A Case Study on

Multifetal Gestation; Malpresentation

In Partial Fulfillment of the Requirements in NCM 209-RLE

OB-Gyne Nursing Rotation

BSN - 2E Group 3

March 8, 2020

TABLE OF CONTENTS
INTRODUCTION……………………………………………………………….……………..2

OBJECTIVES……………………………………………………………..…………………..3

DATA……………………………………………………………………...………………….. 4

BIOGRAPHICAL DATA……………………………………...……………………….4

CLINICAL DATA………………………………………………………………..……..5

OBSTETRICAL DATA……………………………………………………….………..5

HISTORY…………………………………………………………………………….………...5

FAMILY HISTORY………………………………………………………………….....5

PAST HEALTH HISTORY……………………………………………...….…….…...6

PRESENT HEALTH HISTORY…………………………………....…………..…….6

DEVELOPMENTAL TASKS ……………………………………………………..……..…..7

PHYSICAL ASSESSMENT …………………………...………..……………………...…...9

DIAGNOSIS ……………………………………….……………………………………..… 17 

ANATOMY AND PHYSIOLOGY………………………………………………………...…20

PATHOPHYSIOLOGY ……………………………………………………………………...31

MEDICAL MANAGEMENT ………………………………………………………………...37

DIAGNOSTIC EXAMS

NURSING CARE PLANS

NURSING THEORIES ……………………………………………………….……………...51

DISCHARGE PLANNING METHOD ……………………………………………………...52

PROGNOSIS …………………………………………………………………………………56

REFERENCE ………………………………………………………………………………...57

INTRODUCTION
 Obstetrics was originally a separate branch of medicine, and gynecology was a

division of surgery. Over time, an increasing knowledge of the pathophysiology of the

female reproductive tract led to a natural integration of these two areas, and obstetrics

and gynecology merged into a single specialty. After completing an approved residency,

the obstetrics and gynecology specialist may practice general obstetrics (care of the

woman during pregnancy, labor, and the postpartum period) and gynecology

(traditionally care of the female reproductive organs and breasts, but now

encompassing comprehensive women’s health care from before puberty to beyond the

menopause).

         The group 3, subgroup 1 of BSN 2E, chose patient C.R.G. as their client for she

was diagnosed with term twin pregnancy, 37 weeks by Ballard score, cephalic-

transverse lie in presentation, delivered to a live twin A baby boy, and twin B baby boy

via cesarean section for malpresentation. In consideration of the selection of the client,

the case may help the student nurses in learning about complex pregnancies and

possible complications brought about by it. There is malpresentation, and in that case,

the client only over qualifies to be the main focus of our study in obstetrics/gynaecology

concept. With great efforts, we have attained the consent of the client in conducting the

study.

The predisposing factors to malpresentation include: prematurity, abnormalities

of the uterus such as fibroids, partial septate uterus, abnormal fetus, placenta previa,

primiparity, and multiple gestation. Twins are by far the most common form of multiple

births in humans. The U.S. Centers for Disease Control and Prevention report more

than 132,000 sets of twins out of 3.9 million births of all kinds each year, about 1 in 30.
Without fertility treatments, the probability is about 1 in 60; with fertility treatments, it can

be as high as 1 in 4. In the Philippines, observed were 15 twin pregnancies per 1000

live births. (Unicef, 2016)

Usually the fetal head engages in the occipito-anterior position and then

undergoes a short rotation to be directly occipito-anterior in the mid-cavity. Malpositions

are abnormal positions of the vertex of the fetal head relative to the maternal pelvis.

Malpresentations are all presentations of the fetus other than vertex.

Fetal malpresentation is an important cause of the high cesarean delivery rate

around the world. This includes breech, face, brow, and compound presentations as

well as transverse lie. Risk factors include multiparity, previously affected pregnancy,

polyhydramnios, and fetal and uterine anomalies. 

As occipito-posterior position pregnancies often result in a long labour, close

maternal and fetal monitoring are required. An epidural is often recommended and it is

essential that adequate fluids be given to the mother. The mother may get the urge to

push before full dilatation but this must be discouraged. If the head comes into a face to

pubis position then vaginal delivery is possible as long as there is a reasonable pelvic

size. Otherwise, forceps or caesarean section may be required.

GOALS AND OBJECTIVES

General Objective:

At the end of the three week OB/Gyne nursing rotation, we, the BSN-2E Group 3

Subgroup 1 students will be able to improve our knowledge about the factors affecting

the patient’s condition and acquire new skills related to obstetrics and gynecology

Specific Objectives:

In order to achieve the general objective, the group specifically aims to:

a. Introduce the patient’s case through a well- written introduction;

b. Present the patient’s database;

c.  Evaluate the developmental tasks of the patient based on the theories of Erik

Erikson and Robert Havighurst;

d. Discuss the cephalocaudal physical assessment of the client;

e. Define the patient’s diagnosis with the use of 3 reliable sources;

f. Review the anatomy and physiology of the female reproductive system and the

process of fertilization;

g. Identify the etiology of cesarean section;

h. Identify the symptomatology of our patient’s condition ;

i. Illustrate a schematic diagram of cesarean section;

j. Analyze the laboratory findings of the patient;

k. Discuss the medications given to the patient;

l. Relate a nursing theory to the case of our patient;

m. Formulate six nursing care plans for the patient;

n. Create a discharge plan for the patient; 

o. Identify the prognosis of our patient’s case;

 p. Cite books, references, and internet websites used as sources of information;

and

q. Present the case study in a comprehensive manner.

CASE SCENARIO

A. BIOGRAPHICAL DATA

 Name: C.R.G.

 Age: 27 years old

 Birth date:March 4, 1992

 Gender: Female 

 Place of Birth: Davao City

 Home Address: Narra Street, Vista Verde, Panacan, Davao City

 Religion: Catholic

 Educational Attainment: BS Management Accounting

 Civil Status: Single

 Nationality: Filipino

 Occupation: Virtual assistant (BPO)

 Monthly Income: 30,000 - 40,000 php

B. CLINICAL DATA:

 Chief Complaint: Labor pains

 Attending Physician: Dr. Mabel Fuentes

 Final Diagnosis: G2P1 (1012), pregnancy uterine, term, 37 weeks by Ballard

score, cephalic-transverse lie in presentation, delivered to a live twin A baby boy,

 and twin B baby boy by primary low segment transverse cesarean section for

malpresentation;  multifetal gestation (dichorionic/diamniotic)

 Date and Time of Admission: March 2, 2020 4:22 pm

 Manner of Admission: Ambulatory

 Case Type: Private

 Ward Room and Bed Number: 251-5

C. OBSTETRICAL DATA

 Last Menstrual Period: June 26, 2019

 GPA: G P A
2 1 1

 TPAL: T P A L
1 0 1 2

 Fundic Height: 43 cm

 EDC: April 1, 2020

 Menstruation Cycle: Irregular, lasting 3-5 days, 3 pads per day.

 Gestational Age in Weeks: 35 weeks, 5 days by LMP

 Gestational Age in Months: 8 months, 7 weeks

D. FAMILY HEALTH HISTORY

On the parental side, grandfather L.G. was hypertensive, while grandmother

M.G.is known to have arthritis. Both are deceased. L.G. died due to a

cerebrovascular accident while M.G. died with old age. Two of C.G. 's aunts on

the paternal side, L.G. and H.G. are hypertensive same as their father. The rest
 of the siblings A.G., M.G., G.G., A.G., Y.G., and H.G. did not acquire any disease

and are living well. On the maternal side, grandfather F.R. has arthritis, while

grandmother A.R. is diabetic. Both are still alive and are on management of their

conditions. Two of C.G. 's aunts, J.R. and B.R., and uncle R.R. on the maternal

side are hypertensive and are managing their conditions as well. R.R. and I.R.

did not acquire any disease. Client C.G. herself and her brother T.G. did not

acquire any genetic disease that is depicted in the first and second generation.

