cesarean section casestudy

8/18/2019 Cesarean Section CaseStudy

1/23

Introduction:

In this semester, at the maternity course, I chose this case with my

instructor which it is about NSVD after C-section , I Believed that if awoman had delivered one baby by C-section, all other children had to be

delivered the same way. But after takin this case and readin about it I

reali!e that "oday many women can have vainal deliveries after a

#revious C-section delivery. "his is referred to as a vainal birth after

cesarean $. %ttem#tin to have a vainal birth after a #revious cesarean

section is called a trial of labor after cesarean &"'(%C$. I ho#e this case

will be interestin case and hel# me to im#rove my knowlede, skills and

#ractice, and to a##ly what I study at the university.

Demographic data:

)atient name* %.S.+.S Date* /0

Date of admission* /0 %e* 1 years

2os#ital* %(-%2(I 2os#ital

%ddress* 2ebron

'ccu#ation * 3nineerin s#ace

DX:

3arly labor #revious cs

Chief complain:

4terine contractions, 5in labor6 .labor #ain ,


2/23

History of present pregnancy

%1 year old woman admitted to %(-%2(I hos#ital as a case of 3arly

labor #revious cs .her B) //7/ .#ulse 18,9.% 0:week ,(+) /0

and the 3'D in1/0 ,9)%/ .canula a##lied and la# test

&CBC ,Crosshatch %;,2Bs%%9 the result was neative ,C"9$was

taken .due to #rolon nd stae of labor active manaement done at 0rd

stae &3#isiotomy e//cc =($ ,a male

baby was born at :*/> %+ his ?t 0,7>/ m .%B9%= score was 1: . She

is conscious .look very tired ,with #oor #ushin durin the delivery, the

baby in ood condition and his mother .

Past medical history:

Medical history: no hy#ertension , no diabetes , and no tuberculosis.

Surgical history: #revious cesarean due to fetal distress.

Allergic * unknown allery to medication or food .

Medications* she didn@t take any reular medication

No ynecological disorder .

!amily History:

2er father 2ave 2"N and D+ , other than this the family history is freeA

there is no medical or surical history, or conenital abnormalities.

'bstetric history*

She delivered before a baby irl , maturity at term and the mood of the

delivery was CS due to fetal distress.


3/23

Nutritional assessment ha"its:

)t is on reular diet. She eats 0 meals #er day.

)t was takin olic acid and iron su##lement durin #renancy.

4nknown allery for any kind of food.

)t had nausea and vomitin in the first trimester .

- she ained wt. durin #renancy was about 0 k.

- Doesnt smoke and doesn@t drink alcohol

Allergies:- 4nknown allery for any ty#e of food or dru .

#a"or $ its stages

I=S" S"%93 ' (%B'=--"2=33 )2%S3S $ %arly.& In this #hase, the mother feels slow, rhythmic contractions. "he

contractions last from 0/ to > seconds with the intensity radually

increasin. "he freEuency of contractions is from > to / minutes. "here

is some cervical effacement. Dilation is from cm. FBloody showF is

#resent. "he mother was able to walk, talk, lauh durin this #hase..

Acti&e. In this #hase, the contractions become stroner and last loner,

for > to 7/ seconds. "he freEuency is from 0 to > minutes. "he cervi<

dilates 8 cm... She, then, becomes involved with bodily sensations and

tends to withdraw from the surroundin environment. She is not able to

walk, but, desires com#anionshi# and encouraement .

'ransient . In this #hase, the contractions are shar#, more intensified, and last from 7/ to :/ seconds. "he freEuency is from to 0 minutes. "he

cervi< dilates from 1 to / cm. "he mother e


4/23

mothers #rofile for &9)%/ ,first day in (+)/0 ,

3DD1/0,9%0: .earlier and latest 4S ,and #roblem durin

#renancy$. )erformed leo#oleds maneuver to determine fetal #osition,

lie , and #resentation.all were normal. Insert IV catheter , start hydration

accordin to fetal and maternal condition &IV NS >//cc$

'riented the #atient to the surroundins &that is, room, call bell$.

