University of Baguio

School of Nursing

An Operating Room Write-Up

Presented to the Faculty of the

School of Nursing

In

Partial Fulfillment of the

Requirements for the subject

NCENL03

By:

Bautista, Dyanne G.

NCA 2

Submitted to:

Charmaine Paloga RN, MAN

Clinical instructor

September 2018
 TABLE OF CONTENTS

I. Introduction …………………………………………………………………………………………………………………3

II. Biographical Data …………………………………………………………………………………………………5

A. Patient’s Profile

B. Patient’s Medical History

B.1 Present Health History

B.2 Past Health History

B.3 Family Health History

B.4 Socio-economic History

B.5 Obstetric History

III. Anatomy and Physiology …………………………………………………………………………………7

A. Female Reproductive System

B. Physiology of Pregnancy

B.1 Physiological Changes

B.2 Psychological Changes

C. Fetal Development

D. Stages of Labor

E. Mechanisms of Labor

F. Products of Conception

VII. Pathophysiology ………………………………………………………………………………………………………22

X. Instrumentation………………………………………………………………………………………………………………24

XI. Procedure……………………………………………………………………………………………………………………………26

X. Bibliography………………………………………………………………………………………………………………………29

2
 I. INTRODUCTION

A. Brief Introduction

Nursing process is a patient centered, goal oriented

method of caring that provides a frame work to the nursing

care. The nursing process exists for every problem that the

patient has, and for every element of patient care, rather

than once for each patient. The nurse's evaluation of care

will lead to changes in the implementation of the care and the

patient's needs are likely to change during their stay in

hospital as their health either improves or deteriorates.

Nursing process was used in this case study for a more

systematic to care for a client who have undergone a cesarean

section birth.

Cesarean delivery, also known as cesarean section, is a

major abdominal surgery involving 2 incisions (cuts), One is

an incision through the abdominal wall (laparotomy) and the

second is an incision involving the uterus (hysteretomy) to

deliver the baby.

B. GOALS & OBJECTIVES

GOALS:

After the completion of the write up, he shall be able

to: Enhance his knowledge and Skills in Operating Room, the

process done such as Cesarian Section, Open Reduction and

Internal Fixation Surgery and other. Using instruments, doing

aftercare and others.

OBJECTIVES:

3
The significance of the study is for us third year students to

apply the principles and concepts that we have learned in the

NCM 103 (Operating Room Nursing) in our successive clinical

rotations, with the following learning objectives:

1. Cognitive

To be able to review concepts and theories in Operating

Room Nursing.

To be able to describe the development, pathophysiology,

medical-surgical management, and nursing care of a client who

have undergone a cesarean section birth.

To be able to design a Nursing Care Plan for the patient

who have undergone cesarean birth.

To be able to provide information and heath teachings to

the patient in the postpartum period.

2. Psychomotor

To be able carry-out hospital routines and the treatment

prescribed to the patient.

To be able to perform nursing procedures and nursing

considerations for a client in the preoperative and

postoperative stages

To be able to implement the nursing care plan.

3. Affective

To be able to establish a good working relationship with

the patient and hospital staff.

4
 II. BIOGRAPHICAL DATA

A. Patient’s Profile

Name: Patient X

Age: 22 y/o

Gender: Female

Civil status: Single

Address: 52 Lower Fairview, Baguio City, Benguet

Birthday: November 21, 1995

Birthplace: Baguio City

Nationality: Filipino

Religion: Roman Catholic

Admission date and time: September 11 2018 / 3:40 PM

B. Patient’s Medical History

B.1 Present Health History

Two hours prior to admission, patient felt painful

contractions lasting 40 to 60 seconds and occur approximately

every 3 to 5 minutes. The clerk on duty performed internal

examination and cervical dilatation was at 4 cm; thus, she was

brought to labor room. And her admission diagnosis was G1P0

Pregnancy uterine, 39 1/7 weeks Age of Gestation

B.2 Past health history

Last September, Patient had cough and colds but she

didn’t sought for medical intervention. According to her, she

hasn’t hypertensive, with diabetes mellitus and any infection

on the past few months, this is revealed in her chart.

