Philippine Christian University

MARY JOHNSTON COLLEGE OF NURSING

415 Morga Street, Tondo, Manila 1012, Philippines

A CASE PRESENTATION ON:

CESAREAN DELIVERY

Submitted By:

Angeles, Angelica E.

Bernandino, Jake Wilson M.

Labto, Justine Bernadeth D.

Matibag, Micah Kiel Sherinne C.

Plomines, Angeline Marie G.

BSN-II, Class 2022

Submitted To:

Ms. Gladys T. Cruz

Clinical Instructor

26 February 2020
I. INTRODUCTION

  In a C-section, surgery is performed, with an incision made in the mother’s abdomen and
uterus, so the baby can be taken directly from the uterus instead of traveling through the birth
canal.

Cesarean sections are done most often when:

 The mother has had a previous baby by Cesarean delivery

 The obstetrician feels that the baby’s health might suffer if born vaginally
 The fetus’s heartbeat slows abnormally or becomes irregular (in which case the
obstetrician will perform an emergency C-section instead of taking the chance of
allowing labor to progress)
The birth experience with a C-section is very different from that of a vaginal delivery.
For one thing, the whole operation ordinarily takes no more than an hour, and—depending on the
circumstances—you may not experience any labor at all. Another important difference is the
need to use medication that affects the mother and may affect the baby. If given a choice of
anesthetic, most women prefer to have a regional anesthesia—an injection in the back that blocks
pain by numbing the spinal nerves—such as an epidural or a spinal. Because of the effects of the
anesthesia and the way the baby is delivered, babies born by C-section sometimes have difficulty
breathing in the beginning and need extra help. A pediatrician or other person skilled in newborn
problems usually is present during a Cesarean section to examine and assist the baby’s breathing,
if necessary, immediately after birth.

If the patient is going to breastfeed, try to nurse the baby as soon as you feel well enough.
Even if the baby is drowsy, her first feeding should provide a reason for her to wake up and meet
her new world—and her mother. It will also help stimulate breast milk production.

As mentioned, many obstetricians believe that once a woman has a C-section, her
subsequent babies should be delivered the same way because of higher rates of complications
with vaginal deliveries after previously having a C-section. However, many women are
candidates for a vaginal birth after Cesarean section (VBAC). But a decision to do this will
depend on a number of factors and should be made together between the patient and the doctor.
 The rate of cesarean sections around the world is increasing at an "alarming" rate,
reported an international team of doctors and scientists. Since 1990, C-sections have more than
tripled from about 6 percent of all births to 21 percent, three studies report in The Lancet. And
there are no "signs of slowing down,”

C-sections now outnumber vaginal deliveries in parts of southeast Europe, Latin America
and China. Even in poor countries, the rates can be extremely high at clinics. For example, in
Bangladesh, less than 60 percent of births occur at a clinic, but when they do, about 65 percent of
them are C-sections.

The rates can be even higher in private clinics. For example, in Brazil, 80-90 percent of
births in private clinics are now C-sections, compared with about 30-40 percent of births in
public hospitals.

For a mom, an elected C-section can raise the chance of death by at least 60
percent and in some circumstances as much as 700 percent, several studies have reported. And
it increases a woman's risk of life-threatening complications during childbirth, such as bleeding,
uterine rupture, hysterectomy and cardiac arrest by about fivefold. This risk rises even further in
subsequent deliveries.

Statistics Report for CS Deliveries from Department of Health’s Office

TYPES OF 2010 2011 2012 2013 2014 Remarks

DELIVERIES
NSD 2964 2488 3013 2,280 2,217(86% 3%

 High Risk )

Condition 1,358
(52%)
CS 102 122 298 251 374(14%) 49%
TOTAL 3066 2610 3311 2,531 2,591
COMPARATIVE DATA ON THE TYPES OF DELIVERIES, 
LPGH & STC, 2010 & 2014

 
 Among the total number of deliveries handled and admitted, 86% delivered by NSD and
14% by Caesarean Section. Of all those delivered through NSD, 52% (N=1358) were with High
Risk conditions. High risk condition was based on the WHO High Risk coding for pregnant
women.  

            CS rate is 14%, this is higher than the acceptable level of 3-4% based on Western
Standards, as per FOGS indicator their acceptable level is 15%.

Our group chose this topic in relation to our course, “Care of Mother, Child at Risk or
with Problems (Acute and Chronic)”. Nowadays, the statistics for CS delivery is gradually
increasing as years passed by due to several factors that are associated with pregnancy. We took
this opportunity to take care of a client who underwent Cesarean Delivery for the second time
and applied our knowledge and skills to give the best quality of care the client needed after
delivery. With this case that we had, we also gained knowledge as we impart ours to the client;
it’s like a give and take process. The client learned from us and we also learned from her
situation. Most of us have no experience of taking care of a post-partum client after a CS
Delivery and that’s what pushed us to choose this client and her case for us to study and for us to
dig into deeper information to properly handle all her worries and problems that a student nurse
can take care of. Out of the wildest curiosity and eagerness we had on ourselves, we conducted
our assessment to further know her complaints and to build rapport that could help us in doing
our interventions individually and confidently. In line with this, we also conducted health
teachings that the patient can bring and practice on their home for the whole post-partum period
and until the patient wished to bear another baby.

Our level of happiness and enlightenment rose to ecstatic as we know that this case study
we had will unfold new beginnings and knowledge as we embark to our different paths with
same desires in our hearts – to become a Nurse.
II. DEMOGRAPHIC DATA
Name: C. R.G.
Age: 27 years old
Sex: Female
Address: C-2 1f Numancia Res, Urbiztundo St. Brgy. 282, Bdo, Mla
Birthdate: December 5, 1992
Occupation: Staff at Puregold Ylaya
Civil Status: Single (with live-in partner)
Religion: Roman Catholic
Nationality: Filipino
Educational Attainment: College Graduate
Informants: Mr. Ruel Dañosa – Live-in partner
Ms. Jennelyn Dañosa – Sister-in-law
Case Number: 821598
Room No.: 306-2
Date of Admission: February 17, 2020
Time: 12:15pm
Attending Physician: Dr. Santiago

III. NURSING HISTORY

• History of Present Illness

Few hours, client noted hypogastric pain without other associated signs and symptoms
noted. Patient sought consult, IE was done which revealed 1 cm dilatation, beginning
effacement, cephalic, intact BOW hence admitted.

• Past Medical History

Client has complete vaccines since birth, no history of any accidents, no history of
asthma, urticaria or allergy to food and medications
 • Obstetric History

G2P2, without any history of preterm births and abortion, advised for LTCS-1 due to
the failure of the pelvic bones to open. LTCS-2 was done because of previous cesarean
delivery, 37 weeks and 6 days of gestation, age of menarche was 13 years old, LNMP was
last May 28, 2019. Took Folic Acid and Ferrous Sulfate during pregnancy.

• Family History

Has a history of hypertension in the father side. No history of asthma, diabetes and
cancer in the family.

• Social History

TOBACCO: Client does not smoke neither does any of the members of their
family

ALCOHOL: Client drinks alcohol occasionally before pregnancy during events,

parties and get together.

SOFTDRINKS: Client drinks soft drinks before pregnancy, most especially

during afternoon snack or merienda

COFFEE: Client drinks coffee every day before pregnancy

PETS: Client does not own any pets, neighbors also do not own any pets.

TRAVEL HISTORY: Client does not have any travel history last year 2019 and
this year 2020

ALLERGY HISTORY: Client has no history of allergy and is not allergic to

anything
IV. GORDON’S FUNCTIONAL HEALTH PATTERN

Pattern Before Present Interpretation

[Link] Perception- Patient went to Patient is conscious/ Patient can function
Health Management hospital for prenatal aware about her normally because of
checkup. All in all, second cesarean her first CS before she
she thinks she is in a section thinking that it is aware of the
healthy state. would be the same changes to her body
“Healthy naman ako like her first CS. and health like what
sa tingin ko”, as happened before in
verbalized by the her first CS.
patient.
2. Nutritional- Prior to confinement, During Patient’s nutritional
Metabolic patient loves eating hospitalization, the and metabolic status
Management sweets and fatty foods patient is on soft diet. has been changed due
like fries and burgers. She eats banana and to her confinement.
She also drinks a lot mangoes. She eats
of water a day. She porridge and white
basically loves eating bread. She said she
whatever she likes. loss her appetite since
her onset of labor.
[Link] Bowel: Bowel: Bowel:
Pattern Patient defecates 2-3 Patient defecates once There was a change in
times a day, usually a day but not on a the frequency and
twice in the morning regular basis. Stool is amount.
and in the evening. soft, minimal in
Stool is yellowish to amount and brown in
brown in color and color.
well-formed.

