ENGLISH

EXAMINATION
1. Ibi Yulia Setyani
(P1337420617032)

2. Mutiarra Ramadhani S.
(P1337420617043)

3A3 RKI
NURSING MATERNITY’S
CASE REPORT
Caesarean Section
a surgical procedure involving incision of the walls of the abdomen and uterus for delivery
of baby.
A caesarean section is often necessary when a vaginal delivery would put the baby or
mother at risk.
This may include obstructed labor, twin pregnancy, high blood pressure in the mother,
breech birth, or problems with the placenta or umbilical cord.
Preeclampsia
Pre-eclampsia is a pregnancy complication condition that
affects some pregnant women, usually during the second half
of pregnancy (from around 20 weeks) or soon after their
baby is delivered. characterized by high blood pressure

PROM
Premature rupture of membranes (PROM) is the rupture of
the fetal membranes before the onset of labor.
when membrane rupture occurs before 37 weeks’ gestation, it
is known as preterm PROM
Date of Assesment : Tuesday, 1st of September, 2019 14:20 PM
Ward / Hospital : Obstetric Room / GHC Dr. Kariadi Semarang

A. Client’s General Data

• Initial client : Ny. R
• Age : 40 years
• Marital status : Married
• Occupation : Housewife
• Last education : high school
• Address : East Ungaran
• Medical diagnosis : P3A2 Post Sectio caesarea
 Sign and symptoms of preeclampsia may include:
High blood pressure may develop slowly, or it may have a sudden onset.
blood pressure that exceeds 140/90 millimeters of mercury (mm Hg
)
1. Excess protein in your urine (proteinuria)
2. Severe headaches
3. Changes in vision, including temporary loss of vision, blurred vision or
light sensitivity
4. Nausea or vomiting
5. Decreased levels of platelets in your blood (thrombocytopenia)
6. Shortness of breath, caused by fluid in your lungs
B. Medical History

Main Complaints

The patient complained of pain due to a postoperative cesarean section with

a scale of 4 from 1-10. 3 days after giving birth the patient also complained
of breast milk has not come out
Present Nursing History

On 22nd of September, 2019 The Patient said that water came out of the birth canal
like amniotic fluidthen the patient went to the midwife to check it out, from the
midwife it was suggested to be referred to Ken Saras Hospital for hospitalization.

On 22nd of September, 2019

- The patient came to Ken Hospital Saras and hospitalized for a week.
- performed an ultrasound examination and found a breech baby presentation, it was
recommended to do a caesarea sectio because of indications of premature rupture
of membranes and breeches, but because they did not have adequate tools then
they were referred to the General Hospital center Dr.Kariadi Semarang.

In the ER, vital signs were measured with a BP = 147/92 mmHg, pulse = 92x/beats,
RR = 20x/breaths, Temperature = 36.8 ℃. when at Dr.Kariadi Hospital in Semarang
the membranes had ruptured for 6 days, the client had felt the tightness.
Then performed caesarea sectio. After a cesarean section was performed, a male
baby born with a body weight = 1900 grams was treated at PBRT, then the patient
was transferred to the obstetric room. Then after 3 days the patient was moved in the
puerperium.
Previous history of the patient

• had experienced P3A2 and 1 time Caesarean Sectio with indications of KPD.
• At present the client's pregnancy is indicated by breech and experiencing KPD.
• at this time the client also suffers from hypertension which results in the client
suffering from severe preeclampsia. This makes the client have to give birth by
Caesarean Sectio
 C. Data Analysis

Date Focus Data Etiology Nursing Diagnose Sign

Tuesday, SD: - invasive procedure Risk of infection

1st of September,
2019 14:20 PM OD:There is a cross section of
caesarean section along ± 18 cm, with
20 stitches between the symphysis pubis
and umbilicus, the wound does not
appear to dry out, the incision wound
does not appear to close.
Temperature: 37 ℃
Tuesday, SD: the patient said that breast milk has mother in the Inadequate milk
1st of September,
2019 14:20 PM not come out treatment program production
OD: when milked it appears to only
produce as much as 1 spoonful milk, the
rooting effect (-) is due to a 7 month
premature baby with weight 1900 grams
in intensive care
 D. Nursing Care Plan

Nursing Intervensi
No. Date
Diagnose (NOC) (NIC) Sign
1 Tuesday, Risk of After the intervention Infection Protection
1st of
September, infection 1x24 hours the patient • Monitor vital signs
2019 14:20 related to does not occur with • Teach and advise
PM
invasive infection patients about proper
procedure Result criteria: hand washing
• Leukocytes are within techniques
normal limits • Monitor the
• There is no infection description of the
• Patients and families condition of the skin
can mention the signs • wound care
and symptoms of
infection
 Nursing Intervensi
No. Date
Diagnose (NOC) (NIC) Sign

1 Tuesday, Inadequate After taking nursing • Teach how to care for

1st of breasts
September, milk actions for 3 x 24 hours, • Teach oxytocin
2019 14:20 production it is expected that the massage techniques
PM
related to ability of breast milk
mother in production can increase
the with the expected results:
treatment • ASI production
program increases
E. Implementation
DOING WOUND CARE
Purpose:
• prevent from infection
• accelerate wound healing

How to do?
1.
Evaluation

S  The patient said no sign of infection

O
• There is a cross section of caesarean section along ± 18 cm, with 20
stitches between the symphysis pubis and umbilicus.
• The skin does not appear blisters
• Incision wounds are no longer bleeding
• pus (-)
• The wound looks clean but has not closed and dried
• Leukosit=
• Suhu = 36,8 ℃ RR = 20 x/breath Pulse= 88x/beats
A mother in the treatment program
P
• Continue wound care intervention (dressing)
• Monitor the wound condition
DOING OXYTOSIN MASSAGE
massage done in the area along the spine to facilitate the expenditure of breast milk. This
massage can trigger the release of oxytocin, in which oxytocin is a hormone needed to
express milk.

Purpose:
• Reduces swelling
• Reducing the blockage of breast milk
• Stimulates the release of the hormone oxytocin
• Maintain breast milk production when both mother and baby are sick.

How to do ?
1. k
Evaluation

S  Patient said breast milk only came out a little

O  breast milk looks out only one tablespoon
The rooting effect (-) is due to the baby undergoing intensive care at PBRT
A  Inadequate production of breast milk related to the mother in the
treatment program
P  Continue intervention
• Perform breast care routinely
• Perform oxytocin massage techniques
I have Injected to the patient

Medicine:
Purpose: