 Birthaccomplished through abdominal

incision into uterus

1970
5.5% of births
Currently
30% of births
 Assessment
 Nursingdiagnosis
 Outcome identification, planning
 Implementation
 Outcome evaluation
 Scheduled vs. emergency
 Effects of surgery
Stress response
Body defenses
Circulatory function
Body organ function
Self-image or self-esteem
 Preoperative interview
 Operative risk
 Nutritional status
 Age
 General health
 Fluid, electrolyte imbalance
 Fear
 Operative risk to newborn
 Diagnostic procedures
 Teaching
 Immediate preoperative care
Informed consent
Hygiene
GI-tract preparation
Baseline intake, output
Hydration
 Immediate preoperative care
Preoperative medication
Checklist
Transport
Role of support person
 Intraoperative care
Anesthesia
Skin preparation
Surgical incision
Types of incisions
Birth
Postpartal care
 Pain control
 Fluid volume
 Output
 Circulation
 Parenting
 infection
1. Postpartum hemorrhage – major cause of
maternal death, occurs in 4% of deliveries
- defined as blood loss greater than 500 ml
after vaginal birth or 1000 ml after CS
Classifications:
According to severity:
a. Mild – 750 – 1250 ml
b. Moderate – 1250 – 1750 ml
c. Severe – 2500 ml
According to time:
1. Early Postpartum hemorrhage – occurs within 24 hours of birth
2. Late postpartum hemorrhage – occurs after 24 hours until 6
weeks after birth

Major Risk: Hypovolemic Shock (low volume)

- occurs when the circulating blood volume is decreased which
interrupts blood flow to body cells
- manifested as:
a. Tachycardia (first sign)
b. hypotension
c. cold and clammy skin
d. mental changes such as anxiety, confusion, restleness
e. decrease urine output
Conditions that increase risk for PP hemorrhage
1. Over distension of the uterus
› Multiple births
› Hydramnios
› Macrosomia
2. Trauma r/t forceps, uterine manipulation
3. Prolonged labor
4. Uterine infection
5. Trauma removing placenta
1.Uterine Atony: Uterus without tone or lack of
normal muscle tone (90% of cases)
- uterine atony allows blood vessels at the
placenta site to bleed freely and usually
massively.
 - uterine muscle unable to contract around
blood vessels at placental site
Risk Factors:
1. Deep anesthesia
2. >30 years old
3. prolonged use of magnesium sulfate
4. previous uterine surgery
5. Over exhaustion

Symptoms:
1. uterus is difficult to feel and is boggy (soft)
2. lochia is increased and may have large blood clots
3. Blood may “gush” or come out slowly
Nursing Management:
1. Massage the uterus until firm
2. have mother to urinate or catheterize because bladder
distension pushes the uterus upward or in the side and
interferes with the ability of the uterus to contract
3. Encourage mother to breastfeed because sucking
stimulation causes the release of oxytocin from PPG
4. Administration of IV oxytocin or Methylergonovine
(Methergine) to control uterine atony
5. Hysterectomy is performed to remove the bleeding
uterus that does not respond to other measures
2. Lacerations – tearing of the birth canal
- normally occurs as a result of child bearing

Risk factors:
a. difficult or precipitate births
b. primigravidas
c. birth of a large infant
d. use of a lithotomy position and instruments
(forceps)
Sites of lacerations:
1. Cervical Lacerations
- characterized by gushes of bright red blood from the
vaginal opening if uterine artery is torn
- difficult to repair because the bleeding may be so intense
that it can obstruct visualization of the area.
2. Vaginal Lacerations
- rare case but easier to assess
- oozing of blood after repair, vaginal packing is necessary to
maintain pressure from the suture line
- catheterize the mother because packing causes pressure on
urethra
- packing is removed after 24-48 hours (at risk for infection)
3. Perineal Lacerations
- usually occurs when mother is placed on lithotomy positions
(increases pressure on perineum)