5
 B.3 Family Health History

The family has history of asthma on the father side

while in the mother side has the history of hypertension,

Diabetes mellitus, and heart diseases. Presently her

grandmother has Diabetes mellitus.

B.4 Socio-Economic History

The patient communicates well and answers immediately

the questions that he asked. He is cooperative to the

therapeutic regiment or care management done. She was still

living with her parents in the reason that he acclaimed that

she doesn’t have husband, and no one can support except her

family. The family support her during the hospitalization.

They live in a bungalow house is a bit near to the highway. In

their backyard they have bayabas, and some flowering plants.

B.5 Obstetric History

The patient is primigravida. Her first menstruation

period or menarche is when she is 13 years old. Mother

partially immunized with the First tetanus toxoid. TPAL termed

as term, preterm, abortion, and live revealed (1,0,0,0). She

acclaimed that her last Menstrual Period was February 26,

2014. She also consults to the near local health unit for

prenatal check-up, that according to her, she done 5 times

before she admitted to the labor room

6
 II. ANATOMY AND PHYSIOLOGY

A. Female Reproductive System

Vagina

 a muscular passageway that leads from the vulva

(external genitalia) to the cervix.

Cervix

 a small hole at the end of the vagina through which

sperm passes into the uterus. Also serves as a

protective barrier for the uterus. During childbirth,

the cervix dilates (widens) to permit the baby to

descend from the uterus into the vagina for birth.

Uterus

 hollow organ that houses the baby during pregnancy.

During childbirth, the uterine muscles contract to push

out the baby.

Ovaries

 two organs that produce hormones and store eggs, that

was then fertilized with sperm cells from males.

Fallopian tubes

– muscular tubes that eggs are released from the ovaries

and must be transverse to reach the uterus.

7
 B. Physiology of Pregnancy

B.1 Physiological Changes

a. Uterine Changes

The length is ranges from 6.5 to 32 cm, the depth

ranges from 2.5 to 22 cm, width would be from 4 to 24 cm; and

it can weighs from 50 to 1000 g. The uterine wall thickens

early pregnancy from 1 cm to 2cm; thins in pregnancy about6.5

cm thick. The uterine volume can ranges from 2ml to more than

1000 ml. The uterus can hold 4000 g.

The uterine increases it’s size, the blood flow;

before preganancy is 15 to 0 ml/in and end of pregnancy will

become 500 to 750 ml. Other changes will be Hegar’s sign

(softening of the cervix); ballottement (rebound that

occur)and Braxton hicks contractions (false labor

contractions)

b. Cervical Changes

The cervix become edematous and vascular cause by the

increase circulating estrogen; Goodell’s sign (soft

consistency in the earloebe or “ripe” cervix just befor

labor—butterlike.

C. Vaginal Changes

The pinkish or violet discoloration of the vagina

known as Chadwick’s sign; secretes white vaginal discharges

composed of loosen epithelial cells and connective tissues.

The vaginal environment will become acidic from 7 pH to 4 or

5 pH—this is to favor the growth of Candida Albicans.

d. Breast Changes

Tenderness, fullness, tingling (about 6 weeks) can be

present; increase in breast size; areolas darkens and

increase in diameter. There is also increase in the

vascularity of the breast, there will be prominent veins.

8
Montgomery’s tubercles enlarge and become protuberant. In the

16th week—colostrums (thin, watery, high-protein fluid that

is a precursor to the breastmilk) can be expelled from the

nipples.

e. Integumentary System

There will be the presence of Striae gravidarum (pink

or reddish streaks); linea nigra—-a narrow, brown line

running from the umbilicus to the symphysis pubis; melasma

usually appears in the face caused by the increase in

melanocyte stimulating hormone secreted by pituitary gland.

