HOLY ANGEL UNIVERSITYCOLLEGE OF NURSING

ANGELES CITY

In Partial Fulfillment of the Requirements in Nursing Care Management II: Related Learning Experience

A Case Study for Obstetric Cases:

CHORIOAMNIONITIS

Ms. Maryknoll Balboa, RNClinical Instructor

Submitted by:

GROUP 2AN204

Dingal, Paolo JunelleFlores, CharyGalang, Aina

Garcia, Cyrielle ClaireGuintu, Anthony

Ordonez, Jesy

March 25, 2010

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TABLE OF CONTENTS

I. INTRODUCTION………………………………………………………3-4

II. NURSING HISTORY

a. Demographic Data………………………………………………4b. Socio-economic and Cultural Factors…………………………..4-5c. Environmental Factors………………………………………….5d. Maternal-Child History…………………………………………5e. Family-Health Illness History………………………………….. 6-7f. History of Past Illness…………………………………………..7g. History of Present Illness……………………………………….7

III. PHYSICAL ASSESSMENT…………………………………………..7-10

IV. DIAGNOSTIC AND LABORATORY PROCEDURES……………11-14

V. THE PATIENT AND HIS ILLNESSa. Anatomy and Physiology………………………………….........15-22b. Pathophysiology

i. Book-Based………………………………………………23-28ii. Patient-Based…………………………………………….39-31

VI. THE PATIENT AND HIS CAREa. Medical Management……………………………………………32-33b. Drugs…………………………………………………………….34-41c. Diet………………………………………………………………42d. Activity…………………………………………………………..42-43e. Surgical Management……………………………………………44-49

VII. NURSING CARE PLAN…………………………………………..50-57

VIII. LEARNING DERIVED FROM THE STUDY……………………58

IX. REFERENCES……………………………………………………… 59

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I. INTRODUCTION

Maternal fever during labor, and perhaps other signs and symptoms of chorioamnionitis, often results in a call to the family practitioner, pediatrician, or neonatologist related to concern for the neonate. Early onset bacterial infections in the newborn may occur when the mother has abnormal bacterial colonization of the urogenital tract, an ascending but silent amniotic fluid infection, or symptomatic chorioamnionitis. The said infection can either lead to premature labor or intrauterine fetal death or demise.

Maternal chorioamnionitis, intra-amniotic infection or amnionitis, perhaps occurs when protective mechanisms of the urogenital tract and/or uterus fail during pregnancy or when increased numbers of microbial flora or highly pathogenic microorganisms are introduced into the genital environment Ascending infection into the vagina, then the cervix, and finally into the uterine cavity, fetal membranes, and placenta is the consequence of many factors (ie, innate host defenses, healthy bacterial flora, bacterial burden, bacterial pathogenetic factors). Recently, a short cervix has been recognized as either a risk factor or a surrogate for microbial invasion of the amniotic fluid.Urinary tract infection during pregnancy can bathe the vagina with bacterial pathogens and is a recognized risk factor for chorioamnionitis. Abnormal bacterial colonization of the rectum and anus during pregnancy may create an abnormal vaginal and cervical microbial environment. Studies have demonstrated that other types of bacteria residing in the vagina, cervix, or both ascend through intact or ruptured fetal membranes and initiate amniotic fluid infection.

The organisms usually responsible for chorioamnionitis are those that are normally present in the vagina, including Escherichia coli (E. coli). Group B streptococcus may also cause the infection.

The infection occurs in 0.5 percent to 10 percent of births.

The time-honored clinical signs and symptoms of chorioamnionitis include the following:

o Fever (an intrapartum temperature >100.4 º F or >37.8 º C)o Significant maternal tachycardia (>120 beats per minute [bpm])o Fetal tachycardia (>160-180 bpm)o Purulent or foul-smelling amniotic fluid or vaginal dischargeo Uterine tendernesso Maternal leukocytosis (total blood leukocyte count >15,000-18,000 cells/μL)

In addition to a complete medical history and physical examination, chorioamnionitis is diagnosed by symptoms and by laboratory tests for infection. Testing of the amniotic fluid by

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amniocentesis (withdrawing fluid with a needle) may be needed. Antibiotics are used to treat chorioamnionitis as soon as the infection is diagnosed. Antibiotics are usually continued after delivery as well. Delivery is often necessary to prevent complications in the mother, or if the fetus is in danger.

