CHAPTER I

INTRODUCTION

Childbearing is one of life’s miracles; a mother carries a baby in her uterus

normally 9 months, some deviate having a preterm or post-term baby. On this
endeavour not always will there be a great result. On rare occasion some
experience death of their baby while having them, and it is what we are going to
explore here. Specifically, a case of a mother who bore a child for 9 months only to
have lost her baby due to an unforeseen incident, there was Intrauterine fetal
demise related to Cephalopelvic Disproportion.
Cephalopelvic disproportion (CPD) occurs when a baby’s head or body is too
large to fit through the mother’s pelvis. It is believed that true CPD is rare, but many
cases of “failure to progress” during labor are given a diagnosis of CPD. When an
accurate diagnosis of CPD has been made, the safest type of delivery for mother
and baby is a caesarean (Scott, James R., et al, Ch. 22.). In this case there was
failure to detect early diagnosis of CPD, which caused the series of complications to
the patient focused by this case study.
Even though there was fetal demise, the delivery of the baby must still be
performed and order to prevent complications for the mother to occur. The stillborn
baby was delivered through Caesarean delivery, also known as caesarian section,
which is a major abdominal surgery involving 2 incisions (cuts), one is an incision
through the abdominal wall (laparotomy) and the second one is an incision involving
the uterus (hysteretomy) to deliver the baby. Legend has it that that the Roman
Leader Julius Caesar was delivered by this operation, and the procedure was
named after him.
According to Stanford Medicine (2018), Cesarean delivery (also called a
cesarean section or C-section) is the surgical delivery of a baby by an incision
through the mother's abdomen (belly) and uterus (womb). This procedure is done
when it is determined to be a safer method than a vaginal delivery for the mother,
baby, or both. In a cesarean delivery, an incision (cut) is made in the skin and into
the uterus at the lower part of the mother’s abdomen. The incision in the skin may be
vertical (longitudinal) or transverse (horizontal), and the incision in the uterus may be
vertical or transverse. A transverse incision extends across the pubic hairline,
whereas, a vertical incision extends from the navel to the pubic hairline. A transverse
uterine incision is used most often, because it heals well and there is less bleeding.
Transverse uterine incisions also increase the chance for vaginal birth in a future
pregnancy. However, the type of incision depends on the conditions of the mother
and the fetus.

Caesarean section delivery is also called as C-section delivery. This method

involves the deployment of surgery for delivering babies i.e. one or more. The
caesarean section delivery is often essential when there is risk on the life of mother
or baby due to vaginal delivery. This may include issues with the umbilical cord or
placenta, breech birth, high blood pressure in the mother, twin pregnancy, and
obstructed labour. The caesarean section delivery will be performed on the basis of
previous history of C-section delivery or shape of the mother's pelvis. After the C-
section delivery, the mother might be go for the vaginal birth delivery. As per the
recommendations of the World Health Organization, the Caesarean section delivery
will be performed when there is a medical requirement, because in many cases this
method of delivery saves the life of both the mother and the baby. But sometimes,
C-sections deliveries are done without any medical need, or due to the request of
the mother. The duration of C-section delivery is between 47 minutes to 1 hour. It
may be performed by using spinal block when the mother is under general
anesthesia or awake.

Although this method of delivery has it perks, it also offers an array of

complication that can occur if not handled properly. Prompt management must be
performed immediately to mitigate complications. These are:

 Cesarean delivery is associated with a higher rate of injury to abdominal organs

(bladder, bowel, blood vessels), infections (wound, uterus, urinary tract), and
thromboembolic (blood clotting) complications than vaginal delivery.
 Cesarean surgery can interfere with mother-infant interaction in the delivery
room.
 Recovery takes longer than with vaginal delivery.
 Cesarean delivery is associated with a higher risk that the placenta will attach to
the uterus abnormally in subsequent pregnancies, which can lead to serious
complications.
 Cutting the uterus to deliver the baby weakens the uterus, increasing the risk of
uterine rupture in future pregnancy. This risk is small and depends upon the type
of uterine incision.

There are few risks of cesarean delivery for the infant. One risk is birth trauma,
which is rare. Temporary respiratory problems are more common after cesarean
birth because the baby is not squeezed through the mother's birth canal. This
reduces the reabsorption of fluid in the infant's lungs.

Potential complications:

 Infection – The risk of postoperative uterine infection (endometritis) varies

according to several factors, such as whether labor had started and whether the
fetal membranes have ruptured. Endometritis is treated with antibiotics. Wound
infection, if it occurs, usually develops four to seven days after surgery, but
sometimes appears during the first day or two. In addition to antibiotics, wound
infections are sometimes treated by opening the wound to allow drainage and
removing infected tissue if needed.
 Hemorrhage – One to two percent of all women having cesarean deliveries
require a blood transfusion because of hemorrhage (excessive bleeding).
Hemorrhage usually responds to medications that cause the uterus to contract or
procedures to stop the bleeding. In rare cases, when all other measures fail to
stop bleeding, a hysterectomy (surgical removal of the uterus) may be required.
 Injury to pelvic organs – Injuries to the bladder or intestinal tract occur in
approximately one percent of cesarean deliveries.
 Blood clots — Women are at increased risk of developing blood clots in the legs
(deep vein thrombosis or DVT) or the lungs (pulmonary embolus) during
pregnancy and especially the postpartum period. This risk is further increased
after cesarean delivery. The risk can be reduced by using a device that gently
squeezes the legs during and after surgery, called an intermittent compression
device. Women at high risk of DVT may be given an anticoagulant (blood
thinning) medication to reduce the risk of blood clots.