In this #hase o#stractic history taken revious CS$

mothers

%t this stae VS were taken ,#osition the mother in semi lateral

,encourae her to o to the bathroom and walk .the mid wife done

abdominal e


5/23

Post natal condition:

She looks fully conscious ,in ood mood , tidy , has clean clothes and

body ,she take care of himself , no bad odor , her ?eiht when she was

#renant is1k, now her wt is 8>k 2eiht* 7>cm.)atient eneral

condition stable, no headache, no e#iastric #ain, no visual disturbances.

VS taken and recorded, B)H /7/mmh,#ulse:/."em 07.>c. "he

second day the uterus well contracted. she has stable VS, )t out of bed ,

no di!!iness and #assed urine,lokia mild , e#isiotomy sutures no bleedin

,no hematoma ,ood a##ro


6/23

no redness or swellin or masses, lactated, both ni##les are normal, no

abnormal dischare.

Abdomen: "he uterus is in the mid line of umbilicus, uterus contracted,transverse incision from #revious CS , clean and dry, normal bowel

habit, intact bowel sounds, central umbilicus, femoral #ulses are

#al#ated.

+ac*: 2as ood #ostured sha#e, s#inal vertebral is normal sha#e. no

masses, or #rominent curves, no #ain

%tremities: Both are symmetrical, have ood refle


7/23

(a# test

%ntenatal #eriod*

Blood CBC

"he CBC is used as a broad screenin test to check for such disorders as

anemia, infection, and many other diseases. It is actually a #anel of tests

that e


8/23

joint pain, or

general ill

feeling;

unusual bleeding (nose,

mouth, vagina,

or rectum),

purple or red

pinpoint spots

under your

skin;

;

• diabetes;

• gallbladder

disease;

• a stomach

or intestinal

disorder

such as

colitis;

• if you are

allergic to

penicillin

!iolent uterine

contraction

leads to rupture

" fetal

asphy#iation,

arrhythmias,

maternal

hypertension,

$ypertonic

uterine action,

%echanical

obstruction to

delivery, &ail

trial labour, &etal

distress, placenta

preavia,

'yntocinon is

used to

nduce "

augmentation

of labour

nduce and

augmentation

of labour,

stimulate

uterine

contractions,

for post

hemorrhage

+ntoinon*unit with +

.**ccc, !

/ausea, vomiting,constipation,

drowsiness,

di00iness, dry

mouth and

sweating

Central Nervous+stem-

/ervousness,

headache,

restlessness,

uneasiness,

fatigue,

confusion,

depression,

hallucinations,

tremors, muscle

twitches,

increased

intracranial

pressure and fits

patients withhistory of severe

respiratory

problems, fits, head

injuries, increased

eye pressure, heart

or liver problems,

diabetes,

depression, genetic

disorder, any

allergy, who are

taking other

medications,

elderly and

children

abor pain,1pisiotomy

procedure

opioidanalgesic,

prescribed for

moderate to

severe pain, for

e#ample labor

pain, before and

during a

surgical

operation t

changes the

way the body

senses pain

)it2i&in2100mg M

2hourly


9/23

Pathophysiology:

It is a vainal birth after one or more cesareans. +ore than 1/J of women

will be able to have a VB%C.

%C'9 recently u#dated their o#inion on VB%C and stated FVB%C is safer

than re#eat cesarean and VB%C with more than one #revious cesarean does

not #ose any increased riskF.

