I.

INTRODUCTION
A Caesarean section 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. The first modern Caesarean section was performed by German gynecologist Ferdinand Adolf Kehrer in 1881. 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. In recent years the rate has risen to a record level of 46% in China and to levels of 25% and above in many Asian and European countries, Latin America, and the United States. There are several types of Caesarean section (CS). An important distinction lies in the type of incision (longitudinal or latitudinal) made on theuterus, 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 thebladder and results in less blood loss and is easier to repair. An unplanned Caesarean section is a Caesarean performed once labour has commenced due to unexpected labor complications. A crash/emergent/emergency Caesarean section is a Caesarean performed in an obstetric emergency, where complications of pregnancyonset suddenly during the process of labour, and swift action is required to prevent the deaths of mother, children 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, especially in Argentina, the United States, United

Kingdom, Canada, Norway, Sweden, Finland, Australia, and New Zealand 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 labour 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 labour 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)

Bicornuate uterus

Patient X has placenta previa often present with painless, bright red vaginal bleeding. This bleeding often starts mildly and may increase as the area of placental separation increases. Previa should be suspected if there is bleeding after 24 weeks of gestation. Abdominal examination usually finds the uterus non-tender and

relaxed. Leopold's Maneuvers may find the fetus in an oblique or breech position or lying transverse as a result of the abnormal position of the placenta. Previa can be confirmed with an ultrasound. In parts of the world where ultrasound is unavailable, it is not uncommon to confirm the diagnosis with an examination in the surgical theatre. The proper timing of an examination in theatre is important. If the woman is not bleeding severely she can be managed non-operatively until the 36th week. By this time the baby's chance of survival is as good as at full term. Placenta previa is classified according to the placement of the placenta: Type I or low lying: The placenta encroaches the lower segment of the uterus but does not infringe on the cervical os. Type II or marginal: The placenta touches, but does not cover, the top of the cervix. Type III or partial: The placenta partially covers the top of the cervix. Type IV or complete: The placenta completely covers the top of the cervix. Placenta previa occurs approximately one of every 250 births. One third of all antepartum hemorrhage occurs due to placenta previa.[ The following have been identified as risk factors for placenta previa:

Previous placenta previa, caesarean delivery, or D&C e.g. used for incomplete or missed miscarriage, abortion, to treat or investigate heavy bleeding or other diagnostic purposes.

Women who have had previous pregnancies, especially a large number of closely spaced pregnancies, are at higher risk.

Women who are younger than 20 are at higher risk and women older than 30 are at increasing risk as they get older.

Women with a large placentae from twins or erythroblastosis are at higher risk. Race is a controversial risk factor, with some studies finding that people from Asia and Africa are at higher risk and others finding no difference. Placenta previa is itself a risk factor of placenta accreta. The main risk with a vaginal

delivery with a previa is that as you are trying to bring down the head or a leg, you might separate more of the placenta and increase the bleeding. Placenta previa increases the risk of puerperal sepsis and postpartum haemorrhage because the lower segment to which the placenta was attached contracts less well post-delivery. And we are doing caesarean section to avoid complications in delivering the baby.

The patient has low lying placenta previa. The patient had also undergone BTL or Bilateral Tubal Ligation because she didnt want to be impregnated anymore. Tubal ligation or tubectomy (also known as having one's "tubes tied" (ligation) is a surgical procedure for sterilization in which a woman's fallopian tubes are clamped and blocked, or severed and sealed, either method of which prevents eggs from reaching the uterus forfertilization. Tubal ligation is considered a permanent method

of sterilization and birth control. A tubal ligation is approximately 99% effective in the first year following the procedure. In the following years the effectiveness may be reduced slightly since the fallopian tubes can, in some cases, reform or reconnect which can cause unwanted pregnancy. Method failure is difficult to detect, except by subsequent pregnancy, unlike with vasectomy or IUD. Of those failures, 15-20% are likely to be ectopic , 84% of those failures occurred a year or more after sterilization. According to one study, Approximately 5% of women who have had tubal ligation will have a failure due to ectopic pregnancy. Time seems to be a factor as the risk of failure increases after 1 or more years post-surgery. The risk of ectopic pregnancy is 12.5% for women having tubal ligation but less than those women who have not had the surgery. Recanalization or formation of tuboperitoneal fistuals occur, the openings of which are small enough for passage of sperm but too small to allow an ovum to push through, resulting in fertilization/implantation in the distal tubal segment. Two economic studies suggest that laparoscopic bilateral tubal ligation could be less cost-effective than the Essure procedure, which uses a special type of fiber to induce a benign fibrotic reaction. The patient had undergone two surgeries at a time. Caesarian section and Bilateral Tubal Ligation. The patient is 29 years old. She is now a mother of two children.