In all four countries in South East Asia, prophylactic antibiotics are

administered almost uniformly, with only one tertiary hospital in The Philippines
reporting a slightly lower rate of 91%. There was variation in the timing of
prophylactic antibiotics, both between countries and between hospitals within
countries. In Indonesia, prophylactic antibiotics were universally given post-
operatively. In one Malaysian hospital they were always given pre-operatively, while
in the other they were given post-operatively 95% of the time. In one hospital in The
Philippines, mothers were given prophylactic antibiotics pre-operatively almost
universally, while in the other hospital 41% of mothers received antibiotics pre-
operatively and 43% post-operatively, with the remainder given intra-operatively
after umbilical cord clamping. In Thailand almost 90% of women were given
prophylactic antibiotics intra-operatively after umbilical cord clamping, with the next
most common time of administration being pre-operatively. Cephalosporin was the
most common class of prophylactic antibiotics used across all hospitals with a rate of
73%. Ampicillin was the next most commonly used antibiotic in Malaysia and
Thailand, while 'other' antibiotics were the next most common in Indonesia and The
Philippines. The frequency of dose for prophylactic antibiotics varied both between
countries and between hospitals in countries. Mothers in Indonesia received multiple
doses of prophylactic antibiotics while mothers in Malaysia received either a single
dose or multiple doses depending on their births or the hospital. In the Philippines
and Thailand rates ranged from 1% to 93% for single doses of prophylactic
antibiotics and from 7% to 99% for multiple doses.

In Indonesia, Malaysia, and Thailand, the majority of women were reported to

have a less than 500 ml estimated blood loss, while in the Philippines 79% were
estimated to have a greater than 500 ml blood loss. The reported postpartum
haemorrhage rate > 500 ml for Indonesia was only 4%. Malaysia reported the
highest rate for postpartum maternal transfusion (9%). Mothers were often given
prophylactic antibiotics postnatally with rates varying between countries and
between hospitals within countries. All mothers in Indonesia were given prophylactic
antibiotics postnatally. Rates varied widely between hospitals in Malaysia (3% and
94%), The Philippines (38% and 98%) and Thailand (15% to 97%). The main reason
for giving antibiotics postnatally to women was prophylaxis and this was commonly
practiced in Indonesia (100%), Thailand (90%) and Malaysia (90%), although it was
less common in The Philippines (36%) where wound infection was the main reason
reported (52%) for postnatal antibiotic administration.

The mean gestational age at birth of babies born by caesarean across the
hospitals was similar (range 37.7 (SD 2.2) to 39.2 (SD 1.4) weeks). The preterm
birth rate (< 37 weeks gestation) varied widely from 3% to 18% between hospitals
although similar from 10% to 13% between countries. Overall, 16% of the babies
born by caesarean were of low birth weight (< 2500 g), with rates ranging from 8% to
28% between hospitals. The mean birth weight of babies ranged from 2.76 kg (SD
0.63) to 3.13 kg (SD 0.57) between hospitals and 2.8 kg (SD 0.60) to 3.06 kg (SD
0.60) between countries.

The rates for caesarean section where the baby was stillborn ranged
between 0% to 1% between countries and 0% to 2% between hospitals within
countries. The rates for babies born alive by caesarean who then died were reported
as 0% overall for Indonesia, Malaysia and The Philippines, with these three
countries recording a rate of 1% in one hospital each, while Thailand recorded a rate
of 1% in all hospitals as well as overall.

The use of prophylactic antibiotics is recommended to reduce endometritis

and wound infection after elective or non-elective caesarean section. This
knowledge has been applied in all hospitals of the four South East Asian countries
audited, where prophylactic antibiotics were almost always given. Evidence
suggests that prophylactic antibiotics should be administered pre-operatively to
result in the lowest risk of surgical wound infection. The variation in timing of
antibiotic prophylactic administration between hospitals, and the lack of consistent
timing in relation to the type of institution may suggest that some individual hospitals
have developed standardized policies for use of antibiotic prophylactics, while some
individual health professionals may practice in line with their own preferences at
other hospitals.

First generation cephalosporin and ampicillin have been found to be equally

effective agents for antibiotic prophylaxis for women who underwent a caesarean
and this recommendation was followed in nearly 90% of all cases reviewed in the
four South East Asian countries. Multiple doses of prophylactic antibiotics have been
found no more effective than a single dose and are more expensive.

Procedure

After being admitted to the hospital for a planned cesarean delivery, a woman may
be given an oral dose of an antacid to reduce the acidity of the stomach contents.
Another medication may be given to reduce the secretions in the mouth and nose.
An intravenous line will be placed into the hand or arm, and an electrolyte solution
will be infused. An antibiotic will be given through the IV to help prevent a
postoperative infection. Monitors will be placed to keep track of blood pressure, fetal
heart rate, and blood oxygen levels.

Anesthesia — The woman is usually accompanied to an operating room before

anesthesia is administered. A spouse or partner can usually stay with the woman in
the operating room.

There are two types of anesthesia used during cesarean delivery: regional and less
commonly, general. For a planned cesarean delivery, regional anesthesia is usually
performed. Meeting with the anesthesiologist allows the woman to ask specific
questions about anesthesia, and allows the anesthesiologist to identify any medical
problems that might affect the type of anesthesia that is recommended.

With epidural and spinal anesthesia, the anesthetic is injected near the spine, which
numbs the abdomen and legs to allow the surgery to be pain-free while allowing the
mother to be awake.

General anesthesia, now infrequently used for cesarean, induces unconsciousness.

This means that the mother will not be awake or aware during the procedure. After
the anesthesia is given, the woman will fall asleep within 10 to 20 seconds and a
tube will be placed in the throat to assist with breathing. General anesthesia carries
a greater risk of complications than epidural or regional anesthesia because of the
need for an endotracheal (breathing) tube and because drugs given to the mother
affect the infant.

Women who have general anesthesia will not be awake during the cesarean
delivery. Regional anesthesia is generally preferred because it allows the mother to
remain awake during the procedure, enjoy support from staff and a family member,
experience the birth, and have immediate contact with the infant. It is usually safer
than general anesthesia.

After the anesthesia is given, a catheter is placed in the bladder to allow urine to
drain out during the surgery and reduce the chance of injury to the bladder. The
catheter is usually removed within 24 hours after the procedure.

Skin incision — There are two basic types of incision: horizontal (transverse or

"bikini line") and vertical (midline). Most women have a transverse skin incision,
which is made 1 to 2 inches above the pubic hair line. The advantages of this type of
incision include less postoperative pain, more rapid healing, and a lower chance that
the wound will separate during healing.

Less commonly, the woman will have a vertical ("up and down") skin incision in the
midline of the abdomen. The advantages of this type of incision include a slightly
more rapid access to the uterus (eg, if the baby is in distress or if the woman is
bleeding excessively).