There is also vascular spiders (small, fiery red and

branching spots); increase in perspiration; scalp hair growth

and palmar erythema.

f. Respiratory System

There is nasal stuffiness due to increased production

of estrogen; acute sensation of shortness of breath; and

breathing rate is more rapid than normal causes by the

hormonal changes.

g. Temperature

Body temperature increases (the temperature which

increased at ovulation remains elevated) temperature usually

ranges to 36.5 to 37 above.

h. Cardiovascular System

Blood volume increases by atleast 30% up to 50%; at

the end of 1st trimester, blood volume increases gradually;

28th to 32nd will be the peak level. False anemia

(Pseudoanemia)can also happen this is when the concentration

of Hgb and erythrocytes decline because Plasma volume is

greater than RBC production. In NSD, blood loss can be 300 to

400 ml. Cardiac output becomes 35% to 50% increase; heart

rate will become 80 to 90 bpm. Blood pressure decreases in

2nd trimester, prepregnancy level in 3rd trimester.

9
 There is also impaired blood flow to the lower

extremities. Supine Hypotension Syndrome can be happen to

pregnant women when they lies on their back; the weight of

the uterus compresses the vena cava, trapping blood in the

lower extremities which causes decreased CO and hypotension.

This can be manifested with lightheadedness, faintness and

palpitations.

i. Gatrointestinal System

There will be slow intestinal peristalsis and the

emptying time of the stomach; decreased gastric acid

secretions. The pregnant can also experience heartburn

(reflux of gastric content); constipation and flatulence

cause by the misplacement of stomach; hemorrhoid or pressure

of uterus affect the anal canal. There is also nausea and

vomiting. Lastly, gingival hypertrophy or enlargement of gums

and hypertyalism or increased salive formation.

j. Urinary System

Women can experience fluid retention caused by the

production of progesterone; increased urine output and

specific gravity decreases. There is also increased GFR

(Glomerular Filtration Rate). Urinary frequency increase; the

ureter’s diameters increases and bladder capacity. There can

be pressure on the right ureter.

k. Skeletal System.

There is gradual softening of the woman’s pelvic

ligaments and joints this is caused by the ovarian hormone

relaxin and placental progesterone. There is also wide

separation of symphysis pubis makes the pregnant woman

difficulty in walking because of the pain waddling gait.

l. Endocrine System

There is slight enlargement of the thyroid gland and

hormone cause the increase production of BMR and 02

10
consumption; in early pregnancy, there is decreased insulin

because of heavy metal glucose demand. After 1st trimester,

increased production of insulin due to antagonist action of

estrogen, progesterone and others. In placenta there is

estrogen and progesterone produced.

m. Immune System

There is decreased IgG (immunoglobulin G) will cause

the mother prone to infection. There’s also increased in WBC

to help counteract the decrease in IgG response.

B.2 Psychological Changes

The pregnant women can experience the following:

a. Ambivalence – interwoven feelings of wanting and not

wanting the pregnancy. Patient X experienced this kind of

feeling though, she’s young, and acclaimed that she has no

husband, that will support her.

b. Grief – the feeling of sadness or melancholy that may

arise vague sense of want or loss, there is assuming of new

roles.

c. Narcissism – also known as the self-centeredness; an early

reaction to pregnancy. According to patient, she is the

center in the family, all of her needs was given by her

family.

d. Body image – the way the women appears theirselves.

Patient X feels shy when she go out, because she’s pregnant.

e. Stress – this can make the women difficult to make

decisions, awareness to the surrounding as usual or maintain

time management with her usual degree or skill.

f. Mood swings – mood changes; emotional imbalance; the woman

finds acceptable one week, she may find intolerable the next

week.

11
g. Changes in Sexual Desire – there can be decrease or

increase of sexual desire. During ovulation, sexual hormones

will increase. During 1st trimester, libido decreases.

Psychological tasks to adjust for pregnancy are the

following:

a. 1st Trimester (Accepting the Pregnancy)

Making the woman feel “more pregnant”. Promoting the

reality of the pregnancy.

b. 2nd Trimester (Accepting the Baby)

Helps her realize that not only she is pregnant but

also there is child inside her.

c. 3rd Trimester (Parenthood Preparation)

“Nest-building activities” such as planning the

infant’s sleeping arrangements, buying clothes and choosing

names for the infant.