E. PAST HEALTH HISTORY

Patient C.G was born on March 22, 1992 via normal spontaneous vaginal

delivery. She completed her immunizations before she turned 1 year old. From birth,

she had common illnesses such as cough and fever. At 6 years old, she had chicken

pox and mumps at 10 years old (2002). Her first menstrual period started when she was

13 years old, she was having an irregular period with an interval of 2-3 months. She

found out that she had Polycystic Ovary Syndrome diagnosed by Dr. Espino when she

was 23 years old (2016). She treated it with Althea pills and changed it to Dufastol after

a year as prescribed to her by Dr. Stewart. She can consume 3 pads per day with a

duration of 3 to 5 days. She was positive of Bronchial Asthma when she was 13 years

old (2005). Her last attack was year 2018. Her asthma can be triggered with dust. She

takes Salbutamol tablet taken orally to treat her asthma. She got pregnant in 2011 but

was terminated at 7 weeks due to German measles. She has astigmatism and was

diagnosed last 2016. In 2017, she started going to the gym and stopped early 2019

because of having conflict at work. Our patient had no allergies in terms of food and
medicine. She does not smoke and drinks occasionally, and consumes 2 bottles. Before

pregnancy, she takes multivitamins and vitamin E daily. 

E. PRESENT HEALTH HISTORY

One week prior to admission, the patient had an onset of irregular contractions,

an ultrasound was done revealing a cephalic-transverse lie of twin gestation, henced

caused admission. She came in ambulatory on March 2, 2020 Tuesday at 4:15 PM and

was admitted per wheelchair to the delivery room for cesarean section under the service

of Dr. Fuentes.

 She was assessed and was negative of hypertension and diabetes mellitus. The

client was G P (0110) with a gestational age of 35 weeks and 5 days in active labor.
2 2

Her internal exam revealed 3 centimeters dilated, 80% effaced, station -3 and intact bag

of water, with moderate uterine contractions every 7 to 11 minutes. She was prescribed

with postoperative antibiotic Cefuroxime 1.5 grams IVTT.

On March 3 at 11 PM, the patient was transferred in to St. Mary’s ward per

stretcher, post-cesarean section and prescribed with Cefuroxime 750 mg, Ranitidine 50

mg, Parecoxib 40 mg, and Tramadol 50 g.

DEVELOPMENTAL TASKS
Robert Havighurst’s Developmental Task Theory

Task Rationale Justification

1. Choose a
As individuals begin to establish more CG has achieved
life partner
intimate relationships, most adults this task. The client

between 18 – 35 years old develop has had a live-in

more long-term connections with partner since 2015

others. and they have plans

to marry soon.
(Cherry, 2019)

 
 

2. Establish a As young adults enter the culminating CG has achieved this

family phase of early adulthood (33–45), they task. The client’s

enter the settling down (33–40) stage. pregnancy was planned

By this time, they have established a as the couple had

career and found a spouse. If the decided that they

couple have not already done so, they wanted to start a family

will probably decide to have one or together.

more children and start a family.

(CliffNotes, n.d.)

3. Take care
The transition to adulthood includes CG has yet to achieve this
of a home
 completing schooling, beginning full- task. She and her partner

time employment, and entering long- are still living in the home

term family roles. Leaving home is she grew up in with her

an important transition as part of this mother and brother. They

process.  do not have any immediate

plans to move out and be

(Curtin, Goldscheider & Hofferth,
independent.
2014)

4. Establish
Early adulthood, which lasts from CG has achieved this task.
a Career
age 20-40, and is the time between She graduated BS

adolescence and middle age. During Management Accounting

this time, people are working to be and has been working as a

financially independent of their home-based virtual

parents and to establish their own assistant for a BPO

lives as adults. A major part of this Company.

process of becoming independent

involves career choices.

(National Academy of Sciences,

2015)
Erik Erikson’s Psychosocial Development Theory

“Intimacy vs Isolation” – Early Adulthood Stage

Stage Rationale Justification

Intimacy CG is very confident and has a

20s through early 40s;
vs positive outlook in life. No noted

Isolation After developing a sense of “self”, it signs for Postpartum Blues. She is

is now time to share it with others described by her partner and

and establish long-term mother as “artistahin” because she

relationships. If previous stages has always been popular due to her

have not been resolved, individuals looks, talent and friendly disposition.

in the early adulthood stage may The client expressed that she is

have trouble developing and very grateful to have good

maintaining successful relationships relationships with family and

with others. Erikson emphasized friends. 

that a strong sense of self is vital

before anyone can develop a

successful intimate relationship.

Adults who do not develop a

positive self-concept may

experience feelings of loneliness

and emotional isolation.

(Lumen, n.d.)
PHYSICAL ASSESSMENT

The client was assessed upon admission on March 2, 2020 at 4:15 PM, and

revealed the following:

 Temperature: 37 c

 Pulse Rate: 83 bpm

 Respiration Rate: 20 cpm

 Blood Pressure: 120/80 mmHg

 Weight: 61 kg

REGIONAL SURVEY

 EENT: anicteric sclera, pink conjunctiva

 Chest: adynamic precordium

 Breast: equal, no discharge

 Lungs: clear breath sounds

 Fundal height: 43 cm

 Abdomen: gravid, normo-active bowel sounds

 Extremities: full pulses, CRT < 2 seconds, (-) edema

 Neurologic: conscious, coherent.

A. GENERAL SURVEY
A thorough cephalocaudal assessment was done on March 3, 2020 at 1:00 PM in the

afternoon to client C.R.G., 27 years old, a secundigravida woman. The client was

conscious, alert, and cohesive during the assessment wearing her hospital gown. An

IVF of D LR 1 liter infused with 10 units of Oxytocin at 120 cc per hour at 850 cc level
5

located at the left metacarpal vein. She was breathing normally without the use of

oxygen therapy on moderate high backrest. Skin was warm to touch, her eyes open to

speech and verbalizes properly with appropriate words and emotion. She had a

postoperative dressing that was dry and intact with an abdominal binder. Her uterus

was well contracted with lochia rubra in minimal amounts. She had tolerable

postoperative pain as verbalized. 

VITAL SIGNS NORMAL RANGE RESULTS

TEMPERATURE 36.5-37.5 c 36.0

PULSE RATE Adult: 80-90 bpm 62 bpm

RESPIRATION RATE 16-20 cpm 19 cpm

CARDIAC RATE 60-100 bpm 64 bpm

BLOOD PRESSURE Adult: 110/70 – 130/90mmHg  100/80 mmHg

B. SKIN
Her complexion was fair with no pallor noted. Skin is uniform in color, smooth and warm

to touch. Skin turgor returned to its original form at 2 seconds, which is considered fair.

No presence of skin lesions were noted.

C. HAIR

Hair is black and is evenly distributed. It is thick, smooth and soft touch. Upon

inspection, no infestations were noted. No alopecia is noted, and scalp is free from

dandruff and lice. 

D. NAILS

Nails of the hands and feet were clean, not jagged nor broken and well-trimmed.

Cyanosis and clubbing were absent, and nails were complete without the presence of

hangnails. Capillary refill test was performed revealing <2 seconds of CRT time.

