CESARIAN SECTION: A CASE PRESENTATION

INTRODUCTION
o A cesarean section (also C-section) is a surgical procedure in which the delivery o a !a!y or rarely to
re"ove a dead etus through a cut (incision) in the "other#s !elly and uterus$ In "ost cases% a wo"an
can !e awa&e during the !irth and !e with her new!orn soon aterward$
o A late-ter" a!ortion using Caesarean section procedures is ter"ed a hysterecto"y a!ortion and is very
rarely peror"ed$
o The irst "odern Caesarean section was peror"ed !y Dr 'a"es (arry in Cape Town% )outh Arica on
*+ 'uly ,-*.$
/0N0RA1 O('0CTI20)
o TO DI)CU)) A CA)0 O3 R040AT C0)ARIAN )0CTION
)40CI3IC O('0CTI20)
o To discuss a!out actors or increasing Cesarean )ection Rate$
o To &now indications or Cesarean )ection$
o To discuss a!out Advantages and Disadvantages o 1O50R )0/60NT O20R C1A))ICA1
O40RATION
Case Presentation:
/0N0RA1 DATA
o This is the case o I)(% ** years old% e"ale% single% 3ilipino% Ro"an Catholic% /74,(,8,,)% 4U 79
*:9 wee&s AO/ !y 164% residing in (antayan% 6angaldan% 4angasinan% who was ad"itted in this
institution on )epte"!er .% *8,7 at around .;*8p"$
C<I03 CO641AINT
o 1u"!osacral 4ain
<I)TOR= O3 4R0)0NT I11N0))
o 4U 79 *:9 wee&s AO/ !y 164% /74,(,8,,)
o ,* hours 4TA > the patient went or regular prenatal chec&up in 4angasinan 4rovincial <ospital%
(olingit and was advised to get ad"itted !y the o!stetrician as the cervical dilatation was already ,
c"$ Also she was inor"ed that she would !e hersel arranging (lood or possi!le (lood transusion
as it?s not availa!le there in the hospital$ <ence% she waited or the arrange"ent$
o 3ew hours 4TA > the patient started to e@perience "ild lu"!osacral pain !ut no other associated
sy"pto"s o la!or li&e vaginal discharge% !leeding or a!do"inal pain$ )he was then reerred to this
institution and hence ad"ission was done$
4A)T 60DICA1 <I)TOR=
o No history o illnesses or hospitaliAation other than hospitaliAation or Delivery via Cesarean )ection
o *8,, > 0ctopic pregnancyB Dilatation and Curettage
o 'une ,*% *8,* > 1TC) with co"plicationsB 1(/
o No &nown allergies to any oods or drugs
3A6I1= <I)TOR=
o 6aternal; (C) <4N% (C) C2D
o 4aternal; (C) <4N
40R)ONA1:)OCIA1 <I)TOR=
o 4atient has stopped wor&ing during recent pregnancy and her hus!and is a service cell "e"!er in a
restaurant$
o Diet; eating "ostly rice with vegeta!les and "eats$
o (-) s"o&ing
o (-) drin&ing
O()T0TRICA1 D /=N0CO1O/ICA1 <I)TOR=
o /74, (,8,,)
o 164; Dec ,E *8,*
o AO/; 79 wee&s *:9 days
o 0DC; )ep *+ *8,7
o 6enstruation; ,F years
o Interval; irregular% every ater another "onth
o Days; 9days
o A"ount; *-7 pads:days
o )y"pto"s; (-) dys"enorrhea
R02I05 O3 )=)T06)
o /0N0RA1; (-) everB (-) !ody wea&ness
o )GIN; (-) Haundice% (-) pallor% (-) rashesB (-) pruritus
o <00NT;
i$ <ead; NCAT% (-) diAAiness
ii$ 0yes; anicteric sclera% 40RRT1% no !lurring o vision
iii$ 0ars; (-) discharge
iv$ Nose; (-) dischargeB (-) epista@is
v$ Throat; (-) hoarsenessB (-) T4C
o N0CG; supple% (-) 1A4
o (R0A)T; (-) painB (-) discharge
o R0)4IRATOR=; (-) deor"itiesB (-) coughB (-) dyspneaB (-) tachypneaB (-) wheeAesB (-) rales
o CARDIO2A)CU1AR; (-) palpitationsB (-) chest painB (-) orthopneaB (-) easy atiga!ility
o /A)TROINT0)TINA1; (-) a!do"inal pain% (-) diarrheaB (-) constipation
