INDENTIFICATION DATA OF THE PATIENT

Name Mrs. ParamjitKaur W/O Baljinder Singh

Age 29 years
Sex Female
LMP 09-09-2017
EDOD 16-06-2018
GPAL G1P1L1A0
Marital status Married
Religion Hindu
Educational status 10th+2
Occupation Housewife
Address Amritsar
Date of admission 14-6-2018
Diagnosis breech with severeoligohydramnios
Doctor in charge Dr. Anujit Kaur
Name of Surgery Emergency Lower Segment Cesarean Section

Date of Surgery 18-6-2018

Present medical history Hypertension

Present surgical history Patient is having lower segment cesarean section.

Present Obstetrical History G1 P1 L1 A0 S0

Fundal height – 12.5cms

Lochia Lochia is healthy, discharge is normal & red in color i.e. Lochia Rubra

Past Medical History Not Significant

Past Surgical History Not significant

Past Obstetrical History Not significant

Personal History No Contraceptives they have used.

No history of Smoking & Alcoholism

FAMILY HISTORY
 Sr. Name of the Relationship Age Marital Occupation Health Educational
No. family member with patient /sex Status Status Background
1. Lakhi Devi Mother-in- 58y Married Housewife Good Illiterate
law /F
2. Roopa Lal Husband 32y Married Private job Good +2
/M
3. Yash Son 2da Good
ys ……… ………….. ………..
FAMILY TREE

Mother-in-law
58years house wife Father-in-law

Patient 29 years house wife

Son 2days

OBSTETRICAL HISTORY
Married since 2014
Obstetrical Score G1 P1 L1 A0
Sr.No. Year Pregnancy Event Sex of Baby Baby Status
1. 2015 LSCS Male Normal

MENSTRUAL HISTORY
 Age of Menarche 14 years
 Flow Normal
 Duration 3-5 days
 Dysmenorrhea Absent
 Cycle 28 days

PHYSICAL EXAMINATION
General Appearance
 Height 160cm
Weight 80kg
Vital signs
Temp. 99oF
Pulse 84/min
Respiration 24/min
B.P. 110/70mm Hg
Mental status conscious
Head
Hair Equally distributed and black in color
Scalp Dandruff is present
Eyes
Position Symmetrical
Conjunctiva Yellow
Eye lids Normal
Vision Blurred vision
Nose
Nasal discharge No any abnormal discharge
Nostrils Nostrils are moist
Epistaxis Absent
Mouth
Gums Fowl smelling are present
Lips Black and dry
Teeth
Alignment Symmetrical
Color Yellowish
Dental Caries Absent
Tongue Coated

Ear
Alignment Symmetrical
 Discharge Absent
Neck
Lymph nodes Not Enlarged
ROM Normal
Breast
Enlarged due to pregnancy
Shape Round
Areola Dark in color and primary and secondary areola are present
Nipples Protruded
Montgomery sign Present
Absence of lesions
Extremities
Upper extremity
Deformity Absence of any deformity
Edema Edema is not present
ROM Normal
Lower extremity
Deformity Absence of any deformity
Edema Edema is present
ROM Normal
Nails
Shape Flat
Color White
Thickness Uniform
Capillary refill time Normal
Abdomen
Appetite normal
Dysphagia absent
Nausea/ Vomiting no
Striae Gravida present
Linea nigra present
 Shape flat
Fundal height 12.5cm
Texture of the skin shine & wrinkled
Sutures normal
Discharge no (from suture site)
Pain present at suture site
Lochia rubra

Genitalia
Discharge normal red in color
Vulva normal
Itching no
Hygiene maintained
Any abnormality not any

Rectum
Absence of redness , hemorrhoids.
Constipation is present
Bladder habits are regular
Bowel habits are regular.