Bladder: Bladder: Bladder:

 Patient voids usually Patient voids 3-4 There was a change in
5-6 times a day. Urine times a day without the frequency and
is yellow in color. No pain and discomfort. amount.
pain when voiding.
[Link], Leisure, Patient is a housewife Patient’s activities in During patient’s
and Recreation so she is in charge of the hospital are confinement in the
Pattern the household chores. ambulation and deep hospital, there is a
During her pregnancy breathing. She also limitation in her
she used to walk a day did walking for a little activities of daily
served as her exercise. time. She initiate living and a disruption
breastfeeding in her usual daily
immediately. exercise/ activity..
[Link] and Rest Patient can’t sleep Due to her Patient’s sleep and
Pattern because of frequent uncomfortable rest pattern changed
urination. She usually condition, patient when she was
sleeps at around 9pm complains of admitted. She cannot
to 5am with in difficulty of sleeping put himself to sleep
between wake up. She because of anymore due to
feels restless and breastfeeding, baby’s present condition and
sleepy at morning. often crying also, time discomfort plays a big
to time check of her factor for her sleep
vital signs and the disturbances.
feeling of heat in her
body.
[Link] – Patient is a college Patient’s present No changes/
Perceptual Pattern graduate. She can read condition is not a alterations.
and write. She can hindrance to her
speak and be cognitive- perceptual
understood by others. pattern.
7. Self-Perception / Patient is a friendly During the times of There is a slight
Self-Concept Pattern person; she loves to her confinement, she change in her self-
socialize with her doesn’t think that she perception due to
 friends in their is a holistic person present condition.
neighborhoods. She anymore. However,
considers himself as she is positive that she
holistic human being will be ok after
as long as she is confinement.
healthy, complete, and
his family is always
there.
8. Role Relationship Patient can understand The patient’s family is Normal/ No
English and Tagalog. supportive to the alterations.
She has 2 siblings. patient. She is happy
She has a live in with their presence
partner because they and support.
are not yet married.
9. Sexuality/ Patient sexual life is Patient reserved her Patient reserved her
Reproductive active even she’s right to privacy. right to privacy.
Pattern pregnant .
[Link] and Stress When patient is The recent Patient accepts
Tolerance stressed, she eats hospitalization of the present condition with
comfort foods like patient was not that a positive attitude.
sweets, burgers, fries, stressful since it is her
and her favorite ice second time.
cream. When it comes However, she is
to problems, she lets positive that she will
herself think be able to cope up
immediately for a with current
solution. condition.
[Link]- Belief Patient is a Roman She keep her strong Due to her
Pattern Catholic. She has a faith to God accounts confinement, patient
strong faith to God. for her fast recovery. is trusting God that
she will be discharge
soon and will recover
 without any
complications.

V. PHYSICAL ASSESSMENT (HEAD-TO-TOE)

A. HEAD and HAIR
 Symmetrically round
 No lesions on the scalp
 Hair is black and evenly distributed
B. EYES
 Black pupil
 Normal Sclera
 Pale Conjunctiva
C. EARS
 Ears are of the same level
 No discharge noted
D. MOUTH
 Lips, Gums and Tongue are pink
 Complete Teeth with braces
E. NECK
 Supple
 Can rotate freely
 No palpable lymph nodes noted
F. LUNGS
 Symmetrical Chest Expansion
 Clear breath sounds heard upon auscultation
 With normal breathing pattern

G. ABDOMEN
 With abdominal binder
 Strae Gravidarum is present
 H. EXTREMETIES
 No lesions
 No signs of Edema
 No involuntary movement noted
G. SKIN and NAILS
 Light brown in color
 No lesions or abrasions
 With good skin turgor
 With capillary refill of 1-2 seconds

BUBBLE-HE

BREASTS

 No engorgement
 Nipples have no cracks, fissures and not inverted

UTERUS

 Firm
 At the level of umbilicus

BLADDER

 Undistended Bladder
 With catheter
 No signs and symptoms of UTI

BOWEL MOVEMENT

 No presence of Bowel Sound since labor process

LOCHIA
  Bright red lochia with moderate amount

EPISIOTOMY

 The client underwent C-section, there was no episiotomy done

HOMANS SIGN

 No pain had been noted through dorsiflexion of both legs

EMOTIONAL STATUS

 Exhausted and needs to rest because of the procedure that has been done

VI. ANATOMY AND PHYSIOLOGY OF THE AFFECTED SYSTEM/ORGAN

 The uterus or womb is a pear shaped organ that is found in the pelvis at the top of the
vagina. The uterus in a woman that is not pregnant does not extend above the pubic bone
(Figures 1, 2 and 3)

Figure 1 - Anatomy of the uterus and Figure 2 - Uterus as seen from in front.
surrounding organs as seen in a section
through the middle of the body.
 Figure 3 - View of the uterus,
ovaries, Fallopian tubes, and round
ligament through a laproscope.

 In the pregnant woman at the end of pregnancy, the uterus enlarges to approximately 40
centimeters (16 inches) above the pubic bone
 The cervix is found at the lowermost portion of the uterus and is the opening through
which the fetus passes during delivery. Normally, this opening is closed until late in the
pregnancy
 Fertilization occurs within the fallopian tubes. The fallopian tubes are found at the top of
the uterus, one on each side. The end of each fallopian tube has fingerlike projections
called fimbria which guide the egg from the ovary into the Fallopian tube
 The fertilized egg then passes from the Fallopian tube into the cavity within the uterus
where the fertilized egg implants into the wall of the uterus. The site of implantation
becomes the
 As the egg develops into a fetus the remains attached to the fetus through the umbilical
cord. Thus the blood supply to the fetus originates in the uterine wall
 The umbilical cord extends from the to the fetus where it inserts at umbilicus (belly
button) of the fetus

During the delivery of the baby:

 The surgeon traverse all the layers that separate him/her from the fetus. First, the skin is
incised, followed by the subcutaneous tissues. The next layer is the fascia overlying the rectus
abdominis muscles. The anterior abdominal fascia usually consists of two layers. One is
composed of the aponeurosis from the external oblique rectus muscle, and the other is a fused
layer which contains the aponeuroses of the transverse abdominis and internal oblique muscles.
After separating the rectus muscles, which run from cephalad to caudal, the surgeon enters the
abdominal cavity through the parietal peritoneum. The uterus consists of the serosal outer layer
(perimetrium), the muscle layer (myometrium), and the inside mucosal layer (endometrium). All
three of these layers are incised to make the uterine incision or hysterotomy.

VII. RISK FACTORS

The risks associated with cesarean delivery can be divided into those that are
short term, those that are longer term, and those that present risks to future pregnancies.
Certainly, the clinical situation that gives rise to the cesarean delivery has a great impact on
the risk of complications. A primary cesarean section performed for an average-weight
woman who is not in labor confers a much lower risk of complications than an emergency
cesarean section performed on an obese woman who has chorioamnionitis and has been in
labor for hours. Therefore, when comparing a trial of labor with a cesarean delivery, one
must recognize that although there is a lower risk for many of the complications discussed
below when the delivery is vaginal, the risks associated with a cesarean section performed in
labor are greater than those associated with planned deliveries.

Short-term Risks of Cesarean Delivery

• Maternal Death

According to studies the risk of maternal death during childbirth is greater with
cesarean delivery compared with vaginal delivery, although very low.

• Thromboembolism
 One of the leading causes of maternal mortality related to cesarean delivery is deep vein
thrombosis resulting in pulmonary embolism.