Vaginal Birth After C-Section (VBAC)3he old phrase 4once a 5-section always4 is no longer true n the past, the belief was

that if a woman had delivered one baby by 5-section, all other children had to bedelivered the same way 3oday many women can have vaginal deliveries after a

previous 5-section delivery 3his is referred to as a vaginal birth after cesarean

(!675) 7ttempting to have a vaginal birth after a previous cesarean section is called

a trial of labor after cesarean (3875)

Candidates For VBAC7ccording to the 7merican 5ollege of 8bstetricians and 9ynecologists (7589), the

following women are candidates for 3875:

T2e oman 2as 2a& no more t2an one rior lo-transverse C-setion &eliver. T2is refers to t2e ut on our uterus6 not t2eone on our bell. f ou7ve 2a& a rior -setion6 our 2ealt2are rovi&er ma as ou to get a o of t2e reort fromour first surger to 2e 2at te of inision ou 2a& on t2euterus. as m ase.

• 3he woman has had no other uterine scars or ruptures, whether from previous

5-sections or other surgeries

•

3he woman has a pelvis large enough to allow a vaginal delivery

• elivery will be at an institution with a physician immediately available

throughout active labor who can monitor the fetus and perform an emergent 5-

section if needed

• elivery at an institution where anesthesia and staff is also immediately

available if an emergent 5-section needs to be performed

7589 has specifically stated that whenever a woman is planning a 3875 delivery,

there should be an appropriate medical team available, including an anesthesiologist,

throughout the active labor so that an emergency 5-section may be done if necessary'maller hospitals may not have the resources to monitor a !675 delivery or to


10/23

provide an emergency c-section for 3875 situations, and !675 delivery may not

be possible

Women Who Should NOT Hae VBAC8ne of the main concerns with having a vaginal delivery after a 5-section is the

potential rupture of the uterus, which could be harmful to you and the baby3herefore, 7589 has made recommendations for women who should not try a

!675 delivery 3hese women include:

•


11/23

rupture of the uterus in previous classical 5-section is > to A* percent n a recent

large study, about A in B,*** women who tried to 3875 had a uterine rupture that

caused permanent brain damage for the baby


12/23

N./SIN 0A#S :

.?ithin hour of receivin #ain medication, client will state #ain level has been reduced to 5/-F on #ain scale.

."hrouhout shift, client will state that #erineal #ain has lessened to atolerable level .

N./SIN IN'%/(%N'I0NS :

. %ssess clients #ain level throuhout shift &ask client to identify level usin #ain scale at least E-0h$ and when analesic is due.

=ationale* to monitor clients #ain, #reventin it from escalatin and tooffer a##ro#riate interventions as needed .

.'ffer analesics #er doctors order

=ationale* to maintain clients comfort level by controllin #ain and #reventin it to escalate.

0. %##ly ice #ack to #erineum #rn.

=ationale* to reduce swellin and numb #erineum in order to relieve #ain.

.'ffer sit! bath to client #er doctors order .

=ationale* warm water cleansin the #erineum is soothin and reduces #ain. "he warm water will encourae blood flow to the area, encourain

healin .

>.Visually assess the clients #erineal area Eshift . =ationale* to monitor level of swellin and redness and to identify any

infection or worsenin of skin breakdown. %llows for early interventions to #revent com#lications if needed .

%(A#.A'I0N :

9oal K. %chieved. "hirty minutes after receivin "ylenol K0 tabs ii, theclient stated that her #erineal #ain level was at 5.F

9oal K. %chieved. "hrouhout the shift, the client took the "ylenol K0 E hours and stated that it lessened her #ain. ?hen asked, client stated #ain

was at 5/-F throuhout shift. Client stated that. She did not like the ice #ack, so refused to have it re#eated. She hsaid that a##lyin a warm wet

washcloth to the #erineum after voidin sto##ed the stinin caused byurine.

N*!+N% 9,%N=++'8-

=isk for ineffective tissue #erfusion related to hemorrhae


13/23

oal

%fter 1 hours of nursin interventions, the #atient will demonstrate

adeEuate #erfusion and stable vital sins.

Inter&ention-+onitor amount of bleedin by weihin all #ads. "o measure the

amount of blood loss.

