I.

INTRODUCTION Background of the Study A Caesarean section (also C-section, Cesarean section) is a surgical procedure in which one or more incisions are made through a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies, or, rarely, to remove a dead fetus. A late-term abortion using Caesarean section procedures is termed a hysterotomy abortion and is very rarely performed. The first modern Caesarean section was performed by Dr James Barry in Cape Town, South Africa on 25 July 1826. A Caesarean section is usually performed when a vaginal delivery would put the baby's or mother's life or health at risk; although in recent times it has also been performed upon request for childbirths that could otherwise have been vaginal. In recent years, the rate has risen to a record level of 46% in China and to levels of 25% and above in many Asian, European and Latin American countries. The rate has increased significantly in the United States, to 33 percent of all births in 2012, up from 21

percent in 1996, and in the rate in 2009 varied widely between hospitals (ranging from 6.9% to 69.9% of births). Across Europe, there are significant differences between countries: in Italy the Caesarean section rate is 40%, while in the Nordic countries it is only 14%.Medical professional policy makers find that elective cesarean can be harmful to the fetus and neonate without benefit to the mother, and have established strict guidelines for non-medically indicated cesarean before 39 weeks. Etymology The Roman Lex Regia (ruling law), later the Lex Caesarea (imperial law), of Numa Pompilius (715673 BCE), required the child of a mother dead in childbirth to be cut from her womb. This seems to have begun as a religious requirement that mothers not be buried pregnant, and to have evolved into a way of saving the fetus, with Roman practice requiring a living mother to be in her tenth month of pregnancy before resorting to the procedure, reflecting the knowledge that she could not survive the delivery. Speculation that the Roman dictator Julius Caesar was born by the method now known as C-section is apparently false. Although Caesarean sections were performed in Roman times, no classical source records a mother surviving such a delivery, the earliest recorded survival dates to the 12th century scholar and physician Maimonides (see Commentary to Mishnah Bekhorot 8:2). The term has also been explained as deriving from the verb caedere, to cut, with children delivered this way referred to as caesones. Pliny the Elder refers to a certain Julius Caesar (an ancestor of the famous Roman statesman) as ab utero caeso, "cut from the womb" giving this as an explanation for the cognomen "Caesar" which was then carried by his descendents. Notably, the Oxford English Dictionary does not credit a derivation from

"caedere", and defines Caesarean birth as "the delivery of a child by cutting through the walls of the abdomen when delivery cannot take place in the natural way, as was done in the case of Julius Caesar". History Successful Caesarean section

performed by indigenous healers in Kahura, Uganda. As observed by R. W. Felkin in 1879. The mother of Bindusara (born c. 320 BCE, ruled 298 c.272 BCE), the second Mauryan Samrat (emperor) of India, accidentally consumed poison and died when she was close to delivering him. Chanakya, the Chandragupta's teacher and adviser, made up his mind that the baby should survive. He cut open the belly of the queen and took out the baby, thus saving the baby's life. According to the ancient Chinese Records of the Grand Historian, Luzhong, a sixthgeneration descendant of the Yellow Emperor, had six sons, all born by "cutting open the body". The sixth son Jilian founded the House of Mi that ruled the State of Chu (c. 1030223 BCE). In the Irish mythological text the Ulster Cycle, the character Furbaide Ferbend is said to have been born by posthumous Caesarean section, after his mother was murdered by his evil aunt Medb. The Babylonian Talmud, an ancient Jewish religious text, mentions a procedure similar to the Caesarean section. The procedure is termed yotzei dofen. Pliny the Elder theorized that Julius Caesar's name came from an ancestor who was born by Caesarean section, but the truth of this is debated (see the article on the Etymology of the name of Julius Caesar). The Ancient Roman Caesarean section was first performed to remove a baby from the womb of a mother who died during childbirth. Caesar's mother, Aurelia, lived through childbirth and successfully gave birth to her son, ruling out the possibility the Roman ruler and general was born by Caesarean section. The Catalan saint Raymond Nonnatus (1204 1240), received his surnamefrom the Latin non-natus ("not born")because he was born by Caesarean section. His mother died while giving birth to him. An early account of Caesarean section in Iran is mentioned in the book of Shahnameh, written around 1000 AD, and relates to the birth of Rostam, the national legendary hero of Iran. According to the Shahnameh, the Simurgh instructed Zal upon how to perform a Caesarean section, thus saving Rudaba and the child Rostam.