o /0NITO-URINAR=; (+) vaginal bleeding; (-) dischargeB (-) reIuencyB (-) dysuria
o N0URO1O/IC; (-) syncopeB (-) seiAures
4<=)ICA1 0JA6INATION
o /eneral )urvey; Conscious% Coherent% A"!ulatory% not in Cardio-respiratory distress
o 2ital )igns; ($4- ,,8:-8 ""<g
K 4R- -8 !eats:"inute
K RR- **cycles:"inute
K Te"perature > 7.$* LC
o )&in; (-) rashesB (-) pallorB (-) HaundiceB (-) chloas"aB nor"al s&in turgorB (-) nodulesB (-) lu"ps
o <00NT;
o <ead; Nor"ocephalic% Atrau"atic
o 0yes; 4upils eIually reactive to lightB !ris& constricting ro" ,-7""% anicteric sclera%
pin&ish palpe!ral conHunctivae
o 0ars; (-) discharge% intact ty"panic "e"!raneB "ini"al distri!uted wa@
o Nose; pin&ish nasal "ucosaB (-) discharge% nasal septu" at "idline
o Throat; (-) TonsillopharyngitisB (-) 1eu&opla&iaB (-) 0rythropla&ia
o Chest and 1ungs; )C0% eIual tactile and vocal re"itusB resonant upon percussionB Clear !reath
soundsB (-) wheeAesB (-) ralesB (-) stridorB (-) rhonchi
o <eart; 46I at +th IC) 16C1B discrete and adyna"ic precordiu"B Nor"al Rate and Rhyth"B (-)
"ur"ur
o Abdomen: globular; (+) striae gravidarum; (+) linea nigra; !R " #$% b&m; ! " $# 'm( (+)
)etal movements
o *enito+,rinar- S-stem: (+) vaginal bleeding; Cervi'al dilation " .+$ 'ms
o 0@tre"ities; (-) ede"a
C1INICA1 I64R0))ION;
o /74, (,8,,) 4U 79 500G) D *DA=) AO/ (= 164% C04<A1IC 4R0)0NTATION% IN
1A(OR% 4rev C)
COURSE IN THE WARDS
This is the case o I)(% ** years old% e"ale% single% 3ilipino% Ro"an Catholic% /74,(,8,,)% 4U
79 *:9 wee&s AO/ !y 164% residing in (antayan% 6angaldan% 4angasinan% who was ad"itted in this
institution on )epte"!er .% *8,7 at around .;*8p" with a chie co"plaint o lu"!osacral pain$ As the
patient hersel was the inor"ant% the inor"ation related to the patient was gathered !y ver!al interview%
hence relia!ility was E8M$ The patient was conscious% coherent% a"!ulatory% co-operative and not in
cardio-respiratory distress$
,* hours 4TA$ the patient went or regular prenatal chec&up in 4angasinan 4rovincial <ospital%
(olingit and was advised to get ad"itted !y the o!stetrician as the cervical dilatation was already , c"$
Also she was inor"ed that she would !e hersel arranging (lood or possi!le (lood transusion as it?s
not availa!le there in the hospital$ <ence% she waited or the arrange"ent$
3ew hours 4TA% the patient started to e@perience "ild lu"!osacral pain !ut no other associated
sy"pto"s o la!or li&e vaginal discharge% !leeding or a!do"inal pain$ )he was then reerred to this
institution and hence ad"ission was done$ Upon Ad"ission% the vital signs were ta&en and recorded (($4-
,,8:-8 ""<g% 4R- -8 !eats:"inute% RR- **cycles:"inute% Te"perature > 7.$* LC)$ 4hysical e@a"ination
revealed glo!ular a!do"en with striae gravidaru"% linea nigra with 3<T o ,7+ !p" % 3< o 7, c" and
presence o etal "ove"ents$ Upon Internal 0@a"ination% there was vaginal !leeding and cervical
dilatation o *-7 c"s$
<ence% the irst i"pression was /74, (,8,,) 4U 79 500G) D *DA=) AO/ (= 164% C04<A1IC
4R0)0NTATION% IN 1A(OR% 4rev C)$
The patient was then ad"itted and was transerred to the O( ward or urther "onitoring o 3etal
heart tone and 2ital signs every shit$ )he was hoo&ed to I23 o D+1R) i1 or ,* hours$ Diagnostics