The case study was chosen by the group to be more knowledgeable on the distinctive aspects of such conditions resulting for the students to be equipped with supplementary information and acquaintance regarding the present situation. With this, provision of health teachings and explanations about the patient’s condition as well as nursing care would be operational and effective.

Consequently, confirming the principle that when the a health care provider become much well-informed and prepared, the more efficient he/she becomes in imparting nursing care.

Nurse-centered Objectives:

After the completion of this case study for 2 to 3 days, the student-nurse will be able to:

1. Determine major causes of Intrauterine Fetal Death.2. Enumerate the predisposing and precipitating factors that contribute to Intrauterine Fetal

Death.3. Perform comprehensive assessment to the clientele cephalocaudally.4. Identify the apparent signs and symptoms of the clientele in relation to Intrauterine Fetal

Death.5. Decisively analyze the different laboratory and diagnostic procedures and relate the

results to the condition6. State and identify the appropriate nursing diagnosis and make essential interventions.7. Provide suitable health teachings to promote awareness, empowerment and wellness to

the clientele.

II. NURSING HISTORY

A. Personal History

a. Demographic Data

The group has decided to employ the pseudo name “Pooh Kwang” instead for the elected patient’s authentic name to preserve her personal discretion and confidentiality.

Pooh Kwang is a 19 year-old female born as a Filipino citizen at December 21, 1990 in San Juan , City of San Fernando, Pampanga. The patient herself currently resides in Sindalan, City of San Fernando, Pampanga, together with her boyfriend and immediate family members. Pooh Kwang was admitted in a certain hospital in City of San Fernando last February 11, 2010 and was discharged at February 14, 2010.

b. Socioeconomic and Cultural Factors

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Pooh is a vocational undergraduate with a course of computer operations at Systems Plus College. She stays at home at present because she stopped studying this ongoing semester due to the actuality that she was pregnant. She lives together with her mother, grandfather, her siblings and her boyfriend. She is Roman Catholic by faith. The family is not experiencing any financial constraints since their family’s income is 10,000 pesos which is given by their father who works abroad as a construction worker. They usually spent their money on their food, water, electricity and for telecommunications expenditures. She does not seek advice from a “manghihilot” in cases of illnesses but she does self-medication such as Paracetamol and Biogesic for fever and body pains and is doing water therapy to relieve any discomforts. She is fond of eating fish and vegetables and limits her fat and sugar intake since their family is at risk for hypertension and diabetes, respectively. According to her, she sleeps at 11 in the evening and usually wakes up at around 7 in the morning. After waking up, she usually eats breakfast and watches television. She is fond of drinking soft drinks during lunch time and drinks coffee twice a day. Her grandfather who is living with them is smoking and she is then predisposed to second-hand smoking.

c. Environmental Factors

Pooh lives at Sindalan, City of San Fernando Pampanga. They are currently renting their house for 2 years since the subdivision where they are living was just recently constructed. The location of their house was a great help in allocating their primary resources and their basic needs. There is a barangay hall, health center, grocery near them.