E. HEAD

Head was normocephalic without scalp lesions. Skull is symmetrical in shape;

deformities, depression, lumps, and tenderness were absent. Facial features were

symmetrical in movement with strong muscle strength of the jaw.

F. EYES

Eyebrows were aligned symmetrically. Eyelashes were distributed equally and curled

slightly outward indicating no abnormalities. The client involuntarily blinks bilaterally at

approximately 14 blinks per minute. Her sclera is white in color, palpebral conjunctiva

appears pink, pupils were black in color and equal in size with a diameter of

approximately 2 millimeters. Edema, tenderness, and swelling were absent in the

lacrimal duct, and reaction to light was brisk. 

G. EARS

The pinna was not tender and showed no signs of redness and edema. External canal

was fairly clean with a minimal amount of cerumen. Upon palpation, no tenderness was

noted on the mastoid process. Hearing acuity is normal as observed by how she was

attentive and responded appropriately to the questions being asked. 

H. NOSE

The nasolabial fold is symmetrical in appearance, and her septum is midline. No

deviations noted. Inspection of the nostrils revealed both nares were patent and mucosa

is pinkish in color without any mucoid discharges. No tenderness was noted upon

palpation of the sinuses. 

I. MOUTH

Lips were symmetrical, pinkish, and slightly dry. No lesions were present. The tongue is

in the midline without any lesions. She has fillers on both the left and right sides of her

first and second  premolars. She had a cracked tooth on her upper right bicuspid which

also had filling. Her gums were intact and and pinkish in color without any lesions. Hard
palate is lighter in color while the soft palate is pinkish. Swelling and tenderness were

absent. A slight odour was noted during assessment.

J. PHARYNX

Uvula is in midline, not deviated nor inflamed. Mucosa was pinkish with no ulcerations

nor swelling present. Inflammation of the tonsils was absent and the client was positive

for gag reflex upon pressing down the back of her tongue with a tongue depressor. She

was asked to say “ahh'' to assess the function of her 10th cranial nerve (vagus nerve)

wherein her soft palate raised enabling a full visual of her larynx. No color changes nor

enlargement was noted. 

K. NECK

Neck muscles were symmetrical anteriorly and posteriorly. No masses were present

upon palpation. Movements such as left and right lateral, right and left rotation, flexion,

extension, and hyperextension were all done smoothly without any discomfort. Range of

motion and muscle strength is normal. The trachea is in midline; lymph nodes were non-

palpable. The thyroid gland is not enlarged or palpable. Jugular vein distention was not

noted, and pulsations of the carotid arteries were symmetrical in strength and rhythm.

L. THORAX

Thorax was aligned with her spine and free from any bulging and tenderness. There is

good skin turgor, no pain or tenderness noted. Breathing pattern is effortless. Chest wall
is intact without any masses, with an anteroposterior of 1:2. Adventitious sounds were

present upon auscultation with a respiration rate of 19 cycles per minute. 

M. HEART

Precordium was normodynamic. Heart sounds were distinguishable without any

abnormalities in rhythm. Heaves, thrills, murmur, S3 and S4 were not noted. Pulses in

the temporal, carotid and apical were all thready and strong. 

N. BREAST

Left and right breasts were fairly symmetrical in appearance, but the left breast was

bigger than the right breast. No masses, tenderness nor edema were present upon

palpation. Nipples were protruding outwards, nipples and areola were brown in color.

No discharges were noted. 

O. ABDOMEN

The abdomen was uniform in color with postoperative dressing clean, dry, and intact.

Linea nigra and striae gravidarum were present. An incision was noted measuring 3-4

inches located infraumbilically. Tolerable post-op pain was verbalized by the client

located at the right lower quadrant of the abdomen. No other signs of bulges, lumps, or

spleen enlargement was noted aside from the well contracted uterus upon palpation.

The bladder was not distended. Bowel sounds of 16 per minute were auscultated. 
 P. EXTREMITIES

The range of movement of the upper extremities showed no difficulty in performing

adduction, abduction, medial, and lateral rotation, and circumduction. The client’s lower

extremities still had difficulty in exerting effort to walk for she still could not bear weight

on her right leg. However, knee flexion, extension, plantar flexion, ankle inversion and

eversion, were demonstrated with ease while in a supine position in bed. Upon

dorsiflexion of the ankles, Homan’s sign was negative. Brachial, radial, popliteal,

posterior tibialis, and pedal pulses were noted symmetrical in rate and rhythm. Bilateral

hand grip was equal and firm. Foot strength showed no signs of difficulty of the left leg

in applying resistance, but had some signs of weakness in the right leg. Numbness and

tingling sensation were absent with good skin integrity. Deep tendon reflex was brisk

and graded 2+.

Q. BACK

The back had good skin integrity upon making the client turn to the sides. No signs of

scoliosis were noted. Tenderness was absent upon palpation. Lateral flexion was

performed easily while the patient was on the bed, in a supine position. 

R. GENITO-URINARY
The pubic hair was shaved upon inspection. The left and right labia were symmetrical in

appearance. Labia minora was pale to pinkish in color, without any discoloration nor

edema noted. Lochia rubra in minimal amounts was observed. No foul odors were

noted. 

S. MUSCULO-SKELETAL

Muscles were equal in size, with no signs of hypertrophy, flaccidity, disproportions,

abnormal contractures, spasticity, atrophy, and tremors noted. Sternocleidomastoid,

triceps, hip muscles, quadriceps, fingers, wrists and hamstring were all able to

demonstrate abduction, adduction, and against resistance. During palpation of the

skeletal structures, tenderness, deformities and gross symmetry were not noted. There

were no signs of asymmetry in length. The interphalangeal, metacarpophalangeal, wrist,

elbow, shoulder, metatarsophalangeal, ankles, knees, and hip joints were all

symmetrical without signs of redness, swelling, abnormalities, crepitation, tenderness

and warmth noted. Range of motion joints were elicited normally by extension,

abduction, adduction, rotation and lateral bending. 

CRANIAL NERVES ASSESSMENT

CRANIAL NERVE ASSESSMENT REMARKS

The patient was able to identify  odors such as

I OLFACTORY Present
rubbing alcohol and the fruits beside her.
 The patient was able to identify colors, such as
II OPTIC Present
the medicine tray (pink), table (brown), and

pineapple (yellow).
The patient’s extraocular movements were
III OCULOMOTOR Present
smooth, coordinated in all directions (six

ocular movements). Both pupils were positive

IV TROCHLEAR Present
of consensual reflex and accommodation

reflex, the pupils constrict simultaneously

when light was illuminated . It had a papillary

size of 2mm.
Upon touching lightly the lateral sclera of the
V TRIGEMINAL Present
eye with a small piece of cotton while the

patient looks forward, the patient was able to

elicit blink reflex.

The patient’s extraocular movements were

VI ABDUCENS Present
symmetrical when looking in all six directions.

The eyeballs were able to move laterally

without difficulty or asymmetry noted.

The patient was able to smile, wrinkles her

VII FACIAL Present
forehead, shows her teeth, and raises her

eyebrows. All movements were symmetrical.

 Patient could hear whispered words when the
VIII AUDITORY Present
examiner was 2 feet away from her and with a

normal tone of voice.

The patient elicited gag reflex when a tongue
IX Present
depressor was pressed behind her tongue.
GLOSSOPHARYNGEAL 
When given a glass of water, the patient did
X VAGUS not have any difficulty in swallowing the water. Present 

The patient was asked to shrug her shoulders

XI SPINAL ACCESSORY Present
against the resistance of the examiner’s hand

and then the patient was instructed to turn her

head to the left side also against the

resistance of the examiner’s hand and again

on the other side. She was able to perform the

movements with no difficulty.