C. Fetal Growth and Development

Milestone of fetal growth and development in the mother’s

womb:

a. End of 4th Gestational Week

The embryo’s length is 0.75 cm weighs 400 mg. The

spinal cord is fused and formed at the midpoint. Head is

12
about one third of the entire proportion. Heart appears as

prominent bulge on the anterior surface. Arms and legs are

bud-like structures. Eyes, ears and nose are rudimentary.

b. End of 8th Gestational Week

Fetal length is 2.5 cm and weighs about 20 grams.

Organ formation is complete; heart is with septum and valves,

beating rhythmically. Facial feature are discernible. Arms

and legs are developed genitalia are forming, but sex cant

determine yet. And abdomen bulges forward.

c. End of 12th gestational Age

Fetal length becomes 7-8 cm, and weighs about 45 g.

Nailbeds are reforming on fingers and toes. Spontaneous

movements are possible. Babinski reflex is elicited. Bone

ossification begin to form. Tooth buds are present, the sex

is now distinguishable.

d. End of 16th Gestational Week

Fetal length becomes 10-17 cm, and weighs about 55-120

g. Lanugo is well formed. Liver and pancreas are functioning.

Urine is present in the amniotic fluid.

e. End of 20th Gestational Week

Fetal length is 25 cm, weighs 223 g; spontaneous

movement can be sensed by mother; hair including eyebrows,

forms on the head. Vernix caseosa begisnd to cover the skin.

Meconium is presnt in the upper intestine. Passive antibody

transfer fro mother to fetus begins

f. End of 24th Gestational Week

Fetal length is 28 to 36 cm, weighs 550g. There is

active production of surfactant. Hearing can be demonstrated

by sudden sounds. This is the age of viability.

g. End of 28th Gestational Week

13
 Fetal length is 35 to 37 cm and weighs 1200g. lung

alveoli are almost mature. Testes begins to desecend from

lower admoninal cavity; blood vessels of retina are formed.

h. End of Gestational Week

Fetal length is about 38 to 43, weighs 1600g.

Subcutaneous fat begin to deposited. Moro reflex is elicited.

Iron storage begins; Fingernails reach the end of fingertips.

i. End of 36th Gestational Week

Fetal length is 42 to 48 cm, weighs 1800 to 2700. Sole

of foot has only one to two crisscross creases. Amount of

lanugo begins to diminish.

j. End of 40th Gestational Week

Fetal length becomes 48-52 cm and weighs 3000g. Fetus

kicks actively, hemoglobin convert to adult hemoglobin.

Vernix caseosa is fully formed. Creases on the sole of the

feet cover atleast two thirds of the surface.

D. STAGES OF LABOR

The process of labor and birth is divided into three stages:

 FIRST STAGE begins with having contractions that cause

progressive changes in the cervix and ends with cervix

that is fully dilated.

This stage is divided into two phases:

Latent Phase : your cervix gradually effaces (thins out)

and dilates (opens).

Active Phase: the cervix begins to dilate more rapidly, and

contractions are longer, stronger, and closer together.

People often refer to the last part of active labor as

transition.

14
  SECOND STAGE begins once you’re fully dilated and ends

with the birth of your baby. This is sometimes referred

as the “pushing stage”.

 THIRD STAGE begins right after the birth of the baby and

ends with the delivery of the placenta.

***Every pregnancy is different like the length of labor.

For primigravidas, labor often takes between ten to twenty

hours. For some women, it lasts longer. Labor generally

progresses more quickly for women who’ve already given birth

vaginally.

FIRST STAGE: Cervical Stage

First stage of labor is divided into three phases; the

latent, the active and the transition phase.

LATENT PHASE

It begins with the onset of regular contractions,

effacement and dilation of the cervix to 0-3 cm. It lasts

an average of 6.4 hours for nulliparas and 4.8 hours for

multiparas. Contraction ecome increasingly stronger and

more frequent. A woman should continue to walk and make

preparations for birth.

ACTIVE PHASE

15
 Dilation continues from 3 to 4 to 7 cm. Contractions

becomes stronger, more frequent and more painful, lasting

40 to 40 seconds and occur approximately 3-5 cm. it can be

the frightening time because the labor is progressing and

contractions continue to become stronger.

TRANSITIONAL PHASE

The culmination of the first stage; cervix dilates

from 8 to 10 cm. Intensity, frequency and duration of

contractions peaks and there is now an irresistible urge to

push.