• Hemorrhage

Blood loss during a cesarean delivery may be greater than during a vaginal
delivery; however, the transfusion rate remains low at 1% to 2% of patients undergoing
cesarean section. Excessive blood loss during a cesarean section typically results from
laceration of uterine vessels that occurs with extension of the uterine incision. Additional
lacerations may extend into the vagina and result in significant bleeding and increased
operative time. The risk of hemorrhage requiring blood transfusion increases substantially
with increasing number of prior cesarean deliveries.

• Infection

Infection is one of the most common complications of cesarean delivery. In the absence
of prophylactic antibiotics, the rates of postpartum endomyometritis can be as high as 35% to
40%. Another common complication of cesarean delivery is wound infection. Wound infections
may occur in 2.5% to 16% of cesareans.

• Incidental Surgical Injuries

Bladder injuries are the most common injuries to surrounding structures occurring at the
time of cesarean delivery. Nevertheless, they are rare.

• Extended Hospitalization

A woman who has had a cesarean delivery typically remains hospitalized longer than one
who has had a vaginal delivery and has increased risk for readmission. Patients who delivered
abdominally are usually discharged on the 3rd or 4th postpartum day compared with the 1st or
2nd postpartum day for those who deliver vaginally.

• Emergency Hysterectomy
The risk of the need for hysterectomy after or during a cesarean delivery is greater than after a
vaginal delivery.

• Pain

Women who undergo cesarean delivery more commonly experience pain after delivery
compared with those having vaginal deliveries. A study of 242 primiparous women reported that
all those who underwent cesarean deliveries (both planned and unplanned) required narcotic pain
medications compared with 11% of those who delivered vaginally. Having to relieve pain with
narcotic pain medications can have a significant impact on initial bonding between the mother
and the newborn and on breastfeeding success rates, as well as maternal functioning postpartum;
in addition, the risk for postpartum depression may be greater.

Long-term Risks of Cesarean Delivery

• Pain

Women who undergo cesarean deliveries are more likely to report pain to be a problem in the
first 2 months after delivery.

• Adhesion Formation.

Adhesion formation resulting from cesarean delivery is common and significantly contributes to
the risk of complications at future deliveries. These adhesions may also be contributing to the
reported increased risk of ectopic pregnancy among women with prior cesarean deliveries.

• Infertility/Subfertility.

An observational study of nearly 4000 women reported that women who had undergone
cesarean delivery were more likely to be unable to conceive a pregnancy for more than 1 year

VIII. 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 Contraction Ripening of the cervix

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

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

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)

IX. DIAGNOSTIC AND LABORATORY TESTS

Lab No: 021820-15 Location: 306-2
Name: Cabacungan, Romina Grabol Date Received: 02-18-2020 7:15pm
Age: 27 Date Printed: 02-18-2020 7:17pm
Sex: Female
Case No. 377134

Test Name Result Unit Reference Range

Hematology
CBC+DIFF
Complete Blood
Count
Hemoglobin L 11.0 g/dl 12.5-16.5
Hematocrit L 33.8 % 37.0-42.0
RBC Count 3.89 10^3/UL 3.8-5.4
MCV 89.9 fl 80.0-97.0
MCH 28.3 Pg 23.0-29.0
MCHC 32.5 g/dl 31.0-35.0
Leukocyte Count H 17.50 10^3/UL 5.0-10.0
Differential Count
Segmenters H 76 % 36.0-66.0
Lymphocytes L 15 % 22.0-40.0
Monocytes H9 % 4.0-8.0
Eosinophils L0 % 1.0-4.0
Basophils 0 % 0.0-1.0
Platelet Count 331 10^3/UL 150-400
NOTE: Time Extracted: 7:00am 02/18/2020

G2P2 (2002) PU delivered via LTCS II to a live term cephalic baby girl with 139 39009, L

Interpretation:

This laboratory result (complete blood count) shows that there is a decrease in number of
hemoglobin and hematocrit with a value of 11.0 g/dl (12.5-16.5) and 33.8% (37.0-42.0)
respectively while there is an increase number of Leukocyte count with a value of 17.50 (5.0-
10.0) which reflects in differential count ; Segmenters 76% (36.0-66.0), Lymphocytes 15%
(22.0-40.0), Monocytes 9% (4.0-80), Eosinophils 0 (1.0-4.0).

Due to the operation done to the patient it is common to have blood loss during the
procedure which implies the low hemoglobin and low hematocrit level that are being shown to
the table above. Since it was an invasive procedure it is the normal response of the body which
causes inflammatory response as evidenced by the increase number of leukocyte count and
differential count.

Nursing Implication:

Due to low hemoglobin and hematocrit level as a nurse, increase fluid intake must be
emphasized. One way to do it is monitor IV fluids and instruct to drink plenty of water, if
ordered by the physician. Leukocyte count must be monitored by means of taking vital signs
especially temperature to identify whether it is still an inflammatory response or a sign of
infection.

X. DRUG STUDY

Doctor's order: Give Cefuroxime 500mg/cap BID x7 days

Date ordered: February 18, 2020

 Drug Name: Cefuroxime

  Brand Name: Elixime, Ceftin, Zinacef
 Classification: Antibiotic
 Mechanism of Action: Cefuroxime, like the penicillins, is a beta-lactam antibiotic. By
binding to specific penicillin-binding proteins (PBPs) located inside the bacterial cell
wall, it inhibits the third and last stage of bacterial cell wall synthesis. Cell lysis is then
mediated by bacterial cell wall autolytic enzymes such as autolysins; it is possible that
cefuroxime interferes with an autolysin inhibitor.
 Contraindications: Antimicrobial Resistance, Viral Infection, Cephalosporin
Hypersensitivity, penicillin hypersensitivity, Renal Failure, Renal Impairment, Diabetes
Mellitus
 Side Effects: an allergic reaction, hives; difficulty breathing; swelling of face, lips,
tongue, or throat, severe stomach pain, diarrhea that is watery or bloody, seizure (black-
out or convulsions)
 Nursing Implications:
o Determine history of hypersensitivity reactions to cephalosporins, penicillins, and
history of allergies, particularly to drugs, before therapy is initiated.
o Lab tests: Perform culture and sensitivity tests before initiation of therapy and
periodically during therapy if indicated. Therapy may be instituted pending test
results. Monitor periodically BUN and creatinine clearance.
o Report onset of loose stools or diarrhea. Although pseudomembranous colitis (see
Signs & Symptoms, Appendix F) rarely occurs, this potentially life-threatening
complication should be ruled out as the cause of diarrhea during and after
antibiotic therapy.
o Monitor for manifestations of hypersensitivity. Discontinue drug and report their
appearance promptly.
o Monitor I&O rates and pattern: Especially important in severely ill patients
receiving high doses. Report any significant changes.

Doctor's order: Give Mefenamic Acid 500mg/tab TID

Date ordered: February 18, 2020

  Drug Name: Mefenamic Acid
 Brand Name: Istan, Ponstel
 Classification: Analgesic
 Mechanism of Action: Mefenamic acid is a potent inhibitor of prostaglandin synthesis in
vitro. Mefenamic acid concentrations reached during therapy have produced in vivo
effects. Prostaglandins sensitize afferent nerves and potentiate the action of bradykinin in
inducing pain in animal models. Prostaglandins are mediators of inflammation. Because
mefenamic acid is an inhibitor of prostaglandin synthesis, its mode of action may be due
to a decrease of prostaglandins in peripheral tissues.
 Contraindications: Known hypersensitivity (e.g., anaphylactic reactions and serious skin
reactions) to Mefenamic Acid or any components of the drug product,
 Side Effects: stomach pain, nausea, vomiting, heartburn, constipation, diarrhea, rash,
dizziness, tinnitus (ringing in your ears)
 Nursing Implications:
o Assess patients who develop severe diarrhea and vomiting for dehydration and
electrolyte imbalance.
o Lab tests: With long-term therapy (not recommended) obtain periodic complete
blood counts, Hct and Hgb, and kidney function tests.
o Discontinue drug promptly if diarrhea, dark stools, hematemesis, ecchymosis,
epistaxis, or rash occur and do not use again. Contact physician.
o Notify physician if persistent GI discomfort, sore throat, fever, or malaise occur.
o Do not drive or engage in potentially hazardous activities until response to drug is
known. It may cause dizziness and drowsiness.

