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Running Header: Postpartum Care: C-Section with Breech Presentation

Case Study of Postpartum Client C-section with Breech Presentation

Leroyda Kearney
A.D.N. Program/San Jacinto College South
RNSG 2260, Clinical Nursing
February 18, 2016

Running Header: Postpartum Care: C-Section with Breech Presentation

Case Study of Postpartum Client C-section with Breech Presentation

Pregnant women usually have some degree of trauma to the soft tissues of the birth canal and
adjacent structures giving birth. Breech presentation is the malpresentation of the fetus in utero.
Even though the exact reason for breech presentation is unknown, several factors increase the
risk. My client G.V. had a cesarean delivery (C-section) due to breech presentation. My paper analyses

the postpartum health care/problems of a client I cared for in the hospital. It will have all of G.V. important
demographics, disease process, medications, and lab results. It will also address how her health history played a
role in her breech presentation C-section delivery at 36 weeks. In the end, regardless of all the anticipatory
education prepared for before conception, during pregnancy, and after birth; whether vaginal delivery or Csection, a baby is here. To be a good parent you have to be healthy and take care of yourself first because a little
one is dependent on you.
Demographic Data
G.V. is a pleasant 28 year old Hispanic female. She was a part-time housekeeper, but now will be a stay
at home mom. G.V. stated, My husband wants me to stay at home and have more children because Im getting
older. She has resided in Houston, Texas for the past 10 years, but she is originally from El Salvador. She
moved to America with her parents when she was eight. She has a younger brother and a younger sister. She
continues to be a devout Catholic from which she was raised. G.V. was admitted to the hospital yesterday after a
routine checkup revealed breeched presentation, fatigue, and elevated blood sugar. Medical history of anemia
and diabetes type 2 (since age 19).
Physiology
Education is the foundation of every pregnancy and the care there after. Teaching the client about what
to expect after the birth of her child is essential because it gives her and/or her partner the appropriate

Running Header: Postpartum Care: C-Section with Breech Presentation

knowledge to care for herself and her child. A mother needs to have some knowledge of her reproductive and
related structures, endocrine, urinary, gastrointestinal, breasts, cardiovascular, respiratory, neurologic,
musculoskeletal, integumentary, and Immune System will aid in how well postpartum care is given to herself
and her baby.
Breech (buttocks, feet, or both first) presentation, occurs in 3% of births. FHR is heard above the
mothers umbilicus. There is risk of prolapse of the cord if the membranes rupture in early labor, trapping of the
after-coming fetal head (especially with preterm infants), and trauma resulting from extension of the fetal head
or nuchal position of the arms. If external cephalic version (ECV) an attempt to turn the fetus from a breech or
internal version, where the fetus is turned by the health care provider does not work criteria for vaginal delivery
are assessed. If nothing shows there could be a healthy outcome, a Cesarean (C-section) is performed. G.V. had
a scheduled C-section because the ECV attempt did not work. G.V has a lower transverse incision. Her
obstetrician sutured dissolvable stitches that heal over a few weeks. Usually, after the birth of an infant the
fundus is massaged and oxytocin is given to aid in uterine contractions. G.V. order did not allow for the
massage of the fundus. The estimated blood loss (EBL) is 500ml to 1,000 ml after delivery. G.V. EBL was 400
ml. The surgeon suctions blood and fluids from the uterus and wipes the lining of the uterus The amount of
lochia is usually less after a cesarean birth because the surgeon suctions the blood and fluids from the uterus or
wipes the uterine lining before closing the incision.

Pregestational diabetics are more likely to have c-section births because failure of the fetus to descend or
the progress of labor. There are major hormonal changes, decrease in tolerance to glucose, increased insulin
resistance, decreased hepatic glycogen stores, and increased hepatic production of glucose. After birth, when the
placenta is removed insulin requirement is reduced greatly. Because G.V. had a c-section her first 24 hours she
could have been put on an IV infusion of glucose and insulin. Because her blood sugar levels were stable, she

Running Header: Postpartum Care: C-Section with Breech Presentation

was put on a clear liquid diet the first day and when I cared for her she was able to resume a regular diet. Her
blood sugar levels were monitored and she resumed her regular diabetic medications: Metformin 500mg twice a
day and Glyburide 2.5 mg twice a day because they provided adequate glycemic control. G.V. breastfed, which
provided antidiabetogenic effects and decreases the likelihood of her infant being obese. These effects are
beneficial because an infant born to a mother with diabetes has a 70% chance of also acquiring type 2 diabetes
later in life (Lowdermilk, D., Perry, S., Cashion, K., & Alden, K., pg. 698).