SECOND STAGE: Fetal Stage

Begins with complete dilation of the cervix

and ends with delivery of the newborn. Duration may differ

among primiparas whis is longer and multiparas –shorter,

but this stage should be completed within 1 hour after

completing dilation. Contractions are severe at 2-3 minutes

interval, with duration of 50-90 seconds. There is now the

mechanisms of labor. “Crowning” occurs when the newborn’s

head or presenting part appears in the vaginal opening.

Episiotomy may be done to facilitate delivery and avoid

laceration of the perineum.

THIRD STAGE: Placental Stage

16
 Begins with delivery of the newborn and ends with

the delivery of the placenta. It occurs in two phases; the

placental separation and expulsion.

PLACENTAL SEPARATION – when the uterus contracts down on an

almost empty interior, there is disproportion between

placenta and contracting wall of the uterus that folding

and separation of placenta occurs. Signs are: globularity

of the uterus, fundus rising in the abdomen, lengthening of

the cord and increased bleeding.

PLACENTAL EXPULSION – after the separation of placenta, it

will now delivered either by natural bearing of mother or

gentle pressure on the contracted uterus.

Contraction of the uterus controls uterine

bleeding, oxytocic drugs are administered to help uterus to

contract.

FOURTH STAGE: Recovery and Bonding Stage

It lasts from 1 to 4 hours after birth. Mother and her

baby both recover from the physical process of birth;

maternal organs undergo initial readjustments to the

nonpregnant state. The newborn body system begin to adjust

to extrauterine life and stabilize. Skin to skin contact or

mother-child dyad happens. Mother can breastfeed her baby

to acquire the colustrum that contains antibody that can

protect her baby from disease in atleast 2 months.

17
 E. MECHANISMS OF LABOR

1. DESCENT

The fetus head is pushed deep into the pelvis in

sideways position, face is to left and the occiput is to

the right.

- in primigravidas, this may occur two weeks before

delivery. This referred to as “lightening”. Lay people

Might call this “dropping”

- in multiparas, this may not occur until dilatation

of the cervix.

18
2. FLEXION

As fetus head descends, the chin is flexed to come

into contact with the infant’s sternum. Occiput position

allows the occipital bone in the back of the head to laed

the way (smallest diameter of the head).

3. INTERNAL ROTATION

The amount of internal rotation depends on the

position of the fetus and the way the haed rotates to

accommodate itself to the changing diameters of the pelvis.

Enables the fetal head to progress through the

maternal pelvis. The largest diameter of the fetal haed

aligns with the largest diameter of the pelvis.

4. EXTENSION

Occurs when the occiput passes under the symphysis

pubis. This bony structure acts as stable point and

provides leverage, enabling the head to leave the pelvis.

Actual delivery of the head is done by extension.

5. EXTERNAL ROTATION (RESTITUTION)

Occurs as the shoulders and body move through th birth

canal, using the same maneuvers as the head. Shoulders are

delivered similarly to the head, with the anterior shoulder

pressing under symphysis pubis.

After shoulders are delivered , the delivery of the

fetus ends with expulsion.

6. EXPULSION

The top of the anterior shoulder is seen next just

under pubis; gentle downward pressure by the physician

delivers the anterior shoulder; the head is gently raised

to deliver the posterior shoulder; the rest of the body

follows the head, which then completes expulsion. The fetus

remains completely passive as it moves through birth canal.

19
F. PRODUCTS OF CONCEPTION

The aggregate of tissues present in a fertilized gestation

; in a pregnancy that has been terminated or aborted or

deivered, chorionic villiand/or fetal tissue must be present i

n a specimen to make a definitive diagnosis of intrauterine–

1. FETUS

The passenger is the fetus; the part of the fetus that

has the widest diameter is the head, so this part least

likely to be able to pass through the pelvic ring. The

fetus delivered via NSD 38-40 weeks is appropriate Age of

Gestation, if least or greater, there is possible

complications.