d. Maternal-Child History

Pooh is not yet married to Manny Pookyaw because staying permanently together as couples was still unplanned and evidently, of their young age. This is her first pregnancy and she has not experienced any complications during the early stage except for recurrent headaches in the course of her first trimester. She has an obstetric history of G1P0 (gravida 1, para 0, term 1, preterm 0, abortion 0, live births 0, multiple 0). She did not attend to any prenatal check ups for the first five months of her pregnancy and had just her first prenatal check up last November 11, 2009 at a certain hospital in Angeles City. Her OB-Gynecologist prescribed her to drink supplements such as Beneforte and Natalvis. Subsequently, she also had her prenatal check up in a certain hospital in City of San Fernando when her baby was already 34 weeks of gestation. After so, she visited Dr. Dizon, an OB-Gynecologist in a certain hospital in City of San Fernando last February 5, 2010 where she was then admitted. Pooh has attended three prenatal check-ups to total up. She had her menarche when she was 11 years old and has an irregular menstrual pattern. Her last menstrual period was May 14, 2009 while the estimated day for child’s delivery will be on February 21, 2010. Upon evaluation, the age of gestation of her baby was 39 weeks. After having an ultrasound check up on February 11 2010, that was the only time Pooh had discovered that her baby died in utero. She stated that last February 10 which was the day prior to her check up, Pooh has not felt any fetal movement the whole day. She was not bothered then because she believed that her baby was healthy and was just preparing to be born.

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e. Family-Health Illness History (Diagram)

**LEGENDS:

* PK= Pooh Kwang

- male - Pooh kwang - Hystorotomy - Deceased

- Diabetes Mellitus - Myoma - Asthma - Cancer

PK ; 19 yrs old

2nd sibling: 18 yrs old

3rd sibling: 17 yrs old

4th sibling: 15 yrs old

Manny Pookyaw: 19 yrs old

Poohpooh

PK’s father ; 43 yrs old

PK’s mother ; 40 y/o

PK’s aunt ; 35 y/o

Grandmother: 68 y/o

MOTHER’s SIDE

Grandfather: 65 y/o

Grandmother: 69 y/oGrandfather:

70 y/o

PK ‘s aunt: 58 y/o

FATHER’s SIDE

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e. Family- Health Illness History

Pooh has no history of reproductive or fertility problems. Her grandfather, grandmother and aunt on her father side as well as her grandmother on her mother side died because of old age. Her grandfather on her mother side was diagnosed with diabetes mellitus same as with her aunt from the said side plus the history of breast. Pooh’s mother has a history of asthma and is currently suffering from myoma where as her father present no signs and symptoms of any major illness She never saw her father again for the last 8 years counting at present. Among Pooh’s four siblings, she was the eldest and the only one who had experienced intrauterine fetal death or IUFD and has undergone hysterectomy in the family. She was living with her partner, Manny Pookyaw, in the same house for almost 3 years and got pregnant.

f. History of Past Illness

According to Pooh, she had already experienced common coughs and colds, fever, mumps, measles and chickenpox. She has no known allergies and was exposed to any serious injuries. Pooh was always been susceptible to infection as evidenced by her recurrent urinary tract infection even during her non-pregnant years. The said infection started when she was 17 years old by which Pooh holds her urine instead of voiding frequently since she was still studying by that time. Her physician prescribed her to drink Amoxicillin TID for 3 days to treat the underlying pathogenic cause. She was never hospitalized until the day she was diagnosed with intrauterine fetal death secondary to chorioamnionitis and was admitted in a certain hospital in City of San Fernando. She has received 2 doses of Tetanus Toxoid Immunization during the course of her pregnancy.

g. History of Present Illness

On the afternoon of February 11, 2010, Pooh was admitted at a certain hospital in City of San Fernando for an unscheduled childbirth and her mother verbalized “Ena ne kanu daramdaman ing baby na gagalo keng achan na buong aldo. Bala na matudtud yamu”. Her mother then stated that a day prior to admission, patient Pooh had her pre-natal checkup last February 5, 2010. Then she was scheduled to have her next pre-natal checkup last February 7, 2010 but she was not able to attend. Pooh noticed that her baby, aging 39 weeks of gestation, was no longer active which opted them to see a doctor. Upon evaluation, the fetus presented absence of heart tone and heart beats as well as movements or kicks. Pooh was the diagnosed with stillbirth or Intrauterine Fetal Death which was related to maternal infection secondary to acute chorioamnionitis. Her doctor observed for increased temperature or hyperpyrexia with a temperature of 37.6C upon admission and palpated uterine tenderness. Maternal tachycardia with a heart rate of 121 beats per minute was also taken into record. Foul smelling vaginal discharge was noted as well during induced labor. Due to present condition, her OB-Gyne opted for CS delivery and decided to perform hysterotomy by February 12, 2010.