XI. COURSE IN THE WARD

Date: February 17, 2020 – Day 1

VS: BP – 120/80mmHg | PR – 85bpm | RR – 17bpm | Temp: 36.3° C

Doctor’s Order:

12:45pm - D5LR 1L x 8 hrs

 - Cefuroxime 1.5g IV (-) ANST

30 mins. prior to OR

1:30pm - VS q15mins till stable

- Merphine precautions watch out for bradycardia, hypotension, somnolence,

pruritus, nausea and vomiting

- NPO

- IVF to ff:

#1 D5LR 1L + Oxytocin 10u x 8 hrs

#2 D5LR 1L + Diclofenac Sodium 75mg x 8 hrs

#3 D5NM 1L + Diclofenac Sodium 75mg x 8hrs

5:30pm - May transfer patient to room

- WOF profuse way of bleeding, bradycardia

8:10pm - Give Metoclopramide 1cap IM

Date: February 18, 2020 – Day 2

VS: BP – 100/60mmHg | PR – 78bpm | RR – 20bpm | Temp: 37.2° C

Doctor’s Order:

6:00am (+) F - May have sips of H2O

- Soft Diet after lunch

- Start oral meds

- Cefuroxime 500mg/cap BID x 7days after soft diet

 - Mefenamic Acid 500mg/tab

- IFC removal at 5:00pm

- WOF profuse bleeding, hypotension, bradycardia

- ENC Breastfeeding

- Daily perineal/body hygiene

6:30pm - For CBC at 7:00am

- Continue pain management

- DAT once with BM

- IVF to consume

- Cefuroxime 500mg/cap BID

- Mefenamic Acid 500mg/tab

- Apply abdominal binder

Date: February 19, 2020 – Day 3

VS: BP – 110/70mmHg | PR – 88bpm | RR – 20bpm | Temp: 36.7° C

Doctor’s Order:

7:00am - May go home once with BM

- Please inform pedia service of the discharge

- Please see discharge instruction or prescription

- Give bisacodyl rectal suppository if still without DB

XII. NURSING THEORIES USED

Kolcaba’s Theory of Comfort

Hospitalization is one of the most stressful events that adults can experience. Not only are
the physical surroundings different, but the procedures that patient encounter for the first time
are new. Anxiety, Fear, withdrawal, depression, regression and defiance are a few reactions
shown by patients as well as adults, and they can be more severe than their own reaction to
illness.

Nurses uses various kinds of strategies in reducing discomfort in children. Polkki T,

Vehvilainen-Julkunen K, Pietila did survey on use of non-pharmacological methods in relieving
children’s (8-12 year) postoperative pain on hospital nurses in Finland. The study showed that
emotional support, creating a comfortable environment and assisting with day by day activities
were accounted for to be utilized routinely, though the cognitive behavioural and physical
techniques incorporated some less much of the time utilized and less surely understood
strategies.
 Katherine Kolcaba’s theory of comfort explains comfort as a fundamental need of all
human beings for relief, ease, or transcendence arising from health care situations that are
stressful. Comfort can enhance health-seeking behaviours (HSBs). HSBS can be internal,
external, or a peaceful death if that is the most realistic outcome. When patients and/or family
members engage in HSBs, institutional integrity is also enhanced.

Kocaba’s theory successfully addresses the four elements of nursing meta-paradigm.

Providing comfort in physical, psycho-spiritual, social, and environmental aspects in order to
reduce harmful tension is a conceptual assertion of this theory. When nursing interventions are
effective, the outcome of enhanced comfort is attained.

We chose this nursing theory because our patient is postoperative and we as nurses to her,
we provided comfort for her postoperatively. We assessed the patient’s comfort needs in the
process of developing and implementing appropriate nursing care plan, and evaluating the
patient’s comfort after the care plans have been carried out. We provided the managements that
the patient needs. Through this model theory, we were able assessed comfort needs and was able
to design comfort measures in order to address those needs

Dorothea Orem’s Self-Care Deficit Theory

Dorothea Orem’s Self-Care Deficit Theory defined Nursing as “The act of assisting
others in the provision and management of self-care to maintain or improve human functioning
at home level of effectiveness.” It focuses on each individual’s ability to perform self-care,
defined as “the practice of activities that individuals initiate and perform on their own behalf in
maintaining life, health, and well-being.”
 “The condition that validates the existence of a requirement for nursing in an adult is the
absence of the ability to maintain continuously that amount and quality of self-care which is
therapeutic in sustaining life and health, in recovering from disease or injury, or in coping with
their effects. With children, the condition is the inability of the parent (or guardian) to maintain

continuously for the child the amount and quality of care that is therapeutic.” (Orem, 1991)

Self-care agency is the human’s ability or power to engage in self-care and is affected by
basic conditioning factors.

Basic conditioning factors are age, gender, developmental state, health state, socio-
cultural orientation, health care system factors, family system factors, patterns of living,
environmental factors, and resource adequacy and availability.

This theory delineates when nursing is needed. Nursing is required when an adult (or in
the case of a dependent, the parent or guardian) is incapable of or limited in the provision of
continuous effective self-care. Orem identified 5 methods of helping: Acting for and doing for
others; Guiding others; Supporting another; Providing an environment promoting personal
development in relation to meet future demands; Teaching another.

This is represented by a situation in which the individual is unable “to engage in those
self-care actions requiring self-directed and controlled ambulation and manipulative movement
or the medical prescription to refrain from such activity. Persons with these limitations are
socially dependent on others for their continued existence and well-being.”

Orem’s theory is relatively simple, but generalizable to apply to a wide variety of

patients. It explains the terms self-care, nursing systems, and self-care deficit which are very
essential to students who plan to start their career in nursing.

Moreover, this theory signifies that all patients want to care for themselves, and they are
able to recover more quickly and holistically by performing their own self-care as much as
they’re able. This theory is particularly used in rehabilitation and primary care or other settings
in which patients are encouraged to be independent.

Though this theory greatly influences every patient’s independence, the definition of self-
care cannot be directly applied to those who need complete care or assistance with self-care
activities such as the infants and the aged.

We chose this theory because our patient was a post-operative cesarean section, post-
partum client. As we care for our patient we set goals by using the nursing process in her model
to deliver care in the means of Nursing Care Plans. Aside from that, we established rapport and
interpersonal relationship to support our goals and make interventions that will be appropriate to
alleviate her condition.

Goal Attainment Theory by Imogene King

According to King, a human being refers to a social being that is rational and sentient. He
or she has the ability to perceive, think, feel, choose, set goals, select means to achieve goals, and
make decisions. He or she has three fundamental needs: the need for health information when it
is needed and can be used; the need for care that seeks to prevent illness; and the need for care
when he or she is unable to help him or herself.

The Theory of Goal Attainment defines nursing as “a process of action, reaction and
interaction by which nurse and client share information about their perception in a nursing
situation” and “a process of human interactions between nurse and client whereby each perceives
the other and the situation, and through communication, they set goals, explore means, and agree
on means to achieve goals.” In this definition, action is a sequence of behaviors involving mental
and physical action, and reaction is included in the sequence of behaviors described in action.
King states that the goal of a nurse is to help individuals to maintain their health so they can
function in their roles. The domain of the nurse “includes promoting, maintaining, and restoring
health, and caring for the sick, injured and dying.” The function of a professional nurse is “to
interpret information in the nursing process to plan, implement, and evaluate nursing care.” King
gives detailed information about the nursing process in her model of nursing. The steps of the
nursing process are: assessment, nursing diagnosis, planning, implementations, and evaluation.

The theory explains that assessment occurs during interaction. The nurse brings special
knowledge and skills whereas the patient brings knowledge of him or herself, as well as the
perception of problems of concern to the interaction. During the assessment, the nurse collects
data regarding the patient including his or her growth and development, the perception of self,
and current health status. Perception is the base for the collection and interpretation of data.
Communication is required to verify the accuracy of the perception, as well as for interaction and
translation. The nursing diagnosis is developed using the data collected in the assessment. In the
process of attaining goals, the nurse identifies problems, concerns, and disturbances about which
the patient is seeking help.