The patient was able to protrude her tongue at
XII HYPOGLOSSAL Present
the midline, and move it side to side.

DIAGNOSIS

A. According to Hacker, Gambone and Hobel

Multiple gestation is defined as any pregnancy in which two or more embryos or

fetuses occupy the uterus simultaneously. It is of utmost importance to recognize

multiple gestation as a complication of pregnancy. Because the mean gestational age of

delivery of twins is about 36 weeks, the perinatal mortality and morbidity in multiple

gestation exceeds that of singletons disproportionately. Because of the additional

physiologic stresses associated with two fetuses and placentas and a rapidly enlarging

uterus, maternal morbidity is also increased. Multiple gestation is known to have

increased risk of many complications, including preterm delivery, growth disorders, and

malpresentation. 

Reference: 

Hacker, F., Gambone, J. & Hobel, C. (2015). Multifetal gestation and malpresentation. 

         In J. Gambone (Ed.), Hacker & Moore's Essentials of Obstetrics and Gynecology  

         (6th ed.), (p. 170).  Philadelphia, PA: Elsevier.

B. According to Heard

The term multifetal gestation includes twins, triplets, and higher-order multiples.

Multiple births are increasing in the United States and account for a large proportion of

neonatal morbidity and mortality. In addition, these pregnancies often present a

challenge in management for the obstetrician Multiple pregnancies are always at high

risk of malpresentation. Mothers need greater antenatal care, and twins are more prone

to complications associated with low birth weight and prematurity.

Reference: 

Heard, A. (2016, March 9). Multifetal Pregnancy. Retrieved from: https://emedicine.

        medscape.com/article/1618038-overview#showall.
 C. According to Katke and Thakre

Multiple pregnancy is simultaneous development of more than one fetus in the

uterus. Multifetal gestations also are associated with significantly higher maternal

morbidity and associated health care costs. Women with multiple gestations are nearly

6 times more likely to be hospitalized with complications, including fetal

malpresentation, preeclampsia, preterm labor, preterm premature rupture of

membranes, placental abruption, pyelonephritis, and postpartum hemorrhage. 

Reference:

Katke, R. & Thakre, N. (2015). Multifetal Pregnancy: Maternal and Neonatal Outcome. 

       Obstet Gynecol Int J 3(1): 00068. DOI: 10.15406/ ogij.2015.03.00068.

ANATOMY AND PHYSIOLOGY

Female Reproductive System

         The female reproductive system is designed to carry out several functions. It

produces the female egg cells necessary for reproduction. The female reproductive

system includes all of internal and external organs that help with reproduction. The

external genital organs have three main functions: enabling sperm to enter the body,

protecting the internal genital organs from infectious organisms and providing sexual

pleasure.

The mons pubis is a rounded mound of fatty tissue that covers the pubic bone.

During puberty, it becomes covered with hair. The mons pubis contains oil-secreting
(sebaceous) glands that release substances that are involved in sexual attraction

(pheromones).

The labia majora are relatively large, fleshy folds of tissue that enclose and

protect the other external genital organs. They are comparable to the scrotum in males.

The labia majora contains sweat and sebaceous glands, which produce lubricating

secretions. During puberty, hair appears on the labia majora.

The labia minora can be very small or up to 2 inches wide. The labia minora lie

just inside the labia majora and surrounds the openings to the vagina and urethra. A

rich supply of blood vessels gives the labia minora a pink color. During sexual

stimulation, these blood vessels become engorged with blood, causing the labia minora

to swell and become more sensitive to stimulation.

The clitoris, located between the labia minora at their upper end, is a small

protrusion that corresponds to the penis in the male. The clitoris, like the penis, is very

sensitive to sexual stimulation and can become erect. Stimulating the clitoris can result

in an orgasm.

The area between the opening of the vagina and the anus, below the labia

majora, is called the perineum. It varies in length from almost 1 to more than 2 inches

(2 to 5 centimeters). The labia majora and the perineum are covered with skin similar to

that on the rest of the body. In contrast, the labia minora are lined with a mucous

membrane, whose surface is kept moist by fluid secreted by specialized cells.

The opening to the vagina is called the introitus. The vaginal opening is the

entryway for the penis during sexual intercourse and the exit for blood during
menstruation and for the baby during birth. When stimulated, Bartholin glands (located

beside the vaginal opening) secrete a thick fluid that supplies lubrication for intercourse.

The opening to the urethra, which carries urine from the bladder to the outside,

is located above and in front of the vaginal opening.

The internal genital organs form a pathway (the genital tract). The hymen, a

mucous membrane, is located at the beginning of the genital tract, just inside the
opening of the vagina. The hymen helps protect the genital tract but is not necessary for

health.

The vagina is a tubelike, muscular but elastic organ about 4 to 5 inches long in

an adult woman. It connects the external genital organs to the uterus. The vagina is the

organ of sexual intercourse in women. The penis is inserted into it. It is the passageway

for sperm to the egg and for menstrual bleeding or a baby to the outside. The vagina is

lined with a mucous membrane, kept moist by fluids produced by cells on its surface

and by secretions from glands in the cervix (the lower part of the uterus). A small

amount of these fluids may pass to the outside as a clear or milky white vaginal

discharge, which is normal.

The uterus is a thick-walled, muscular, pear-shaped organ located in the middle

of the pelvis, behind the bladder, and in front of the rectum. The uterus is anchored in

position by several ligaments. The main function of the uterus is to sustain a developing

fetus.

The cervix is the lower part of the uterus, which protrudes into the upper part of

the vagina. It can be seen during a pelvic examination. Like the vagina, the cervix is

lined with a mucous membrane, but the mucous membrane of the cervix is smooth.

Sperm can enter and menstrual blood can exit the uterus through a channel in the

cervix (cervical canal). The cervical canal is usually narrow, but during labor, the canal

widens to let the baby through. The cervix is usually a good barrier against bacteria,

except around the time an egg is released by the ovaries (ovulation), during the

menstrual period, or during labor. Bacteria that cause sexually transmitted diseases can

enter the uterus through the cervix during sexual intercourse.

 The corpus of the uterus, which is highly muscular, can stretch to accommodate

a growing fetus. Its muscular walls contract during labor to push the baby out through

the cervix and the vagina. During the reproductive years, the corpus is twice as long as

the cervix. 

The primary function of the fallopian tube is to transport sperm toward the egg,

which is released by the ovary, and to then allow passage of the fertilized egg back to

the uterus for implantation. The two fallopian tubes, which are about 4 to 5 inches

(about 10 to 13 centimeters) long, extend from the upper edges of the uterus toward the

ovaries. The tubes do not directly connect with the ovaries. Instead, the end of each

tube flares into a funnel shape with fingerlike extensions (fimbriae). When an egg is

released from an ovary, the fimbriae guide the egg into the relatively large opening of a

fallopian tube. The fallopian tubes are lined with tiny hairlike projections. The cilia and

the muscles in the tube's wall propel an egg downward through the tube to the uterus. 

The

ovaries

are usually

pearl- colored,

oblong,

and about

the size of a

walnut.

They are

attached to the uterus by ligaments. In addition to producing female sex hormones

( estrogen and progesterone) and male sex hormones, the ovaries produce and release

eggs. The developing egg cells (oocytes) are contained in fluid-filled cavities (follicles) in

the wall of the ovaries. Each follicle contains one oocyte.

Fertilization occurs when a sperm and an oocyte combine and their nuclei fuse.