reIuested were Co"plete (lood Count and (lood Typing$ A"picillin *"g I2 ( ) AN)T was given$
The result o C(C is as ollows;
4ARA60T0R) RES,/TS NOR0A/ RAN*E
<e"oglo!in ,*.$F ,*8-,.8 g"s:1
Total R(C count F$* J ,8
,*
F$* > +$F J ,8
,*
:1
Total 5(C count ,,$7 J ,8
9
:1 F$+ > ,,$. J ,8
9
:1
)eg"enters 8$9+ 8$+F > 8$97
1y"phocytes 8$*+ 8$*.-8$-+
<e"atocrit 8$7- 8$79 > 8$F9
(1OOD T=4IN/; 1O2 Positive
On the ,st <ospital Day (4re op)% the patient still had lu"!osacral pain !ut she was conscious%
coherent with vital signs as (4 N ,,8:-8 ""<g% 4RN 9- !p"% T N 7.$- LC% RRN *8 !p"$ )he was
scheduled or repeat C) at E p"$ Consent or operation was secured or "edico-legal purposes$ Ater the
Cesarean )ection% the patient was unconscious due to the eect o anesthesia given during the procedures$
The vital signs were sta!le as (4 N ,,8:-8 ""<g% 4RN 9- !p"% TN 7.$- LC% RRN *8 !p"$
The post-op orders were given as to "onitor the patient or any signs o prouse vaginal !leeding
or hypotension$ )he was still hoo&ed to I23 o D+1R i1 incorporated with ,8 OuP O@ytocin J 78 gtts:"in
which was ollowed up !y D+5 i1 J *+ gtts:"in$ Getorolac 78 "g I2 I . hours AN)T J F doses then
every . hours% Ranitidine +8 "g I2 every - hours% 6etoclopra"ide ,8 "g I2 every - hours were
given$ The patient had to !e &ept ther"o regulated% with "onitoring o 3luid Input D Output every , hour
and then recorded$ It was also instructed to chec& the contraction o uterus$ The patient was lied down in a
"oderate high !ac& rest position$
On the *nd <ospital Day (4ost Op)% the patient was conscious% coherent% ae!rile% not in Cardio-
respiratory distress !ut with tolera!le post-op pain at incisional site and headache$ 6ini"al vaginal
!leeding was noticed$ (ut the vital signs were sta!le as (4 N ,,8:-8 ""<g% 4RN 9- !p"% T N 7.$+ LC%
RRN *8 !p"$ )he was still given I23 o D+1R) in - hours J 7 cycles$ /eneral liIuids e@cept "il& D
car!onated drin&s% sot diet instructed once the patient would have latus$ I2 "edications to !e continued
until the patient had latus% the oral "eds could !e given$ The oral "edications were Ceale@in +88
"g:cap , cap I . hours J 9 days% 3errous u"arate , ta! OD% )odiu" ascor!ate , ta! OD% 6eena"ic
acid +88 "g:cap , cap I - hours or pain$ I3C was re"oved and advised or gradual a"!ulation$ The
patient see"ed to !e pale hence% Repeat C(C was reIuested$
R040AT C(C R0)U1T
PARA0ETERS RES,/TS NOR0A/ RAN*E
<06O/1O(IN -9 (,*.$F) ,*8-,.8 g"s:1
Total R(C count *$- J ,8
,*
(F$* J ,8
,*
) F$* > +$F J ,8
,*
:1
Total 5(C count -$F J ,8
9
:1 (,,$7 J ,8
9
:1) F$+ > ,,$. J ,8
9
:1
)eg"enters 8$9E (8$9+) 8$+F > 8$97
1y"phocytes 8$*, (8$*+ ) 8$*.-8$-+
<e"atocrit 8$*9 (8$7-) 8$79 > 8$F9
Ater the Repeat C(C result was relayed% the patient was transused with , OUP 4R(C properly
typed and cross "atched with (T precaution due to low he"oglo!in count and R(C count$
On the 7rd <ospital Day (4ost Op)% the patient had "ini"al% tolera!le post-op pain at incisional
site% diAAiness and had latus$ <ence% Diet as Tolerated instructed once she would have !owel "ove"ent$
The vital signs were as (4 N E8:98 ""<g% 4RN 9- !p"% T N 7.$+ LC% RRN *8 !p"$ The present I23
was to !e continued and to !e ollowed !y 4N)) ,1 at sa"e rate$ Oral "edications were to !e continued$
