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Demographic data:
Patient name: A.S.M.S
Date of admission: 1/11/2013
Hospital: AL-AHLI Hospital
Address: Hebron
Occupation : Engineering space
DX:
Early labor previous c/s
Chief complain:
Uterine contractions, in labor .labor pain ,
Date: 2/12/2013
Age: 28 years
Family History:
Her father Have HTN and DM , other than this the family history is free;
.there is no medical or surgical history, or congenital abnormalities
Obstetric history:
She delivered before a baby girl , maturity at term and the mood of the
. delivery was C/S due to fetal distress
Allergies:
-
Physical assessment
Vital signs: Blood Pressure: 120/6o
Pulse: 90
Temperature: 36.5 C
Respiration: 19 breathe per m.
Weight: Before delivery her wt was 82 kg , her wt now is 75kg.
Height : 156 cm.
Skin: Pink in color, smooth in texture, warm, no lesions, her skin is clear
and free of spots. vertical linea niagra extend from pubic area to
umbilicus, striae gravidanum after delivery is present
Heart: Lub-dub heart sound, regular rhythm 90 beat/ min. Apex beat is
chentrally placed, no murmur, no abnormal sounds, peripheral pulse is
palpated. The Pt did not complain from heart problems , no hypertension
during pregnancy. Palpation is clear in the apical area, Jugular veins
are not visible. Peripheral pulses. Peripheral veins is normal, no
tenderness on palpation of limbs, radial pulse palpable in both arteries in
the both hands.
Lap test
Antenatal period:
Blood CBC
The CBC is used as a broad screening test to check for such disorders as
anemia, infection, and many other diseases. It is actually a panel of tests
that examines different parts of the blood.
Prenatal test: 1/11/2013
Test
Value
WBC
RBC
HGb
PLT
10.5 K/ul
4.93M/uL
13.3 g/dl
142K/UL
Normal
value
4.1-10.9 K/ul
3.5-5.5M/uL
12-18g/dl
140440K/UL
Meaning of
abnormal values
Normal
Normal
normal
normal
HBSAG/SCREEN
Urine analysis
Color
Appearance
Ph
Bacteria
Straw
Clear
Alkaline
Nill
Medication
Medication
uses
ceftriaxone
Rocephin
I.V
N/S 150cc
is used to treat
many kinds of
bacterial
infections,
including
severe or lifethreatening
forms such as
meningitis
rational Contraindicat
ion
Prophylactic
from
infection
kidney
disease (or
if you are
on dialysis);
liver
disease;
side effect
diarrhea that is
watery or
;bloody
fever, chills,
swollen glands,
rash or itching,
diabetes;
gallbladder
disease;
a stomach
or intestinal
disorder
such as
colitis;
if you are
allergic to
penicillin.
Syntocinon
Induce and Syntocinon is
Hypertonic
30unit with R/L augmentation
used to
uterine action,
.500ccc., I.V
of labour,
Induce &
Mechanical
stimulate augmentation
obstruction to
uterine
of labour
delivery, Fail
contractions,
trial labour, Fetal
for post
distress, placenta
.hemorrhage
.,preavia
Pithidinh opioid
, Labor pain patients with
analgesic,
100mg IM
Episiotomy history of severe
hourly 4 prescribed for
procedure respiratory
moderate to
severe pain, for
example labor
pain, before and
during a
surgical
operation. It
changes the
way the body
senses pain.
joint pain, or
general ill
;feeling
unusual
bleeding (nose,
mouth, vagina,
or rectum),
purple or red
pinpoint spots
under your
;skin
;
Violent uterine
contraction
leads to rupture
& fetal
asphyxiation,
arrhythmias,
maternal
.,hypertension
Nausea, vomiting,
constipation,
drowsiness,
dizziness, dry
mouth and
sweating.
Central Nervous
SystemNervousness,
headache,
restlessness,
uneasiness,
fatigue,
confusion,
depression,
hallucinations,
tremors, muscle
twitches,
increased
intracranial
pressure and fits.
Pathophysiology:
It is a vaginal birth after one or more cesareans. More than 80% of women
will be able to have a VBAC.
ACOG recently updated their opinion on VBAC and stated "VBAC is safer
than repeat cesarean and VBAC with more than one previous cesarean does
not pose any increased risk".
