PAMANTASAN NG LUNGSOD NG MAYNILA

(University of the City of Manila)

COLLEGE OF NURSING

A CASE STUDY OF A POSTPARTUM WOMAN WHO

DELIVERED VIA CESAREAN SECTION

In Partial Fulfillment of the Requirements in

Maternal and Child Health Nursing II

(Related Learning Experience)

Submitted by:

Manangan, Rhoda L.

Medina, Cherrylle Jem A.

Melendres, Francesca Irish P.

Modillas, Camille-Ann D.

BSN II-1

Group C1

Submitted to:

Prof. Manuela P. Tirazona

 TABLE OF CONTENTS

I. Introduction

II. Objectives

A. General Objective

B. Specific Objectives

III. Demographic Profile

IV. Chief Complaint

V. History of Present Illness

VI. Obstetric-Gynecologic History

VII. Past Medical History

VIII. Family Medical History

IX. Psychosocial History

X. Gordon’s Functional Health Pattern

XI. Review of Systems

XII. Physical Assessment

XIII. Anatomy and Physiology

XIV. Pathophysiology

XV. Medical Management

A. Diagnostic Procedures and Lab Analysis

B. Surgical Management

C. Drug Analysis

XVI. Nursing Care Plans

XVII. Discharge Planning

I. INTRODUCTION

Cesarean section, also known as C-section, is the use of surgery to deliver one or more
babies. A Cesarean section is often performed when a vaginal delivery would put the baby or
mother at risk. This may include obstructed labor, twin pregnancy, high blood pressure in the
mother, breech birth, problems with the placenta, umbilical cord or shape of the pelvis, and
previous C-section.

This procedure has been part of human culture since ancient times and there are tales in
both Western and non-Western cultures of this procedure resulting in live mothers and offspring.
According to Greek mythology, Apollo removed Asclepius, founder of the famous cult of
religious medicine, from his mother's abdomen. Numerous references to cesarean section
appear in ancient Hindu, Egyptian, Grecian, Roman, and other European folklore. Ancient
Chinese etchings depict the procedure on apparently living women.

Yet, the early history of cesarean section remains shrouded in myth and is of dubious
accuracy. Even the origin of "cesarean" has apparently been distorted over time. It is commonly
believed to be derived from the surgical birth of Julius Caesar. Roman law under Caesar
decreed that all women who were so fated by childbirth must be cut open; hence, cesarean.
Other possible Latin origins include the verb "caedare," meaning to cut, and the term
"caesones" that was applied to infants born by postmortem operations. Ultimately, though, we
cannot be sure of where or when the term cesarean was derived. Until the sixteenth and
seventeenth centuries the procedure was known as cesarean operation. This began to change
following the publication in 1598 of Jacques Guillimeau's book on midwifery in which he
introduced the term "section." Increasingly thereafter "section" replaced "operation."

Based on the systematic review conducted by the World Health Organization, when
cesarean section rates in a country move towards 10%, there is a significant decrease in
maternal and newborn deaths. According to United Nations International Children’s Emergency
Fund (UNICEF), 9.5% of all births in the Philippines are delivered by cesarean section as of
2013. This only shows that our country’s goal of reducing maternal and infant mortality rate, as
stated in the Millenium Development Goal 5, has made some progress because of a shift
toward increasing numbers of cesarean section births.

In our country, cesarean in a previous pregnancy was the most common indication for a
cesarean for mothers who gave birth again (85%). This is the case of the patient involved in this
study. She is Patient AB, a 26-year-old housewife living in Caloocan City. She is a gravida 6,
para 4 woman who recently gave birth to her sixth child by a Low Transverse Cesarean Section
(LTCS), followed by a Bilateral Tubal Ligation (BTL). The student nurses chose this particular
case because they were able to build a good rapport with the patient, they gained the patient’s
trust and they had a relevant nurse-patient interaction. They also applied their interpersonal
communication skills which helped them to gather their needed data.
II. OBJECTIVES

General Objective:

Generally, this study aims to gain extensive knowledge and fully understand the
condition of the postpartum patient who has undergone an elective Low Transverse Cesarean
Section (LTCS) Delivery, a Bilateral Tubal Ligation (BTL), and multiple blood transfusions, and
subsequently be able to provide at least three comprehensive nursing care plans with the
application of the nursing process.