During ejaculation, hundreds of millions of sperm are released into the vagina. Almost

immediately, millions of these sperm are overcome by the acidity of the vagina and

millions more may be blocked from entering the uterus by thick cervical mucus. Of those

that do enter, thousands are destroyed by phagocytic uterine leukocytes. Thus, the race

into the uterine tubes, which is the most typical site for sperm to encounter the oocyte,

is reduced to a few thousand contenders. Their journey is thought to be facilitated by

uterine contractions and usually takes from 30 minutes to 2 hours. If the sperm do not

encounter an oocyte immediately, they can survive in the uterine tubes for another 3-5

days. Thus fertilization can still occur if intercourse takes place a few days before

ovulation. In comparison, an oocyte can survive independently for only approximately

24 hours. Intercourse more than a day after ovulation will therefore usually not result in

fertilization.
         In most pregnancies a single embryo develops in the uterus, but in some cases,

two embryos develop together. These are called twins. Most twins are fraternal or

dizygotic twins, meaning that they originate from two separate eggs that are fertilized

individually. A minority are identical or monozygotic twins, meaning that they originate

from a single zygote that quickly splits into two separate groups of cells. Fraternal twins

are from two separate eggs that are

fertilized by different sperm, so they

have completely separate genetic make

ups. They don't look any more or less

alike than regular siblings, although the

resemblance can still be very close. 

Identical twins come from a single

zygote splitting to form two separate embryos with identical genetic material. The split

can happen at any time during the first thirteen days of development, and how and

when this division occurs affects how the identical twins share space and resources in
the uterus. Because identical twins have identical DNA, they share many physical traits

that have a strong genetic basis, like biological sex, hair and eye color, blood type, and

other physical features. In fact, subtle differences between identical twin babies actually

shows how the environment—even the environment of the uterus—can affect

development! Identical twins can

be categorized based on how they

share space and resources in the

womb. During a single-child

pregnancy, one embryo grows

inside a fluid-filled bubble called

the amniotic sac, and receives

nutrients and gases from the

parent via the umbilical cord and

placenta. With twins, two embryos

arise, but this doesn’t necessarily mean each fetus gets its own individual ticket to the

placenta buffet and a separate amniotic sac to hang out in. Twins’ access to maternal

real estate depends on when exactly the split occurs to turn one embryo into two.

Integumentary System

         The integumentary system consists of the skin, hair, nails, glands, and nerves. Its

main function is to act as a barrier to protect the body from the outside world. It also

functions to retain body fluids, protect against disease, eliminate waste products, and

regulate body temperature. In order to do these things, the integumentary system works
with all the other systems of your body, each of which has a role to play in maintaining

the internal conditions that a human body needs to function properly. The integumentary

system is formed by the skin and its derivative structures. The skin is composed of three

layers: the epidermis, the dermis, and subcutaneous tissue. 

The outermost level, the

epidermis, consists of a specific

constellation of cells known as

keratinocytes, which function to

synthesize keratin, a long,

threadlike protein with a

protective role. The middle layer,

the dermis, is fundamentally

made up of the fibrillar structural protein known as collagen. The dermis lies on the

subcutaneous tissue, or panniculus, which contains small lobes of fat cells known as

lipocytes. The thickness of these layers varies considerably, depending on the

geographic location on the anatomy of the body.

         A number of components are common to both the dermis and epidermis. These

are: pores, hair, sebaceous glands, and sweat glands. Pores are formed by a folding-in

of the epidermis into the dermis. The skin cells that line the pore (keratinocytes) are

continuously shed, just like the cells of the epidermis at the top of the skin. The

keratinocytes being shed from the lining of the pore can mix with sebum and clog the

pore. Hair grows out of the pores and is composed of dead cells filled with keratin

proteins. At the base of each hair is a bulb-like follicle that divides to produce new cells.
The follicle is nourished by tiny blood vessels and glands. Hair prevents heat loss and

helps protect the epidermis from minor abrasions and exposure to the sun's rays.        

Sweat glands are long, coiled, hollow tubes of cells. The coiled section is where

sweat is produced, and the long portion is a duct that connects the gland to the pore

opening on the skin's surface. Perspiration excreted by the sweat glands helps cool the

body, hydrate the skin, eliminate some toxins, and maintain the acid mantle.

         In a cesarean delivery, an incision is made in the skin and into the uterus at the

lower part of the mother’s abdomen. The incision in the skin may be vertical or

transverse, and the incision in the uterus may be vertical or transverse. A transverse

incision extends across the pubic hairline, whereas, a vertical incision extends from the

navel to the pubic hairline. A transverse uterine incision is used most often, because it

heals well and there is less bleeding. Transverse uterine incisions also increase the

chance for vaginal birth in a future pregnancy. However, the type of incision depends on

the conditions of the mother and the fetus.

The skin is then prepared

using an antiseptic solution and

antibiotics are administered just

prior to the ‘knife to skin’ incision.

There are multiple ways to

perform a Caesarean, but what

follows is a standard technique:

Skin incision is usually with either

a Pfannenstiel or Joel-Cohen –
these are both transverse lower abdominal skin incisions.Sharp or blunt dissection into

the abdomen is made through several layers: The skin, Camper’s fascia (superficial

fatty layer of subcutaneous tissue), Scarpa’s fascia, (deep membranous layer of

subcutaneous tissue), Rectus sheath (anterior and posterior leaves laterally, that merge

medially), Rectus muscle, Abdominal peritoneum (parietal), and this reveals the gravid

uterus.

The visceral peritoneum covering the lower segment of the uterus is then incised

and pushed down to reflect the bladder, which is retracted by the Doyen retractor.

Uterine incision is made on the lower uterine segment beneath the line of peritoneal

reflection. This is a transverse curvilinear incision which is digitally extended. The baby

is then delivered cephalic/breech with fundal pressure from the assistant. The uterine

cavity is ensured empty, then closed with two layers. The rectus sheath is then closed

and then the skin (either with continuous/interrupted sutures or staples).

PATHOPHYSIOLOGY

A. Etiology

The predisposing factors are as shown present is the gender which is female, and

genetic influence. Precipitating factors include premature labor and sedentary lifestyle.

Due to these factors, multiple gestation occurs that may have signs and symptoms for

gestational hypertension, gestational diabetes, and abnormal amounts of amniotic fluid

and even anemia. While it could lead to uterine atony, miscarriage, twin to twin

transfusion syndrom and birth defects. 

 In the case of our client, premature labor and malpresentation occurred which

revealed a cephalic-transverse lie presentation. Hence, the expectant management for

the client was cesarean section.

I. Predisposing Factors

PREDISPOSING PRESENT/ABSENT JUSTIFICATION RATIONALE

FACTOR

Age Absent The patient was 27 Women aged 35 and

years old at the time older who scheduled

of delivery. C-sections have been

found to be at  risk for

severe maternal

morbidity, like

complications in

delivery, twice as

much as a woman

aged below 35.

Gender Present The patient is female. Cesarean delivery is a

surgical delivery of a

baby by incision

through a woman’s

abdomen and uterus.

 Up to 30% of

deliveries are

cesarean.

Genetic Present There are genetic There is a hereditary

Influences influences regarding risk for having a

multiple gestation. multiple gestation.

Lifestyle Absent The patient’s job Activities that may put

does not involve any a woman at risk for

extraneous physical falls should be

activities. She also avoided during

does not do any other pregnancy. When a

physically straining woman becomes

activities. pregnant, the belly

expands due to the

shift of the center of

gravity, so even a

minor fall may result

in injuries.

Environment Absent The patient lives in a Lead, which is a

residential area and common substance

works at home. Her found in paint and

house is well kept by other tools, can cause

 her mother. There are harm to both the

no evident hazards in mother and baby. 

here home. The baby may

develop allergies if

the mother is exposed

to dust.