Uterine incision - The uterine incision can also be either transverse or vertical. The
type of incision depends upon several factors, including the position and size of the
fetus, the location of the placenta, and the presence of fibroids. The main
consideration is that the incision must be large enough to allow delivery of the fetus
without causing trauma.

The most common uterine incision is transverse. However, a vertical incision may be
required if the baby is breech or sideways, if the placenta is in the lower front of the
uterus, or if there are other abnormalities of the uterus.

After opening the uterus, the baby is usually removed within seconds. After the baby
is delivered, the umbilical cord is clamped and cut and the placenta is removed. The
uterus is then closed. The abdominal skin is usually closed with absorbable sutures
(ie, absorbed by the body so they do not need to be removed).

After the mother and baby are stable, she and her partner may hold the baby.

Post-operative Care

After surgery is completed, the woman will be monitored in a recovery area. Pain
medication is given, initially through the IV line, and later with oral medications.

When the effects of anesthesia have worn off, generally within one to three hours
after surgery, the woman is transferred to a postpartum room and encouraged to
move around and begin to drink fluids and eat food.

Breastfeeding can usually begin any time after the birth. A pediatrician will examine
the baby within the first 24 hours of the delivery. Most women are able to go home
within a few days after delivery. The abdominal incision will heal over the next few
weeks. During this time, there may be mild cramping, light bleeding or vaginal
discharge, incisional pain, and numbness in the skin around the incision site. Most
women will feel well by six weeks postpartum, but numbness around the incision and
occasional aches and pains can last for several months.

After going home, the woman should notify her health care provider if she develops
a fever (temperature greater than 100.4ºF [38ºC]), if pain or bleeding worsens, or if
there are other concerns (e.g, severe headache, abdominal pain, difficulty
breathing).
 CHAPTER II

COMPREHENSIVE NURSING HEALTH HISTORY

I. PERSONAL DATA

A. Personal Data

Patient’s name is Marlil Asis, she is 32 years old and was born on

March 10, 1987. She lives in Magsaysay, Dulag, Leyte and lived together

with her partner, having 1 male child. The patient is a government teacher.

She and her husband are both Roman Catholics. Patient’s LMP was on

March 16, 2019. The number of Gravida the patient had was 2, Preterm 0,

Term 2, Abortion 0, Living 1, and Miscarriage 0. She was admitted on

December 2, 2019 Monday around 11:30 PM with an admitting diagnosis

G2P1(2001) Intrauterine Fetal Demise 37 2/7 Weeks AOG, Cephalic, ILPL

S/P CS 1x Secondary to CPD. Her vital signs were: T= 36.1°C P= 100bpm

R= 20cpm BP= 110/70mmHg.

B. Reason for Admission

The reason for admission was fetal heart tone not appreciated.

C. Obstetric History

The client’s menstruation started when she was 17 years old in the

year 1999 having a duration of 4 days and 2-3 number of pads soaked per

day. She has a regular menstruation every month with a duration of 3-4 days,

moderate flow on the first day that consume 3 sanitary napkins. The patient

experiences dysmenorrhea. The patient does not have any family planning

method.

Year Pregnancy Duration Mode of Live Birth/ Sex / Place of Status of TT

Order of Labor Delivery Still Birth Birth Delivery Immunization
weight
2014 G1 1 hour CS Live Birth M / N/A QMMC 1 DOSE
2019 G2 1 hour CS Still Birth M/ EVRMC N/A
3095mg
D. History of Present Illness

15 hours prior to admission, the patient suddenly experienced

hypogastric pain rated as 4 out of 10, nonradiating to the back, the patient

also noted no fetal movement. No interventions done. 13 hours prior to

admission, the hypogastric pain now rated 6 out of 10 and now radiating to

the back, still no fetal movement noted. 6 hours prior to admission, symptoms

persisted which prompted to seek consult at LPH, no Fetal Heart Tone was

noted hence referred and admitted to EVRMC.

E. Past Medical History

The patient has no childhood disease nor allergies. The patient

cannot recall what immunization that she received when she was a child but

believes she was fully immunized. No accident or injuries and maintenance

medication noted. She was only hospitalized due to past delivery of her 1 st

child. Regarding on mental health history, no mental illnesses noted.

F. Family History

The patient’s father and mother are still alive with and it was noted

that her mother was asthmatic. The type of family they have is nuclear. Her

partner’s name is Glycer Asis, and they have 1 male child.

G. Environmental History

The patient’s house is owned and the housing structure is mixed

materials. Their drainage system is closed with a water-sealed toilet. The

family’s source of water is from the water district and their way of garbage

disposal is by city collection and compost pit. They also practice garbage

segregation.
II. REVIEW OF FUNCTIONAL HEALTH PATTERN

A. Health Perception and Health Maintenance Management Pattern

The patient’s general health is stable. The patients view on how to

keep the body healthy is keeping the body moving by being able to go to

work, she also verbalized that she always eats fruits and drink 8 glasses of

water a day. The patient has never used tobacco and drugs in the past. She

performs breast self-examination. In following nurses/ doctors’ orders is easy

for her to follow because she believes it is for her own good. It is important

for her whenever she’s in the hospital to follow what the doctors advises to

make her feel better. The client doesn’t believe in traditional practices,

alternative medicines, and indigenous healers.

B. Nutritional and Metabolic Pattern

The patient’s typical food intake is 1 cup of rice, 1 piece of fish and 1

serving of any vegetable available in their fridge, drinks 8 glasses of water a

day she also eats chicken and pork twice a week. Her favorite food is

kakanin. Gain weight is noted due to pregnancy. The patient can heal well.

There are no signs of abnormalities in her integument. The client does not

manifest any dental problems.

C. Elimination Pattern

The client usually defecates every morning with consistency of soft,

smooth and colored brown and urinates 3x a day with yellowish in color and

varies if the patient keeps on drinking water with no discomfort in urinating

noted. No excessive perspiration and odor problems noted.

D. Activity- Exercise Pattern

The patients do not have proper exercise, the only physical activities

done is by doing household chores. The patient verbalizes that when she is
 going to work, she has sufficient energy to sustain the day. The client

verbalized that upon admission, she can do full self-care independently.