After the diagnosis, the nurse and other health care team members create a care plan of
interventions to solve the problems identified. The planning is represented by setting goals and
making decisions about the means to achieve those goals. This part of transaction and the
patient’s participation is encouraged in making decisions on the means to achieve the goals. The
implementation phase of the nursing process is the actual activities done to achieve the goals. In
this model of nursing, it is the continuation of transaction. Evaluation involves determining
 whether or not goals were achieved. The explanation of evaluation in King’s theory addresses
meeting goals and the effectiveness of nursing care.

We chose this theory because our patient was a post-operative cesarean section, post-
partum client. As we care for our patient we set goals by using the nursing process in her model
to deliver care in the means of Nursing Care Plans. Aside from that, we established rapport and
interpersonal relationship to support our goals and make interventions that will be appropriate to
alleviate her condition.

XIII. CONCEPTUAL PARADIGM

XIV. NURSING CARE PLAN

INPUT PROCESS OUTPUT

 Demographic Data  Assessment  Evaluation

 Obstetric History  Nursing Diagnosis
 History of Present  Planning
Illness  Nursing
Interventions
 Health Teachings
Date: February 18, 2019

Assessment:

Subjective Data: “Hindi ako makakilos ng mabuti sa ngayon feeling ko kasi biglang bubuka tong
tahi ko kapag gumalaw-galaw ako” as stated.

Objective Data: Limited Range of Motion; Guarding Behavior in the incisional site;
Restlessness; Irritable; Pale

Vital Signs: Blood Pressure – 110/70mmHg

Pulse Rate – 82bpm

Respiratory Rate – 20bpm

Temperature – 36.3°C

Nursing Diagnosis: Alteration in Comfort related to Abdominal Incision

Goals and Outcomes: At the end of 8 hours duty:

 The patient will verbalize feeling of comfort

 The patient will be able to rest
 The patient will manage to increase activity and be able to move freely without hesitation

Interventions:

 Encourage verbalization of feelings regarding limitations.

R: It helps the patient to cope. Acknowledgement that living with discomfort is both
physically and emotionally difiucult.
 Explain the procedure that was done
R: Information helps the patient to minimize anxiety, which can exacerbate discomfort.
 Schedule structured activity and rest periods.
 R: Providing rest periods may promote relief and relaxation.
 Maintain a pleasant and quiet environment.
R: Conducive environment may promote relaxation and sleep that leads to comfort.
 Demonstrate proper positions that she may use
R: To avoid or minimize pressure on muscles and skin in the affected part that leads to
comfort.

Evaluation:

Goal met, the client verbalized that she feels comfortable and claimed that she was able
to rest.

Date: February 18, 2020

Assessment:

Subjective Data: “Yung tulog ko paputol-putol kasi maya’t maya may mga pumapasok na tao
ehh” as stated.

Objective Data: Presence of eye bags; weakness and restlessness; taking a nap whenever there is
a chance or there is a free time; yawning

Vital Signs: Blood Pressure – 110/70mmHg

Pulse Rate – 85bpm

Respiratory Rate – 20bpm

Temperature – 36.6°C

Nursing Diagnosis: Disturbed Sleeping Patterns related to interruptions for therapeutics,

monitoring and other generated awakening and excessive stimulation (noise and lighting).

Goals and Outcomes: At the end of 8 hours duty:

 The patient will verbalize feeling of good rest

  The patient will be able to sleep
 The patient will be able to reestablish and maintain normal sleep

Interventions:

 Encourage the client to express concerns when unable to sleep.

R: Verbalizing concerns may promote relaxation.
 Do as much care as possible without waking up the client and do as much care as
possible while the client is still awake.
R: To avoid disturbances during sleep. And also to maximize the sleep and rest of the
client.
 Provide a quiet and peaceful environment during sleep through minimizing people who
enters the room.
R: To help in providing better sleep/rest
 Explain necessity of disturbances for monitoring vital signs and care when hospitalized.
R: For the patient to have an understanding of the importance of care being done to her
and to minimize the complaints.

Evaluation:

Goal met, the client verbalized that she feels comfortable and claimed that she was able
to sleep even for a few hours as evidenced by the decrease of the usual yawning.

Date: February 18, 2020

Assessment:

Subjective Data: “Hindi ko malinisan ung ari ko kasi di ko alam kung pano maglinis ng naka
catheter ako”, as verbalized by the patient.

Objective: Patient lying on bed without bathroom privilege; with long nails; Unpleasant odor
noted
Vital Signs: Blood Pressure – 110/70mmHg

Pulse Rate – 80bpm

Respiratory Rate – 17bpm

Temperature – 36.3°C

Nursing Diagnosis: Self- Care Deficit related to lack of knowledge of proper hygiene care

Goal: At the end of 8-hour duty;

 The patient will be able to perform personal hygiene.

 The patient will be able to carry out ADLs (feed, bathe, toilet, transfer and ambulate) on
regular basis.
 Resources are identified which are useful in optimizing the autonomy and independence
of the patient.

Interventions:

 Assess pt. ability to do proper hygiene

R: Use of observation of function provides complementary assessment data for goal and
intervention planning.
 Encourage independence, but intervene when patient cannot perform
R: An appropriate level of assistive care can prevent injury with activities without
causing frustration
 Assess pt. incision
R: To prevent infection and to promote comfort
 Use consistent routines and allow adequate time for pt. to complete tasks
R: This helps pt. organize and carry out self-care skills
 Provide privacy during perineal care as appropriate
R: The need for privacy is fundamental for most patients
 Encourage use of clothing one size larger
R: This ensures easier dressing and comfort
Evaluation: Goal was met; Patient was able to perform self-care activities with minimal
supervision or assistance.

Date: February 18, 2020

Assessment:

Subjective Data: “Konti lang talaga lumalabas na gatas, nabubusog kaya siya? Nung unang CS
ko, ganito rin problema ko. Konti lang talaga gatas na lumalabas.” as stated by the patient.

Objective Data: Awake while breastfeeding the baby; frowns; continues breastfeeding every
hour

Vital Signs: Blood Pressure – 120/80mmHg

Pulse Rate – 82bpm

Respiratory Rate – 20bpm

Temperature – 36.3°C

NURSING DIAGNOSIS:

Ineffective Breastfeeding related to insufficient breast milk

GOALS AND OUTCOMES:

At the end of 8-hour duty, the client will:

 Verbalize breastfeeding problems and know how to manage it

 Demonstrate different breastfeeding positions

INTERVENTIONS:
  Provide chances to express and verbalize worries and concerns
R: Verbalization will lead to exploring issues and will have an informed decision making
 Determine the presence of ineffective breastfeeding and the different alternatives
R: This will help the mother and support groups not to be discouraged in
breastfeeding the infant. It will help them meet the desired goal in all acceptable
methods.
 Explain briefly the mechanics of breastfeeding process such as milk letdown, signs of
breastfeeding readiness, and signs of infant hunger
R: Knowledge of the process of correct breastfeeding will help bring client expectations
in line with reality
 Teach and demonstrate correct infant holds and breastfeeding positions
R: It will let the mother and baby to have a successful breastfeeding. Correct positioning
will prevent disruption of the process.
 Encourage mother to drink at least 2000ml of fluid per day or 6 to 8 oz. every hour
R: To make up for what the body used in milk production
 Encourage to eat green leafy vegetables
R: Green leafy vegetables contain phytoestrogens, which have been shown to have a
positive effect on milk production.

Evaluation:

Goals fully met as client verbalized breastfeeding problems such as having no enough
milk production and improper positioning during breastfeeding; client also demonstrated
different breastfeeding positions and identified cradle hold as the best position for her.

Date: February 19, 2020

Assessment:

Subjective: “Kagabi ako na-CS” as verbalized by the patient

Objective:
  Weak in appearance
 Clean and intact abdominal dressing

Vital signs taken as follows:

BP: 100/90mmHg RR: 16 bpm PR: 75bpm Temp: 37°C O2sat: 98%

Nursing Diagnosis: Risk for Infection R/T cesarean delivery secondary to post-surgical incision

Goals and Outcomes: After the 8 hours of nursing interventions, the patient will:

 Not show any signs and symptoms of infection as manifested by absence of fever.
 Achieve timely wound healing without complications

Interventions:

 Monitor client’s vital signs every 4 hours.