. Education about early prenatal care can promote a good pregnancy outcome because provides early
risk assessments and teaches good nutrition habits and good behaviors, like quit smoking. A womans body goes
through many changes is pregnancy. G.V. does not really remember how long her nausea and vomiting lasted,
but she exclaimed, It was awful. I could not keep anything down. The direct cause of morning sickness is
unknown, but it occurs with over 50% of pregnancies. G.V. experienced pain, tingling, and larger breast. This
is caused by the increase in hormonal stimulation in the mammary glandular tissue. G.V noticed
that her skin became darker in the second trimester, even the areola around her nipples. I hope
these stretch marks go away. I have a few things like aloe vera and cocoa butter to help. Linea
negra is not preventable, but usually resolves about six weeks after childbirth when the mothers
body is returning to her nonpregnant state. This is due to a melanocyte-stimulating hormone.
Along with all the normal physiological changes a woman undergoes, having diabetes
entails more endocrine, vascular, and chemical changes. Water imbalance is one of the most
complicated features of diabetes. G.V stated even though she has had diabetes for 10 years, she
feels does not have any increased risks because her diabetes has been controlled by diet and
medication. G.V. did routine prenatal laboratory tests, daily blood sugar checks before meals and

Running Header: Postpartum Care: C-Section with Breech Presentation

and her doctor checked her urine for sugar. Blood sugar levels should be kept within normal
limits, and the urine free of sugar as much as possible.

An infant swallows amniotic fluid in the fifth gestational month. Sometimes with breech presentation an
infant passes meconium in utero. If they fail to pass after birth this could cause atresia somewhere in the
digestive tract, an imperforate anus, or meconium ileus because of the meconium plug that the blocks passage.
(Lowdermilk, D., Perry, S., Cashion, K., & Alden, K., pg. 275)
Recovery from a c-section can be difficult. The usual hospital stay after a C-section is 3-4 days, if are no
complications. G.V. had dissolvable internal stitches.

Lab Work and Diagnostic Studies

DATE & NAME OF

TEST/STUDY

RESULTS

VALUES
WITHIN
APPROPRIATE
PARAMETERS

1/29/2016
Before delivery H/H

9.9g/dL/30.8%

Normal

9g/dL/27.8%

Normal

23.9

Normal

1/30/2016
after delivery H/H
platelets

PURPOSE OF
TEST FOR
THIS
PATIENT

EXPLANATION
OF ABNORMAL
VALUES

Monitor uterine
bleeding and
make sure H/H
does not get
below
8g/dL/23%

Values within
appropriate
parameters

Ensures fetus is
getting
sufficient
oxygen from
maternal blood.

Running Header: Postpartum Care: C-Section with Breech Presentation

1/30/2016
POC glucose

79 mg/dL

1/30/2016

Values within
appropriate
parameters

Normal

143

Normal

Not only does

elevated
sodium
contribute to
high blood
pressure, it can
lead to heart
problems.

Values within
appropriate
parameters

4.3

Normal

Potassium
helps the heart
to beat. If
levels are
abnormal, will
have effects on
the heart.

Values within
appropriate
parameters

1/30/2016

Creatinine 0.8

Normal

BUN and creatinine

BUN 11

Normal

Abnormal
levels put stress
on the heart,
findings can
suggest there is
something
abnormal with
the heart
muscles.

Values within
appropriate
parameters

Sodium

1/30/2016
Potassium

Pharmacology

Medication
Name:
Generic (Trade)

Action &
Recommended
Dose:

Rationale:

Potential side
Effects/Advers
e Reactions

Patient Response to
Medication:

Patient/Family
Teaching

Running Header: Postpartum Care: C-Section with Breech Presentation

metformin and
Two oral
MetforminHeadache
glyburide
( Glucovance) hypoglycemic biguanide aids
agents,
to regulate the metallic taste
in the mouth
decreases
amount of
hepatic
glucose in the diarrhea
glucose
blood;
production
decreases the weakness
and increases
amount of
peripheral
stomach pain
glucose
sensitivity to
absorbed from
insulin
food and the gas
amount of
Oral:
indigestion
glucose made
1.25 mg/250 mg by your liver. constipation
2.5 mg/500 mg
Glyburide5 mg/500 mg
heartburn
sulfonylurea
works by
causing the
pancreas to
release insulin,
which helps to
lower blood
sugar levels.

glyburide
(Prinzide)

causes the
maternal
pancreas to
produce more
insulin

10/12.5 mg

Two or more
Cough,
drugs from
headache, dry
different
mouth,
pharmacologic
weakness,
classes are
depressed
often used to mood, diarrhea,
attain adequate
constipation,
blood pressure upset stomach
control
or mild skin
rash, increased
sweating. Rare,
angioedema.