II. Precipitating Factors

PRECIPITATING PRESENT/ABSEN JUSTIFICATION RATIONALE

FACTOR T

Obesity Absent The patient’s height It can be harder to

is 5’1” while her monitor the baby

weight is 61kg. Her during labor. For these

BMI is classified as reasons, obesity

overweight (25.4). during pregnancy

increases the

likelihood of having a

cesarean delivery.
Large infant size Absent Baby A weighs 2.16 When babies weighed

kg, while Baby B more than 4,500

weighs 2.18 kg. grams (4.5 kg), the

Cesarean rate

increased to 27%

(Dekker, 2019).

Premature labor Present The patient’s AOG Cesarean section may

during delivery was be indicated for

35 weeks, 5 days by premature labor since

LMP. Her EDC is on  most babies are at a

April 1, 2020.   position not suitable

for vaginal delivery

when not full term.

Sedentary Present The patient Lack of physical

Lifestyle  verbalized that she activity slows down

does not perform the body’s

any physical metabolism,

activities both in and circulation, breakdown

outside the house. of body fat, and

regulation of blood

sugar and blood

pressure. Lack of
 physical activity can

lead to increased risk

of Caesarean births.

B. Symptomatology

SYMPTOMS PRESENT/ABSEN JUSTIFICATION

Prolonged Absent  The client was admitted per wheelchair to the

Labor delivery room at 3:55 PM and was for STAT

CS at 6 PM. 

Abnormal Present  Upon ultrasonography, the results revealed

positioning multifetal gestation in cephalic-transverse

presentation.
Fetal Distress Absent  There were no signs of fetal decelerations. 

Birth Defects Absent  No birth defects were noted in the ultrasound

and during actual delivery. 

Chronic health Present The patient is positive for Polycystic Ovarian

condition Syndrome (PCOS). 

Cord Coiling Absent  There was no cord coiling or nuchal cord

present upon delivery. 

Placenta Issues Absent  No issues of the placenta were noted upon

delivery.
 Carrying Present  Ultrasound revealed a multifetal gestation in

Multiples cephalic-transverse presentation. 

MEDICAL MANAGEMENT

A. THERAPEUTICS

Date Order Rationale

March NPO Nothing per orem reduces the incidence of

2, postoperative nausea and vomiting without an

2020 increased risk of adverse outcome.

VS q15 minutes @ To obtain baseline data and to monitor for any

PA/DR q4 hours at ward unusualities.

Start IVF of D5LR 1L + 10 Lactated Ringer’s and 5% dextrose solution is a

units oxytocin @ 120cc/hr sterile and non - pyrogenic solution for fluid and

electrolyte replenishment and caloric supply.

 Added with 10 units of oxytocin for prevention and

treatment of postpartum uterine atony and

hemorrhage. 

Meds:  

Cefuroxime (Zegen)  Cefuroxime is a broad-spectrum antibiotic, which

750mg IVTT q8 hours x 2 means that it is active against a wide variety of

bacteria. Cefuroxime is used to treat many kinds of

 
bacterial infections. It is used for the prevention of

  postpartum hemorrhage and infection.

  Ranitidine decreases the amount of acid made in

the stomach. It is used to prevent and treat

Ranitidine 50mg IVTT q8
heartburn and other symptoms caused by too
hours x 2
much acid in the stomach.
 
 
 
Parecoxib is a water soluble injectable drug that is
Parecoxib 40mg IVTT q
used for the prevention and treatment of pain. It
12 hours x 2 (8am-8pm)
can be used to relieve pain and reduce
then shift to Etoricoxib
inflammation after surgery. Etoricoxib is also a
120 grams OD (6am)
non-steroidal anti-inflammatory drug that is used

  for relieving pain and inflammation but taken

orally.
    

  It provides effective analgesia in postoperative

pain. It belongs to the group of medicines called

Tramadol 50g q8 hours x
opioid analgesics. Tramadol is used to treat
2 (8am - 4pm)
moderate to severe pain in adults.

O2 at 2 liters per minute If the surgical procedure was around the chest or

for pain abdominal areas supplying oxygen aids in

lessening the pain after the surgery.

Thermoregulate patient Thermoregulation helps in controlling the loss or

gain of heat and helps maintaining an optimum

temperature range of a patient.

March May have sips of water, To reduce incidence of vomiting and to allow the

3, then clear liquids gastrointestinal system goes back to its normal

2020 progress to general peristaltic activity.

liquids and crackers once

tolerated

Moderate-high backrest Elevating the upper body facilitates fast wound

healing and comfort.

 C.DRUG STUDY

Generic Name

Tramadol

Brand Name -

Classification Analgesic

Mode of Action Binds to mu-opioid receptors. Inhibits reuptake of  serotonin and

norepinephrine in the CNS.

Dose / Route 50 g, IVTT

Indication  To treat moderate to severe pain.

Contraindication   Should not be given to patients who have previously

demonstrated hypersensitivity towards tramadol or any of the

other ingredients

 Patients suffering from acute intoxication with alcohol,

hypnotics, centrally acting analgesics, opioids or psychotropic

 drugs. 

 Patients with epilepsy are not adequately controlled by

treatment.

 Contraindicated in narcotic withdrawal treatment. 

 Have severe asthma or breathing problems.

Side Effects  Constipation, nausea, vomiting, stomach pain, dizziness,

drowsiness, tiredness, headache or itching. 

Adverse Effects Slows heart rate or weakens pulse, seizure, loss of appetite, noisy

breathing, shallow breathing, light-headed feeling. 

Drug Interactions Diphenhydramine: may increase side effects such as dizziness,

drowsiness and confusion. 

Nursing  Assess type, location, and intensity of pain before and 2– 3 hr

Interventions (peak) after administration. 

 Assess BP and respiratory rate before and periodically during

administration. 

 Assess bowel function routinely. Prevention of constipation

should be instituted with increased intake of fluids and bulk

and with laxatives to minimize constipating effects. 

  Assess previous analgesic history. 

 Prolonged use may lead to physical and psychological

dependence and tolerance, although these may be milder

 than with opioids. 

 Monitor patients for seizures. May occur within recommended

dose range. 

 Monitor for serotonin syndrome (mental-status changes (e.g.,

agitation, hallucinations, coma), autonomic instability (e.g.,

tachycardia, labile BP, hyperthermia), neuromuscular

aberrations (e.g., hyperreflexia, incoordination) and/or

gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea)

in patients taking these drugs concurrently.

 Explain therapeutic value of medication before administration

to enhance the analgesic effect. 

Generic Name

Parecoxib   

Brand Name Dynastat

Classification Analgesic, antipyretic and anti-inflammatory agent

Mode of Action Parecoxib is the prodrug of valdecoxib. It is a selective cyclo-

oxygenase-2 (COX-2) inhibitor primarily responsible to reduce

 mediators of pain and inflammation. Its action is due to inhibition of

prostaglandin synthesis via inhibition of COX-2.

Dose / Route Adult: IV/IM 40 mg, then 20 or 40 mg 6-12 hrly. Max: 80 mg/day.

Postoperative pain

Adult: 40 mg via slow IM or IV inj, then 20 or 40 mg 6-12 hrly as

required. Max dose: 80 mg/day.

Elderly: <50 kg: Half the usual dose. Max: 40 mg/day.

Indication  For the short-term treatment of postoperative pain in adults.