R: To assess any signs and symptoms that may indicate infection
 Emphasize the importance of hand washing technique.
R: It serves as a first line of defense against infection
 Maintain aseptic technique when changing dressing or caring for the wound
R: Regular wound dressing promotes fast healing and drying of wounds
 Keep the area around the wound clean and dry.
R: Wet areas can be a lodge area of bacteria
 Emphasize the importance of taking antibiotics as ordered.
R: Discontinuation of medication when client begins to feel well may result in return of
infection.

Evaluation: Goal met after 8 hours of duty the patient did not show any signs and symptoms of
infection with a temperature of 36.3°C. The wound of the client is healing timely without any
complications

XV. HEALTH TEACHINGS

TOPIC #1: C-SECTION POST PARTUM EXERCISE

After your cesarean delivery

A cesarean delivery is a surgery where an incision is made through the abdominal wall to
deliver a baby quickly and safely. Cesarean deliveries are sometimes medically necessary, but
the recovery time is slightly longer than a vaginal birth. For this reason, caution should be taken.
Moms should get their doctor’s OK before returning to regular exercise. Some key muscles that
require retraining after pregnancy include the transverse abdominis. These are the corset-like
muscles that wrap around the midline to the spine, the pelvic floor muscles, and the abdominal
and lower back muscles. After a cesarean delivery, it’s important to activate and strengthen these
areas so that they can provide support, decrease your risk of injury, and help you make a full
recovery postpartum. Try these gentle exercises after a cesarean delivery. They require no
equipment and can be performed from anywhere.

1. Belly breathing

This exercise is a great relaxation technique. It also helps retrain the core muscles to work
together during daily activities. Muscles worked: transverse abdominis

 Lie on your back on a comfortable bed or couch.

 Place your hands on your belly and relax your body.
 Take a deep breath in through your nose, feeling your abdomen expand into your hands.
 Breathe out through your mouth. As you exhale, pull your bellybutton in toward your
spine, contracting your abdominal muscles. Hold for 3 seconds.
 Repeat 5 to 10 times, 3 times a day.

2. Seated Kegels

Kegels are an excellent exercise to strengthen and activate the pelvic floor. They have
been shown to decrease stress incontinence following childbirth. After a C-section you may have
a urinary catheter and these exercises will help after the catheter is removed. Muscles
worked: pelvic floor

 Sit on the edge of a chair with your feet on the floor.

  Contract the muscles of the pelvic floor. It should feel like you’re trying to hold back the
flow of urine.
 Imagine you’re closing all the openings of the vagina, anus, and urethra. Imagine lifting
them up away from the chair.
 Hold this contraction as long as possible. Start with 5 seconds and work up to a longer
duration.
 Take a deep breath in and then breathe out fully, relaxing the contraction.
 Try Kegels in different positions like standing or lying on your side.
 Perform 8 to 12 times with a 2-minute rest between contractions. Repeat 2 times per day.

3. Wall sit

This full-body isometric exercise is an excellent way to get all the muscle groups to work
together in unison. Muscles worked: quadriceps, hamstrings, pelvic floor muscles, core, and
lower back

 Stand with your feet 1 to 2 feet away from the wall.

 Slowly lean back toward the wall, lowering yourself into a sitting position. Your hips and
knees should be at 90-degrees to one another.
 Engage your core. Take a deep breath in and while you exhale, feel as if you’re pulling
your belly button into the wall.
 For an added bonus, contract your pelvic floor by doing a Kegel while holding this
position.
 Hold for as long as possible. Rest 1 minute, then repeat 5 times.

4. Cesarean delivery scar massage

As a cesarean delivery scar heals, the different layers of skin and fascia can become
adhered to each other, limiting your range of motion. These adhesions may lead to future
problems like urinary frequency, or hip or back pain. A scar tissue massage, also referred to as
scar tissue release, helps break up the adhesions and assists with proper tissue healing. Only
begin scar massage after your scar is healed and your doctor gives you the green light. Areas
worked: fascia, connective tissue
  Lie on your back with your fingers positioned above your scar. Pull the skin with your
fingertips around the scar and observe its movement. Try sliding it up and down and side
to side. Notice if it moves more easily in 1 direction than another.
 Working in 1 direction, slowly move the scar back and forth. You will want to start off
gently and gradually move up to a more aggressive massage.
 Move the scar up and down, side to side, and even around in circles. Small movements
are better, but tissue mobilization can be done in all areas of the abdomen.
 If the scar is painful, stop and try again at a later date. Once you feel comfortable, you
can perform this massage once a day.

5. Leg slides

Generally, exercise should not start until six to eight weeks after the surgery and you
should always check with your doctor before beginning. Low impact exercise such as yoga,
Pilates, or swimming is the best way to begin. This beginner core exercise helps engage the core
muscles in a gentle but effective way. The transverse abdominis muscle is an important area to
strengthen as it supports the body core. Also, it supports the linea alba, a fibrous structure that
extends from the xiphoid process down to the pubic bone and also supports core
stability. Muscles worked: transverse abdominis

 Lie on your back on the floor with your knees bent and feet flat on the ground. Wear
socks or put a towel under your feet to allow your feet to slide easily on the floor.
 Take a deep breath. As you exhale, contract your abdominal muscles by pulling your
belly button to your spine without changing the curve of your lower back.
 While maintaining this contraction, slowly extend your foot away from your body until
the leg is fully extended.
 Slowly bring it back to the starting position.
 Repeat 10 times on each side. Perform once per day.

TOPIC #2: COUGHING TECHNIQUE

Recovering after a Caesarean section

 After a caesarean section pain from your wound can make moving difficult. The
following exercises can help the mother recover from both the operation and the pregnancy. It is
important to have enough to drink (aim for 1 1/2 – 2 1/2 litres per day then drink to when thirsty)
and regular pain relief, as this will help the bladder and bowel function and help the mother to
move around more easily.

The first 24 hours:

Wound support and breathing

 Support your wound with your hands or a pillow if you need to cough, sneeze, laugh or
go to the toilet to open your bowels.
 Relaxed abdominal breathing - feeling the tummy gently rise and fall with deep breaths in
through the nose and out through the mouth, up to 5 breaths at a time - can help to relieve
the discomfort of wind pain and after birth pains.

Chest Management
It is important to start deep breathing and huffing/coughing exercises as soon as possible
to keep your chest clear.

 Sit in an upright position and take a deep breath into your lower chest and out again.
 Take 3-4 deep breaths followed by a huff (forced breath out) while supporting your
wound with a pillow or your hands.
 Tighten your pelvic floor muscles at the same time

Do deep breathing, huffing and coughing exercises every hour that you are awake until
you can comfortably get in/out of bed and walk around.

Circulation
Simple leg exercises should be done until you are up and about to increase the circulation
in your legs and reduce the risk of clotting. Bend and stretch your ankle and legs 10 times every
hour that you are awake until you can comfortably get in/out of bed and walk around.
The next few days

Wind pain, pain when moving and back ache are common in the first few days.

Deep breathing for wind pain

 Lie on your back with your knees bent up.

 Take a deep breath in and let your tummy rise up at the same time.
 Hold this for a few seconds and then relax and slowly breathe out.
 Repeat 4-5 times.

Getting in and out of bed

 When rolling or getting in and out of bed it is important to support your wound using
your tummy muscles.
 Don't try sitting straight up from lying on your back.
 You need to roll onto your side with knees bent while bracing with your tummy muscles.
 Then push yourself up into a sitting position using your lower elbow.
 While you are in hospital this is made easier by having the
head of the bed raised up.

Pelvic tilting (for backache and for strengthening tummy muscles)

 Lie on your back with your knees bent.

 Place one hand on your pubic bone (the bone at the lower end of your tummy) and the
other under your ribs.
 Breathe in and then as you breathe out slowly tighten your tummy muscles (so that your
tummy is drawn in), and flatten your back against the bed.
 Your hands should move closer together.
 By doing this you are shortening your tummy wall muscles (rectus abdominis muscles).
 Try to hold the muscles tight for a count of 5 to 10 while breathing normally.
 Relax and repeat this 5 to 10 times.
This position – knees bent with 2 pillows under them and one for your head is a lovely position
to rest in while in hospital. If you have lower back pain try lying in this position.