E. Sleep-Rest Pattern

The normal sleeping hours of patients at night is 8 hours. No difficulty

in falling asleep and does not take any sleep medications. Continuous but

she does not feel tired upon waking up. She doesn’t take a nap at the

afternoon. For relaxation, she watches movies and using her cellphone. But

when she was admitted, she has difficulty sleeping because on

environmental factors and discomfort.

F. Cognitive- Perceptual Pattern

No difficulty in hearing noted. The patient uses an eyeglass with an

anti-radiation lens. She doesn’t easily forget things. She has no difficulty in

learning and can easily learn through observing other people.

G. Self- Perception and Self-Concept Pattern

The patient describes herself as someone who is independent to

others. The changes in her body are the scars from the CS operation but she

has no problem with it. She feels guilt on the loss of her baby boy because of

the anatomy of her pelvis and the size of the head of her baby not being

proportionate, having inadequacy in the passage, and feels sorrow every

time she is reminded of that. The client easily gets annoyed from noisy

people.

H. Role Relationship Pattern

 The patient lives with her husband and one child. The family only has

misunderstandings and they are able to handle their problems through

discussing it calmly. The family depends on her as one would expect from a

mother, to nurture and guide her child, and do some house chores. Their

family felt worried and sad when they found out that there was fetal demise in

her uterus. It was as verbalized by the patient “damaging” for them. The

patient has no problem in handling her own child. The patient does not

belong to any social group but the patient said that she feels part of their

neighborhood and she has a best friend named Jillian who she can easily

rely on.

I. Sexuality- Reproductive Pattern

There are no changes or problems in their sexual relations. She has

had three sexual partners but is currently with her husband. The client did not

feel comfortable on sharing her first sexual contact. The client only uses

withdrawal as a family planning method.

J. Coping-Stress Pattern

In order to relieve stress or problems the patient just simply relaxed

and watch a movie. When she feels stress, she talks or share her problems

with her husband and she is always available whenever she needed her. A

big change to their life is the fetal demise of her baby as it would leave a scar

to them forever, but the client believes that it is God’s plan and if it happened,

there is nothing much to do than to move on and accept it.

K. Value-Belief Pattern

The patient believes that it is through God’s plan that life accords.

The thing that is most significant for the patient is the well-being of her family.
 The client verbalizes that she believes in God and when she prays every

day, she can overcome all the difficulties that arises.

III. NURSING HEALTH ASSESSMENT

A. Physical Assessment

General Survey

The patient has difficulty at ambulation at first, but a few day later is

able to move around more freely. The patient’s appearance is of blank

spacing. Her mental status is in sorrow as she had lost her baby.

B. Vital signs

The patient’s temperature was 36.1°C, a heart rate of 100bpm,

respiratory rate 20cpm, and a blood pressure of 110/70mmHg.

C. Organ System Assessment

i. The Integument

The patient has a fair skin tone and uniform in color, intact,

smooth and no rashes or redness noted. Skin is warm to touch with no

lesion palpated, elasticity and recoil immediately. Presence of

perspiration is noted. No edema noted. Surgical incision in the

abdomen was seen due to the caesarean birth. Hair is black and is

equally distributed. The armpit is dark in color. Nails are short but

there is presence of dirt on sides, hard, and immobile. Pink tone

returns less than 2 seconds as the pressure is released.

ii. The Head

The face is symmetric and the head is proportion to the body. No

lesions noted. Head is round and temporal artery is non-tender and

can perform mastication easily. The patient was able to do all facial

movement without difficulty. The eyebrows are symmetrically aligned

 and showed equal movements. Eyelids in normal position with no

abnormal widening. No redness, discharge or crusting noted on lid

margins. The vision acuity is 20/20. The patient can perform easily the

visual field test. Light reflex and pupil accommodation noted. The ears

are symmetric and smooth. No lesion noted. The nose is midline and

symmetric, no palpable sinuses and can sniff to every nostril. The

gums and tongue are pinkish in color. The teeth are white and no

presence of dental cavities. There are no signs of inflammation in the

tonsil.

iii. The Neck

The neck is symmetric. No bulging masses and lymph nodes are

noted. Thyroid cartilage and cricoid move upward symmetrically.

Trachea is midline.

iv. The Thorax and Lungs

Fast breathing was noted. It is symmetric and no tenderness or

pain and also free from lesions. Upon auscultating, clear sounds was

heard. The patient does not use any accessory muscle while

breathing.

v. The Cardiovascular and Peripheral Vascular System

Arms and also legs are symmetric and no edema noted on both

lower and upper extremities. No edema noted and color are bilaterally

same but differ on parts that constantly exposed to the sun. The

extremities are warm to touch. Capillary refill returns in 2 seconds or

less. Radial pulses on both extremities are strong and brachial pulse

have equal strength bilaterally. No palpable nodes noted. Allen test

was conducted and pink tone returns with 3-5 seconds. The patient

was able to perform ROM easily. The breast is symmetric and no pain
 or discomfort noted but no milk discharge observed. 3 inches wide

areola and half an inch nipple. Left breast is smaller than the right

breast.

vi. The Abdomen

Upon Inspection, there is surgical wound noted. Warm to touch

and the client feel pain in the area.

vii. The Musculoskeletal System

The patient wasn’t able to perform ROM easily. Both extremities

are symmetric.

viii. The Neurologic System

The patient was able to identify the scent (alcohol and soap).

Visual acuity of 20/20 both eyes. Eye movement was smooth and

coordinated. The pupil constricts as it accommodates light. Temporal

and masseter muscles contract bilaterally. The patient was able to

correctly identify the sharp, dull and ticklish sensation on both lower

and upper extremities. Facial movements are coordinated and

symmetric. The patient was able to hear properly and efficiently. Uvula

is midline and no signs of redness in the oral mucosa.

ix. The Genito-Urinary System

The patient refuses to be assessed on this area.

x. The rectum and Anus

The patient refuses to be assessed on this area.