Specific Objectives:

1. To build rapport with the patient and her significant others to gain their trust and have
a purposeful nurse-patient interaction.

2. To apply interpersonal communication skills to be able to collect the veracious

demographic profile and other pertinent data of the patient about her past medical,
family, and psychosocial history.

3. To properly perform a thorough general health assessment and review of systems of

the patient.

4. To discuss the underlying anatomy and physiology, as well as the pathophysiology of

the patient’s condition

5. To analyze medications given to the patient, their classifications, indications, modes of

action, side effects, and the nursing considerations that must be observed

6. To review other medical management given to the patient, specifically her laboratory
work-ups, and be able to interpret those results on how they are associated with the
patient’s condition.

7. To formulate at least three comprehensive nursing care plans as evidenced by the

subjective and objective data gathered, make smart diagnoses, determine necessary
goals or objectives, plan nursing interventions along with their rationale, and evaluate
the patient’s response to such interventions.

8. To give appropriate health teaching for the patient’s health enhancement and
prevention of further complications.
III. DEMOGRAPHIC PROFILE

Name: Patient AB

Age: 26 years old

Address: Caloocan City

Birthday: September 17, 1990

Place of birth: Manila City

Gender: Female

Nationality: Filipino

Civil Status:

Religion: Roman Catholic

Educational attainment: High school Graduate

Height: 5’1”

Weight: 68 kg

BMI: 28.3 (Overweight)

Occupation: Housewife

Source of Information: Patient and Chart

Reliability of Source of information: 70% Patient and 30% Chart

Date of Admission: February 22, 2017 at 9:30 AM

Date of History taking: February 24 and March 2, 2017

Date and Time received: February 24, 2017 at 9 AM

IV. CHIEF COMPLAINT

“Masakit na yung tiyan ko nung araw na nagpunta ako dito. Buti naka-schedule na ako
na i-CS.”, as verbalized by the patient.
V. HISTORY OF PRESENT ILLNESS

24 hours prior to scheduled operation, Patient AB felt a light pain in her abdomen, which
prompted her to go to Gat Andres Bonifacio Memorial Medical Center since she was scheduled
on February 23.

On the day of operation, the patient had her personal hygiene. Pre-operation
medications were also given by the nurses.
VI. OBSTETRIC-GYNECOLOGIC HISTORY

She had her first menstruation when she was 11 years old. Her menstruation is irregular
that lasts seven to nine days. She uses three pieces of diapers per day on the first and second
day of her menstruation and three pads of napkin per day on the third day of her menstruation
and onwards. She experiences dysmenorrhea when menstruating.

She had her first sexual intercourse when she was fourteen years old. She has one
sexual partner. She does not use any contraceptives.

The patient’s last menstrual period is June 3, 2016 and the estimated date of delivery is
March 10, 2017. The age of gestation before she delivered her baby is 41 6/7 weeks. She did
not experience any discomforts, bleeding nor cramping. She has no previous infections.

Her OB Scoring is G6 P4 (4,1,1,4,0); gravida (6), para (4), term (4), preterm (1),
abortion (1), live birth (4) and her multiple pregnancy is zero.

Year of Type of Place of Type of

Gravida Gender Complications
Birth Delivery Delivery Feeding

G1 - - - - - Abortion

Gat
Andres
Bonifacio
G2 Female 2007 CS Breastfed Breech
Memorial
Medical
Center

G3 - - - - - Preterm

Gat
Andres
Bonifacio
G4 Male 2012 CS Breastfed -
Memorial
Medical
Center

G5 Male 2015 CS Gat Breastfed -

 Andres
Bonifacio
Memorial
Medical
Center

Gat
Andres
Bonifacio
G6 Male 2017 CS Breastfed -
Memorial
Medical
Center
VII. PAST MEDICAL HISTORY

Patient AB has experienced the usual childhood illnesses like measles, mumps, chicken
pox, common colds, pediculosis, conjunctivitis, and sore throat when she was young. She hasn’t
experience any severe complications from the aforementioned diseases.