2. FETAL MEMBRANE

The membranous structure that surrounds the developing

fetus and forms the amniotic cavity is derived from fetal

tissue and is composed of two layers; the amnion (inner

layer) and the chorion (outer layer). The amnion is a

translucent structure adjacent to the amniotic fluid, which

provides necessary to the amnion cells. The chorion is more

20
opaque that is attached to the decidua (maternal tissue

that lines the uterus during pregnancy)

The amnion and chorion are separated by the exocelamic

cavity until approximately three months gestation, when

they become fused. Intact, healthy fetal membranes are

required for an optimal pregnancy outcome.

3. FUNIS (Umbilical Cord)

Also known as birth cor or furnicularis umbilicalis,

is the connecting cord from the developing embryo or fetus

to the placenta. During prenatal developmet, umbilical

cordis physiologically and genetically part of the fetus

normally conatins 2 arteries and one vein, buried within

Wharton’s jelly.

4. PLACENTA

The placenta is an organ that connects the developing

fetus to the uterine wall to allow nutrient uptake, waste

elimination and gas exchange via mother;s blood supply.

It forms from both embryonic and maternal tissues, and

hosts an astonishing array of hormonal, nutritional,

respiratory and immunological functions. It is expelled

after the baby is delivered.

5. AMNIOTIC FLUID

This fluid is clear, slightly yellowish liquid that

surrounds the unborn baby (fetus) during pregnancy. It is

contained in the amniotic sac.

While in the womb, the baby floats in the amniotic

fluid. The amount of amniotic fluid is greatest at about 34

weeks (gestation) into the pregnancy, when it averages 800

ml. approximately 600 ml of amniotic fluid surrounds the

baby at full term (40 weeks gestation)

21
 VII. 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 sperm in the ampulla)

Zygote travels from the fallopian tube

to the uterus

Implantation

Development of the fetus/embryo &

placental structure until full term

PRELIMINARY SIGNS OF LABOR

Lightening Braxton Hicks Ripening of the

(descent of the Contraction cervix
fetal head into (false labor) (Goodell’s Sign
the pelvis) wherein the
>begin and remain cervix feels
irregular softer like
>1st felt consistency of
abdominally the earlobe)
>pain disappears
with ambulation
>do not increase
in duration and
intensity
>do not
achieve cervical
dilatation

22
 TRUE LABOR

Uterine SHOW Rupture of Membranes

Contractions (pink- (rupture of the
>increase in tinge of amniotic sac)
duration blood, a
and intensity mixture of
blood and
>1st felt at the fluid)
back &
radiates to
the abdomen
>pain is not
relieved no
matter what
the activity
>achieve
cervical
dilatation

Failed to progress labor

(due to previous cesarean birth, cervical arrest,
cervical atrophy)

increase risk for fetal distress

(meconium staining, hypoxia)

Increase risk of fetal death

Emergent cesarean delivery

(the incision made on the lower part of the abdomen)

Expulsion of the fetus

Expulsion of the placenta

(accompanied by blood approximately
500-1000 mL)

23
 VIII. INSTRUMENTATION

The following instruments are used during Cesarean Section

Delivery

1. MAYO SCISSOR

-Used for cutting heavy

fascia and sutures such as

the perineum during

episiotomy

2. STRAIGHT KELLY FORCEP

- Used for grasping anything

which would be inconvenient or

impracticable to grasp with

fingers, such as clamping the

cord.

3. TISSUE FORCEP

- a forcep without teeth, designed

for handling tissues with minimal

trauma during surgery such as

episiotomy and perineal repair.

4. CURETTE

- Designed for scraping

biological tissue or debris in

a biopsy, excision or cleaning

procedure such as the

24
 evacuation of the blood clots after the delivery of the

baby and placenta.

5. METZ SCISSORS

- surgical scissors designed

for cutting delicate tissue and

blunt dissection. The scissors

come in variable lengths and

have a relatively long shank-

to-blade ratio. They are constructed of stainless steel and

may have tungsten carbide cutting surface inserts. Blades

can be curved or straight.

6. MAYO BASIN

- used as the storage of the

sterile instruments, and for the

placenta.

7. NEEDLE HOLDER

- also called needle

driver, is a surgical

instrument, similar to

a hemostat, used

by doctors and surgeons to hold suturing needle for closing

wounds during suturing and surgical procedures.