Tolerated well.
WNL
BS_79 mg/dL
A1C 6

Take with meals to

decrease risk of GI
upset.

Monitor blood sugar

levels and labs
regularly.

Swallow slow-releas
tablets whole: do no
crush, break, or chew

Discontinue
metformin for 48
hours after any
radiologic procedure
involving iodine.

May cause dizziness

This effect may be
worse if you take it
with alcohol or certai
medicine

May cause low blood

sugar levels sugars,
keep reliable source o
glucose.
Blood pressure
stable 139/80. No
reports of
undesirable effects.

Report any signs of

infection like fever o
sore throat.

Report any breathing

problems or swelling
of face, eyes, lips, or
tongue.

Do not use salt

substitutes containing
potassium.

Encourage to rise
slowly due to risk of
orthostatic

Running Header: Postpartum Care: C-Section with Breech Presentation

hypotension.

Continue to use
lisinopril/hydrochloro
hiazide even if you
feel well. Do not mis
any doses.

Clinical Workup
D.S. was initially admitted to hospital for chest pain, but after diagnostic and lab testing he was
diagnosed with GERD. The following will list the clients history and details in the assessment obtained.
Thorough assessments are needed to give holistic nursing care.
History
D.S. had a healthy birth. At six years D.S. had chicken pox, age seven fractured his scapula, and 15
years had an Appendectomy. He was vaccinated with all of the required vaccinations during childhood
development.
D.S. is an only child. Both of his parents are still living, but no information is known about his father.
Hypertension runs in his family, from great grandmother, grandmother, to mother. He married his high school
sweetheart 20 years ago and they have two daughters.
Has consistent unhealthy lifestyle. He usually wakes up every morning at 0500 for his construction job,
he works six days a week, a 10 hour shift. If his wife wakes up to make breakfast he has breakfast, if not he
will eat a pastry and have a large coffee. I dont really like water, he says with a frown. D.S. denies drinking
eight cups a water a day, he typically drinks two if it is too hot at the construction site. Denies smoking. Drinks

Running Header: Postpartum Care: C-Section with Breech Presentation

1-2 beers per week. D.S. does not purchase the groceries, his wife does. He states she packs him a fruit and a
vegetable in each lunch and generally prepares moderately health meals. I eat unhealthy when my wife is not
around, he claims. Due to his long work hours D.S. does not exercise and does not remember the last time he
did. D.S. complains of waking up in the middle of the night being awaken out his sleep regurgitating with
heartburn, most days only sleeps 5-6 hour. I dont know how Im going to stop drinking coffee since I was
diagnosed with GERD. I been drinking coffee every day for the last five years, he says sadly. D.S. recognizes
that he is severely obese, but does not have a problem with his weight because he already married the love of
his life and she accepts him. For fun, D.S. and his friends take turn having dominoes and card parties, a
tradition they had since high school. D.S. is consulting with his credit union and friends to start their own
construction business. Im tired of working for other people and not saving for my retirement. D.S denies
struggling to pay bills, but he is unsatisfied with his savings. D.S. verbalizes that he knows he needs a lifestyle
change.
Physical Examination
General. He has gained over 10 pounds a year since high school.
Neurologic. Alert and oriented to person, place, time, and situation. Memory immediate. Speech clear
without slur or stutter. Expresses feelings and ideas openly and concisely. Follows verbal prompts. Denies
fainting, seizures, motor or sensory loss. Denies pain at this time.
Skin and nails. Skin warm, dry, and intact. Dryness over elbows. Capillary refill <3 secs.
Head, Eyes, Ears, Nose, Throat (HEENT). Neck. Denies history of head injury. No hair, smooth bald
head. Denies any history of eye exam. Denies diplopia, itching, blurring, discharge, redness, or trauma to eyes.
Able to hear.
Breasts. Denies pain, lumps, or discharge.