The woman has had no more than one prior low-transverse Csection delivery. This refers to the cut on your uterus, not the
one on your belly. If youve had a prior c-section, your health
care provider may ask you to get a copy of the report from
your first surgery to check what type of incision you had on the
uterus. as my case.
The woman has had no other uterine scars or ruptures, whether from previous
C-sections or other surgeries.
ACOG has specifically stated that whenever a woman is planning a TOLAC delivery,
there should be an appropriate medical team available, including an anesthesiologist,
throughout the active labor so that an emergency C-section may be done if necessary.
Smaller hospitals may not have the resources to monitor a VBAC delivery or to
provide an emergency c-section for TOLAC situations, and VBAC delivery may not
.be possible
Women with a high vertical (or classical, T-shaped) incision on the uterus
Women with a small pelvis or delivering a large baby - it may not be safe for
the baby to pass through the pelvis
Women with more than two prior C-sections and no previous vaginal
deliveries
Shorter hospitalization
No abdominal surgery
May avoid multiple future c-sections if you are considering a large family
(with three or more children)
Notably, however, some women who try to have a vaginal delivery end up with a c.section. They dont get to experience these benefits
Risks
The most serious risk with TOLAC is rupture of the uterus. The risk of rupture of the
uterus after a prior low transverse c-section is about 1 percent, whereas the risk of
Relegating to my patient
:NURSING DIAGNOSIS
:-DIAGNOSIS1
:NURSING GOALS
Within 1 hour of receiving pain medication, client will state pain level .1
.has been reduced to 0-2" on pain scale
Throughout shift, client will state that perineal pain has lessened to a .2
.tolerable level
:NURSING INTERVENTIONS
Assess clients pain level throughout shift (ask client to identify level .1
.using pain scale at least q2-3h) and when analgesic is due
Rationale: to monitor clients pain, preventing it from escalating and to
.offer appropriate interventions as needed
Offer analgesics per doctors order .2
Rationale: to maintain clients comfort level by controlling pain and
.preventing it to escalate
.Apply ice pack to perineum prn .3
.Rationale: to reduce swelling and numb perineum in order to relieve pain
.Offer sitz bath to client per doctors order .4
Rationale: warm water cleansing the perineum is soothing and reduces
pain. The warm water will encourage blood flow to the area, encouraging
.healing
.Visually assess the clients perineal area qshift .5
Rationale: to monitor level of swelling and redness and to identify any
infection or worsening of skin breakdown. Allows for early interventions to
.prevent complications if needed
:EVALUATION
Goal #1. Achieved. Thirty minutes after receiving Tylenol #3 tabs ii, the
."client stated that her perineal pain level was at 1
Goal #2. Achieved. Throughout the shift, the client took the Tylenol #3 q 4
hours and stated that it lessened her pain. When asked, client stated pain
was at 0-1" throughout shift. Client stated that. She did not like the ice
pack, so refused to have it repeated. She hsaid that applying a warm wet
washcloth to the perineum after voiding stopped the stinging caused by
.urine
:-NURSING DIAGNOSIS2
Goal
After 8 hours of nursing interventions, the patient will demonstrate
adequate perfusion and stable vital signs.
Intervention
1-Monitor amount of bleeding by weighing all pads. To measure the
amount of blood loss.
2-Frequently monitor vital signs. Early recognition of possible adverse
effects allows for prompt intervention
3-Massage the uterus To help expel clots of blood and it is also used to
check the tone of the uterus and ensure that it is clamping down to
prevent excessive bleeding
4-Place the mother in Trendelenberg position to Encourages venous
return to facilitate circulation, and prevent further bleeding
5-Administer medication as indicated To promote contraction and
prevents further bleeding.
Evaluation
After 8 hours of nursing interventions ,the patient was able to
demonstrated equate perfusion and stable vital signs
NURSING DIAGNOSIS3:
The cut may tear and become larger during the delivery. The tear may reach
into the muscle around the rectum, or even into the rectum itself.
Sex may be painful for the first few months after birth.
If you are pushing as the babys head is close to coming out, and you tear up
toward the urethral area
If labor is stressful for the baby and the pushing phase needs to be shortened
to decrease problems for the baby
If the baby's head or shoulders are too big for the mother's vaginal opening
If the baby is in a breech position (feet or buttocks coming first) and there is a
problem during delivery
If instruments (forceps or vacuum extractor) are needed to help get the baby
out
Not every woman will need an episiotomy during childbirth. Many women get
.through childbirth without tearing on their own, and without needing a cut
Episiotomies don't heal better than tears. They often take longer to heal since the cut
is usually deeper than a natural tear. In both cases, the cut or tear must be stitched
.and properly cared for after childbirth
What Happens if I Need an Episiotomy?
