An OR write-up on

CESAREAN SECTION

Presented to
The Faculty of the School of Nursing
University of Baguio

In Partial fulfilment of the

Requirements for the Subject NCENLO5

Presented by:
NMB 4
Am-maran, Shara Mae
Bicol, Myra
Bisares, Krizza Febrylle
Fernandez, Gladys Armie
Menor, Gwen
Nogal, Bernadette
Nuez, Charlene Patricia
Paguinto, Joyce

Clinical Instructor:
Mr. Jonathan P. Vicente, RN, MAN
May 2014

TABLE OF CONTENTS

Introduction............................................. 3
CHAPTER I
Patients Profile......................................... 4
CHAPTER II
Anatomy and Physiology................................... 5
CHAPTER III
Pathophysiology.......................................... 8
Narrative........................................... 8
Schematic........................................... 9
CHAPTER IV
Procedure............................................... 10
CHAPTER V
Instrumentation......................................... 15
CHAPTER VI
Drug Study.............................................. 22
REFERENCES.............................................. 25

Introduction
Cesarean delivery is defined as the delivery of a fetus
through surgical incisions made through both the abdominal
wall and the uterine wall. The words Cesarean and
section are both derived from verbs that mean to cut; the
phrase caesarean section is a tautology.
Cesarean deliveries were initially performed to
separate the mother and the fetus in an attempt to save the
fetus of a moribund patient. This operation subsequently
developed into a surgical procedure to resolve maternal or
fetal complications not amenable to vaginal delivery.
The caesarean delivery was evolved from a vain attempt
performed to save the fetus to one in which the physician
and patient both participate in the decision-making process,
striving to achieve the most benefit for the patient and her
unborn child. Currently, caesarean deliveries are performed
for a variety of fetal and maternal indications. The
indications have expanded to consider the patients wishes
and preferences.
There are many reasons why a health care provider might
feel that you need to have a caesarean delivery. Some
cesareans occur in critical situations, some are used to
prevent critical situations, and some are elective. Some
reasons that a caesarean section is needed: placenta previa,
uterine rupture, breech position, cord prolapsed, fetal
distress, and multiple births.

CHAPTER I
Patient Profile
Name: Patient X
Sex: Female
Birthday: October 17, 1990
Age: 43
Nationality: Filipino
Religion: Roman Catholic
Address: Burgos, La Union
Pre-Operative Diagnosis: G2P1(2-0-0-1) Pregnancy uterine 39
weeks AOG cephalic in labor, previous Cs 1x for CPD
Operation Performed: Emergency LSCS 2x for previous scar for
CPD
Post-Operative Diagnosis: G2P2 (2-0-0-2) Pregnancy Uterine
delivered cephalic term , alive baby girl
Surgeon: Dr. Tino
Assistants: Dr. Lampacan
Anesthesiologist: Dr. Leao
Anaesthesia: SAB
Anaesthesia started: 7:26 PM
Operation started: 7:32 PM
Operation finished: 8:00 PM

CHAPTER II
ANATOMY AND PHYSIOLOGY

The ovary is the organ that produces ova (singular,

ovum), or eggs. The two ovaries present in each female are
held in place by the following ligaments:

The broad ligament is a section of the peritoneum

that drapes over the ovaries, uterus, ovarian ligament, and
suspensory ligament. It includes both the mesovarium and
mesometrium. The mesovarium is a fold of peritoneum that
holds the ovary in place.

The suspensory ligament anchors the upper region

of the ovary to the pelvic wall. Attached to this ligament
are blood vessels and nerves, which enter the ovary at the
hilus.