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PHYSICAL ASSESSMENT (IPPA-CEPHALOCAUDAL APPROACH)

Initial Assessment: February 11, 2010, 1:00 pm

General Appearance upon NPI

Pooh is wearing a white shirt and pajama pants.. When the group arrived, Pooh was in a supine position, unconscious and incoherent, with an IVF of D5LRS 1L at 650cc level, running at 65 drops per minute, infusing well on the right hand, with foley catheter, draining pinkish yellow urine @ 400 cc level.During the Nurse-Patient Interaction (NPI) last February 11, 2010, the group obtained Pooh’s vital signs, which are as follow:

Blood Pressure : 90/60mmHgPulse Rate : 121 beats per minute (bpm)Respiratory Rate : 22 cycles per minute (cpm)Temperature : 37.6°C/axilla

In addition with the NPI, the group also performed physical assessment cephalocaudally. The data obtained are as follow:

INTEGUMENTARYSkin Light brown in color Generally uniform, except in areas exposed to the sun Absence of edema Absence of abrasion, bruises, lesions Moist in skin folds and in the axillae Good skin turgor: when pinched, skin springs back to previous state within

2-4 secondsNails Had clean fingernails and toenails with no clubbing on both hands and feet Smooth texture Nail bed has pale pigmentation with intact epidermis Capillary refill test: prompt return of usual color for 3 secondsHair Evenly distributed Thick, greasy hair No infection/infestation With variable amount of body hair

HEADSkull and Face Rounded (normocephalic and symmetrical, with

frontal, parietal, and occipital prominences)

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Smooth skull contour Absence of nodules, masses and edema Symmetric facial features Palpebral fissures equal in size Presence of pimples

EYES Eyebrows were symmetrically aligned with black

hair evenly distributed Eyelashes were black in color, equally distributed

and curled slightly outward Eyelids had intact skin with no discharges and

discoloration Palpebral conjunctiva was pale with no discharge Pupils were brown in color, equal in size, round and

with smooth border

EARS Auricles has same color as the facial skin, symmetrical, mobile, firm and not tender Auricle aligned with outer canthus of eye and pinna recoils after it is folded Sticky, wet cerumen in various shades of brown

NOSE AND SINUSES External nose was symmetric and straight, with no lesions and are not tender No discharge or flaring Uniform color Nasal septum intact and in midline Nasal mucosa was pale

MOUTH AND THROAT Lips are pale, soft but dry and symmetrical in contour Buccal mucosa is pale pink in color , moist and smooth Has 32 permanent teeth, 16 teeth in the upper jaw and in the lower jaw Smooth, white to yellow in color, shiny tooth enamel

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Pallor in gums, moist and firm in texture Tounge is in central position, moist, slight pink in color and is slightly rough

NECK Muscles equal in size Lymph nodes are not palpable, not tender Head centered Trachea is in central placement in the midline of the neck and tracheal spaces are equal on both sides

RESPIRATORY/CHEST Chest symmetrical in shape Skin intact Absence of lesions, tenderness, masses Full and symmetric chest expansion Quiet, rhythmic and effortless respirations Absence of sputum and cough Absence of adventitious breath sounds

CARDIOVASCULAR/HEART S1

heard at all times, louder at apical area S2

heard at all times, louder at the base of the heart Carotid arteries have symmetric pulse volume Jugular veins are not visible Peripheral pulses have symmetric pulse volume Peripheral perfusion: skin color of the hands and feet are slightly pink, skin temperature is warm, no edema seen

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Capillary refill test: immediate return of color within 3 seconds