Classifications:
a. First Degree – vaginal mucous membranes and skin of the
perineum to the fourchette
b. Second Degree – vagina, perineal skin, fascia and perineal
body
c. Third Degree – entire perineum and reaches the external
sphincter of the rectum
d. Fourth Degree – entire perineum, rectal sphincter and
some of the mucous membrane of the rectum
Management (Perineal)
1. sutured and treated using episiotomy repair
2. diet high in carbohydrate and a stool softener is
prescribed for the first week postpartum to prevent
constipation which could break the sutures
3. do not take rectal temperatures because the hard tips
of equipment could open sutures
3. Retained Placental Fragments – placenta does not deliver
its entire fragments and left behind leading to uterine bleeding
Causes:
a. Placenta Succenturiata –a placenta with accessory lobe
b. Placenta Accreta – a placenta that fuses with myometrium
because of an abnormal basalis layer

Signs and Symptoms:

1. if Large fragments
- Patient bleeds immediately at delivery
- Uterus is boggy
2. if Small fragments
- bleeding occurs at 6th – 10th day PP
- Can cause subinvolution
Management:
1. Dilatation and Curettage (D&C) will be performed to
remove placental fragments and to stop bleeding
2. administration of Methotrexate to destroy the retained
placental tissue
3. instruct the mother to observe the color of lochia
discharge
4. check the completeness of the placenta after birth
4. Disseminated Intravascular Coagulation (DIC)
- deficiency in clotting ability caused by vascular injury
characterized by bleeding the IV sites, nose, gums etc.
Associative Factors:
a. premature separation of the placenta
b. missed early miscarriage
c. fetal death in utero
MEDICAL MANAGEMENT:
 Heparin Therapy ( Anticoagulant) to halt
the clotting; thus aid coagulation
throughout the rest of the body
 Blood or Platelets Transfusion - it can be
delayed until after heparin therapy so the
new blood factors are also not consumed
by the coagulation process.
NURSING MANAGEMENT:
 Explain her condition to the patient if she
is unaware of it in order to instill and
maintain confidence.
 Fetal assessment in order to evaluate the
sufficiency of placental circulation.
 Referring to the physician all blood
coagulation studies.
5. Perineal Hematoma – is a collection of blood in the
subcutaneous layer tissue of the perineum caused by injury to
blood vessels after birth
Risk Factors:
a. rapid spontaneous birth
b. perineal varicosities
c. episiotomy or laceration repair sites

Signs and Symptoms:

1. severe pain in the perineal area
2. feeling of pressure between the legs
3. purplish discoloration/swelling on perineum
4. concealed bleeding
Management:
1. assess the size by measuring it in centimeters
2. administer a mild analgesic as pain relief
3. apply an ice pack (covered by towel to prevent
thermal injury to the skin)
4. incision and drainage of the site of hematoma and
is packed with gauze
- Infection of the reproductive tract associated with giving
birth
- Usually occurs within 10 days of birth
- Another leading cause of maternal death
- Predisposing factors:
a. Prolonged rupture of membranes (>24 hours)
b. C-section
c. Trauma during birth process
d. Maternal anemia
e. Retained placental fragments
 - Infection may be localized or systemic
a. Local infection can spread to peritoneum (peritonitis) or circulatory
system (septicemia).
b. Fatal to woman already stressed with childbirth