-reEuently monitor vital sins. 3arly reconition of #ossible adverse

effects allows for #rom#t intervention

0-+assae the uterus "o hel# e


14/23


15/23

Ob Gyns Issue Less Restrictive VBAC Guidelines

July 21, 2010)ashington, DC -- %ttem#tin a vainal birth after cesarean &VB%C$ is a safe and

a##ro#riate choice for most women who have had a #rior cesarean delivery,

includin for some women who have had two #revious cesareans, accordin to

uidelines released today by "he %merican Collee of 'bstetricians and

9ynecoloists.

"he cesarean delivery rate in the 4S increased dramatically over the #ast four

decades, from >J in :8/ to over 0J in //8. Before :8/, the standard #ractice

was to #erform a re#eat cesarean after a #rior cesarean birth. Durin the :8/s, as

women achieved successful VB%Cs, it became viewed as a reasonable o#tion for some women. 'ver time, the VB%C rate increased from ust over >J in :1> to 1J

by ::7, but then bean a steady decline. By //7, the VB%C rate fell to 1.>J, a

decrease that reflects the restrictions that some hos#itals and insurers #laced on trial

of labor after cesarean &"'(%C$ as well as decisions by #atients when #resented with

the risks and benefits.

F "he current cesarean rate is undeniably hih and absolutely concerns us as ob-

yns,F said =ichard N. ?aldman, +D, #resident of "he Collee. F"hese VB%C

uidelines em#hasi!e the need for thorouh counselin of benefits and risks, shared

#atient-doctor decision makin, and the im#ortance of #atient autonomy. +ovin

forward, we need to work collaboratively with our #atients and our colleaues,hos#itals, and insurers to swin the #endulum back to fewer cesareans and a more

reasonable VB%C rateF.

In kee#in with #ast recommendations, most women with one #revious cesarean

delivery with a low-transverse incision are candidates for and should be counseled

about VB%C and offered a "'(%C. In addition, F"he Collee uidelines now clearly

say that women with two #revious low-transverse cesarean incisions, women carryin

twins, and women with an unknown ty#e of uterine scar are considered a##ro#riate

candidates for a "'(%C,F said effrey (. 3cker, +D, from +assachusetts 9eneral

2os#ital in Boston and immediate #ast vice chair of the Committee on )ractice

Bulletins-'bstetrics who co-wrote the document with ?illiam %. 9robman, +D, from Northwestern 4niversity in Chicao.


16/23

(+AC Counseling on +enefits and /is*s

F In makin #lans for delivery, #hysicians and #atients should consider a woman@s

chance of a successful VB%C as well as the risk of com#lications from a trial of labor,

all viewed in the conte


17/23

)ractice Bulletin K>, FVainal Birth after )revious Cesarean Delivery,F is

#ublished in the %uust // issue of 'bstetrics L 9ynecoloy.

=oer ?. 2arms, +.D.

3#isiotomy

%n e#isiotomy is minor surery that widens the o#enin of the vaina durin

childbirth. It is a cut to the #erineum -- the skin and muscles between the vainal

o#enin and anus.

What Are he Ris!s""here are some risks to havin an e#isiotomy. Because of the risks, e#isiotomies are

not as common as they used to be. "he risks include*

• "he cut may tear and become larer durin the delivery. "he tear may reach

into the muscle around the rectum, or even into the rectum itself.

• "here may be more blood loss.

• "he cut and the stitches may et infected.

• Se< may be #ainful for the first few months after birth.

Sometimes, an e#isiotomy can be hel#ful even with the risks.

Will I #eed An $%isi&t&'y""imes when an e#isiotomy is often #erformed include*

• If you are #ushin as the babys head is close to comin out, and you tear u#

toward the urethral area

•

If labor is stressful for the baby and the #ushin #hase needs to be shortenedto decrease #roblems for the baby

• If the baby@s head or shoulders are too bi for the mother@s vainal o#enin

• If the baby is in a breech #osition &feet or buttocks comin first$ and there is a

#roblem durin delivery

• If instruments &force#s or vacuum e


18/23

3#isiotomies don@t heal better than tears. "hey often take loner to heal since the cut

is usually dee#er than a natural tear. In both cases, the cut or tear must be stitched

and #ro#erly cared for after childbirth.