Caesarean section usually resulted in the death of the mother; the first recorded incidence of a woman surviving a Caesarean section was in the 1580s, in Siegershausen, Switzerland: Jakob Nufer, a pig gelder, is supposed to have performed the operation on his wife after a prolonged labour. However, there is some basis for supposing that women regularly survived the operation in Roman times. For most of the time since the 16th century, the procedure had a high mortality rate. However, it was long considered an extreme measure, performed only when the mother was already dead or considered to be beyond help. In Great Britain and Ireland, the mortality rate in 1865 was 85%. Key steps in reducing mortality were: Introduction of the transverse incision technique to minimize bleeding by Ferdinand Adolf Kehrer in 1881 is thought to be first modern CS performed. Modification by Hermann Johannes Pfannenstiel in 1900. The introduction of uterine suturing by Max Snger in 1882. Adherence to principles of asepsis Anesthesia advances Blood transfusion Antibiotics European travelers in the Great Lakes region of Africa during the 19th century observed Caesarean sections being performed on a regular basis. The expectant mother was normally anesthetized with alcohol, and herbal mixtures were used to encourage healing. From the welldeveloped nature of the procedures employed, European observers concluded they had been employed for some time. The first successful Caesarean section to be performed in America took place in what was formerly Mason County, Virginia (now Mason County, West Virginia), in 1794. The procedure was performed by Dr. Jesse Bennett on his wife Elizabeth. On March 5, 2000, in Mexico, Ins Ramrez performed a Caesarean section on herself and survived, as did her son, Orlando Ruiz Ramrez. She is believed to be the only woman to have performed a successful Caesarean section on herself. Complications 1. Increased risk of infection 2. Hemorrhage 3. Longer hospitalization (which equal higher cost) 4. Post operative pain and more difficult recovery 5. Possible injury to other organs 6. Increased in subsequent pregnancies of: placenta previa, retained placenta, future c-sections, uterine rupture.

Types of Uterine Incision

Types of Abdominal Incision

II.

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 (descent of the fetal (false labor)

Ripening of the cervix (Goodells Sign the cervix feel softer like consistency of the earlobe)

Braxton Hicks Contraction >begin and remain irregular like consistency of the >1st felt abdominally earlobe) >pain disappears with ambulation >do not increase in duration and intensity >do not achieve cervical Dilatation

TRUE LABOR

Uterine Contractions Increase in duration and intensity 1st felt at the back and radiates to the abdomen Pain is not relieved no matter what the activity Achieve cervical dilation

Show Pink-tinge of blood, a mixture of blood and fluid

Rupture of Membrane
Rupture of the amniotic sac

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)

III.

DIAGNOSTIC TEST 1. Complete blood count 2. Blood type and screen, cross-match 3. Screening tests for human immunodeficiency virus, hepatitis B, syphilis 4. Coagulation studies (eg, prothrombin and activated partial thromboplastin times, fibrinogen level) 5. Fetal Heart Monitoring 6. Imaging studies

In labor and delivery, document fetal position and estimated fetal weight. Although ultrasonography is commonly used to estimate fetal weight, a prospective study reported the sensitivity of clinical and ultrasonographic prediction of macrosomia, respectively, as 68% and 58%. IV. INDICATIONS or RISK FACTORS

1. Medical indications: abruption, placenta previa, herpes genetalis in active stage, prolapsed cord and severe mental illness 2. Multiple gestations 3. Cephalopelvic disproportion and fetal malposition 4. Fetal distress 5. Previous cesarean section. About 1/3 of caesareans are done on women who have had a caesarean section in the past. 6. Abnormal labor: Prolonged labor, uterine inertia 7. Failed trial and induction of labor, failed forceps and vacuum extraction 8. Other maternal conditions: preeclampsia and eclampsia, heart disease, Rh and ABO incompatability, maternal exhaustion

V.