The patient was still pale as she was waiting or the (lood transusion$
On the Fth <ospital Day (4ost Op)% she didn?t have any su!Hective co"plaints other than "ini"al
to no pain$ Nor"al vital signs as (4 N ,,8:-8 ""<g% 4RN 9- !p"% T N 7.$+ LC% RRN *8 !p"$ I23
instructed to !e consu"ed$ As the patient has no co"plaints% ir" and well contracted uterus% "ini"al
paleness% she was advised to go ho"e with the ollowing "edications$
a$ Ceale@in +88 "g:cap , cap every . hours to co"plete or 9 days
!$ 3errous u"arate , ta! (ID
c$ )odiu" ascor!ate , ta! OD
d$ 6eena"ic acid +88 "g:cap , cap every - hours or pain
The patient was encouraged or !reasteeding and was advised or ollow-up on O4D !asis ater ,
wee& o discharge ro" the hospital$
3INA1 DIA/NO)I)
o /74* (*8,*) 4U 79 *:9 wee&s AO/ C04<A1IC 4R0)0NTATION% D01I20R0D 5IT<
R040AT 1)C) TO A 1I20 (A(= (O=
3ISC,SSION
o R040AT C0)ARIAN )0CTION
o An operative procedure where!y the etuses ater the end o ,-th wee& are delivered through
an incision on the a!do"inal and uterine walls$ The irst operation peror"ed on a patient is
reerred to as a pri"ary to a 4ri"ary Cesarean section$ 5hen the operation is peror"ed in
su!seIuent pregnancies% it is called R040AT C0)AR0AN )0CTION$
3ACTOR) 3OR INCR0A)IN/ C0)AR0AN )0CTION RAT0
o Identiication o at ris& etuses !eore ter"
o Identiication o at ris& "others
o Rising incidence o elderly pri"igravidae
o Decline in vaginal !reech delivery
o Increased diagnosis o etal distress and ear o litigation
o 5ider use o repeat C$)$ in cases with previous cesarean delivery
INDICATION) 3OR C0)AR0AN )0CTION
Common
indi'ations
Absolute indi'ations Relative indi'ations
,$ Cephalopelvic
disproportion
(C4D)
*$ 3eta distress
(non-
reassuring etal
3<R)
7$ Dystocia
,$ 2aginal delivery is not possi!le
*$ 4lacenta previa
7$ C4D
F$ 4elvic "ass causing o!struction
(cervical or !road liga"ent
i!roid)
+$ Advanced carcino"a cervi@
.$ 2aginal o!struction (atresia%
stenosis)
,$ C4D
*$ 4revious Cesarean delivery
7$ 3eta distress (non-reassuring etal
3<R)
F$ Dystocia
+$ Antepartu" he"orrhage (placenta
previa% a!ruptio placenta)
.$ 6alpresentation
9$ 3ailed surgical induction o la!or%
ailure to progress in la!or
-$ Recurrent a!ortions or "iscarriages
E$ <ypertensive disorders ()evere pre-
ecla"psia% 0cla"psia)
AD2ANTA/0) AND DI)AD2ANTA/0) O3 1O50R )0/60NT O20R C1A))ICA1 O40RATION
/O4ER SE*0ENT C/ASSICA/
T0C<NIQU0) ,$ T0C<NICA11= )1I/<T
DI33ICU1T
*$ 10)) (1OOD 1O))
7$ T<IN 5A110D
,$ T0C<NICA11= 0A)=
*$ 6OR0 (1OOD 1O))
7$ T<ICG 5A110D
4O)T-
O40RATI20
,$ 10)) C<ANC0) O3
<06ORR<A/0 AND )<OCG
*$ 10)) C<ANC0) O3
40RITON0A1 AD<0)ION)
AND INT0)TINA1
O()TRUCTION
7$ CON2A10)C0NC0 I)
(0TT0R
F$ 6OR(IDIT= AND
6ORTA1IT= AR0 6UC<
1O50R
,$ <I/< C<ANC0) O3
<06ORR<A/0 AND )<OCG
*$ 6OR0 DU0 TO I640R30CT
40RITONI)ATION
7$ R01ATI201= 4OOR
CON2A10)C0NC0
F$ <I/< 6OR(IDIT= AND
6ORTA1IT= RAT0
5OUND
<0A1IN/
,$ (0TT0R <0A1IN/ O3 )CAR
(0CAU)0 O3;
A$ 6INI6A1 5OUND
<06ATO6A
($ T<0 5OUND R06AIN)
QUI0)C0NT DURIN/
<0A1IN/ 4ROC0))
,$ T<0 )CAR I) 50AG (0CAU)0
O3;
a$ 6OR0 5OUND <06ATO6A
3OR6ATION
!$ T<0 5OUND I) IN )TAT0 O3
T0N)ION DU0 TO
CONTRACTION AND
R01AJATION O3 U440R
)0/60NT
DURIN/
3UTUR0
4R0/NANC=
10)) C<ANC0) O3 )CAR
RU4TUR0
6OR0 RI)G) O3 )CAR
RU4TUR0
Submitted b-: A&&u 56a Avinas6
5unior 0edi'al Intern( 700C