The ovarian ligament anchors the lower end of the

ovary to the uterus.
The uterus (womb) is a hollow organ about the size and
shape of a pear. It serves two important functions: It is
the organ of menstruation and during pregnancy it receives
the fertilized ovum, retains and nourishes it until it
expels the fetus during labor. The uterus is located between

the urinary bladder and the rectum. It is suspended in the

pelvis by broad ligaments.
Division of uterus
The uterus consists of the body or corpus, fundus,
cervix, and the isthmus. The major portion of the uterus is
called the body or corpus. The fundus is the superior,
rounded region above the entrance of the fallopian tubes.
The cervix is the narrow, inferior outlet that protrudes
into the vagina. The isthmus is the slightly constricted
portion that joins the corpus to the cervix.
The walls of the uterus
The walls are thick and are composed of three
layers: The endometrium, the myometrium, and perimetrium.
The endometrial is the inner layer or mucosa. A fertilized
egg burrows into endometrium (implantation) and resides
there for the rest of its development. When the female is
not pregnant the endometrial lining sloughs off about every
28 days in response to the changes in levels of hormones in
the blood. This process is called menses. The myometrium is
the smooth muscle component of the wall. These smooth muscle
fivers are arranged. In longitudinal, circular, and spiral
patterns, and are interlaced with connective tissues. During
the monthly female cycles and during pregnancy, these layers
undergo extensive changes. The perimetrium is a strong,
serous membrane that coats the entire uterine corpus except
the lower one fourth and anterior surface where the bladder
is attached.

The cervix is a narrow region at the bottom of the

uterus that leads to the vagina. The inside of the cervix,
or cervical canal, opens to the uterus above through the
internal os and to the vagina below through the external os.
Cervical mucus secreted by the mucosa layer of the cervical
canal serves to protect against bacteria entering the uterus
from the vagina. If an oocyte is available for
fertilization, the mucus becomes thin and slightly alkaline.
These are attributes that promote the passage of sperm. At
other times, the mucus is viscous and impedes the passage of
sperm.

CHAPTER III
PATHOPHYSIOLOGY

NARRATIVE:
Cephalopelvic disproportion (CPD) occurs when a
babys head or body is too large to fit through the
mothers 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
cesarean.
The disorders pathophysiological aspects include the
mother being unable to birth the child naturally due to the
babys head being too large to fit through the pelvis. This
is a rare condition, and there are only theories as to why
this occurs. It is thought that the physiology of the mother
may have something to do with the condition. If a mothers
pelvis is abnormally shaped, this can happen. It can also
occur if the mother has a small pelvis. This may also occur
if the due date is long past and the baby is still growing,
causing the head to surpass the size of the pelvis.

SCHEMATIC:
CAUSE: Increased fetal
weight

Baby cannot pass

through the inlet of
pelvis

Poor fetal descent

Prolonged first stage

of labor

CPD

Cesarean Section

CHAPTER IV

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PROCEDURE
The patient is brought to the operating room per
stretcher with an ongoing IVF of D5LRS at full level
accompanied by IWDO. She was transferred to the operating
table, placed in a supine position comfortably. She was
attached to cardiac monitor and prepared accordingly.
A. Anesthesia
The anesthesia provider, typically an anesthesiologist
or a nurse anesthetist, will begin the surgery by giving a
sedative by IV to relax the patient. Once the patient is
relaxed, a breathing tube, or endotracheal tube, is threaded
through the mouth and into the windpipe before being
connected to the ventilator.
The breathing tube is necessary because general
anesthesia causes paralysis in addition to rendering the
patient unconscious. While paralyzed, the patient cannot
breathe without assistance and depends upon the ventilator
to supply air to the lungs.
Subarachnoid Block (SAB) was infiltrated at the lumbar
area specifically T3 to T4 to locate the cerebrospinal fluid
by Dr. Macaballog.
Once the anesthesia has taken full effect, the surgeon
can begin making the incision, without the patient feeling
pain or waking. During the surgery, the patient will be
closely monitored by the anesthesiologist, with the vital
signs being observed throughout the surgery and medications
given as needed.

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B. Position
During caesarean section operation, patient will lie on
an operating table in supine position, which is tilted or
wedged to the left. It's tilted so the weight of your uterus
doesn't reduce the blood supply to the lungs and make the
blood pressure drop. Arms may be extended on arm-boards.