Assessment findings:
1. Temp of 100.4 for more than 2 consecutive days, excluding the first 24
hours.
2. Abdominal, perineal, or pelvic pain
3. Foul-smelling vaginal discharge
4. Burning sensation with urination
5. Chills, malaise
6. Rapid pulse and respirations
7. Elevated WBC, positive culture and sensitivity
(Remember, 20-25,000 is normal after delivery—MASKING infection)
8. inflammation of the suture line with pus
PREVENTION:
 well balanced diet
 avoid coitus in late pregnancy
 separation of infected patient from
non- infected patients
 strict aseptic technique
 proper perineal care
 good handwashing technique to prevent
cross- contamination
Nursing interventions
1. Force fluids; may need more than 3L/day
2. Administer antibiotics after culture and sensitivity of the organism
(Group B streptococci and E. Coli) and other meds as ordered
3. Treat symptoms as they arise
4. Encourage high calorie, high protein diet
5. Position patient in a semi-Fowlers to promote drainage and
prevent reflux higher into reproductive tract
6. Use of sterile equipments on birth canal during labor, birth and
postpartum
7. Educate the mother about proper perineal care including wiping
from front to back
8. remove the suture to drain the area
9. hot sitz bath or warm compress
10. instruct the mother to observe for problem in their infant (such as
oral candida) This occur due to portion of maternal antibiotic passes
into breast
11. Milk and can cause the overgrowth of fungal organism in an infant


 - refers to the infection of the endometrium, the
lining of the uterus at the time of birth or during
Postpartal period

Signs and Symptoms:

1. fever on the third or fourth day postpartum(increase in oral
temperature above 38C for 2 consecutive 24 hour periods,
excluding the first 24 hours period after birth)
2. chills, loss of appetite and general body malaise
3. uterine tenderness
4. foul smelling lochia
Management:
1. ATBC administration such as Clindamycin after culture
2. oxytocin is given to encourage uterine contraction
3. encourage increase fluid intake to combat fever
4. analgesic as ordered for pain relief due to after pains
and abdominal discomforts
5. encourage client to ambulate or in Fowler’s position
to promote lochia drainage and prevent pooling of
infected secretions
6. IV therapy
 - localized infection of the suture line from an
episiotomy site

Signs and Symptoms:

1. feeling of heat, pain and pressure on the suture line
2. 1 or 2 stitches are sloughed away
3. purulent discharges on suture lines