Eight years ago, an accident happened in Batangas when she was just 18 years old. An
incised wound 1 inch in length will be noted on her chest area from a stab she got during the
trouble. Also, there’s no occurrence of serious or chronic illness as well as sexually transmitted
diseases in the patient.

Furthermore, her only confinements were during her previous deliveries (3 cesarean
section, and 2 dilatation and curettage procedure). Before admission, the patient has not yet
undergone blood transfusions. According to the patient, she has received complete childhood
immunizations. Her first dose of tetanus toxoid was given on her first pregnancy. She doesn’t
receive any other doses on her subsequent pregnancies, not until her sixth pregnancy.

Patient AB is currently 5 feet 1 inches tall (61 inches) and weighs 68 kg. Her
prepregnancy weight was 66 kg, and had gained a total of approximately 8 to 10 kg throughout
her pregnancy. She does not have allergies to any drugs, foods or environmental agents. The
patient usually has three meals a day without any snacks in between. She drinks a cup of coffee
with her dinner. She does not have any food intolerance, and eats a variety of foods that fits
their food budget. She does not have any ethnic or religious food restrictions or preferences.

She used to wake up early in the morning to walk in their neighborhood as her regular
exercise. She also wakes up as early as 4 am to prepare and send two of her kids to school.
She was prescribed to take prenatal vitamins before every morning, but she stated that she
doesn’t take them every day and made it twice a week because of financial constraint. Her last
dose was several days before admission.
VIII. FAMILY MEDICAL HISTORY

LEGEND:

Female Hypertension Patient AB

Male Bronchial Asthma Deceased

Interpretation:

The father of the patient has a history of hypertension that was inherited from her
grandmother. In her mother side, her grandmother has a history of bronchial asthma that has
been passed to her youngest sister who is currently 22 years old. Her another sister has already
passed away because of suicide. The patient does not manifest any signs and symptoms of
bronchial asthma, but she is at risk for hypertension due to her high blood pressure taken last
March 3, 2017.
IX. PSYCHOSOCIAL HISTORY

Patient AB is a 26-year-old Filipino female, living in Caloocan City. Eldest in three

children, her second sister committed suicide when she was 17 years old. She is a high school
graduate and finished a vocational course in Technical Education and Skills Development
Authority (TESDA)

When she was a teenager, she described herself as a “happy-go-lucky” person who is
living her life to the fullest. She dreamed of being a nurse, but when she had miscarriage in her
first pregnancy she became afraid of blood, so she didn’t pursue the nursing career.

According to her, she is not a drinker and a smoker, and using illegal drugs never
crossed her mind. She once became the bread winner of her family, paying for bills and house
rent, until she got pregnant for the second time and became a mother to her first baby.

She moved to Caloocan City from Pritil, Tondo to start her own family. They are renting
a small house with enough space for them and their children. She stopped working after she
gave birth to her third child to give more focus and time to her children. And Mr. B., her husband
who is a fish seller in the market is the only source of income they have.
XIII. ANATOMY AND PHYSIOLOGY

FEMALE REPRODUCTIVE SYSTEM

The female reproductive system (or female genital system) is made up of the internal
and external sex organs that function in human reproduction. The female reproductive system is
immature at birth and develops to maturity at puberty to be able to produce gametes, and to
carry a fetus to full term. The internal sex organs are the uterus and Fallopian tubes, and the
ovaries. The uterus or womb accommodates the embryo, which develops into the fetus. The
uterus also produces vaginal and uterine secretions, which help the transit of sperm to the
Fallopian tubes. The ovaries produce the ova (egg cells). The external sex organs are also
known as the genitals and these are the organs of the vulva including the labia, clitoris and
vaginal opening. The vagina is connected to the uterus at the cervix.

Internal Organs

 The vagina is a fibromuscular (made up of fibrous and muscular tissue) canal leading
from the outside of the body to the cervix of the uterus or womb. It is also referred to as
the birth canal in the context of pregnancy.