 CHAPTER III

Clinical Management

I. Medical Management

CHEMISTRY RESULT FORM

NAME : ASIS, MARLIL DIOLA

PATIENT ID: 00267912
AGE/SEX : 32 Y/F
ROOM/WARD: OB-LOW RISK
REQUESTED BY : SANTOS, ROSA DESTURA
RESULT DATE: 12/04/2019 6:41:59 PM
DEPARTMENT : LABORATORY – RHNC
CHAARGE TO: PHILHEALTH

EXAMINATION RESULT UNIT REFERENCE

RANGE
FBS L 2.7 mmol/l 3.9-5.8
 HEMATOLOGY RESULT FORM
COMPLETE BLOOD COUNT RESULT

NAME : ASIS, MARLIL DIOLA

PATIENT ID: 00267912
AGE/SEX : 32 Y/F
ROOM/WARD: OB-LOW RISK
REQUESTED BY : SANTOS, ROSA DESTURA
RESULT DATE: 12/04/2019 6:51:19 PM
DEPARTMENT : LABORATORY – RHNC
CHAARGE TO: PHILHEALTH

EXAMINATION RESULT UNIT REFERENCE

RANGE
Hemoglobin L 109 g/L 120-150
Hematocrit L 0.33 U/L 0.37-0.47
 HEMATOLOGY RESULT FORM
COMPLETE BLOOD COUNT RESULT

NAME : ASIS, MARLIL DIOLA

PATIENT ID: 00267912
AGE/SEX : 32 Y/F
ROOM/WARD: ER
REQUESTED BY :
RESULT DATE: 12/03/2019 8:01:03 AM
DEPARTMENT : LABORATORY – RHNC
CHAARGE TO:

EXAMINATION RESULT UNIT REFERENCE

RANGE
Hemoglobin L 116 g/L 120-150
Hematocrit L 0.36 U/L 0.37-0.47
RBC L 3.96 X10^12/L 4.2-5.4
WBC H 19.32 X10^9/L 4.8-10.8
Differential Count
Neutrophils H 0.70 0.43-0.65
Lymphocytes L 0.19 0.20-0.45
Monocytes 0.06 0.05-0.12
Eosinophils H 0.04 0.01-0.03
Basophil 0.01 0-0.01

MCV 92 fL 81-99
MCH 29 Pg 27-31
MCHC L 318 g/L 320-360
Platelet 290 X10^9/L 150-400
Blood Type “O”
RH POSITIVE
NAME : ASIS, MARLIL DIOLA
PATIENT ID: 00267912
AGE/SEX : 32 Y/F
ROOM/WARD: ER
REQUESTED BY :
RESULT DATE: 12/03/2019 8:38:13 AM
DEPARTMENT : LABORATORY – RHNC
CHAARGE TO:

EXAMINATION RESULT UNIT REFERENCE

RANGE
HBsAg NONREACTIVE
PRE-INTRA-POST NURSING RESPONSIBILITIES
The role of nurses in collecting, labeling, and ensuring the timely and proper delivery
of specimens to the laboratory plays a very important thing in the hospital setting.
With this, nurses should be knowledgeable enough about the hospital’s policy and
procedures for specimen collection. However, nurses should not only possess the
right knowledge, but as well as the skill and understanding in performing necessary
procedures in accordance with the organization’s protocols, policies, and guidelines

Midstream “Clean-Catch” Urine Specimen

Midstream “clean-catch” urine collection is the most common method of obtaining

urine specimens from adults, particularly men. This method allows a specimen,
which is not contaminated from external sources to be obtained
without catheterization. It is important to follow the “clean-catch” protocol in order to
have accurate results from an uncontaminated sample.

Purpose

The clean-catch urine method is used to prevent germs from the penis or vagina
from getting into a urine sample. It is a method of collecting a urine sample for
various tests, including urinalysis, cytology, and urine culture.

Supplies and Equipment

 Sterile specimen cup

 Zephiran, a soap solution, or three antiseptic towelettes
 Three cotton balls (to use with zephiran or soap solution)
 Laboratory request form

Preparation

Explain to the patient that this kind of urine collection involves first voiding
approximately one half of the urine into the toilet, urinal, or bedpan, then collecting a
portion of midstream urine in a sterile container, and allowing the rest to be pass into
the toilet. Discuss that this is done to detect the presence or absence of infecting
organisms and, therefore, must be free from contaminating matter that may be
present on the external genital areas.

Procedure

For female patients:

1. Wash hands with soap and water.

2. Instruct the patient to clean perineal area with towelettes or cotton balls.
3. Tell the patient to separate folds of urinary opening with thumb and
forefinger and clean inside with towelettes or cotton balls, using
downward strokes only; keep labia separated during urination.
4. Instruct the patient to void a small amount of urine into the toilet to rinse
out the urethra, void the midstream urine into the specimen cup, and the
last of the stream into the toilet. The midstream urine is considered to
be bladder and kidney washings; the portion that the physician wants
tested.
5. Fill out the laboratory request form completely, label the specimen
container with patient identifying information, and send to the lab
immediately. A delay in examining the specimen may cause a false result
when bacterial determinations are to be made.
6. Wash your hands and instruct the patient to do it as well.

Note that the specimen was collected. Record any difficulties the patient had or if the

urine had an abnormal appearance.

II. Nursing Management

Patient focus identified:

 Acute pain

 Constipation

 Disturbed sleeping pattern

 Emotional fatigue

 Impaired comfort

 Risk for infection

 Pain at IV site

 Hygiene

 Readiness for enhanced knowledge r/t CS

 Impaired mood regulation

II. Surgical Management

There are pregnant women who have complications in their pregnancy and

are not allowed to give birth vaginally complications may be due to placenta previa,

placental abruption, uterine rupture, Breech Position, Cord Prolapse, Failure to

progress in labor, Fetal distress, Cephalopelvic Disproportion, or Repeat Cesearean.

Cesarean birth becomes the birth method of choice, which is entirely different from

vaginal birth, so from assessment until discharge, healthcare professionals

holistically adjust the care plan to accommodate the woman anticipating cesarean

birth.

Preoperative Assessment

A nursing assessment of a pregnant woman about to undergo cesarean birth is

also important to obtain health history that would become essential later on.

 Assess the woman about past surgeries, secondary illnesses, allergies to

foods or drugs, reaction to anesthesia, and medications that could increase

any surgical risk.