INVESTGATIONS

Date Investigation Patient value Normal value Remarks

 carried out

Hb 12.8 gm/dl 11.5-16.5gm/dl Normal

HBsAg -ve -ve Normal

15-06-2018 HCV -ve -ve Normal

HIV -ve -ve Normal

VDRL -ve -ve Normal

Hb 12.8 gm/dl 11.5-16.5gm/dl Normal

15-06-2018 WBCs 9.07 10^3/ul 4.0-10.0 10^3/ul Normal

ELISA Non-reactive

TLC 9800 5000-10000 Normal

RBS 124mg/dl 80-120mg/dl Mild increase

ESR 20 0-20 Normal

SPECIAL INVESTIGATION:

 ULTRASOUND :
Impression: single live fetus at 35 weeks, 4days of gestation in Brech presentation with
oligohydramnions .

VITAL SIGNS

S.no DATE VITAL PATIENT NORMAL REMARKS

 SIGNS VALUE VALUE

1 15-06-18 Temp. 98o F 98.6o F Normal

Pulse 80 /min. 72-80/ min Normal

B.P 110/70mm of Hg 120/80mm of Hg Mild Decreased

Respiration 22/ min 16-24/ min Normal

2 16-06.18 Temp. 98o F 98.6o F Normal

Pulse 90 / min 72-80/ min Mild increased

B.P 110/60mmofHg 120/80mm of Hg Mild Decreased

Respiration 24/ min 16-24/ min Normal

3 08-02.15 Temp. 99o F 98.6o F Slightly Increased

Pulse 84 / min 72-80/ min Slightly Increased

B.P 110/70mmofHg 120/80mm of Hg Slightly decreased

Respiration 24/ min 16-24/ min Normal

Medication:

Sr.no. Drug Dose Route Time Action

1. Inj. 750mg Iv TDS Antibiotic
Cefuroxime

2. Inj.Rantac 50mg Iv TDS Antacid

3 Cap Firony 100mg orally OD Iron supplement

4 Inj.Diclofenac 75mg IM TDS Analgesic

5 Inj. Amikacin 500mg Iv BD Antibiotic

6 Syrp.Cremaffin I0ml/2tsp orally OD Laxative

CASE IN DETAIL
ANATOMY AND PHYSIOLOGY

UTERUS

The Uterus is the organ of pregnancy as this is where implantation and development of the feotus
occurs. The Uterus is the reproductive organ with the most species variations. These variations
occur in both the anatomical types of uterus as well as the uterine horn appearance and
endometrial linings.

LOCATION OF THE UTERUS

The uterus sits centrally in the pelvis supported by strong fibrous structures called ligaments

FEMALE REPRODUCTIVE SYSTEM

The uterine muscle wall expands greatly during pregnancy and strong contractions of this muscle
wall during childbirth give rise to the pains of labour. You experience similar contractions on a
much smaller scale during menstruation, and this is the cause of the period pain (dysmenorrhoea)
which troubles so many women.
STRUCTURE
The 9, or womb, is shaped like an inverted pear. It is a hollow, muscular organ with thick walls,
and it has a glandular lining called the endometrium. In an adult the uterus is 7.5 cm (3 inches)
long, 5 cm (2 inches) in width, and 2.5 cm (1 inch) thick, but it enlarges to four to five times this
size in pregnancy. The narrower, lower end is called the cervix; this projects into the vagina. The
cervix is made of fibrous connective tissue and is of a firmer consistency than the body of the
uterus. The two fallopian tubesenter the uterus at opposite sides, near its top. The part of the
uterus above the entrances of the tubes is called the fundus; the part below is termed the body.
The body narrows toward the cervix, and a slight external constriction marks the juncture
between the body and the cervix.

The uterus does not lie in line with the vagina but is usually turned forward (anteverted) to form
approximately a right angle with it. The position of the uterus is affected by the amount of
distension in the urinary bladder and in the rectum. Enlargement of the uterus
in pregnancy causes it to rise up into the abdominal cavity, so that there is closer alignment with
the vagina. The nonpregnant uterus also curves gently forward; it is said to be anteflexed. The
uterus is supported and held in position by the other pelvic organs, by the muscular floor or
diaphragm of the pelvis, by certain fibrous ligaments, and by folds of peritoneum. Among the
supporting ligaments are two double-layered broad ligaments, each of which contains a fallopian
tube along its upper free border and a round ligament, corresponding to the gubernaculum testis
of the male, between its layers.