Management:
1. removal of perineal sutures to open and allow for
drainage
2. Topical, systemic ATBC as ordered
3. Analgesic to alleviate discomfort
4. Provide Sitz bath or warm compress to hasten drainage
and cleanse the area
5. Remind the mother to change perineal pads frequently
to prevent contamination/infection
6. Teach proper perineal care wiping from front to back
after bowel movement (to prevent bringing the feces to
the healing area)
- rigid obdomen,
 abdominal pain,
 High fever, rapid pulse,
 vomiting
 - Insertion of NGT .
 - IVF administration
 - Pain relief
 - Intra-abdominal lavage
-inflammation of the lining of a blood
vessel with blood clot formation
- could lead to DVT
Femoral Thrombophlebitis
 - inflammation
 - edema
 - white, drained appearance on the leg
 - pain
 - Homan's sign
A positive Homan's sign (calf pain at dorsiflexion of the foot)
Management:
- bed rest with leg elevated
- anticoagulant and analgesic administration
- moist heat application
- never massage affected area
Pelvic Thrombophlebitis
 - high fever, chills, general malaise
 - vein necrosis
Management:
- bedrest
- anticoagulant and antibiotic administration
- laparotomy-for abscess
Deep Vein Thrombosis
- formation of blood clot in a deep vein
Management:
- anticoagulant
- thrombolysis
- compression stockings
Prevention:
 Aseptic technique
 Ambulation
 Provide padded stirrups
 Support stocking for first 2 weeks postpartum
 -infection of the breast that occurs as early as
7th day postpartum
- usually unilateral
- localized pain, swelling and redness
- fever
- scant milk
Management
 - encourage to continue breastfeeding or manually
express milk
 - antibiotic administration
 - cold or ice compress
 - wear supportive bras
-incomplete return of the uterus to its
prepregnant size and shape
-Uterus is still enlarged and soft at 4-6 weeks
postpartum
-Lochia discharge present at 4-6 weeks
postpartum
- May be tender upon palpation if endometritis
is present
Management
 Oral administration of methylergonovine
 Oral antibiotics for endometritis
- burning on urination
- hematuria
- feeling of frequency
- dysuria
- low-grade fever
- lower abdominal pain
Management
 - broad-spectrum antibiotics except sulfa drugs
 - encourage increased oral fluid intake
 - oral analgesic
-a collection of blood in the subcutaneous layer
of tissue of the perineum
- risk factors:
spontaneous births and
perineal varicosities
 - Severe pain in the perineal area
 - Feeling of pressure between the legs
 - Presence of purplish discoloration
 - Swelling
 - Tender upon palpation
Management
 Administration of mild analgesic
 Ice pack over the area
 Incision and drainage
 Usually absorbed within 6 weeks
 - Prepartal hypertension
 - Proteinuria
 - Edema
 - hypertension
Management
 - Bedrest
 - Quiet atmosphere
 - Frequent vital signs monitoring
 - Urine output monitoring
 - Magnesium sulfate administration
 - Antihypertensive therapy
 Feeling of helplessness during the first 2 weeks after
delivery
 Contributory Factors:
 > Rapid hormonal shifts
 > Anorexia
 > Crying spells
 > Insomnia
 > Irritability, anger, and mood swings
 > Fatigue and feeling of helplessness / hopelessness
Interventions:
 > Provide psychosocial intervention.
 > Advise client to get adequate rest and nutrition.
 > Seek support from significant others.
 > Avoid overstimulation
 A psychiatric illness manifested as the client loses contact
with reality
 > Contributory Factors: Pre-existing mental illness
Interventions:
 > Refer the client to a psychiatrist.
 > Never leave the woman alone with the child.
A. Causes of Infertility
 1. Males
 Disturbance in spermatogenesis (cryptorchidism, varicocele)
Normal sperm count; 20 million/mL
 Obstruction in seminiferous tubules, ducts or vessels
preventing movement of spermatozoa (mumps,
epididymitis, and tubal
 infections)
 Qualitative or quantitative changes in seminal fluid
preventing sperm motility
 Development of autoimmunity that immobilizes the sperm
 Problems in ejaculation or deposition (erectile dysfunction,
hypospadia, epispadias)
 2. Females
· Anovulation
· Tubal-transport problems (PID)
· Uterine problems (endometriosis)
· Cervical problems
· Vaginal problems
B. Diagnostic Tests
 1. Semen Analysis
- 2-4 days of sexual abstinence is required
- the specimen must be examined within an hour
 2. Sperm Penetration Assay and Antisperm Antibody Testing
- determines whether the sperm can penetrate the ova
 3. Ovulation Determination
· Basal Body Temperature
· Test Strip
· Cervical Mucus
 4. Postcoital Test
- determines both ovulation and semen characteristics
- shows presence of sperm and how they interact with vaginal
andcervical environment
 - the couple has coitus and the woman reports within 2-8 hours
 5. Ultrasonography and X-ray Imaging
 C. Nursing Interventions
 1. Provide education about various treatment modalities
 2. Discuss ethical dilemmas concerning treatment
modalities
 3. Teach ovulation prediction and detection techniques
and administration of ovulatory stimulants
 4. Assist with fertilization procedures
 5. Provide guidance about emotional reactions associated
with procedures
 6. Discuss risks with planned procedures
 7. Remind clients about follow-up medications, tests and
examinations
 8. Referral to infertility support group
 D. Medical Interventions
 1. Correction of underlying problem
 a. increase sperm count and motility
 b. reduce presence ot infection
 c. hormone therapy
 d. surgery
 2. Assisted Reproductive Techniques
 a. Artificial Insemination
 b. In Vitro Fertilization and Embryo Transfer
 c. Gamete intrafallopian Transfer
 d. Zygote Intrafallopian Transfer
 e. Surrogate Embryo Transfer
 f. Intravaginal Culture
 g. Blastomere Analysis