 The cervix is the neck of the uterus, the lower, narrow portion where it joins with the
upper part of the vagina. It is cylindrical or conical in shape and protrudes through the
upper anterior vaginal wall.
 The uterus or womb is the major female reproductive organ. The uterus provides
mechanical protection, nutritional support, and waste removal for the developing embryo
(weeks 1 to 8) and fetus (from week 9 until the delivery). In addition, contractions in the
muscular wall of the uterus are important in pushing out the fetus at the time of birth.
The uterus contains three suspensory ligaments that help stabilize the position of the
uterus and limits its 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 female begins menstruation.

 The Fallopian tubes are two tubes leading from the ovaries 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.

 The ovaries are small, paired organs located near the lateral walls of the pelvic cavity.
These organs are responsible for the production of the egg cells (ova) and the secretion
of hormones. The process by which the egg cell (ovum) is released is called ovulation.
The speed of ovulation is periodic and impacts directly to the length of a menstrual cycle.

External organs

 The labia majora enclose and protect the other external reproductive organs. Literally
translated as "large lips," the labia majora are relatively large and fleshy, and are
comparable to the scrotum in males. The labia majora contain sweat and oil-secreting
glands. After puberty, the labia majora are covered with hair.
 Literally translated as "small lips," the labia minora can be very small or up to 2 inches
wide. They lie just inside the labia majora, and surround the openings to the vagina (the
canal that joins the lower part of the uterus to the outside of the body) and urethra (the
tube that carries urine from the bladder to the outside of the body).

 The Bartholin’s glands are located beside the vaginal opening and produce a fluid
(mucus) secretion.

 The two labia minora meet at the clitoris, a small, sensitive protrusion that is
comparable to the penis in males. The clitoris is covered by a fold of skin, called the
prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the
clitoris is very sensitive to stimulation and can become erect.
XIV. PATHOPHYSIOLOGY

Release of FSH by the anterior pituitary gland

Development of the Graafian follicle

Production of estrogen (thickening of the endometrium)

Release of the luteinizing hormone

Ovulation (release of mature ovum from the Graafian follicle)

Ovum travels into the fallopian tube

Fertilization (union of the ovum and the sperm in the ampulla)

Zygote travels from the fallopian tube to the uterus

Implantation

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

PRELIMINARY SIGNS OF LABOR

Lightening Braxton Hicks Contraction (false labor) Ripening of the cervix

(descent of the fetal *begin and remain irregular (Goodell’s Sign)

Head into the pelvis) *1st felt in the abdomen cervix feels softer like
 *pain disappears in positioning earlobe

*do not increase in duration and intensity

TRUE LABOR

Uterine Contractions SHOW Rupture of membranes

*increase in duration and (pink-tinge of blood a mixture (rupture of the amniotic sac)

intensity of blood and fluid)

*1st felt at the back and

radiates to the abdomen

*pain is not relieved no

matter what the activity

*achieve cervical dilatation

Failed to progress labor (due: G2-breech position of the baby and G4, G5 & G6-repeated
cesarean section)

Risk of fetal distress and fetal death

Elective and scheduled CS delivery

(classical incision was done)

Manual extraction of the Fetus

Manual extraction of the Placenta

XV. MEDICAL MANAGEMENT

A. Diagnostic Procedures and Lab Results Analysis

Pelvic Ultrasound

November 9, 2016

Ultrasound report
Within the gravid uterus is a single, live, fetus in varying position, equivalent to 22
weeks and 4 days in age of gestation by biparietal diameter, abdominal circumference,
and femoral length. There are active cardiac pulsation and gross body movements. The
placenta is anterior and high lying in implantation. The amniotic fluid is adequate.

- Single, live, intrauterine pregnancy in

varying positions, active, 22-23 weeks age
of gestation by BPD, AC and FL
Impression - Normochydramnios
- Anterior high lying placenta
- EFW: 530.9 g
- EDC: March 11, 2017

February 8, 2017

Ultrasound report
Within the gravid uterus is a single, live, male, fetus presently in cephalic
presentation Average age of gestation is 35 weeks and 4 days by biparietal diameter,
abdominal circumference, and femoral length. There are active cardiac pulsation and
gross body movements. The placenta is anterior and high lying in implantation with 2-3
maturity. The amniotic fluid is adequate.