 The woman should be in the best possible physical and psychological state

before undergoing any surgery.

 An obese woman with poor nutritional status is at risk for a slow wound

healing.

 Tissue that contains extra fatty cells would be difficult to suture and the

incision will heal much slower and predispose the woman to infection and

dehiscence.

 An obese woman would also have difficulty in initiating ambulation and

turning after surgery as it will increase the risk for pneumonia or

thrombophlebitis.

 A woman with protein or vitamin deficiency is also at risk for poorer healing

because these are needed for new cell formation at the incision site.
 Age can also affect surgical risk because it can cause decreased circulatory

and renal function.

 A woman who has secondary illness is also at greater surgical risk

depending on the extent of the disease because the secondary illness may

affect the woman’s ability to adapt to the demands of the surgery.

 The general medication history of the woman must also be assessed

because there are drugs that could increase the surgical risk by interfering

with the effects of anesthesia.

 A woman with lower than normal blood volume might feel the effects of

surgery more than a woman with normal blood volume.

 An example of this is a woman who began labor and was told later on that

she should undergo cesarean birth instead because she may not have had

anything to eat or drink for almost 24 hours.

 To prevent fluid and electrolyte imbalance, intravenous fluid replacement is

initiated preoperatively and postoperatively.

 There are women who are very worried about the procedure, so they need a

very detailed explanation of the procedure before they can enter surgery

without intense fear.

 A woman who is frightened is at greater risk for cardiac arrest during

anesthesia administration.

 Acknowledge that the woman’s fear of surgery is normal so that she can view

her feelings as expected which could increase her self-esteem.

 The newborn is also at greater risk than those newborn born through vaginal

delivery.

 Infants born through cesarean delivery develop a degree of respiratory

difficulty because when a fetus is pushed through the birth canal, pressure

on the chest helps to rid the newborn lungs of fluid.

Intraoperative Measures

 While anesthesia is being administered, a surgical nurse will assist the

woman first to move from the transport stretcher to the operating table.

 The anesthesia of choice is usually a regional block.

 Encourage the woman to remain on her side or insert a pillow under her right

hip to keep her body slightly tilted to the side to prevent supine hypotension.

 In emergency cases, a spinal anesthesia is administered while the woman is

sitting up.

 It would be difficult for a woman in labor to remain in a curved position during

administration of the anesthetic, so talk to her gently and let her lean on you

while you gently restrain her.

 Epidural anesthesia is administered while the woman is lying on her side,

and it has an effect that lasts for 24 hours, so continuous pulse oximetry

must be used 24 hours post surgery to detect respiratory depression.

 For the skin preparation, shaving away abdominal hair and washing the skin

over the incision site with soap and water could reduce the bacteria on the

skin.

 The woman is then positioned with a towel under her right hip to move

abdominal contents away from the surgical field and lift her uterus away from

the vena cava.

 The woman would be covered by a sterile drape to block the flow of the

bacteria from her respiratory tract to the incision site and also block the

woman’s and support person’s lines of sight from the incision site.

 The incision area is scrubbed by an antiseptic, and additional drapes are

placed around the area so that only a small area of the skin is exposed.

 Prepare the woman and the support person for the sights they might see.
  A classic incision is made vertically through both the abdominal skin and the

uterus.

 A disadvantage of this type of incision is that it leaves a wide skin scar and

also runs through the active contractile portion of the uterus.

 The woman would not be able to have a subsequent vaginal birth because

this type of scar could rupture during labor.

 A low segment incision or low transverse incision is made horizontally across

the abdomen just over the symphysis pubis and also horizontally across the

uterus just over the cervix.

 This is the most common type of incision and is also referred to as “bikini”

incision.

 It is less likely that this type of incision would rupture during labor, so it is

possible for the woman to have VBAC in the future.

 It results in less blood loss, easier to suture, decreases puerperal infections

and less likely to cause postpartum gastrointestinal complications.

 The disadvantage of this incision is that it takes longer to perform, making it

inappropriate for an emergent cesarean birth.

Postpartal Care

The postpartal care period of a woman who has undergone emergent cesarean birth

is divided into two: immediate recovery period and extended postpartal period.

 After surgery, the woman would be transferred by stretcher to the

postanesthesia care unit.

 If spinal anesthesia was used, the woman’s legs are fully anesthetized so

she cannot move them.

 Pain control is a major problem after birth because it was so intense that it

interfered with the woman’s ability to move and deep breathe.

 This may lead to complications such as pneumonia or thrombophlebitis.

 Use a pain rating scale to allow a woman to rate her pain.

 Some women may need patient controlled analgesia or continued epidural

injections to relieve the pain.

 Supplement the analgesics with comfort measures such as change in

position or straightening of bed linen.

 Instruct the woman to ambulate because this is the most effective method to

relieve gas pain.

 Inform the woman that she should not take acetylsalicylic acid

or aspirin because this can interfere with blood clotting and healing.

 Instruct the woman to place a pillow on her lap as she feeds the infant to

deflect the weight of the infant from the suture line and lessen the pain.

 Football hold for breast feeding is a way to keep the infant’s weight off the

mother’s incision.

 During the extended postpartal period, the woman most commonly

experiences gastrointestinal function interference.

 Note carefully the woman’s first bowel movement after surgery because if no

bowel movement has been observed, the physician may order

a stool softener, a suppository, or an enema to facilitate stool evacuation.

 Teach the woman to eat a diet high in roughage and fluid and to attempt to

move her bowels at least every other day to avoid constipation.

 Incisional pain may interfere with the woman’s ability to use her abdominal

muscles effectively, so the physician may prescribe a stool softener.

 Caution the woman not to strain to pass stools because this puts pressure on

their incision.

 Advice the woman to keep their water pitcher full as a reminder for her to

drink fluids.
  Reassure the woman that it is normal not to have bowel movements for 3 to

4 days postoperatively, especially if there is enema administered before

surgery.