The uterus is composed of three layers of tissue

PERIMETRIUM
On the outside is a serous coat of peritoneum (a membrane exuding a fluid like blood minus its
cells and the clotting factor fibrinogen), which partially covers the organ. In front it covers only
the body of the cervix; behind it covers the body and the part of the cervix that is above the
vagina and is prolonged onto the posterior vaginal wall; from there it is folded back to therectum.
At the side the peritoneal layers stretch from the margin of the uterus to each side wall of the
pelvis, forming the two broad ligaments of the uterus.
MYOMETRIUM
The middle layer of tissue (myometrium) is muscular and comprises the greater part of the bulk
of the organ. It is very firm and consists of densely packed, unstriped, smooth muscle fibres.
Blood vessels, lymph vessels, and nerves are also present. The muscle is more or less arranged in
three layers of fibres running in different directions. The outermost fibres are arranged
longitudinally. Those of the middle layer run in all directions without any orderly arrangement;
this layer is the thickest. The innermost fibres are longitudinal and circular in their arrangement.
ENDOMETRIUM
The innermost layer of tissue in the uterus is the mucous membrane, or endometrium. It lines the
uterine cavity as far as the isthmus of the uterus, where it becomes continuous with the lining of
the cervical canal. The endometrium contains numerous uterine glands that open into the uterine
cavity and are embedded in the cellular framework or stroma of the endometrium. Numerous
blood vessels and lymphatic spaces are also present. The appearances of the endometrium vary
considerably at the different stages in reproductive life. It begins to reach full development
at puberty and thereafter exhibits dramatic changes during each menstrual cycle. It undergoes
further changes before, during, and after pregnancy, during the menopause, and in old age. These
changes are for the most part hormonally induced and controlled by the activity of the ovaries.

CERVIX

The cervix can be palpated transrectally and forms a sphincter controlling access to
the uterus.The anatomy of the cervical canal is adapted to suit a particular pattern of reproduction
and its composition will alter under the influence of reproductive hormones. Not only does it
respond to the fluctuation in oestrodiol during the oestrous cycle, but is responsive to
prostaglandins and oxytocin in order to 'soften' for parturition.

STRUCTURE

 The lumen of the cervix is the cervical canal.

 The canal is formed by, and often almost occluded by mucosal folds.
 Single fold and smooth surface in the queen and bitch
 Multiple folds protruding into the cervical canal in the cow, ewe, sow and mare.
 The cervical canal opens cranially into the body of the uterus at the internal uterine
ostium.
 The cervical canal opens caudally into the vagina at the external uterine ostium.
In the nonpregnant state, the cervix comprises the lower one-third of the uterus and connects the
uterine cavity to the vagina. The overall length of the cervix is highly variable but generally falls
in the range of 2.5 to 5.0 cm. Only about one-half to one-third of the cervix extends into the
vagina and this is called the portiovaginalis. The portion of the cervix that opens into the vagina
is called the external cervical os; the uppermost portion that opens into the uterus is called
the internal cervical os. As we will emphasize in later discussion, the internal cervical os is a key
player in the etiology, pathogenesis, and diagnosis of cervical incompetence. The portion of the
cervix that connects the external os and internal os contains the endocervicalcanaland this
narrow tube separates the relatively unsterile environment of the vagina from the uterine cavity.
The endocervical canal is lined by a single layer of mucous producing cells and the chemicals
and immunoglobulins that are secreted into the canal provide the major barrier to ascending
infection by potential pathogenic microorganisms from the vagina and ectocervix.