What (a%%ens i) I #eed an $%isi&t&'y"

ust before your baby is born, and as the head is about to crown, your doctor ormidwife will ive you a shot to numb the area &if you havent already had an

e#idural$.

NeA:0&8$*-

1.

%merican Collee of 'bstetricians-9ynecoloists. 3#isiotomy. Clinical +anaement

9uidelines for 'bstetrician-9ynecoloists. %C'9 )ractice Bulletin. //7A8.

Carroli 9, +inini (. 3#isiotomy for vainal birth. Cochrane Database of Systematic

=eviews. //:A*CD////1.


19/23

Cunninham 9, (eveno Q, Bloom S(, et al. Normal labor and delivery. In*

Cunniham 9, (eveno Q(, Bloom S(, et al, eds. ?illiams 'bstetrics. 0rd ed. New

Pork, NP* +c9raw-2illA //*cha# 8 .

)ostartum 9is2arge lan

Breastfee&ing

• weeks, unless

breastfeeding

Care of isiotom

• 'it0 6ath: sitting in a tub of warm water for A. minutes, B- times per day, will

help relieve the discomfort

• ocal agents, such as 3ucks,


20/23

• 5ontinue taking your prenatal iron and vitamin pills until your postpartum

visit

• t is important to eat a well-balanced diet and drink plenty of fluids rink two

Cuarts of fluid per day if you are breastfeeding

motional C2anges

• Eou may get Fbaby bluesG after delivery Eou may feel let down, an#ious and

cry easily 3his is normal 3hese feelings can begin B- days after delivery and

usually disappear in about a week or two Prolonged sadness may indicate

Postpartum epression

• +estH o not do heavy housework or heavy e#ercise for two weeks 7void

driving for A-B weeks 5heck with your doctor for limitations on activities if

you have had a 5-'ection

• 7void se#ual activity, douching or tampons until your postpartum visit

Birt2 Control

• s advisable as soon as you resume se#ual intercourse &oam and condoms are

safe and easy to use 6irth control methods will be discussed further at your

postpartum visit

)ostartum Visit 5all your obstetricianIs office B- days after discharge to make an

appointment for = weeks

W2en to all our 9otor/Mi&ife8

• &ever greater than A*A, with or without chills

• &oul-smelling or irritating vaginal discharge

• 1#cessive vaginal bleeding

• +ecurrence of bright red vaginal bleeding after it has changed to a rust color

• 'wollen area, painful area on the leg that is red or hot to the touch

• 6urning sensation during urination or an inability to urinate

• Pain in the vaginal or rectal area

• 5rying and periods of sadness beyond the two weeks


21/23

Source* Vainal Birth %fter C-Section &VB%C$ R 4niversity of +aryland +edical

Center htt#*umm.eduhealthmedical#renancylabor-and-deliveryvainal-birth-

after-csection-vbacKi


22/23

/eferences "oo*

enin (ALL.) pharmacology, Philadelphia, ippincoot 5ompany,

fourth edition

Pillitter, 7del, maternal and child health nursing, fourth edition

9il 6ert and human, manual of high risk pregnancy and delivery, third

edition B**

BT$#$M *NV!+T?

:,C*#T? =: N*!+N% ,N9 $,#T$+CNC 9),!TMNT =: N*!+N%

M,T!NT? ""5

C,+ +T*9?8 N+V9 ,:T! C-+CT=N@VB,CA

9=N B?8 M*,N, M=$,MM,9 ,#-$$

)!+NT9 T= 8 W,:, ,# K ,!,B#$


23/23

:,## '01"

cesarean section casestudy

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