Contraindication  Hypersensitivity; history of allergy to sulfonamides; history

bronchospasm, acute rhinitis, nasal polyps, angioneurotic oedema,

urticaria or allergic-type reactions after taking aspirin, NSAIDs

including COX-2 inhibitors. Patient w/ inflammatory bowel disease,

CHF (NYHA class II-IV), ischaemic heart disease, peripheral arterial

disease, or cerebrovascular disease; treatment of post-op pain

following CABG; active peptic ulceration or GI bleeding. Severe

hepatic impairment (Child-Pugh score ≥10). Pregnancy (3rd

trimester) and lactation.

Side Effects  Changes in blood pressure; Dizziness or light-headedness due to

low blood pressure; Back pain; Earache; Feeling numb (your skin

may lose sensitivity to pain and touch); Stomach upset including

nausea (feeling sick), vomiting, heartburn, indigestion, cramps;

Constipation, diarrhoea, pain in the stomach, wind,

bloating;Dizziness; Sore throat; Swollen and sore gums; Increased

 sweating; Passing less urine than normal; Inflammation and pain

after a tooth extraction

Adverse Effects Nausea, pharyngitis, alveolar osteitis (dry socket), anaemia post-op,

hypokalaemia, agitation, insomnia, hypoaesthesia, dizziness, HTN,

hypotension, resp insufficiency, abdominal pain, vomiting,

constipation, dyspepsia, flatulence, pruritus, hyperhidrosis, back

pain, oliguria, peripheral oedema, MI, deep-vein thrombosis,

pulmonary embolism, stroke, deep surgical infections, sternal wound

complications, renal impairment, increased blood creatinine.

Potentially Fatal: Anaphylaxis, Stevens-Johnson syndrome, toxic

epidermal necrolysis.

Drug Interactions May reduce the effect of diuretics and antihypertensives. May

increase the nephrotoxic effect of tacrolimus and cyclosporine. May

increase risk of bleeding complications w/ warfarin or other

anticoagulants. May increase lithium level leading to toxicity.

Nursing 1. Tell your doctor if you have any allergies like medication, foods,

Interventions preservatives or dyes.

2. Monitor Vital Signs

3. Tell patient that dizziness or lightheadedness is the most common

side effect.

4. Instruct the patient to report if she notice any of the following *skin

rash, including hives, raised red, and itchy spots.

5. Raise side rails

Generic Name

Ranitidine

Brand Name Zantac

Classification Antiulcer

Mode of Action Inhibits histamine action at histamine H2-receptors of gastric parietal

cells. Therapeutic Effect: Inhibits gastric acid secretion. Reduces

gastric volume, hydrogen ion concentration.

Dose / Route Duodenal Ulcer

PO: ADULTS, ELDERLY: Treatment: 150 mg twice daily or 300

mg once daily. Maintenance: 150 mg once daily at bedtime.

CHILDREN 1 MO TO 16 YRS: Treatment: 4–8 mg/kg/day in 2

divided doses. Maximum: 300 mg. Maintenance: 2–4 mg/kg/day

once daily. Maximum: 150 mg/day.

Gastric Ulcer (Benign)

PO: ADULTS, ELDERLY: Treatment: 150 mg 2 times/day.

Maintenance: 150 mg once daily at bedtime.

CHILDREN 1 MO–16 YRS: Treatment: 4–8 mg/kg/day in 2 divided

doses. Maximum: 300 mg/day. Maintenance: 2–4 mg/kg/day once

daily. Maximum (healing): 150 mg/day.

Hypersecretory Conditions
PO: ADULTS, ELDERLY: 150 mg twice daily up to 6 g/day.

IV Infusion: 6.25 mg/hr.

GERD

PO: ADULTS, ELDERLY: 150 mg twice daily.

CHILDREN 1 MO TO 16 YRS: 5–10 mg/kg/day  in 2 divided doses.

Maximum: 300 mg/day.

Erosive Esophagitis

PO: ADULTS, ELDERLY: Treatment: 150 mg 4 times/day.

Maintenance: 150 mg twice daily.

CHILDREN 1 MO TO 16 YRS: Treatment: 5–10 mg/kg/day in 2

divided doses. Maximum: 600 mg/day.

Prevention of Heartburn (OTC)

PO: ADULTS, ELDERLY, CHILDREN 12 YRS AND OLDER: 75–

150 mg 30–60 min before eating or drinking beverages that cause

heartburn. Maximum: 2 doses/day. Do not use more than 14 days.

Usual  Parenteral Dosage

IV:   ADULTS, ELDERLY: 50 mg q6–8h.

CHILDREN: 2–4 mg/kg/day in divided doses q6–8h. Maximum: 50

mg/dose.

IV Infusion: 6.25 mg/hr.

Usual Neonatal Dosage

PO: NEONATES: 2 mg/kg/dose q8h.

IV:   NEONATES: Initially, 1.5 mg/kg/dose, then 1.5–2 mg/kg/day 

 in divided doses q8h.

IV Infusion: NEONATES:   Loading dose: 1.5 mg/kg, then 1–2

mg/kg/day (0.04–0.08 mg/kg/hr).

Dosage in Renal Impairment

CrCl less than 50 mL/min: Give 150 mg PO q24h or 50 mg IV q18–

24h.

Dosage in Hepatic Impairment

No dose adjustment.

Indication  Duodenal ulcer, gastric ulcer (benign), hypersecretory conditions,

GERD, erosive esophagitis, prevention of heartburn (otc), renal

impairment, hepatic impairment.

Contraindication  Hypersensitivity to raNITIdine. OTC: Do not use if trouble or pain

when swallowing food, vomiting with blood, or bloody or black stool

is present. Do not use 150 mg with kidney disease (unless medically

advised). Cautions: Renal/hepatic impairment, elderly pts, history of

acute porphyria.

Side Effects  Occasional (2%): Diarrhea.

Rare (1%): Constipation, headache (may be severe).

Adverse Effects Reversible hepatitis, blood dyscrasias occur rarely.

Drug Interactions DRUG:  Magnesium or aluminum antacids may decrease

absorption. May decrease absorption of atazanavir, itraconazole,

ketoconazole.

HERBAL: None significant.

FOOD: None known.

 LAB VALUES: Interferes with skin tests using allergen extracts. May

increase serum ALT, AST, GGT, creatinine.

Nursing Baseline assessment

Interventions Obtain history of epigastric/abdominal pain.

Intervention/evaluation

Assess mental status in elderly. Question present abdominal pain,

GI distress.

Patient/family teaching

• Smoking decreases effectiveness of medication

• Do not take medicine within 1 hr of magnesium- or aluminum

containing antacids.

• Transient burning/pruritus may occur with IV administration.

• Report headache.

• Avoid alcohol, aspirin.

Generic Name

Cefuroxime

Brand Name Zegen

Classification Cephalosporin 
Mode of Action Binds to penicillin-binding proteins and inhibits final transpeptidation

step of peptidoglycan synthesis, resulting in cell-wall death; resists

degradation by beta-lactamase.

Dose / Route 750 mg, IVTT 

Indication   To prevent infection from certain surgeries

 Perioperative prophylaxis

Contraindication  Hypersensitivity to cephalosporins and penicillins.

Renal impairment

History of GI disease (e.g colitis)

Side Effects  Nausea, vomiting, diarrhea, abdominal pain, headache, dizziness.

Adverse Effects Hemolytic anemia, seizures, Stevens-Johnson syndrome, Aplastic

anemia, vaginitis.

Drug Interactions Amikacin: may potentiate the adverse renal effects of nephrotoxic

agents, such as aminoglycosides and loop diuretics.