Although the cervix is contiguous with the body of the uterus, it is structurally different from the
uterus in several key aspects. Both the uterine wall (the myometrium) and the cervix contain
smooth muscle and fibrous connective tissue, but there is a much greater percentage of the
connective tissue in the cervix than in the myometrium. The uterus is “designed” to contract and,
when the time is right, eventually push the baby out, while the role of the cervix, under normal
circumstances, is to keep the baby inside until it is mature enough to survive in the cold cruel
worldoutsidethewomb.
The fibrous connective tissue of the cervix is mostly composed of types I and II collagen, elastin,
and proteoglycans. The collagen is heavily ‘cross-linked’ and this imbues the cervix with
atremendous resistance, again under normal circumstances, to stretching and ‘softening’ until the
biochemical cascade that progresses to labor ensues. At that point, the cervix is capable of
undergoing a remarkably rapid transformation from a structure that has the consistency of a
rubber eraser to the soft, compliant, elastic structure that will permit the relatively easy passage
of the baby from the uterus and into the birth canal – a transformation that results from the
remodeling (uncross-linking) of the collagen and the extracellular matrix.

FEMALE REPRODUCTIVE SYSTEM

CASE IN DETAIL
PGR (primigravida)
It is defined as the women who has conceived 1st time.
Sign & symptoms

Sr. PATIENT PICTURE BOOK PICTURE

no.
1. Nausea /vomiting Present
2. Edema Absent
3. Anxiety Present
4. Fever Present 1st post operative day
5. Pain at suture site Present till 2nd post operative day
6. Lochia Present

BREECH PRESENTATION
Definition

This is defined as the presentation in which the lie is longitudinal & the podalic pole presents at
the pelvic brim. It is the commonest malpresentation.

Varieties / types

There are two types :

1. Complete (Flexed Breech):

The normal attitude of full flexion is maintained. The thighs are flexed at the hips & the legs
at the knees. The presenting part consists of the two buttocks, external genitalia & 2 feet. It is
commonly presents in multiparae.

2. Incomplete:

This is due to varying degrees of extension of thighs or legs at the podalic pole. There are
three varieties are possible:

 Breech with extended legs( frank Breech): in this the thighs are flexed on the
trunk & the legs are extended at the knee joints. The presenting part consists of
the two buttocks & external genitalia only. It is commonly present in
primigarvidae, is due to tight abdominal wall, good uterine tone & early
engagement of breech.
 Footling presentation: in this both the thighs & the legs are partially extended
bringing the legs to present at the brim.
 Knee presentation: in this the thighs are extended but the knees are flexed,
bringing the knees down to present at the brim.

Clinical classification of breech:

 1. Uncomplicated: it is defined as one where there is no other associated obstetric
complications apart from the breech, prematurity being excluded.
2. Complicated: when the presentation is associated with the conditions adversely influence
the prognosis such as prematurity, twins, contracted pelvis, placenta praevia etc.

SURGICAL MANAGEMENT
Lower segment cesarean section

Definition

It is an operative procedure where the fetus has delivered through an incision on the abdominal
& uterine wall.

INDICATIONS

Sr. BOOK PICTURE PATIENT PICTURE

No.
1. Caphalo pelvic disproportion Absent
2. Placenta previa Absent
3. Abruption placenta Absent
4. Meconium stained liquor Present
5. Fetal distress Present
6.. Contracted pelvis Absent
8. Placenta previa Absent
9. Previous cesarean section Absent
10. Malpresentation Absent
11. Medical &gynaecological diseases Absent
12. complicating pregnancy. Present
Non reassuring fetal heart rate. Absent
Failure to progress of labor.
TYPES Of OPERATION ( Acc. To Time)

Sr. BOOK PICTURE PATIENT PICTURE

No.
1. Elective Absent
2. Emergency Present

TYPES OF OPERATION (Acc. To Incision)

Sr. BOOK PICTURE PATIENT PICTURE

No.
1. Upper segment cesarean section Absent
2. Lower segment cesarean section Present
  Lower segment transverse Present
 Lower segment vertical Absent

DIAGNOSTIC EVALUATION

Sr. BOOK PICTURE PATIENT PICTURE

No.
1. Haemoglobin Present
2. TLC Present
3. DLC Present
4. Urine culture Present
5. RBS Present
6. TORCH Absent