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Running Header: Postpartum Care: C-Section with Breech Presentation

Respiratory. Upon admission chest pain level was 8/10 on a numerical pain scale 10/10, now pain has
subsided. Some SOB, aggravated by moderate activities. Complains of fatigue most days after work. Never
had chest x-ray. Denies ever having upper respiratory infections.
Cardiovascular. Denies heart disease. Has high blood pressure. Last blood pressure taken at 1100, BP
139/80. Denies palpitations. Last electrocardiogram (EKG) done yesterday, normal.
Gastrointestinal. Appetite good. Denies nausea and vomiting now. Occasionally has vomiting
associated with dyspepsia and flatulence approximately twice a week. Bowel movements after every meal,
normal color and consistency. History of hemorrhoids. Denies jaundice, gallbladder, or liver problems.
Urinary. Voids two to three to times per day, clear yellow urine. Denies dysuria, hematuria, polyuria,
hesitancy, incontinence, or nocturia.
Genital. Denies penile infections. Denies testicular pain. Denies history of sexually transmitted
diseases.
Peripheral Vascular. States Sometimes my legs cramp up and are sore after a 10 hour work day.
Denies swelling/edema of legs and feet.
Musculoskeletal. Occasionally has low back pain after a long day of work. No other joint pain or
stiffness. Normal strength in extremities.
Psychiatry. Denies psychiatric treatment.
Hematologic. Except for bleeding gums, denies easy bleeding. Denies anemia.
Endocrine. Denies intolerance to heat or cold. Denies excessive sweat or hunger, polyuria, change in
glove or shoe size.

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Developmental Level
Intimacy vs. Isolation. According to Eriksons stages of development, in the intimacy vs. isolation,
young adults need to form intimate, loving relationships with other people. They began to settle down and start
families, although in recent years it has been pushed back farther. Success leads to strong relationships, while
failure results in loneliness and isolation. D.S. is in what he calls a loving relationship and has a family. He has
an established intimate relationship.
Plan of Care
Assessment
Subjective.

works six days a week, a 10 hour shift

Sleeps 5-6 hours, suddenly being awaken out his sleep regurgitating with heartburn
Fatigue most days after work
Aware of unhealthy diet, main concern on finances
vomiting associated with dyspepsia and flatulence approximately twice a week
No exercise in over 20 years
Denies smoking
Drinks 1-2 beers per week
Some SOB, aggravated by moderate activity
Gained over 10 lbs a year since high school
Objective.

A&Ox4 with appropriate conversation

Steady gait
Severely over weight, 319 lbs
Vitals stable
EKG normal
Recently diagnosed with GERD
Past Diagnosis: HTN, obesity

Diagnoses

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Running Header: Postpartum Care: C-Section with Breech Presentation

1. Risk for aspiration r/t inadequate lower esophageal sphincter AEB client being awaken out his sleep
regurgitating with heartburn for the past six months, for at least twice a week.
2. Imbalanced nutrition: more than body requirements r/t excessive intake that exceeds metabolic needs AEB
weighing 319 lbs. and being unconcerned about being severely obese.
3. Fear r/t potential threat of death AEB client coming to emergency department and stating, After I had pain in
my left shoulder for three days and it came down my arm, I wanted to get checked out.

Patient Goals:
Short Term.
1. Clients head of bed will remain greater than or equal to 30 degrees at the end of my shift (700-1130) and during
hospitalization.
2. Client will eat heart healthy diet and maintain 8 ounces of fluid every day during hospitalization.
3.
Long Term

1._Client will maintain patent airways and clear lung sounds while being treated in the hospital and verbalize when seek
help when at home.______________________
2.

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3.

Interventions
1. Monitor respiratory rate, debt, and effort.
2. Auscultate lungs frequently.

3. Teach client and family signs of aspiration and precautions to prevent aspiration, and to report signs and symptoms
such as dyspnea, cough, cyanosis, wheezing, or fever.

4. Recommend doctor to order consult for nutritionist to assist client to make some positive modified lifestyle change
client keep a journal of meals plan to help adhere to modified diet and began exercise regimen.

Rationales:
1. Signs of aspiration should be detected as soon as possible to prevent further aspiration and to
initiate treatment that can be lifesaving. (Nursing Diagnosis Handbook 8th Ed., Ackley, Betty J.,
Ladwig, Gail., pg 149).
2. Bronchial auscultation of lung sounds was shown to be specific in identifying clients at risk for
aspiration (Nursing Diagnosis Handbook 8th Ed., Ackley, Betty J., Ladwig, Gail., pg 149.)
3. Important to be knowledge about disease, complications, and its process. Prevents fatal outcome.
(Nursing Diagnosis Handbook 8th Ed., Ackley, Betty J., Ladwig, Gail., pg 149.)
4. Goal is allow client to be participate in healthcare as much as possible to increase their
adherence to plan of care (Self).