Do this pelvic tilting exercise regularly during the day when lying, standing
or sitting. Nappy changes are a good time to remember this exercise.

Stand against a wall with your knees bent and feet a little away from the
wall. Breathe in, and as you breathe out tighten your abdominal muscles and flatten your back
against the wall. Hold this position for 10 to 15 seconds or longer while breathing normally.

Pelvic floor muscles

These muscles support your pelvic organs (bladder, uterus (womb) and bowel). They
become weakened during the pregnancy due to hormonal changes and by the increasing weight
of your baby.

If the pelvic floor muscles remain weakened it is possible that you may experience:

 some slight leaking of urine, especially when you laugh, cough or run
 A change in sexual function
 Problems with bowel control - leakage of wind
 Prolapse – the gradual 'falling down' of your pelvic organs.
 For all women after childbirth – including after a caesarean – it is very important that
these muscles are exercised so that they return to normal. For more information have a
look at the topic Pelvic floor exercises.
 Pelvic floor exercises should be continued daily for the rest of your life.

More about abdominal (tummy) muscles

The most important functions of these muscles are to stabilize and protect your spine and
to support your internal organs. During pregnancy these muscles are stretched a lot, so to get
them to work well after the birth of your baby you need to get them back to their normal length
and strength.

During pregnancy the muscles running between your ribs and pubic bone (rectus
abdominis muscles) can separate – which can increase the risk of back pain.

Abdominal bracing

This activates a deep muscle that wraps right around the abdomen rather like a corset.
The muscle is called the transversus abdominis. It helps the back muscles protect your spine
against injury and pain.

Let your tummy muscles soften and relax and them gently draw your lower tummy (belly
button and below) in towards your spine - keep breathing normally. Do this often during the day
and gradually increase the length of hold, up to 5 - 10 seconds. Rest and then repeat this exercise
5 - 10 times. You can practice this exercise when lying down on your side, on hands and knees,
sitting or standing.

If you can't feel much try this: as you breathe in expand your ribs as much as possible.
Hold that expansion while you breathe out and draw in your belly button towards your spine. It
may help if you imagine you are trying to do up a pair of tight jeans.

Every time you lift your baby, push/pull or change your position (eg rolling over in bed
or going from sitting to standing), remember to first tighten your pelvic floor
muscles and then brace your tummy muscles.

Pelvic tilting and abdominal bracing with alternate leg movements

This exercise is important if you have had a separation of your rectus

abdominis muscles. This exercise is encouraged as a progression of the previous tummy
exercises – it is important to check with a physiotherapist to make sure that you are doing this
correctly.

Lie on your back with your knees bent.

Place one hand under your back and do a pelvic tilt. Remember to breathe normally.
Hold the pelvic tilt (your hand should feel a constant pressure from your back).

Slowly slide one leg down the bed keeping your foot in contact with the bed. Then slide the leg
up again.

A Relax, then do this with the other leg.

Repeat 5 times for each leg.

If you are unable to maintain your pelvic tilt as you move your leg, stop and try again when you
feel stronger.

Back care

 Take care of your back by:

 Stand "tall". Imagine you have a piece of string pulling the centre of
your head towards the ceiling.
 Change nappies, dress and bath baby at waist height. If you need to get lower, bend your
knees and hips and keep your back straight.
 If sitting to feed your baby or expressing, sit in a comfortable chair
with good back support. Consider using a footstool and/or pillow(s) to
find the best position for you. Relax the muscles in your neck and
shoulders when holding and feeding your baby.
 Avoid lifting anything heavier than your baby for the first 6 weeks.
 Whenever you are lifting, remember to bend your knees, keeping your
back straight, brace your pelvic floor muscles and low tummy muscles, and hold the
object you are lifting close to your body. Avoid lifting and twisting - move your feet to
turn instead.
 When carrying your baby, avoid carrying on one hip as this increases strain on your back.
 Pelvic tilting and abdominal bracing are essential exercises for maintaining good posture,
and to prevent back ache that is due to bad posture and injury due to poor lifting and
bending techniques.
 When these abdominal muscles support the spine and increase how well the back muscles
work this takes strain off the ligaments and discs of the lower back.
  These exercises will benefit you all of your life.

TOPIC #3: PROPER HYGIENE ‘PERINEAL CARE’

WHAT IS PERINEAL CARE?

Postpartum perineal care is cleaning and caring for your perineum after having a baby.
The perineum is the area between the vagina (birth canal) and the anus (rear end opening). In the
first few weeks after childbirth, you will probably have soreness or pain in your perineum. You
will also have discharge coming out of your vagina.

Perineal care is usually called “peri care.” It means washing the genitals and anal area.
Peri care can be done during a bath or as a separate procedure. Peri care prevents skin breakdown
of perineal area, itching, burning, odor, and infections. Perineal care is very important in
maintaining the clients' comfort. More frequent care is required for clients who are incontinent or
for those who have an indwelling catheter. Make every effort to respect the modesty of clients
and be gentle when cleansing this sensitive area.

SPECIFIC MEASURES RELATED TO PERI CARE

Other than soap and water, different products may be used when giving peri care. Some
clients use a non-rinse peri-wash, a peri-wash that requires rinsing, skin-barrier creams, or pre-
moistened wipes. Use peri care products according to the service plan and follow the
manufacturer’s directions for use. Always wear gloves when giving peri care to protect yourself
and the client. Offer the client a bedpan/urinal or assist him to the bathroom before starting.
Warm water on the perineal area may stimulate the need to urinate. Be very gentle when washing
the area. The perineal area is more sensitive to temperature than the rest of the body. The water
may be more comfortable if it is slightly cooler than the temperature of bath water. Position the
client in the "back-lying" and/or "side-lying" position when giving peri care. A towel or bedpan
may be placed under the hips to assist in peri care.
 When giving peri care to the female client, observe for odors and vaginal discharge that
may indicate vaginal yeast infection. Always wash from front to back to prevent spreading fecal
matter from anal area to vagina or urethra (opening to bladder).

PROCEDURE FOR GIVING PERI CARE TO THE FEMALE CLIENT:

1. Gather necessary equipment.

2. Wash your hands. Put on gloves.

3. Explain what you are going to do.

4. Provide privacy.

5. Assist client to back-lying or side-lying position; place towel or bedpan under hips.

6. Cover client with a towel or sheet.

7. Expose peri area. Gently wash the inner legs and outer peri area along the outside of the labia

NOTE: USE A CLEAN AREA OF WASH CLOTH FOR EACH WIPE OF PERI AREA PER
SERVICE PLAN.

8. Wash the outer skin folds from front to back.

9. Wash the inner labia from front to back.

10. Gently open all skin folds and wash the inner area from front to back.

11. Rinse the area well, starting with innermost area and proceeding outward.

12. Wash and rinse the anal area.

13. Pat the peri area dry.

14. May apply a light dusting of powder to outer peri area (optional) as per service plan.

15. Remove towel, bedpan, or sheet.

16. Remove and dispose of gloves.

17. Remove, clean, and store equipment.

18. Wash your hands.

19. Make the client comfortable.

20. Record observations and report anything unusual to nurse/supervisor.

TOPIC #4: BREASTFEEDING

WHAT IS BREASTFEEDING?

Breastfeeding is the normal way of providing young infants with the nutrients they need
for healthy growth and development. Virtually all mothers can breastfeed, provided they have
accurate information, and the support of their family, the health care system and society at large.
Colostrum, the yellowish, sticky breast milk produced at the end of pregnancy, is
recommended by WHO as the perfect food for the newborn, and feeding should be initiated
within the first hour after birth. Colostrum is rich in nutrients and provides all the calories a baby
needs for the first few days. Exclusive breastfeeding is recommended up to 6 months of age, with
continued breastfeeding along with appropriate complementary foods up to two years of age or
beyond.

WHEN TO START BREASTFEEDING?

It should begin within the first few hours of delivery, by allowing the baby to rest or
nurse, skin-to-skin, on the mother's chest. During this time, most infants are alert and interested
in nursing. However, there is no evidence that it will be more difficult or impossible to
breastfeed if the infant cannot nurse within this time period.