MEDICAL MANAGEMENT ON 1ST-3RD POP DAY

Sr. BOOK PICTURE PATIENT PICTURE

No.
1. Inj. Ampicillin Present
2. Inj. Voveron Absent
3. Inj. Phenergan Absent
4. Inj. Rantac Absent
5. Inj. Gentamycin Present
6. Inj. Emeset Absent
7. Inj. Metrogyl Absent
8. Dressing with butadiene Present

MEDICAL MANAGEMENT OF 3RD -5TH POP DAY

Sr. Book picture Patient picture

No.
1. Inj. Gentamycin Present
2. Tab. Perinorm Absent
3. Tab. Rantac Present
4. Tab. Voveron Present
5. Tab.calcimax Present

NURSING CARE
Sr. SHORT TERM GOALS LONG TERM GOALS
No
1. To enhance the rest & sleep of the mother. To tell the mother for the personal hygiene
 To give the medication at proper time.
2. To motivate the mother for her daily living activities. To advice the mother to take nutritious diet
3. To advice the mother for deep breathing exercises. To advice the mother to give breast feeding
4. To encourage the mother for early ambulation demand of the baby.
5. To guide the mother for breast feeding techniques To tell the mother to come for follow up.
6. To motivate the mother for the breast feeding techniques. To tell the mother if any discharge or leaka
7. To prevent the mother from risk of infection. the incision site then report to the Dr.
8. To advice the mother for her personal hygiene. To advice the mother to take her medicine
9. To assist the mother for baby care. To teach the mother for postnatal exercises
10.

NURSING DIAGNOSIS:-
1. Pain & discomfort related to the surgery manifested verbally by the patient.
2. Weakness & altered physical comfort related to the cesarean section as verbally told
by the patient.
3. Risk for infection related to the surgery as evidenced by poor perineal hygiene by
herself.
4. Improper lactation due to low sucking power of the baby & mothers’ inability to
provide breast feed appropriately.
5. Knowledge deficit related to diet, drugs & incision site as evidenced by her facial
expression seems confused & anxious.
Sr Nursing Nursing Nursing Nursing Planning & Nursing Nursing Nursing
No. Assessment Diagnosis Goals Interventions Implementation Rationale Evaluation
1. Subjective: Pain & Pain &  Comfortable  Comfortable These all The pain of
Patient is discomfort discomfort position should position given to implementations the patient
telling that related to the related to be provided to the patient. will help the has
she is surgery the the patient. patient in relieved of
having pain manifested surgery  Reassure the  Reassurement relieving the the patient
at the suture verbally by manifested patient. provided to the pain. to a little
site. the patient. verbally patient. extent as
Objective: by the  Give injection  Analgesic given evidenced
She is patient. voveron to to the patient as by her
having pain relieve the pain prescribed by the facial
as evidenced as prescribed by doctor expressions
by her facial the doctor. & also
expressions . verbalized
 Tell the patient  Patient has told by the
to do deep to do the deep patient.
breathing breathing
exercises. exercises.

Subjective:- Weakness &  Reassure the  Patient has

Patient is altered patient . reassured. These all Patient is
2. complaining physical To restore  Tell the patient  Patient has told implementations feeling
about the comfort normal to take to take the will help the comfort &
weakness related to the health & nutritious diet. nutritious diet. mother to make her
and cesarean physical herself comfort. weakness
 Tell the patient  Patient has told
bodyache . section as comfort. has
to do some to do some active
Objective:- vehrbally reduced to
active passive passive exercises.
Patient is told by the some
exercises.
looking patient extent.
exhausted.
Sr Nursing Nursing Nursing Nursing Planning & Nursing Nursing Nursing
No. Assessment Diagnosis Goals Interventions Implementation Rationale Evaluation
 Encourage the  Patient has
patient for the increased her
ambulation. ambulation.
 Tell the patient  Patient has told
to take proper to take proper
rest & sleep. rest & sleep.
 Tell the patient  Patient has told
to take hot to prefer hot
liquids & avoid liquids as
the cold liquids compare to cold
as she can. ones.