Amoxicillin, Clarithromycin, Lansoprazole: void the concomitant use

of proton pump inhibitors (PPIs) and cefuroxime. Drugs that reduce

gastric acidity, such as PPIs, can interfere with the oral absorption of

cefuroxime axetil and may result in reduced antibiotic efficacy.

Sodium bicarbonate: antacids can interfere with the oral absorption

of cefuroxime axetil and may result in reduced antibiotic efficacy

 Warfarin:  May increase the international normalized ratio (INR)

which is found using the results of prothrombin time,  thereby

potentiating the risk for bleeding.

Nursing 1. Arrange for sensitivity tests before and during therapy if

Interventions response is not seen. 

2. Advise to avoid alcohol while taking this drug and for 3 days

after because severe reactions often occur.

3. Inform the client they may experience stomach upset or

diarrhea.

4. Report severe diarrhea, difficulty breathing, or unusual

tiredness and pain at the injection site. 

5. Assess for signs and symptoms of infection prior to and

throughout therapy.

6. Obtain history to determine previous use of and reactions to

penicillins or cephalosporins.

7. Observe patient for signs of anaphylaxis (rash, pruritus,

wheezing)

8. Instruct patient to report signs of hypersensitivity.

NURSING CARE PLANS

NURSING THEORIES

Each person has a unique way of feeling comfort.  According to Katherine

Kolcaba, comfort is the “experience of being strengthened through having the human

needs for relief, ease and transcendence met in four contexts (physical, psycho-

spiritual, socio-cultural, and environmental).” Interventions that lead to health seeking

behaviors and enhanced institutional integrity are emphasized in nursing interventions

that are focused in providing comfort to the patient.

This theory connects the concepts of the following: a. Health care needs: the

comfort of the patient is determined based on the needs that were not met; b. Nursing

interventions: interventions will be given with the goal of providing comfort.; c.

Intervening variables: in planning interventions and determination probability of

interventions success, intervening variables are considered; d. Enhanced comfort:

nurses attained the outcome of enhanced comfort with implementation of appropriate

interventions in a caring way; 5. Health seeking behavior: by attaining a state of

enhanced comfort patient, the nurses and family will coordinate to promote health

seeking behaviors that will lead to more comfort; and 6. Institutional integrity: as a

patient’s comfort is enhanced so will be the health seeking behavior which will then lead

to better outcomes.
 The patient’s case can be related to Katherine Kolcaba’s Comfort Theory. Her

theory can be applied to C.G., a post cesarean section woman.In response to the given

interventions the patient's recovery was enhanced now she was actively participating in

care related activities. She verbalized reduction in pain and was mobilized with help.

Katherine Kolcaba’s theory of comfort was applied in this setting for the care of a young

surgical OB/Gyne successfully. Its application to integrate comfort in patient care was

excellent and result oriented.

DISCHARGE PLANNING METHOD

DISCHARGE PLAN JUSTIFICATION

MEDICATIO  Follow the physician’s order for the

N prescribed medication. Upon admission

at San Pedro Hospital, St. Mary’s Ward,

she was prescribed and given

o For
medication of:
prevention of
o Cefuroxime(Zegen)  750mg IVTT
postpartum
q8 hours x 2
hemorrhage
o Ranitidine 50mg IVTT q8 hours x
and infection.
2
o To
o Parecoxib 40mg IVTT q 12 hours
alleviate pain.
x 2 (8am-8pm) then shift to                   
o For fast
Etoricoxib 120 grams OD (6am)
healing.
 o Tramadol 50g q8 hours x 2 (8am o To

– 4pm) promote

wellness and

overall well-

being.

EXERCISE  Do postsurgical deep breathing  Deep

exercises. breathing

keeps your

lungs well-
 Encourage client to ambulate
inflated and

. healthy while

healing.
 Educate client on proper body
 Walking
mechanics.
improves blood

flow which aids

 Abstain from sexual intercourse until in quicker
episiotomy is healed and ceased. wound healing.

 To prevent

muscle strain

and enable

client to relax..
  For faster

healing of the

incision and to

avoid from any

infection. 

TREATMEN  Tell patient to continue submitting self to  To monitor for

T diagnostic examination to make sure any

that she is not having any unusualities

complications. and to make

 Seek pain relief. sure that

treatment is

effective.
 Instruct client to balance activities with
 To alleviate
adequate periods of rest.
pain and to

promote

 Make sure that the incision is dry and comfort.

intact.   This helps

regain the

patient’s

normal

condition

during their

postpartum
 period.

 To be free

from infection.

HYGIENE  Change sanitary pads or diapers at  It helps in

least every 4 hours. maintaining

cleanliness

and good

hygiene. And

also to prevent
 Perform proper perineal care. certain

diseases like

UTIs or yeast

infections. 

 Perineal  care

prevents skin
 Clean nipples properly before and after
breakdown of
breastfeeding.
perineal area,

itching,
 Wash hands before and after feeding.
burning, odor,

and infections.
 Keep the incision site clean, dry and Perineal care
intact. is very
 important in

maintaining

the 

clients'

comfort. 

 To prevent the

baby from

ingesting dirt.

And for good

hygiene.

 It helps

prevent

contamination. 

 To be free

from infection.

OUT  Advice patient to adhere to follow up  This is to

PATIENT checkup. properly

evaluate if the

patient’s
 Call the doctor if any of the following
progress in
occurs:
health has
 o Develop a fever improved.

o Painful Urination

o Shortness of Breath
 This is to
o Dizziness and Faint
immediately
o Nausea and Vomiting address

o Excessive vaginal bleeding unusualities

o Swelling, redness and painful leg that may lead

o Leaking and or opening of the to any other

incision complications. 

DIET  Encourage to drink plenty of fluids.  Drinking plenty

of water is an

important way

to reduce

inflammation,

increase
 Eat nutritious foods.
energy and

diminish

 Increase intake of fiber foods such as swelling from

vegetables, fruits and whole grains. your

pregnancy and

delivery. 

 A healthy diet

is another
 important

factor that

promotes

postnatal

healing and

recovery.

 Food rich in

fiber helps

prevent

constipation

and it helps in

milk

production. 

PROGNOSIS

Even though the frequency of multiple gestations is lower than singleton gestations,

multiple gestations account for a high share of neonatal morbidity and mortality. Most of

these cases are due to a higher rate of preterm labor. The average gestational age at

delivery is 35 weeks for twins. As a result, 25% of twins delivered are admitted to the

neonatal intensive care unit (NICU). Newborns that are products of multifetal

pregnancies are also at three times higher risk to have cerebral palsy, five times higher

risk for stillbirth, and 7x more for neonatal death. Mothers having multifetal gestation are

also at a higher risk for maternal morbidity.They are more likely to be hospitalized due
to complications such as preterm labor, preterm premature rupture of membranes,

preeclampsia, placental abruption, pulmonary embolism, and postpartum hemorrhage.

This makes hospital costs higher (Heard,2016).   In multifetal pregnancy, Cesarean

delivery is done when indicated. This is recommended for twins unless the presenting

twin is in vertex presentation. Higher-order multiples are usually delivered by cesarean

regardless of presentation (Moldehauer, 2020).

The non vertex presentation of the fetus is at increased risk for trauma, cord

prolapse, and head entrapment. Malpresentation includes preterm breech presentations

and non-frank breech term fetuses (Saint Louis,2018).

Our group has concluded that our patient has a good prognosis since she was able

to seek medical help. She underwent a cesarean section and was able to deliver her

twins. She complies with her medications. She also eats healthy food such as fruits and

vegetables. She also practices good personal hygiene with the assistance of her partner

and mother. We believe that the patient has a good prognosis in regards to all the

factors that were mentioned above. 

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