It is normal to produce small amounts of milk in the beginning. With continued frequent
breastfeeding, a larger amount of milk will be produced within three to five days. Infants
normally lose weight during the first few days of life and gradually regain this weight by two
weeks after delivery.
POSITIONING

What breastfeeding positions are best after a C-section?

Breastfeeding after a C-section is uncomfortable at first (at least as soon as the pain meds
wear off). So find a breastfeeding position that puts the least pressure on the incision, including:

Side-lying position - is the most comfortable position for many moms, especially in the first
couple of days following surgery. The side-lying hold allows the mother to nurse while lying
down. When using this position, there should be no excess bedding around the infant. The side-
lying hold should not be used on a waterbed, a couch, or a recliner because this poses a
suffocation hazard to the infant.

Football hold - this allows a woman to easily see the baby at her breast. It is often preferred by
women who have an abdominal incision, after a Cesarean section, or by women with large
breasts or a small or premature baby. The baby is supported by a pillow as the mother sits, which
should allow the baby's head to be at the level of the mother's breast.

Cradle or crossover hold - The cradle hold can be done while the mother sits in a chair. To feed
from the left breast, the infant's head and body are supported by the mother's left forearm. The
mother's left hand usually supports the baby's buttocks or upper thighs. Some women use a
pillow to support this arm. The baby's stomach should be flat against the mother's chest and the
baby's head should be in line with the body (not turned).

Some positions will be more comfortable than others, so give each a try to see what
works best for you. A belly band can also take some of the pressure off your incision, helping
make breastfeeding a little more comfortable.

HOW TO KNOW WHEN YOUR BABY IS READY TO FEED?

Babies show several cues to indicate that they are ready to feed—look for, and respond
to, early feeding cues that your baby displays including:
  eye movement under closed lids (rapid eye movement)
 increased alertness, awakening or changes in facial expression
 movement of arms or legs
 tossing, turning or wriggling
 rooting—opening their mouth and searching to suck on contact
 clicking or tongue sucking
 hand movements to their mouth and sucking on hands
 squeaking noises or light fussing.

Crying is a late sign of hunger. Avoid waiting for this sign as a crying baby can be more
disorganised and therefore more difficult to attach.

DOES HAVING A C-SECTION CHANGE THE MILK SUPPLY?

Some mothers who have had a cesarean find that their milk comes in a little later than
expected, probably due to the extra stress of surgery. They can keep their milk supply on track
by:

 Cuddling skin-to-skin with your baby as often as you can

 Nursing frequently — about every three hours, day and night
 Be sure you’ve documented your wishes in your birth plan and that you’ve got advocates
on your side (your partner, a lactation consultant, a doula, the pediatrician) helping you to
reunite with your baby as soon as possible.

LATCH ON

Latching on refers to the infant's formation of a tight seal around the nipple and most of
the areola with his or her mouth. A correct latch-on allows the infant to obtain an adequate
amount of milk and helps to prevent nipple soreness and trauma.

Signs of a good latch-on include:

● The top and bottom lips should be open to at least 120°

● The lower lip (and, to a lesser extent, the upper lip) should be turned outward against the breast

● The chin should be touching the breast, while the nose should be close to the breast

● The cheeks should be full

● The tongue should extend over the lower lip during latch-on and remain below the areola
during nursing (visible if the lower lip is pulled away)

Suckling and swallowing — An infant must be able to suckle and swallow correctly to
consume an adequate amount of milk. It should be possible to hear the infant swallow. These
early swallows may sound like the letter "C" in cat, and are heard infrequently in the first day or
two of nursing. The infant's jaw should move quickly to start the flow of milk, with a swallow
heard after every one to three jaw movements once the milk supply has increased significantly
after the first few days.

ARE PAIN MEDICATIONS SAFE TO TAKE WHILE NURSING?

Pain meds (often narcotics) will be given after delivery. Don’t hesitate to take them if you
need them, since being in intense pain can unnecessarily interfere with breastfeeding efforts. As
long as you use them only short-term at a safe dose (ask your health care provider what this
would be for you) and watch for excessive drowsiness in baby, they’re safe for your little one
and compatible with breastfeeding.

TO ENCOURAGE AN ABUNDANT MILK SUPPLY:

Nurse as soon after birth as possible. If something prevents the baby from being put to breast
within the 4-6 hours, begin pumping with a hospital-grade breast pump. Get the okay from the
doctor/midwife ahead of time to nurse the baby in the recovery room – this shouldn’t be a
problem unless the mother or the baby is having medical problems.
Nurse frequently. Breastfeed the baby at least every 2 hours (from beginning of nursing to
beginning of the next nursing) during the day, with no more than 4 hours between nursings at
night. You’re aiming for at least 10-12 nursings per 24 hours. More frequent nursing results in
greater milk production at one week and thereafter.

Avoid unnecessary supplements. Do not supplement baby with anything (formula, water, etc)
unless it is medically indicated. Supplementing will do two things – missing feedings will reduce
breast stimulation and milk removal (both needed to increase milk supply), and babies who are
supplemented tend to need to eat again later than if they had nursed – so again, much-needed
nursing time is being lost.

Ensure that baby is nursing well. If baby is not latching well and transferring milk well, then it
can affect milk supply and the speed that the milk comes in.

TOPIC #5: INCISION CARE

Types of C-section Incisions

During a C-section, your doctor makes two incisions: The first is through the skin of your
lower abdomen, about an inch or two above your pubic hair line. The second is into the uterus,
which is where the doctor will reach in to deliver your baby. The type of cut on your abdomen
may not be the same as the one on your uterus. Each will be either:

 Horizontal. A low-transverse incision (or a “bikini cut”) is used in 95 percent of C-

sections today. That’s because it’s done across the lowest part of the uterus, which is
thinner — resulting in less bleeding. It’s also less likely to split if you try to have a
vaginal birth after a C-section (VBAC) when delivering a future baby.

 Vertical. Also known as a “classical” C-section, this cut is down the middle of the
abdomen, usually from below the navel to the pubic hair line. It used to be common, but
now is reserved for specific cases, including if you already have a scar there from a
previous surgery, if the baby is nestled low in your uterus or in another unusual position,
or if an emergency requires immediate delivery (for instance, severe fetal distress or
 excessive bleeding due to placenta previa). Vertical incisions may be slightly more
painful and take a little more time to heal.

Incision Care

 Keep it clean

Once a day (when you shower), let soapy water drip down your wound. There’s no need
to waterproof it, and you should avoid vigorous scrubbing. When you’re done, gently pat the
area dry with a clean towel.

 Air it out

 Air promotes healing in skin injuries, so whenever possible, expose the scar to air. That
doesn't mean, to walk around half-naked — wearing a loose gown at night is enough to get
the air circulating.

 Keep your appointments

 If the incision was closed with stitches that don’t dissolve, be sure to go to your follow-
up postnatal appointments so that the doctor can remove them. Leaving the stitches in for
longer than recommended can lead to a funky-looking scar. The American College of
Gynecologists (ACOG) now recommends that the first postpartum doctor's check-in happens
within three weeks of giving birth instead of four to six as previous guidelines suggested,
with another comprehensive checkup within 12 weeks of delivery. For C-section births, the
timing and frequency of your doctor's visits might be different, so talk to your practitioner
about when to come in after having the baby.

 Hold off on exercise

 Take it easy to allow the scars on the uterus and abdomen to heal. Avoid bending,
twisting of the body or making sudden movements as much as possible, and don’t pick up
anything heavier than the baby.

 Get moving
 Doing light excercise can help increase blood flow, to help with the healing and
decreases chances of developing deep venous thrombosis, or DVT (a blood clot that’s more
common during pregnancy and the postpartum period).

Signs of C-section Scar Infection: When to see your doctor?

 Redness or swelling of the incision or skin surrounding it

 Fever higher than 100.4 F
 Oozing or drainage from the incision site
 Foul smell from the area
 The wound becomes hard or you feel increasing pain around the wound
 Pain or tenderness in a specific spot of the incision (note that while some pain is normal
for the first few weeks, it should be generalized — not pain that you pinpoint to a specific
spot)
 Your incision splits open

XVI. REFERENCES/BIBLIOGRAPHY
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 Gonzalo, A. (2019). Dorothea Orem: Self-Care Deficit Theory.

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