II.

PATIENTS PROFILE
Patient's name: JIMLYN ARABE Address: Bulala Norte, Vigan City, Ilocos Sur Date of birth: September 06, 1982 Birthplace: Bulala Norte, Vigan City, Ilocos Sur Occupation: Housewife Age: 29 y/o Gender: female Marital Status: Married Chief Complaint: G2- P1 (1-0-0-1) pregnancy uterine 37 weeks AOG with placenta previa.

III. PROCEDURE
Cesarean Section Procedure
Before your cesarean section procedure, you will be given anesthesia to numb the pain. The doctor will then make either a vertical or horizontal incision in your abdomen and your uterus. After the incision is made, your baby will be delivered through it, and your placenta will be removed. After the cesarean section procedure, the incision will be closed with either staples or stitches. Before the Cesarean Section Procedure. After you have received cesarean section anesthesia, a catheter (plastic tube) will be placed in your bladder to drain your urine during the surgery. Your lower abdomen is then washed with a special disinfectant cleanser, and you will be covered with sterile sheets. This helps protect you against infections.

During the Cesarean Section Procedure To begin the cesarean section, your doctor will make a 6- to 8-inch incision in your abdomen directly over your uterus. The incision can be either horizontal, which is side to side, or vertical, which is up and down. The direction of the incision will depend on several factors, including:
Your body's The position

shape and size and size of the baby and your uterus needed.

How quickly the delivery is

If you've had a cesarean section before, your surgeon will usually try to go through the previous scar. Once the surgeon is inside, another incision will be made through the uterus. In most women, the incision is side to side on the lower part of the uterus. Your baby is then delivered through this opening. The umbilical cord is cut, and your baby is handed to a healthcare provider, who will take him or her to a small, warmly lit plastic crib called a warmer. Then your baby is cleaned and dried and eventually checked by a pediatrician.

After the Cesarean Section Procedure After your baby has been delivered, your placenta will be carefully removed from your uterus. At this time, you may also receive Pitocin, which is a drug that causes the uterus to contract and helps prevent serious bleeding. Your doctor will then close the

incision on your uterus, and the incisions in your skin will be closed with surgical staples or stitches that will later dissolve on their own.

Tubal Ligation Procedure

Sometimes referred to as "having your tubes tied," a tubal ligation procedure is used to block the fallopian tubes and thus prevent pregnancy. One method of blocking the fallopian tubes involves using an electric current to burn the tubes and create a scar. Another method of performing a tubal ligation involves using a clip or rubber band-type device to close each tube. Bilateral means both sides, and tubal ligation means "blocking" the fallopian tubes so your eggs cannot be fertilized or reach the uterus. This is how BTL prevents pregnancy. Recent studies show that this surgery has a success rate of over 99 percent. It is intended to be a permanent, irreversible form of birth control.

Beginning the Tubal Ligation Surgical Procedure After the anesthesia has taken effect, your doctor will begin the tubal ligation procedure by placing a speculum into your vagina. A small instrument will then be carefully placed into the end of your cervix. This makes it possible for your doctor to gently move the uterus into different positions, so that your pelvic structures can be seen more clearly through the laparoscope. Then a small incision, or cut, will be made in or just below your navel. A tube, called a trocar, will then be inserted into your abdomen. Through this, your doctor will fill your abdomen with carbon dioxide gas, which is like the air you breathe out. This gas helps your doctor see your pelvic structures more clearly. The laparoscope will then be inserted. Through this, your doctor will view the inside of your abdomen on a video screen. The laparoscope can also take pictures and videotape the procedure. The Next Step -- Tying the Tubes Your doctor will then begin by locating your first fallopian tube. After this is located, another incision may be made just above your pubic hair. Through this second incision, your doctor will insert the appropriate instruments to block your tubes. Several options are available to do this.

One choice is to use electric current. For this, your doctor will insert forceps, which are connected to an electrical source. When the tube is grasped, the electrical current gives a small burn to the tube, which safely and painlessly scars it, sealing it off. The procedure is then repeated on the other tube.