GASTROINTESTINAL/ABDOMEN Abdominal incision with dry intact dressing present There is a line of dark pigment on the abdomen (Linea Nigra) Presence of red streaks on her abdomen (Striae Gravidarum) Distended No evidence of enlarged liver and spleen there is tenderness upon palpation,

GENITO-URINARY With tenderness upon palpation With foley catheter draining to pinkish yellow urine @ 400 cc With vaginal discharge (consumed 2 pads)

MUSCULOSKELETAL/EXTREMITIES Equal size on both sides of the body No contractures, fasciculation or tremors Normally firm and smooth No deformities, tenderness nor swelling Bones have no deformities, swellings or tenderness Joints have no swellings, no tenderness, no nodules

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IV. DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic/ Laboratory Procedures

Indications or Purpose

Date OrderedDate Results were released

Results Normal Values

Analysis and Interpretations of Results

COMPLETE BLOOD COUNT

A CBC may be ordered as part of a routine

checkup, or if Pooh is feeling more tired than usual, seems to have an

infection, or has unexplained bruising or bleeding. The complete blood count (CBC) is a common blood test that

evaluates the three major types of cells in the blood: red blood

cells, white blood cells, and platelets.

D.O. February 11, 2010D.R. February 11, 2010

HEMOGLOBIN Indicated to Pooh to evaluate blood loss,

anemia and response to therapy.

D.O. February 11, 2010D.R. February 11, 2010

110 g/L 120-140 g/L The result showed a decreased level of hemoglobin which

indicates that Pooh is experiencing

blood loss and insufficient oxygen going to the body

organs.

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HEMATOCRIT It measures the percentage of RBC in

the blood of Pooh.

D.O: February 11, 2010D.R. February 11, 2010

0.36 0.37-0.47 The result showed a decreased hematocrit of Pooh indicating

a blood loss or hemorrhage

WHITE BLOOD CELLS It is done determine the

presence of an infection of Pooh.

D.O. February 11, 2010D.R. February 11, 2010

18x10³/mm³ 5-10x10³/mm³ It showed that the number of WBC is increased which indicates that Pooh has a

presence of infection.

SEGMENTERS This test may determine any Pooh’s response to acute body stress, whether from infection, infarction, trauma, emotional distress, or other noxious stimuli.

D.O. February 11, 2010D.R. February 11, 2010

0.830.40-0.60 The result is increased and

indicates an imflammatory response of Pooh due to the

presence of infection.

LYMPHOCYTES This is measured to determine if there’s a

lowered immune status in the patient.

D.O. February 11, 2010D.R. February 11, 2010

0.17 0.20-0.40 The result showed a decreased number of lymphocytes

indicating a lower immune status of the Pooh.

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Nursing Responsibilities:BEFORE:

Explain the procedure to the patient or to the SO. Tell the patient that no fasting is required. Explain that the paient may experience mild pain on the site.

DURING: Apply sterile to sterile technique. Collect appropriate amount of blood. Provide support to the patient.

AFTER: Apply pressure to the venipuncture site. Document the procedure done.

Diagnostic/ Laboratory Procedures

Indications or purpose

Date Ordered Date Results were

releasedResults

Normal Values (units used in the

hospital)

Analysis and Interpretation of

results

Obstetric Sonography

It is one of the more well-known uses of sonography:  examining the fetus of a pregnant woman like Pooh.  Ultrasound scan is currently considered to be a safe, non-invasive, accurate and cost-effective

D.O: 2/9/10D.R: 2/11/10

Intrauterine pregnancy with the

fetus in breech presentation. Fetus

does not exhibit spmatic movements and cardiac activity.

There is adequate amount of amniotic

fluid and a 4-quadrant AFI is

Intrauterine pregnancy with the

fetus in cephalic presentation.

There is adequate amount of amniotic

fluid and a 4-quadrant AFI is

12cm. Placenta is intact and

posterofundal in

Intrauterine fetal death. Fetus is in

breech presentation.Normohydramnios.

Normal lying placenta.

Posterofundal.