Management: Acute

 Transfer to postpartum ward when stable

 Vital Signs q15 minutes for 1 hour, then q4 hours

 Monitor intakes and outputs every 4 hours for 24 hours

 Activity:

 Bed rest

 Supine for 8 hours after spinal anesthetic

 Incentive Spirometry every 1 hour while awake

 Standard Diet: (as ordered by the physician)

 Nothing by mouth for 8 hours after cesarean section

 Sips of water after 8 hour window

 Advance to clear liquids as tolerated

 Advance to Regular diet when flatus or Bowel Movement

III. Nursing Management
HASMINE
Health Teaching: Shower as needed. Pat your incision dry. Watch incision for signs
of infection such as redness or drainage. Hold pillow against the incision when
laughing or coughing and when you get up from lying or sitting position. Remember,
it can task as long as 6 weeks for the incision to heal.
Anticipatory grieving: No factors affected. Patient needs to be ensured recovery
from her pregnancy, through follow - up check-up and health teaching on nutritional
needs of the baby.
Spiritual Support: emotional support by the family as their belief is to support the
mother by praying for her and instilling spiritual wisdom that helps her cope with the
process.
Medication: Paracetamol 900mg IVTT mpw, then 600mg IVTT for every six hours x
6 doses, Tramadol 500mg for every 8 hours x 8 doses then PRN for pain,
Cefuroxime 750mg IVTT every 8 hours, Omeprazole IVTT OD, Metronidazole
500mg IVTT every 8 hours
Incision: Educate and teach patient how to perform wound care and wound
dressing. Watch your incision for signs of infection, like more redness or drainage.
Hold a pillow against the incision when you laugh or cough and when you get up
from a lying or sitting position. Inform and educate the patient about the need of pain
medication that the physician prescribed together with the possible side effects.
Inform the client to keep the wound area clean. Inform the client to expect to tire
easily. And don't be active to the point of exhaustion. Educate the patient that it can
take as long as 6 weeks for her incision to heal.
Nutrition: Good nutrition is needed to speed healing after your cesarean and give
you needed energy. Keep up the good eating habit. Eat foods in high in protein,
vitamin C, and iron. Protein helps the healing process and is needed for the growth
of new tissue.
Exercise: Belly breathing for relaxation technique. Seated kegels for strengthening
and activate the pelvic floor, Wall sit for all the muscle groups to work together, and
leg slides like light impact exercises such as yoga, pilates or swimming but exercise
should not start until six to eight weeks after the surgery. Remember, the more
active you are, the more likely you are to have an increase in bleeding. Get lots of
rest. Take naps in the afternoon. Increase your activities so that you don’t have to go
up or down stairs more than needed.
BUBBLESHE
Breast - Encourage patient to wear a well-fitting bra. Educate patient to air dry
nipples after each feeding. Recommend to rinse breasts with water daily for
cleanliness. Advice patient to breast massage when there is insufficient milk
discharge. Advice patient to apply a few drops of breast milk after a feeding and let
air dry if nipples are sore. If breasts are engorged, tell patient to apply warm
compress.
Uterus- Let patient understand that postpartum pains or cramping are normal. This
cramping means that the uterus is contracting to return to its non-pregnant size. The
uterus takes 5-6 weeks to return to its non-pregnant size.
Bowels- Advice patient to consume diet high in fiber and fluids to help avoid
constipation. Recommend walking, this promotes bowel movements, passing gas,
and increased general circulation. Suggest patient to raise feet onto a stool during a
bowel movement, this helps decrease straining
Bladder- Educate patient that pregnancy, labor, and vaginal delivery causes stretch
or injury to pelvic floor muscles which supports the uterus, bladder, small intestine
and rectum. This might cause to leak a few drops of urine while sneezing, laughing
or coughing. Let patient understand that this problem usually improves within weeks.
Advice patient to rinse and clean perineal area every time of voiding.
Lochia - Educate patient there will be vaginal discharge usually lasts about 3 weeks,
but may last as long as 6 weeks. Advice patient to visit clinic / physician if bright red
lochia lasts more than 4 days.
Episiotomy - Educate and teach patient how to perform wound care and wound
dressing. Watch your incision for signs of infection, like more redness or drainage.
Hold a pillow against the incision when you laugh or cough and when you get up
from a lying or sitting position. Inform and educate the patient about the need of pain
medication that the physician prescribed together with the possible side effects.
Inform the client to keep the wound area clean. Inform the client to expect to tire
easily. And don't be active to the point of exhaustion. Educate the patient that it can
take as long as 6 weeks for her incision to heal.
Skin- Educate patient that stretch marks will not disappear after delivery, but
eventually fades from red to silver. Advice patient to provide adequate moisture to
skin to avoid dryness. Apply lotion to area of dryness.
Homan’s Sign- Explain to patient that elevating feet when sitting or lying down and
making sure to drink a lot of fluids will help body to get rid of excess fluid.
Emotions - Educate patient and significant others that one may get “baby blues”
after delivery. There may be presence of feeling let down, anxious, and crying. This
is normal. These feelings can begin 2-3 days after delivery and usually disappear in
about a week or two. Prolonged sadness may indicate postpartum depression.
Encourage patient to verbalize feelings to trusted support persons from time to time.
Encourage patient to seek God’s guidance over healing. Psychological treatment
can also be advised if client has suffered clinical depression which includes
counseling or therapy. Types of treatment may include antidepressant medication,
psychotherapy or both. Client may also be referred to a local support group.
 IV. APPENDICES
I. Physician’s Order
NAME OF PATIENT: Asis, Marlil Diola
SEX: Female
ADDRESS: Brgy. Magsaysay, Dulag
DATE AND TIME SOAP ORDER
12/2/19 (11PM) S> Morning PTA, no  Please admit patient
fetal
movement  under OB service
No abdl manipulation  Secure consent for
 admission and mgt
 TPR every 4 hrs
G2P1 (1001)  NPO
LD 2014, CS IX O>BP 110/70  Diagnostics:
Related to CPD HR 100 CBC, BT with RH, HbSHg,
Anti TP
LMP 3/16/19 RR 20 UA
AOG 37 2/7 wks + 36.1oC FBS
EDC FH 31 cm  For ‘E’ Repeat CS
FHT not appreciated  Secure consent
Pelvic Exam  Inform OR/Anes
PNCU- E/6; Grossly N  Start venoclysis with PLR iL
@ 30gtts
LPH, 8x I’, Parous  Cefazolin 1gm IV ANSTC
prior to
SIE’, (x bluish  OR then every 8 hrs
IE’,(X 3cm dil, 30%  Insert FBC, Fr. 16 attach to
effaced urobag
Cephalic, CDBOW,  Monitor VS every 15 mins
ST-I
 Secure 1 ‘u’ PRBC properly
typed
A>G2P1 (1001) And crossmatched for
Intraulerine Fetal possible OR use
Demise, 37 2/7 wks
AOG, cephalic, ILPL  Monitor 1 & O every shift
s/p CS 1x related to  To OR
CPD
(2014, Quirino Hosp.)  Refer
(Pfannenstrel incision) Dr. Santos

