Partial fulfilment of theRequirements for the Subject NCENLO5

Presented by:NMB 4Am-maran, Shara MaeBicol, MyraBisares, Krizza FebrylleFernandez, Gladys ArmieMenor, GwenNogal, BernadetteNuez, Charlene PatriciaPaguinto, Joyce

Clinical Instructor:

Mr. Jonathan P. Vicente, RN, MANMay 2014TABLE OF CONTENTS

Introduction............................................. 3CHAPTER IPatients Profile......................................... 4CHAPTER IIAnatomy and Physiology................................... 5CHAPTER IIIPathophysiology.......................................... 8Narrative........................................... 8Schematic........................................... 9CHAPTER IVProcedure............................................... 10CHAPTER VInstrumentation......................................... 15CHAPTER VIDrug Study.............................................. 22REFERENCES.............................................. 25

IntroductionCesarean delivery is defined as the delivery of a fetus through surgical incisions made through both the abdominal wall and the uterine wall. The words Cesarean and section are both derived from verbs that mean to cut; the phrase caesarean section is a tautology.Cesarean deliveries were initially performed to separate the mother and the fetus in an attempt to save the fetus of a moribund patient. This operation subsequently developed into a surgical procedure to resolve maternal or fetal complications not amenable to vaginal delivery.The caesarean delivery was evolved from a vain attempt performed to save the fetus to one in which the physician and patient both participate in the decision-making process, striving to achieve the most benefit for the patient and her unborn child. Currently, caesarean deliveries are performed for a variety of fetal and maternal indications. The indications have expanded to consider the patients wishes and preferences.There are many reasons why a health care provider might feel that you need to have a caesarean delivery. Some cesareans occur in critical situations, some are used to prevent critical situations, and some are elective. Some reasons that a caesarean section is needed: placenta previa, uterine rupture, breech position, cord prolapsed, fetal distress, and multiple births.

CHAPTER IPatient ProfileName: Patient XSex: FemaleBirthday: October 17, 1990Age: 43Nationality: FilipinoReligion: Roman CatholicAddress: Burgos, La UnionPre-Operative Diagnosis: G2P1(2-0-0-1) Pregnancy uterine 39 weeks AOG cephalic in labor, previous Cs 1x for CPDOperation Performed: Emergency LSCS 2x for previous scar for CPDPost-Operative Diagnosis: G2P2 (2-0-0-2) Pregnancy Uterine delivered cephalic term , alive baby girlSurgeon: Dr. TinoAssistants: Dr. LampacanAnesthesiologist: Dr. LeaoAnaesthesia: SABAnaesthesia started: 7:26 PMOperation started: 7:32 PMOperation finished: 8:00 PM

CHAPTER II ANATOMY AND PHYSIOLOGY

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: The broad ligament is a section of the peritoneum that drapes over the ovaries, uterus, ovarian ligament, and suspensory ligament. It includes both the mesovarium and mesometrium. The mesovarium is a fold of peritoneum that holds the ovary in place. 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. The ovarian ligament anchors the lower end of the ovary to the uterus.The uterus (womb) is a hollow organ about the size and shape of a pear. It serves two important functions: It is the organ of menstruation and during pregnancy it receives the fertilized ovum, retains and nourishes it until it expels the fetus during labor. The uterus is located between the urinary bladder and the rectum. It is suspended in the pelvis by broad ligaments.Division of uterus The uterus consists of the body or corpus, fundus, cervix, and the isthmus. The major portion of the uterus is called the body or corpus. The fundus is the superior, rounded region above the entrance of the fallopian tubes. The cervix is the narrow, inferior outlet that protrudes into the vagina. The isthmus is the slightly constricted portion that joins the corpus to the cervix.The walls of the uterus The walls are thick and are composed of three layers: The endometrium, the myometrium, and perimetrium. The endometrial is the inner layer or mucosa. A fertilized egg burrows into endometrium (implantation) and resides there for the rest of its development. When the female is not pregnant the endometrial lining sloughs off about every 28 days in response to the changes in levels of hormones in the blood. This process is called menses. The myometrium is the smooth muscle component of the wall. These smooth muscle fivers are arranged. In longitudinal, circular, and spiral patterns, and are interlaced with connective tissues. During the monthly female cycles and during pregnancy, these layers undergo extensive changes. The perimetrium is a strong, serous membrane that coats the entire uterine corpus except the lower one fourth and anterior surface where the bladder is attached. The cervix is a narrow region at the bottom of the 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 becomes thin and slightly alkaline. These are attributes that promote the passage of sperm. At other times, the mucus is viscous and impedes the passage of sperm.