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investigation in the fetus. This examination has many indications, such as: to evaluate the position of the fetus, diagnose congenital abnormalities, and to determine if there are multiple pregnancies, etc. 

12cm. Placenta is intact and

posterofundal in location. Placental

maturity is Grade II.

location. Placental maturity is Grade II.

Nursing Responsibilities:BEFORE:

Explain procedure to the patient. Tell the patient that the procedure will take 30 min to an hour Tell the patient that during the procedure that she will feel light pressure from the transducer. Tell the patient that the procedure has no known side effect.

DURING: Help the patient to position for the procedure.

AFTER: Help the patient remove jelly used for the procedure. Document the results.

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V. PATIENT AND HIS ILLNESS

a. Anatomy and Physiology

THE FEMALE REPRODUCTIVE SYSTEM

The changes that occur in the pregnant patient's body are caused by several factors. Many of these changes are the result of hormonal influence, some are caused by the growth of the fetus inside the uterus, and some are the result of the patient's physical adaptation to the changes that are occurring. This lesson is closely related to anatomy and physiology.

CHANGES OF THE REPRODUCTIVE SYSTEM DURING PREGNANCY

Changes in the body during pregnancy are most obvious in the organs of the reproductive system.

a. Uterus.

(1) Changes in the uterus are phenomenal. By the time the pregnancy has reached term, the uterus will have increased five times its normal size:

In length from 6.5 to 32 cm. In depth from 2.5 to 22 cm. In width from 4 to 24 cm. In weight from 50 to 1000 grams. In thickness of the walls from 1 to 0.5 cm.

(2) The capacity of the uterus must expand to normally accommodate a seven-pound fetus and the placenta, the umbilical cord, 500 ml to 1000 ml of amniotic fluid, and the fetal membranes.

(3) The abdominal contents are displaced to the sides as the uterus grows in size, which allows for ample space for the uterus within the abdominal cavity.

Growth of the uterus occurs at a steady, predictable pace. Measurement of the fundal height during pregnancy is an important factor that is noted

and recorded (see figure 5-1). Growth that occurs too fast or too slow could be an indication of problems.

(d) The size of the uterus usually reaches its peak at 38 weeks gestation. The uterus may drop slightly as the fetal head settles into the pelvis, preparing for delivery. This dropping is referred to as "lightening." This is more noticeable in a primigravida than a multigravida.

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b. Cervix.

(1) The cervix undergoes a marked softening which is referred to as the Goodell's sign."

(2) A mucus plug, which is known as "operculum" is formed in the cervical canal. This is the result of enlarged and active mucus glands of the cervix. It serves to seal the uterus and to protect the fetus and fetal membranes from infection. The mucus plug is expelled at the end of the pregnancy. This may occur at the onset of labor or precede labor by a few days. When the mucus is blood-tinged, it is referred to as a "bloody show."

(3) Additional changes and softening of the cervix occur prior to the beginning of labor.

c. Vagina.

Increased circulation to the vagina early in pregnancy changes the color from normal light pink to a purple hue which is known as the "Chadwick's sign."

d. Ovaries.

(1) The follicle-stimulating hormone (FSH) ceases its activity due to the increased levels of estrogen and progesterone secreted by the ovaries and corpus luteum. The FSH prevents ovulation and menstruation.

(2) The corpus luteum enlarges during early pregnancy and may even form a cyst on the ovary. The corpus luteum produces progesterone to help maintain the lining of the endometrium in early pregnancy. It functions until about the 10th to 12th week of pregnancy when the placenta is capable of producing adequate amounts of progesterone and estrogen. It slowly decreases in size and function after the 10th to 12th week.

EMBRYONIC and FETAL STRUCTURES

1. THE DECIDUA

After fertilization, the corpus luteum in the ovary continues to function rather than atrophying because of the influence of HCG or Human Chorionic Gonadotropin, a hormone secreted by the trophoblast cells, which were the cells that will later form into placenta and membranes. The uterine endometrium, instead of sloughing off, will continue to proliferate and grow in thickness and vascularity.