Your doctor can also use a clip or a rubber band-like device to close each tube. All of these methods are effective in blocking the fallopian tube and preventing pregnancy.

Finishing the Tubal Ligation Procedure Once both tubes have been closed, the instruments are removed and the gas is released. To finish the tubal ligation procedure, the incisions are then closed with stitches and covered with a bandage. These stitches will be absorbed by your body over time, usually about two to four weeks.

IV. OR INSTRUMENTS USED AND THEIR USES

3 handle with 10 blade (inside knife) Used to cut superficial tissue. 4 handle with 20 blade (skin knife) - Used to cut skin. Mosquito- is used to clamp small blood vessels. Kelly is used to clamp larger vessels and tissue Allis- is used to grasp tissue. A "Judd-Allis" holds intestinal tissue; a "heavy allis" holds breast tissue. Babcock- is used to grasp delicate tissue (intestine, fallopian tube, ovary). Towel clip- is used to hold towels and drapes in place. Pick up forcep- is used to pick the instruments soak in a sterile agents, used in holding cottons/cherries with betadine for cleaning the area to be operated. Metzenbaum scissors - Used to cut delicate tissue Curved Mayo scissors - Used to cut heavy tissue (fascia, muscle, uterus, breast). Straight scissor-Used to cut suture and supplies. Bandage scissor- used to cut the umbilical cord. Army-Navy retractor -is used to retract shallow or superficial incisions. Richardson retractor- is used to retract deep abdominal or chest incisions Goulet- is used to retract shallow or superficial incisions. Kidney basin- used as container for the specimens(placenta). needle holders- are used to hold needles when suturing. Surgical suture- is a medical device used to hold body tissues together after an injury or surgery. The uterus is closed in two layers using a large (such as 2-0 or 0) absorbable suture, something like a chromic gut, the fascia is closed using a heavy suture such as a 3-0 ethibond (nonabsorbable), plain gut can be used if any for subcutaneous closure, and an absorbable suture can be used on the subcuticular a smaller guage such as 4-0 vicryl, finally the skin can be closed with either staples (most common), tape (uncommon), or sutured with nylon suture (most eventually be removed). Thumb forceps- are used to grasp tough tissue (fascia, breast). tissue forceps- are used to grasp tissue. OS- used to sponge the incision site to have a clearer view of the operation.

V.

NURSING CARE AFTER THE PROCEDURE/ POST-OPERATIVE CARE

Close observation. 1:1 or 1:2. Monitor vital signs: VS and assessments every 15 minutes x4, q30m x 4, q1hrx4, q4h until 24 hrs has elapsed. Monitor white blood count (WBC) Monitor Elevated temperature, Redness, swelling, increased pain, or purulent drainage at incisions Inspect dressing and dont change first dressing, thats the surgeons prerogative. Standard and emergency equipment should be present. Give oxygen to the patient . Prevent/minimize postoperative complications. Observe complications such as Airway obstruction, Respiratory insufficiency ,bleeding, Shock and other problems like Pain,Nausea and vomiting,neurological problems (delayed emergence, delirium, problems related to the surgery type i.e. carotid endarterectomy vs lumbar laminectomy).Hypothermia. Wash hands and teach other caregivers to wash hands before contact with patient and between procedures with patient. Administer antibiotics Administer bulk-forming agents or stool softeners such as laxatives as indicated or prescribed by the physician. Administer pain relievers as prescribed by the physician. Encourage fluid intake of 2000 ml to 3000 ml of water per day (unless contraindicated). Encourage ambulation such as walking within individual limits Encourage intake of foods rich in fiber such as fruits. Enhance comfort and general well-being. Suggest drinking of warm fluids, especially in the morning to stimulate peristalsis. Promote family unity and bonding. Promote a positive emotional response to birth experience and parenting role. Provide information regarding postpartal needs.

Republic of the Philippines UNIVERSITY OF NORTHERN PHILIPPINES Vigan City

COLLEGE OF HEALTH SCIENCES

In Partial Fulfillment of the Requirement in NCM 104B

OR RIGHT UP

Submitted by: ANGELICA MAE FRIALA BSN(L) III-A

Submitted to: RUTH REGINA CORPUZ, R.N. Clinical Instructor

NOVEMBER 28, 2011