- Single, live, intrauterine pregnancy, male,

Impression cephalic, active, 35-36 weeks age of
gestation by BPD, AC and FL
 - AFI: 15.5 cm (Normochydramnios)
- Anterior high lying placenta Grade II-III
- EFW: 2698 g
- EDC: March 11, 2017
*Both laboratory results with different dates have normal findings.

Complete Blood Count

November 7, 2017 (4 months before delivery)

Result Normal Findings Interpretation

Abnormal finding
Hemoglobin 113 gm/l 120-180 gm/l due to below normal
values
Abnormal finding
Hematocrit 0.337 0.370-0.540 due to below normal
values
Abnormal finding
9 9
Leucocyte Count 9.0 x 10 /L 4.0-6.00 x 10 /L due to above
normal values
Segmenter 0.66 0.60-0.70 Normal finding
Lymphocytes 0.34 0.20-0.40 Normal finding
Platelet Count 311 x 109/L 150-450 x 109/L Normal finding

February 5, 2017 (18 days before delivery)

Result Normal Findings Interpretation

Abnormal finding
Hemoglobin 111 gm/l 120-180 gm/l due to below normal
values
Abnormal finding
Hematocrit 0.343 0.370-0.540 due to below normal
values
Abnormal finding
 Leucocyte Count 9.6 x 109/L 4.0-6.00 x 109/L due to above
normal values
Segmenter 0.67 0.60-0.70 Normal finding
Lymphocytes 0.33 0.20-0.40 Normal finding
Platelet Count 292 x 109/L 150-450 x 109/L Normal finding

February 23, 2017 (after delivery and blood transfusion)

Result Normal Findings Interpretation

Abnormal finding
Hemoglobin 94 gm/l 120-180 gm/l due to below normal
values
Abnormal finding
Hematocrit 0.283 0.370-0.540 due to below normal
values

Blood Compatibilty

February 23, 2017

 Blood Testing
Test Done
 Crossmatching
 Whole Blood
Blood Components
 RBC

BLOOD GROUP Rh
A +

CROSSMATCHING RESULT
Compatible in 3 Phases
*Test Result showed Blood Type of A and is Rh positive, which can be used now for blood
transfusion.
B. Surgical Management

As said earlier, the leading indication in our country for cesarean delivery is previous
cesarean delivery (85%), like in the case of Patient AB who has undergone Low Transverse
Cesarean Section (LTCS) delivery for the fourth time. Concerns about previous scar on the
uterus giving way during normal labor often leads to this decision. Other indications may be
breech presentation, dystocia, and fetal distress.

Maternal indications for cesarean delivery include the following:

 Repeated cesarean delivery

 Obstructive lesions in the lower genital tract, including malignancies, large
vulvovaginalcondylomas, obstructive vaginal septa, and leiomyomas of the lower uterine
segment that interfere with engagement of the fetal head
 Pelvic abnormalities that preclude engagement or interfere with descent of the fetal
presentation in labor
 Certain cardiac conditions that preclude normal valsalva done by patients during a
vaginal delivery

Fetal indications for cesarean delivery include the following:

 Situations in which neonatal morbidity and mortality could be decreased by the

prevention of trauma
 Malpresentations (e.g., preterm breech presentations, non-frank breech term fetuses)
 Certain congenital malformations or skeletal disorders
 Infection
 Prolonged acidemia

Indications for cesarean delivery that benefit the mother and the fetus include the
following:

 Abnormal placentation (e.g., placenta previa, placenta accreta)

 Abnormal labor due to cephalopelvic disproportion
 Situations in which labor is contraindicated

Contraindications:
There are few contraindications to performing a cesarean delivery. In some circumstances, a
cesarean delivery should be avoided, such as the following:

 When maternal status may be compromised (e.g., mother has severe pulmonary
disease)
 If the fetus has a known karyotypic abnormality or known congenital anomaly that may
lead to death (anencephaly)