DEFINITION OF TERMS 1. Caesarean section - is usually performed when a vaginal delivery would put the baby's or mother's life or health at risk, although in recent times it has also been performed upon request for childbirths that could otherwise have been vaginal. 2. Laparotomy - is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as celiotomy. 3. Hysterotomy - is an incision in the uterus, commonly combined with a laparotomy during a caesarean section. 4. Ultrasonography- is an ultrasound-based diagnostic imaging technique used for visualizing subcutaneous body structures including tendons, muscles, joints, vessels and internal organs for possible pathology or lesions 5. Macrosomia - is a condition in which a baby is abnormally large before birth. The average birth weight for babies is about 7 pounds. 6. Cephalopelvic disproportion occurs when a babys head or body is too large to fit through the mothers pelvis. 7. Fetal malposition - Malpositions are abnormal positions of the vertex of the fetal head (with the occiput as the reference point) relative to the maternal pelvis. Malpresentations are all presentations of the fetus other than vertex. 8. Syphilis is a sexually transmitted infection caused by

the spirochete bacterium Treponema pallidum subspecies pallidum. 9. Immunodeficiency virus - a condition in humans in which progressive failure of the immune system allows life-threatening opportunistic infections and cancers to thrive. 10. Prothrombin - are used to determine the clotting tendency of blood, in the measure of warfarin dosage, liver damage, and vitamin K status. VI. NURSING MANAGEMENT Preoperative management Guidelines recommend a minimum preoperative fasting time of at least 2 hours from clear liquids, 6 hours from a light meal, and 8 hours from a regular meal.[6] However, patients are usually asked not to eat anything for 12 hours prior to the procedure.[7] The following are also included in preoperative management: 1. Preoperative Teaching:

a. Explain purpose of procedure to be done b. Clarify misconception c. Teach breathing exercise to be performed after operation and the advantage of early ambulation. 2. Informed Consent 3. Laboratory work Blood type and cross match, CBC, urinalysis 4. Instruct woman on not to eat anything 8 hours before operation of after midnight if CS is to be done in the morning of the next day to prevent vomiting and aspiration once she is placed under anesthesia. 5. Remove hairpins, nail polish, eye glasses, contact lens and dentures. Cover hair with cap. 6. Placement of an intravenous (IV) line 7. Infusion of IV fluids (eg, lactated Ringer solution or saline with 5% dextrose) 8. Placement of a Foley catheter (to drain the bladder and to monitor urine output) 9. Placement of an external fetal monitor and monitors for the patien ts blood pressure, pulse, and oxygen saturation 10. Preoperative antibiotic prophylaxis (decreases risk of endometritis after elective cesarean delivery by 76%, regardless of the type of cesarean delivery [emergent or elective]) 11. Evaluation by the surgeon and the anaesthesiologist Postoperative management 1. Routine postoperative assessment 2. Monitoring of vital signs, urine output, and amount of vaginal bleeding 3. Palpation of the fundus 4. IV fluids; advance to oral diet as appropriate 5. IV or intramuscular (IM) analgesia if patient did not receive a long-acting analgesic or had general anesthesia; analgesia is usually not needed if patient received regional anesthesia, with/without a long-acting analgesic 6. Ambulation on postoperative day 1; advance as tolerated 7. If patient plans to breastfeed, initiate within a few hours after delivery; if patient plans to bottle feed, she may use a tight bra or breast binder in the postoperative period 8. Discharge on postoperative day 3 or 4, if no complications 9. Discuss contraception as well as refraining from intercourse

for 4-6 weeks postpartum.