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Insertion of an Indwelling Foley Catheter was inserted

aseptically by the circulating nurse.

C. Skin preparation
Skin prep aids in preventing surgical site infection
(SSI) by removing debris from, and cleansing, the skin,
bringing the resident and transient microbes to an
irreducible minimum, and hindering the growth of microbes
during the surgical procedure. The skin prep agents should
have the following properties: fast-acting, persistent and
cumulative actions, and non-irritating.
In cesarean section, skin preparation begins at the
incision site (infra umbilical vertical or low transverse)
extending from nipples to mid thighs, and down to the table
at the sides done by the circulating nurse.

D. Draping

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The skin is swabbed with a solution that kills germs to

help prevent infections along the incision. Once the skin is
prepared for surgery, the doctors will cover the patient
with sterile drapes to keep the area as clean as possible
during the procedure which were done by Dr.
The patient is draped with folded towels and a
laparotomy (or transverse) sheet. An additional sheet is
needed to cover a second back table for the infant.

Discussion of the Procedure (Before and after the incision)

The cesarean operation and bilateral tubal ligation
began with the surgeon first making a horizontal incision by
dissecting the abdomen from the skin low across the belly.
Vertical incisions generally allow faster abdominal entry,
cause less bleeding and nerve injury, and can be easily
extended cephalic and one of the most procedures in skin
incision used was a vertical incisions. Before doing the
operation the two surgeons draped the patient exposing her
umbilicus to the symphysis pubis and the surgeon applied
betadine solution on the incision site. Incision thru the
skin with skin knife (#3 scalpel handle with #10 blade).
Subcutaneous tissue and muscle tissue are incised with the

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deep knife (#7 scalpel handle with #15 blade). Fascia is

incised,

and

the

underlying

muscles

are

retracted

with

bladder retractor and richardson. The surgeon grasps the

peritoneum with a thumb forcep and incised it with deep
knife. The incision is completed with curved mayo scissor
and the baby came out. The surgeon carry alive the baby and
they cut immediately the umbilical cord followed by the
removal

of

Richardson

the

placenta.

retractors,

the

Wound
uterus

edges
is

are

retracted

identified

and

by
its

fallopian tube supply ligated and the stump is tied off with
absorbable suture. The peritoneal cavity is irrigated with
NS and the fluid is removed with suction several times. Two
tissue forceps and Adson were used to grasp the peritoneum
to assist in its exposure for closing. The peritoneum is
closed with continuous suture. The abdominal wall is then
sutured by layers; fascia, muscle, subcutaneous tissue, and
skin. After which the wound is dressed. After the surgical
procedure, we then did after care of the mother such as
cleaning of the surgical area, removal of the dirty drapes,
assuring mother is stable and after care of the instrument.

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CHAPTER V
INSTRUMENTATION
5 KELLY CURVE
4 ALLIS
5 STRAIGHT
4 TOWEL CLIPS
1 BAB COCK
1 BLADE HOLDERS
2 NEEDLE HOLDERS
1 MAYO SCISSOR
1 METZENBAUM
1 TISSUE FORCEP
1 THUMB FORCEP
1 RICHARSON
1 BLADDER RETRACTOR
1 PLACENTAL BOWL
1 CORD CLAMP
1 SUCTION TUBE

Surgical Instrument - Curved Mayo Scissors

Classification-Cutting

Use - used for cutting dense tissue

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Surgical Instrument Straight Mayo Scissors

Alias - Suture Scissors

Classification-Cutting

Use-use to cut suture

Surgical Instrument-Curved Metzenbaum Scissor

Classification-dissecting scissor
Use-used to cut delicate soft tissues

Surgical Instrument-Metzenbaum scissors

Classification- cutting/dissecting
Use- dissects medium-fine tissue

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Surgical Instrument-Thumb Forceps

Classification-grasping
Use-use to grasp tough tissue

Surgical Instrument-Tissue Forceps

Classification-grasping
Use-to holds skin/dense tissue.