3. Subjective:- Risk for To prevent  Provide the These all Patient will
Patient is infection the risk for proper perineal  Proper perineal implementations be free
telling I am related to the infection. care to the care has will help the from any
feeling surgery as patient twice a provided. mother to kind of
itching in evidenced by day with prevent herself infection as
the perineal poor perineal betadiene. from the risk of evidenced
ara. hygiene by  Apply the  Antiseptic any kind of by no signs
Objective:- herself. antiseptic ointment infection. of infection
Chances of ointment povidine iodine as no
developing povidine iodine has applied to the redness &
infection at at the perineal perineal site. itching is
the perineal area daily. there.
site due to
lochia
Sr Nursing Nursing Nursing Nursing Planning & Nursing Nursing Nursing
No. Assessment Diagnosis Goals Interventions Implementation Rationale Evaluation
4. Subjective:- Improper To  Reassure the  Patient has These all Lactation
Mother is lactation due establish patient. reassured. implementations has
telling that to low successful  Teach the  Mother has will help to improved
baby is not sucking lactation mother about taught about the establish to some
able to suck. power of the & to the breast breast feeding successful extent as
Objective:- baby & improve feeding techniques. lactation & will evidenced
Baby is not mothers’ baby’s techniques.  Mother has told improve the by proper
fully inability to sucking.  Tell the mother about the sucking of the sucking
contended to provide about the positioning while baby. effect.
breast feed breast feed positioning the breast
due to less appropriately. during feed. feeding.
milk  Assist the  Mother has
secretion & mother for the assisted for the
is crying. exclusive breast exclusive breast
feeding. feeding.
 Check if any  Assessment has
ailment in done for any
breast. ailment regarding
the breast.
 Provide proper  Breast care has
breast care to provided to the
the mother. mother.
 Mother has told
 Tell the mother about the
about the importance of
importance of cleanliness of the
cleanliness of breast.
the breast.
Health education:

1. Patient is educated about the adequate antenatal care for treating of maternal anaemia and
iron folic acid supplementation to antenatal mothers.
2. Instructed parents and family about control of infection in prenatal, natal and neonatal
period.
3. Educated about the universal immunization to mother for prevent chronic illness.
4. Educated about the improvement of living conditions by avoidance of open air defection,
hygienic measures, balanced diet.
5. Diet – advice her to start from balanced diet, the diet should contain plenty of protein,
meat, fresh, fruits and green vegetables.
6. Rest and sleep- Educated her for proper rest and sleep. Advice her to take rest 2 hours a
day in supine position and 8 hours in night.
7. Care of bladder and bowel-encourage her to void frequently to avoid bladder extension.
And to drink plenty of fluids to prevent constipation.
8. Follow up- educate about regular antenatal checkups and regularly taking medication as
prescribed by doctor.
 BIBLIOGRAPHY:

 Dutta DC. Textbook of Obstetrics. Edition sixth 2004, Published by New Centeral Book
agency (P) Ltd. 8/1 Chintamoni, Das Lane: Calcutta 700009 (India). Pp- 216 - 25.

 KumariNeelam, Sharma Shivani, Dr. Gupta Preeti. Midwifery &Gynaecological Nursing.

Ed-Ist. Pee Vee (p) Ltd. Pp 284-6

 SanjuSira. A Textbook of Midwifery and obstetrics. Ed- 2 nd; Lotus Publishers, Pp- 206 -
13.

 Lippincott Williams and Wilkins. Lippincott Mannual of Nursing Practice. Ed- 8 th,
published by- Jaypee brothers, Pp- 1270 -75.
Florence nightingale college of nursing
shajahanpur
SUBJECT: Obstetrics AndGynaecological
Nursing
CASE STUDY
On
Lower Segment Cesarean Section With
PGR With Breech With Severe
Oligohydraminos

SUBMITTED TOSUBMITTED BY
Dr. Karuna SharmaHarshpinderpalkaur
Professor M.Sc (N)2nd Year
Obstetrics AndGynaecological(OBG)
Nursing