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Evaluation

1. Goal met. No sign or symptoms of aspiration noted. RR 18 even and unlabored. Pulse regular, 76. Denies cou

No regurgitation episodes since treatment began. Client correctly verbalized understanding of signs and symp
aspiration.
2. Goal met. Lungs clear bilaterally to auscultation. Call be within reach.________

3. Goal met. Client identified s/s of aspiration. Client stated, Im seek immediate medical attention if I experie
s/s of aspiration. _______

4. Goal met. Client given referral for a nutritionist. He stated he will become more active in his health. I was sc
had chest pain for three days. Im not ready to die.

Health Promotion
Lifestyle changes can be aided through a combination of learning experiences through the creation of
opportunities that open access to environments that make positive health practices the easiest choice that
enhance awareness, increase motivation, and build skills and, most important. A simple risk reduction is to not
eat within two hours of going to be. Another risk reduction is sleeping with head of bed elevated on blocks to
assist with gastric emptying.
References and Style
Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2016). Maternity & Womens

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Running Header: Postpartum Care: C-Section with Breech Presentation

Health Care, (11th ed., pp. 474, 493-494, 802-813). St. Louis, MO: Elsevier.
Ester, C., NSW & John, D, NSW. (2006). Pathophysiology Applied to Nursing. St. Louis:
Elsevier, 213.
Rouse, G. P.. (1958). Pregnancy and Diabetes. The American Journal of Nursing, 58(1), 100101.
http://doi.org/10.2307/3461391

Teaching
Weight loss is important in reducing complications associated with GERD, mainly regurgitation. Also
avoid large meals, eat six small meals a day. Sit upright 30-60 minutes after eating. In your diet avoid colas,
peppermints, and chocolates. These foods case LES relaxation.
Wear supportive maternity bras with pads to absorb discharge, may be worn at night; wash with
warm water and keep dry; breast tenderness may interfere with sexual expression or foreplay but is
temporary
Empty bladder regularly; perform Kegel exercises; limit fluid intake before bedtime; wear
perineal pad; report pain or burning sensation to primary health care provider

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References

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Running Header: Postpartum Care: C-Section with Breech Presentation

Ackley & Ladwig. (2008). Nursing Diagnosis Handbook: A Guide to Planning Care. St. Louis:

Mosby, 8,

146-149.
Christensen, B., & Kockrow, E. (2009). Foundations of nursing (3rd ed.). St. Louis: Mosby.
Hart, Ann. (2015). Escbo: Evidence-based Recommendations for GERD treatment.38, 26-38.
doi:http://dx.doi.org/10.1097/01.NPR.0000431881.25363.84
Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing (5th ed.). St. Louis: Elsevier Saunders.
Rayfield, Sylvia, GNP (2014). Made Insanely Easy: Nursing. Duluth: I CAN, 270-271.

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Running Header: Postpartum Care: C-Section with Breech Presentation

Case Study with Plan of Care Evaluation Sheet
RNSG 1161
Please attach this sheet to your completed paper.

Content

Point Value

Points Earned

1.

Demographic Data

____________

2.

Pathophysiology

____________

3.

Labwork and Diagnostic Studies

____________

4.

Pharmacology Worksheet

____________

5.

Clinical Workup

15

____________

a. History (Genogram)
b. Physical Examination
c. Developmental Stage (use a well-known theorist such as Erikson)
6.

Plan of Care (total 48 points)

a. Assessment

____________

____________

c. Client Goals

____________

d. Nursing Interventions

____________

e. Rationales

____________

f. Evaluation

____________

(Include subjective and objective)

b. Diagnoses
(2 physiological, 1 psychosocial)

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Running Header: Postpartum Care: C-Section with Breech Presentation

7. Health Promotion
2
____________
8.

Client Teaching

____________

9.

References and Style (current edition)

10

____________

Total Possible

100

Student Score__________

Plagiarism: A 15 point penalty will be subtracted from maximum point value for any plagiarized material.

APA Format: Any paper submitted that is not in APA format will be returned to the student ungraded.

Student Name: ______________________________________________________

Instructor
Coments__________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________