Surgical
Instrument-#3

knife handle
Classification-cutting/dissecting
Use-cutting/incisions/dissecting.

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Surgical Instrument-#4 knife handle

Use-cutting/incisions/dissecting
Classification-cutting/dissecting

Surgical Instrument-#10
knife blade
Classification-cutting/dissecting
Use-cutting/incisions/dissecting

Surgical Instrument-#11
knife blade
Classification-cutting/dissecting
Use-cutting/incisions/dissecting

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Surgical Instrument-Straight clamp

Classification-Clamping/occluding
Use-use to clamp or tag sutures.

Surgical Instrument-Curved clamp

Classification-Clamping/occluding
Use-use to clamp deep tissue.

Surgical Instrument- Needle Holder

Classification-suturing
Use-to hold suturing needle

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Surgical instrument-traumatic needle

Classification-suturing
Use- for suturing

Surgical Instrument-adson
Forceps
Classification-grasping
Use-used to grasp delicate tissues.

Surgical Instrumentsponges/lap sponge

Use-used to absorb liquids from a surgical site.

Surgical
Instrument Richardson

Retractor
Classification-Retractor

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Use-used to retract deep abdominal or chest incision.

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CHAPTER VI
DRUG STUDY
Drugs
Ampicillin
500mg IV

Classification
>Anti-infective

Mode of Action

Side Effects

>Destroys
bacteria by
inhibiting
bacterial cellwall synthesis
during microbial
multiplication.
Addition of
sulbactam
enhances drugs
resistance to
beta-lactamase,
an enzyme that
can inactivate
ampicillin.

> CNS: lethargy,

hallucinations,
anxiety, confusion,
agitation,
depression, fatigue,
dizziness, seizure
CV: vein irritation,
thrombophlebitis,
heart failure
EENT: blurred
vision, itchy eyes
GU: nausea,
vomiting, diarrhea,
abdominal pain,
enterocolitis,
gastritis,
stomatitis,
glossitis
Respiratory:
wheezing, dyspnea,
hypoxia, apnea

Nursing
Consideration
>Ask patient
about history of
penicillin
allergy before
giving. Let vial
stan for several
minutes until
foam has
evaporated
before
administering
drug. Give
intermittent
infusion in 50
to 100 ml of
compatible
solution over 15
to 30 minutes

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Ketorolac
30 mg IV

>Analgesic,
antipyretic,
anti-inflammatory

>Interferes with
prostaglandin
biosynthesis by
inhibiting
cyclooxygenase
pathway of
arachidonic acid
metabolism; also
acts as a potent
inhibitor of
platelet
aggregation.

>CNS: drowsiness,
headache,dizziness,
CV: hypertension
GI: nausea,
vomiting, diarrhea,
constipation,
flatulence,
dyspepsia,
epigastric pain,
stomatitis
Skin: rash pruritus,
diaphoresis
Others: excessive
thirst, edema,
injection site pain

>Monitor for
adverse
reactions,
especially
prolonged
bleeding time
and CNS
reactions. Check
IM injection
site for
hematoma and
bleeding.
Monitor fluid
intake and
output.

Tramadol
50mg IV

>Analgesic

>Inhibits
reuptake of
serotonin and
norepinephrine
in CNS

>CNS: dizziness,
vertigo, headache,
drowsiness, anxiety,
stimulation,
confusion,
incoordination,
euphoria, sleep
disorder, asthenia,
seizure
CV:vasodilation
EENT: visual

>Assess
patients
response to drug
30 minutes after
administration.
Monitor
respiratory
status. Withhold
drug contact
prescriber if
respiration

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disturbances.
GI: nausea,
vomiting, diarrhea,
constipation,
abdominal pain,
dyspepsia,
flatulence, dry
mouth, anorexia
GU: urinary
retention and
frequency,
proteinuria,
menopausal symptoms

becomes shallow
or slower than
12 breaths per
minute. Monitor
for physical and
psychological
drug dependence.

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