25
 IX. PROCEDURE

PREOPERATIVE

1. Pre-op checklist

2. starting an IV line

3. shaving the pubic hair

4. inserting a bladder catheter

INTRAOPERATIVE

1. Supine on bed

2. Induction of anesthesia-

Epidural

General

-IV/Inhalation

-ET tube

3. Skin preparation

4. draping

5. INCISION- longitudinal/Bikini-Obstetrician

*skin

*subcutaneous

*fascia

*muscle

*Peritoneum

*uterus

*amniotic sac

The skin of the lower abdominal wall is incised in a transverse

direction just above the pubic hairline in the majority of cases

(side to side rather than up and down). A longitudinal (up and

down) incision is infrequently employed. Just under the skin, a

layer of fat is found which is easily separated to reach the next

layer. The reader will recognize this next type of layer since it

is a dense shiny white layer of fascia called the rectus fascia.

Like the pelvic fascia this is a connective tissue layer, which

26
surrounds the rectus abdominal muscles and offers support,

attachment and strength. This fascia layer is incised to expose

the two rectus abdominal muscles which are big muscles running

from the rib cage to the pubic bone. These are the main muscles

employed to do sit-ups. The two muscles meet in the midline where

they are sometimes fused but quite often, however, they are

separated as the result of the stretching from the distended

uterus. These muscles are now separated (without cutting them) and

pulled to the sides to create a space between them.

After this space has been created, the only layers covering

the uterus are thin fascia and the peritoneum. The peritoneal layer

is a very thin membrane-like layer, which can be described as the

lining of the abdominal cavity. After this layer is penetrated the

uterus will lie directly in view. A second layer of peritoneum,

which is also incised and pushed out of the way, usually covers

the so-called lower segment of the uterus where the incision will

be made. This simple, but essential part of a cesarean section,

helps to prevent injuries to the bladder, which lies on top of the

lowest part of the uterus and the immediate vagina.

After the bladder has been pushed to safety the next step is

to incise the uterus. The incision in the uterine wall is also

made transversely and it is made in the lower segment of the

uterus, just above the cervix, which is the thinnest part. The

incision is usually started with a scalpel but usually completed

by manual stretching. This is done to prevent injury to the

immediately underlying infant.

6. Delivery of the infant

- delivered by guiding its head into the opening with one

hand while the assistant exerts pressure on the uterine fundus

(top of the uterus).

-handed to pediatrician

27
 7. Delivery of the Placenta

8. Abdominal Lavage

9. Suturing- absorbable and non-absorbable

The final two layers that need closing are the rectus sheath

and of course the skin. The rectus sheath is the most important

layer (not surprisingly - it’s fascia!) and needs to be sutured

with strong material. The skin can be closed with sutures, staples

or various other methods, none of which have significant advantages

over the other.

POSTOPERATIVE

1. PACU

2. Removal of suction drain

It is sometimes necessary, especially in subsequent

cesarean births, to place a suction drain underneath the

rectus sheath. This is to prevent the collection of serum or

blood in this area, which could then become a site for

infection. These drains would typically stay in for 12 to 24

hours.

3. The urinary catheter and IV are usually also removed at the

same time.

28
 X. BIBLIOGRAPHY

Pilliteri, A., Maternal and Child Health Nursing, 6th Ed.

Luxner, M. Maternal-Infant Nursing Care Plan, 2nd Ed., 2005

Tortora, G., Anatomy and Physiology, 11th Ed.

Biswas, A; Su, LL; Mattar, C (Apr 2013). "Caesarean section

for preterm birth and, breech presentation and twin

pregnancies.". Best practice & research. Clinical obsLiu S,

Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS (2007).

"Maternal mortality and severe morbidity associated with

low-risk planned cesarean delivery versus planned vaginal

delivery at termtetrics & gynaecology

Goldenberg RL, Culhane JF, Iams JD, Romero R (2008).

"Epidemiology and causes of preterm birth

Luo ZC, Wilkins R, Kramer MS (2004). "Disparities in

pregnancy outcomes according to marital status and

cohabitation status". Obstetrics and Gynecology

29