CHAPTER IIIPATHOPHYSIOLOGYNARRATIVE:Cephalopelvic disproportion (CPD) occurs when a babys head or body is too large to fit through the mothers pelvis. It is believed that true CPD is rare, but many cases of failure to progress during labor are given a diagnosis of CPD. When anaccuratediagnosis of CPD has been made, the safest type of delivery for mother and baby is a cesarean. The disorders pathophysiological aspects include the mother being unable to birth the child naturally due to the babys head being too large to fit through the pelvis. This is a rare condition, and there are only theories as to why this occurs. It is thought that the physiology of the mother may have something to do with the condition. If a mothers pelvis is abnormally shaped, this can happen. It can also occur if the mother has a small pelvis. This may also occur if the due date is long past and the baby is still growing, causing the head to surpass the size of the pelvis.

SCHEMATIC:

CAUSE: Increased fetal weight

Baby cannot pass through the inlet of pelvis

Poor fetal descent

Prolonged first stage of labor

CPD

Cesarean Section

CHAPTER IVPROCEDUREThe patient is brought to the operating room per stretcher with an ongoing IVF of D5LRS at full level accompanied by IWDO. She was transferred to the operating table, placed in a supine position comfortably. She was attached to cardiac monitor and prepared accordingly. A. AnesthesiaThe anesthesia provider, typically an anesthesiologist or a nurse anesthetist, will begin the surgery by giving a sedative by IV to relax the patient. Once the patient is relaxed, a breathing tube, or endotracheal tube, is threaded through the mouth and into the windpipe before being connected to the ventilator. The breathing tube is necessary because general anesthesia causes paralysis in addition to rendering the patient unconscious. While paralyzed, the patient cannot breathe without assistance and depends upon the ventilator to supply air to the lungs. Subarachnoid Block (SAB) was infiltrated at the lumbar area specifically T3 to T4 to locate the cerebrospinal fluid by Dr. Macaballog. Once the anesthesia has taken full effect, the surgeon can begin making the incision, without the patient feeling pain or waking. During the surgery, the patient will be closely monitored by the anesthesiologist, with the vital signs being observed throughout the surgery and medications given as needed.

B. PositionDuring caesarean section operation, patient will lie on an operating table in supine position, which is tilted or wedged to the left. It's tilted so the weight of your uterus doesn't reduce the blood supply to the lungs and make the blood pressure drop. Arms may be extended on arm-boards. Insertion of an Indwelling Foley Catheter was inserted aseptically by the circulating nurse.

C. Skin preparation Skin prep aids in preventing surgical site infection (SSI) by removing debris from, and cleansing, the skin, bringing the resident and transient microbes to an irreducible minimum, and hindering the growth of microbes during the surgical procedure. The skin prep agents should have the following properties: fast-acting, persistent and cumulative actions, and non-irritating. In cesarean section, skin preparation begins at the incision site (infra umbilical vertical or low transverse) extending from nipples to mid thighs, and down to the table at the sides done by the circulating nurse.

D. DrapingThe skin is swabbed with a solution that kills germs to help prevent infections along the incision. Once the skin is prepared for surgery, the doctors will cover the patient with sterile drapes to keep the area as clean as possible during the procedure which were done by Dr. The patient is draped with folded towels and a laparotomy (or transverse) sheet. An additional sheet is needed to cover a second back table for the infant.

Discussion of the Procedure (Before and after the incision)The cesarean operation and bilateral tubal ligation began with the surgeon first making a horizontal incision by dissecting the abdomen from the skin low across the belly. Vertical incisions generally allow faster abdominal entry, cause less bleeding and nerve injury, and can be easily extended cephalic and one of the most procedures in skin incision used was a vertical incisions. Before doing the operation the two surgeons draped the patient exposing her umbilicus to the symphysis pubis and the surgeon applied betadine solution on the incision site. Incision thru the skin with skin knife (#3 scalpel handle with #10 blade). Subcutaneous tissue and muscle tissue are incised with the deep knife (#7 scalpel handle with #15 blade). Fascia is incised, and the underlying muscles are retracted with bladder retractor and richardson. The surgeon grasps the peritoneum with a thumb forcep and incised it with deep knife. The incision is completed with curved mayo scissor and the baby came out. The surgeon carry alive the baby and they cut immediately the umbilical cord followed by the removal of the placenta. Wound edges are retracted by Richardson retractors, the uterus is identified and its fallopian tube supply ligated and the stump is tied off with absorbable suture. The peritoneal cavity is irrigated with NS and the fluid is removed with suction several times. Two tissue forceps and Adson were used to grasp the peritoneum to assist in its exposure for closing. The peritoneum is closed with continuous suture. The abdominal wall is then sutured by layers; fascia, muscle, subcutaneous tissue, and skin. After which the wound is dressed. After the surgical procedure, we then did after care of the mother such as cleaning of the surgical area, removal of the dirty drapes, assuring mother is stable and after care of the instrument.