Types of Cesarean Sections:

 Classical Cesarean Section

 A midline vertical incision on the abdomen and the uterus is made to deliver the
baby. Owing to a large number of complications associated with the technique, it is
hardly practiced any longer.
 Lower Segment Cesarean Section (LSCS)
 It is the most commonly preferred method wherein a horizontal or transverse incision
is made on the lower part of the abdomen to deliver the baby. It involves less blood
loss and is easier to repair than other incisions employed for the purpose. The
incision also is low so cosmetically more acceptable. The LSCS can further be
graded depending on when it is performed
 Emergency C Section: When there is suspected danger to the mother's or baby’s
condition an emergency section is resorted to.
 Elective Cesarean Section (Planned C-Section): The Cesarean is planned and
done on a specific date chosen by the patient and the doctor after assessing the
maturity of the baby.
 Cesarean Hysterectomy
 It is a life-saving procedure in which the uterus is removed after delivering the baby
through a cesarean section. It is performed when bleeding cannot be controlled or
when the placenta adheres to the uterine wall and it is not possible to separate it.
XVII. DISCHARGE PLANNING

DISCHARGE GOALS:

1. Dealing with current situation realistically.

2. Pain relieved/controlled.
3. Complications prevented/minimized.
4. Mobility/function regained or compensated for.
5. Maintain Optimum level of wellness
6. Postpartum care should be done

M – Medications

 Take home medication as prescribed by the Physician such as mefenamic acid

500mg TID; prn for pain
 Report any side effects & adverse reactions as indicated by the health care
provider.
 Instruct to continue intake of multivitamins or iron supplements OD

E – Environment/Exercise

 Instruct patient to stay in calm, quiet environment.

 Home environment must be free from any hazards
 Reinforce the need to continue exercises at home. Active ROM exercises
increase mobility& improve cardiac function.
 Encourage to maintain a clean and healthy environment for both mother and
child
 Instruct patient to gradually ambulate and continue their living on a daily basis
with precaution.

T – Treatment

 Inform patient to have a follow-up check up after 1- 2 weeks. For post-natal

check-ups
 Date of interview: February 24, 2017
 Date Discharge: March 2, 2017
 Follow-up check-up: March 9, 2017
  Advise client that pain may occur right after surgery or not until 4-6 weeks later.
(March 30; if 4 weeks and April 13; if 6 weeks). This explanation will help to
reduce fears associated w/ unknown situations.
 Inform patient to clean/wash & dry the surgical incision. And also change the
dressing.

H – Health Teachings

 Encourage patient to verbalize/describe the effects of incision and also on self-

image and acceptance of change image as part of coping process.
 Instruct patient to increase intake of iron-rich foods and protein-rich foods to
promote faster wound healing and better circulation.
 Instruct to promote adequate fluid intake.
 Discourage patient to participate in strenuous activities that might precipitate
stress and trauma to the incision or wound.
 Encourage patient to breastfeed baby all the time.
 Teach the patient/significant others the correct method of changing the dressing
of wound because an improperly applied dressing contributes to complications
and further infections.
 Emphasize and maintain clean and proper hygiene.

O – Observable Signs and Symptoms

 Instruct patient to monitor the incision, dressing & drainage for indications of
infection (e.g., change in color, odor, or consistency of drainage; increasing
discomfort), and report immediately to physician if any of this signs are seen &
observed.
 Instruct patient to monitor & report promptly the signs of complications (e.g.,
uncontrolled pain; signs of infection; bleeding) to the physician.
 Advise client to consult w/ pain specialists if pain is unmanageable. Pain causes
complications or critical conditions.

D – Diet/ Nutrition

 Stress importance of well-balanced diet, such as iron-rich foods, protein-rich

foods, and adequate fluid intake. Provides needed nutrients for tissue
 regeneration/healing, aids in maintaining circulating volume and normal organ
function, and aids in maintenance of proper weight.
 Instruct to increase fluid intake.
 Inform patient that there are no restrictions in the diet except for foods that could
interact & delay absorption of any medications given.
 BIBLIOGRAPHY
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