DATE & TIME SOAP ORDERS

11/3/19 ANESTHESIA POST OP ORDERS
TO PACU
NPO
Flat on bed for six hours due at 9
am, then may turn to sides
02 inhalation 3-5 Liter/minutes in
the next 6 hours
 Monitor VS every 15 minutes for 2
hours, then every 30 minutes for 5
hours
Infuse IVF of PLR at 80gtts/min
IVF to follow same rate, 2 D5LR at
30gtts/min
Medications:
Paracetamol 900mg IVTT mpw,
then 600mg IVTT for every six
hours x 6 doses
Tramadol 500mg for every 8 hours
x 8 doses then PRN for pain
Cefuroxime 750mg IVTT every 8
hours
Omeprazole IVTT OD
Metronidazole 500mg IVTT every 8
hours
Monitor input and output every shift
Refer any unusualities, watch out
for flatus
Refer accordingly
Dr. Zacate

DATE & TIME SOAP ORDERS

12/4/19 S- (-) DM May have sips then may have clear
liquids
6:50 AM (-) Flatus May have general liquids with
crackers and hardboiled egg once
flatus
(-) Belching Continue IVF & IVTT meds
UO: 62.5 cc/hr Detach FBC now
*Complains pain on Administer medications once there
post op site is flatus
O – BP: 110/80 1. FeSO4 + FA 1 tab OD
HR: 88 2. Ascorbic Acid 500mg 1 tab OD
RR: 16 3. Celecoxib 500mg 1 tab BID PRN
for pain
T: 36.5 Still for UA
For IUD installation Still for FBS
Perinial Hygiene
Monitor I & O every shift
Refer
Dr. Casio

DATE & TIME SOAP ORDERS

12/5/19 S>(-) BM (-) May have Soft Diet
belching
(-) flatus IVF to be consumed then terminate
UO:Freely voiding
Hop: 159 O> BP:130/90 RR:16 Shift to Cefuroxime 500mg every 4
hours
HR: 70 T: 36.2 Continue other PO meds
Please give Lactulose PO OD @
HS
Perineal Care twice a day
VS every 4 hours
I & O every shift
Still for ff results
Refer
Dr. Santos

DATE & TIME SOAP ORDERS

12/6/19 Soft Diet
FF results from lab
Encourage to ambulate
Give Bisacodyl suppository now
Encourage perinial care BID
Dr. Santos

DATE & TIME SOAP ORDERS

12/7/19 8am S>(+)BM DAT
(+) Flatus MGH today
(+) Belching  Home medications:
D5 Freely voiding  Cefuraxine 500 mg 1 tab TID
x 7 days
D4 post op O> BP: 120/80  Metronidazole 500 mg 1 tab
TID x 6 days more
HR: 92 1. Celecoxib 200mg 1 cap
BID PRN for pain
RR: 16 2. Ascorbic acid 500mg 1
cap OD x 1 month
T: 36.1 3. FA + FeSO4 1 cap OD x
1 month
4. For discharge LE
5. For breastfeeding
For wound dressing daily
 Perineal care BID
 TCB after 1 week (12/13/19)
for follow up
 Advised
II. Recommendations

The proponent of this case study recommend that further studies shall be made for

the various diagnosis and problems of the patient. In order for the health care providers

including nurses and student nurses will be equipped with knowledge , skills, values, and

attitude in providing care for patients having this condition. Further studies about the health

condition of the patient will help the family better understand this condition, in order that they

could better take care of their family member.

This study is also recommended for nursing students who will conduct case

presentation that that will have a flow on the proponents needed for a case presentation.

They will be enhanced of knowledge, skills, values, and attitude in conducting a case

presentation especially in making thorough assessment of their patient.

It is also of high consideration that further evaluation be done to determine the

progress and compliance of the patient to the out-patient treatment regimen. Aside from this,

the sources of data for this case presentation is only limited to the assessments, laboratory

results, patient’s chart and personal interview with the patient, as well as on her significant

others. Progression of the patient’s recovery must also be monitored and documented

regularly to determine the necessary changes and improvement of patient’s care.

 Chapter V

REFERENCES

Cephalopelvic Disproportion (CPD): Causes and Diagnosis. (2019, October 13). Retrieved
from https://americanpregnancy.org/labor-and-birth/cephalopelvic- disproportion/

C-Section: Procedure & Recovery. (n.d.). Retrieved from

https://www.livescience.com/44726-c-section.html.

Stanford Children's Health. (n.d.). Retrieved December 12, 2019, from

https://www.stanfordchildrens.org/en/topic/default?id=cesarean-delivery-92-
P07768

Sehdev, H. M. (2019, February 14). Cesarean Section (C-Section) Birth Procedure:

Recovery & Scar Healing. Retrieved December 8, 2019, from
https://www.emedicinehealth.com/cesarean_childbirth/article_em.htm.

Women’s Care Center, Kent Hospital. (2016, January 7) Retrieved from

http://www.kentri.org/services/pregnancy/postpartum-discharge-instructions.cfm

Midline Plus. (2013, March 21). Retrieved from

https://medlineplus.gov/ency/patientinstructions/000624.htm

Nurses Lab. (2013). Retrieved from https://nurseslabs.com/cesarean-birth/

Stanford Medicine. (2015). Retrieved from

https://www.stanfordchildrens.org/en/topic/default?id=cesarean-delivery-92-P07768

Cleveland Clinic. (2016). Retrieved from https://my.clevelandclinic.org/health/articles/7247-

fetal-development-stages-of-growth