CHAPTER V INSTRUMENTATION5 KELLY CURVE4 ALLIS5 STRAIGHT4 TOWEL CLIPS1 BAB COCK1 BLADE HOLDERS2 NEEDLE HOLDERS1 MAYO SCISSOR1 METZENBAUM1 TISSUE FORCEP1 THUMB FORCEP1 RICHARSON1 BLADDER RETRACTOR1 PLACENTAL BOWL1 CORD CLAMP1 SUCTION TUBE

Surgical Instrument- Curved Mayo Scissors Classification-Cutting Use - used for cutting dense tissue

Surgical InstrumentStraight Mayo Scissors Alias- Suture Scissors Classification-Cutting Use-use to cut suture

Surgical Instrument-Curved Metzenbaum Scissor Classification-dissecting scissor Use-used to cut delicate soft tissues

Surgical Instrument-Metzenbaum scissors Classification- cutting/dissecting Use- dissects medium-fine tissue

Surgical Instrument-Thumb Forceps Classification-grasping Use-use to grasp tough tissue

Surgical Instrument-Tissue Forceps Classification-grasping Use-to holds skin/dense tissue.

Surgical Instrument-#3 knife handle Classification-cutting/dissecting Use-cutting/incisions/dissecting.

Surgical Instrument-#4 knife handle Use-cutting/incisions/dissecting Classification-cutting/dissecting

Surgical Instrument-#10 knife blade Classification-cutting/dissecting Use-cutting/incisions/dissecting

Surgical Instrument-#11 knife blade Classification-cutting/dissecting Use-cutting/incisions/dissecting

Surgical Instrument-Straight clamp Classification-Clamping/occluding Use-use to clamp or tag sutures.

Surgical Instrument-Curved clamp Classification-Clamping/occluding Use-use to clamp deep tissue.

Surgical Instrument- Needle Holder Classification-suturing Use-to hold suturing needle

Surgical instrument-traumatic needle Classification-suturing Use- for suturing

Surgical Instrument-adson Forceps Classification-grasping Use-used to grasp delicate tissues.

Surgical Instrument-sponges/lap sponge Use-used to absorb liquids from asurgicalsite.

Surgical Instrument - Richardson Retractor Classification-Retractor Use-used to retract deep abdominal or chest incision.

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CHAPTER VIDRUG STUDY

DrugsClassification

Mode of Action

Side EffectsNursing Consideration

Ampicillin 500mg IV

Ketorolac 30 mg IV

Tramadol 50mg IV

>Anti-infective

>Analgesic, antipyretic, anti-inflammatory

>Analgesic

>Destroys bacteria by inhibiting bacterial cell-wall synthesis during microbial multiplication. Addition of sulbactam enhances drugs resistance to beta-lactamase, an enzyme that can inactivate ampicillin.

>Interferes with prostaglandin biosynthesis by inhibiting cyclooxygenase pathway of arachidonic acid metabolism; also acts as a potent inhibitor of platelet aggregation.

>Inhibits reuptake of serotonin and norepinephrine in CNS

> CNS: lethargy, hallucinations, anxiety, confusion, agitation, depression, fatigue, dizziness, seizureCV: vein irritation, thrombophlebitis, heart failureEENT: blurred vision, itchy eyesGU: nausea, vomiting, diarrhea, abdominal pain, enterocolitis, gastritis, stomatitis, glossitisRespiratory: wheezing, dyspnea, hypoxia, apnea

>CNS: drowsiness, headache,dizziness,CV: hypertensionGI: nausea, vomiting, diarrhea, constipation, flatulence, dyspepsia, epigastric pain, stomatitisSkin: rash pruritus, diaphoresisOthers: excessive thirst, edema, injection site pain

>CNS: dizziness, vertigo, headache, drowsiness, anxiety, stimulation, confusion, incoordination, euphoria, sleep disorder, asthenia, seizureCV:vasodilationEENT: visual disturbances.GI: nausea, vomiting, diarrhea, constipation, abdominal pain, dyspepsia, flatulence, dry mouth, anorexiaGU: urinary retention and frequency, proteinuria, menopausal symptoms

>Ask patient about history of penicillin allergy before giving. Let vial stan for several minutes until foam has evaporated before administering drug. Give intermittent infusion in 50 to 100 ml of compatible solution over 15 to 30 minutes

>Monitor for adverse reactions, especially prolonged bleeding time and CNS reactions. Check IM injection site for hematoma and bleeding. Monitor fluid intake and output.

>Assess patients response to drug 30 minutes after administration. Monitor respiratory status. Withhold drug contact prescriber if respiration becomes shallow or slower than 12 breaths per minute. Monitor for physical and psychological drug dependence.