Just before your baby is born, and as the head is about to crown, your doctor or
midwife will give you a shot to numb the area (if you havent already had an
.epidural)
Next, a small incision (cut) is made. There are two types of cuts: median and medio.lateral
The median incision is the most common type. It is a straight cut in the middle
of the perineum.
.Your doctor will then deliver the baby through the enlarged opening
Keep in mind, even if you do these things, you may still need an episiotomy. Your
doctor or midwife will decide if you should have one based on what happens during
.your labor
References
Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J Jr, Lohr KN.
Outcomes of routine episiotomy: a systematic review. JAMA. 2005;293(17):2141.2148
American College of Obstetricians-Gynecologists. Episiotomy. Clinical Management
.Guidelines for Obstetrician-Gynecologists. ACOG Practice Bulletin. 2006;71
Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database of Systematic
.Reviews. 2009;1:CD000081
Cunningham FG, Leveno KJ, Bloom SL, et al. Normal labor and delivery. In:
Cunnigham FG, Leveno KL, Bloom SL, et al, eds. Williams Obstetrics. 23rd ed. New
.York, NY: McGraw-Hill; 2010:chap 17
If nipples are sore, apply a few drops of breast milk after a feeding and let air
dry.
Uterine Changes
After pains, or cramping, are normal. This cramping means that the uterus is
contracting to return to its non-pregnant size. The uterus takes 5-6 weeks to
return to its non-pregnant size.
Vaginal Discharge
Usually lasts about 10 days to 4 weeks. The color will change from bright red
to brownish to tan and will become less in amount and finally disappear.
Care of Episiotomy
Sitz Bath: sitting in a tub of warm water for 15 minutes, 2-3 times per day, will
help relieve the discomfort.
Local agents, such as Tucks, Witch Hazel and Lanacaine, may be applied to
the stitches.
Pain Relief
Continue taking your prenatal iron and vitamin pills until your postpartum
visit.
It is important to eat a well-balanced diet and drink plenty of fluids. Drink two
quarts of fluid per day if you are breastfeeding.
Emotional Changes
You may get baby blues after delivery. You may feel let down, anxious and
cry easily. This is normal. These feelings can begin 2-3 days after delivery and
usually disappear in about a week or two. Prolonged sadness may indicate
Postpartum Depression.
Rest! Do not do heavy housework or heavy exercise for two weeks. Avoid
driving for 1-2 weeks. Check with your doctor for limitations on activities if
you have had a C-Section.
Birth Control
Is advisable as soon as you resume sexual intercourse. Foam and condoms are
safe and easy to use. Birth control methods will be discussed further at your
postpartum visit.
Postpartum Visit Call your obstetrician's office 2-3 days after discharge to make an
.appointment for 6 weeks
:When to call your Doctor/Midwife
Recurrence of bright red vaginal bleeding after it has changed to a rust color.
Swollen area, painful area on the leg that is red or hot to the touch.
References
From my observation.
Patient chart.
Health team members (nurses and doctor).
From patient.
Internet references
VBAC.com
http://www.webmd.com/baby/vaginal-birth-after-section-vbac-directory
Vaginal Birth After Cesarean FAQ - Childbirth.org
Cesarean: Beyond the Wound - by Ana Alvarez-Errecalde
Vaginal birth after caesarean - Wikipedia, the free encyclopedia
Home Birth After Caesarean
Vaginal Birth After Cesarean (VBAC) | International Cesarean Awareness Network
References book
Lenin (1995) pharmacology, Philadelphia, Lippincoot Company,
fourth edition.
Pillitter, Adel, maternal and child health nursing, fourth edition.
Gil Bert and human, manual of high risk pregnancy and delivery, third
edition 2003.
BETHLEHEM UNIVERSITY
FACULTY OF NURSING AND HEALTH
SCIENCE DEPARTMENT OF NURSING
MATERNITY 335
CASE STUDY: NSVD AFTER C-SECTION
(VBAC)
DONE BY: MUANA MOHAMMAD AL-HEEH
PRESENTED TO : WAFA AL KARABLIEH
FALL 2013