Decidua is the term for the uterine lining (endometrium) during a pregnancy, which forms the maternal part of the placenta. It is formed under the influence of progesterone and forms highly-characteristic cells.

After ovulation, in mammals, the endometrial lining becomes transformed into a secretory lining in preparation of accepting the embryo. Without implantation, the secretory lining will be absorbed (estrous cycle) or shed (menstrual cycle).

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The decidua has three separate areas:

1. Decidua basalis, the part of the endometrium that lies directly under the embryo (or the portion where the trophoblast cells are establishing communication with maternal blood vessels).

2. Decidua capsularis, the portion of the endometrium that stretches or encapsulates the surface of the trophoblast.

3. Decidua vera, the remaining portion of the uterine lining.

As the embryo continues to grow, it pushes the decidua capsularis before it like a blanket. Eventually, enlargement brings the structure into contact with the opposite uterine wall. Here, the decidua capsularis fuses with the endometrium of the opposite wall. This is why at birth, the entire inner surface of the uterus is stripped away, leaving the organ highly susceptible to hemorrhage and infection.

2. CHORIONIC VILLI

Chorionic villi are villi that sprout from the chorion in order to give a maximum area of contact with the maternal blood.

Embryonic blood is carried to the villi by the branches of the umbilical arteries, and after circulating through the capillaries of the villi, is returned to the embryo by the umbilical veins. Thus, the villi are part of the border between maternal and fetal blood during pregnancy.

The chorion undergoes rapid proliferation and forms numerous processes, the chorionic villi, which invade and destroy the uterine decidua and at the same time absorb from it nutritive materials for the growth of the embryo.

3. THE PLACENTA

The placenta is an organ that connects the developing fetus to the uterine wall to allow nutrient uptake, waste elimination and gas exchange via the mother's blood supply. The placenta develops from the same sperm and egg cells that form the fetus, and functions as a fetomaternal organ with two components, the fetal part (Chorion frondosum), and the maternal part (Decidua basalis).

In humans, the placenta averages 22 cm (9 inch) in length and 2–2.5 cm (0.8–1 inch) in thickness (greatest thickness at the center and become thinner peripherally). It typically weighs approximately 500 grams (1 lb). It has a dark reddish-blue or maroon color. It connects to the fetus by an umbilical cord of approximately 55–60 cm (22–24 inch) in length that contains two arteries and one vein.[3] The umbilical cord inserts into the chorionic plate (has an eccentiric

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attachment). Vessels branch out over the surface of the placenta and further divide to form a network covered by a thin layer of cells. This results in the formation of villous tree structures. On the maternal side, these villous tree structures are grouped into lobules called cotyledons.The placenta grows throughout pregnancy. Development of the maternal blood supply to the placenta is suggested to be complete by the end of the first trimester of pregnancy (approximately 12–13 weeks).

*Placental Circulation

a. Maternal

placental circulation

In preparation for implantation, the uterine endometrium undergoes 'decidualisation'. Spiral arteries in the decidua are remodelled so that they become less convoluted and their diameter is increased. This increases maternal blood flow to the placenta and also decreases resistance so that shear stress is reduced. The relatively high pressure as the maternal blood enters the intervillous space through these spiral arteries bathes the villi in blood. An exchange of gases takes place. As the pressure decreases, the deoxygenated blood flows back through the endometrial veins.

Maternal blood flow is approx 600–700 ml/min at term.

b. Fetoplacental circulation

Deoxygenated fetal blood passes through umbilical arteries to the placenta. At the junction of umbilical cord and placenta, the umbilical arteries branch radially to form chorionic arteries. Chorionic arteries also branch before they enter into the villi. In the villi, they form an extensive

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arteriocapillary venous system, bringing the fetal blood extremely close to the maternal blood; but no intermingling of fetal and maternal blood occurs ("placental barrier"[5]).

*Functions of the Placenta

a. Nutrition

The perfusion of the intervillous spaces of the placenta with maternal blood allows the transfer of nutrients and oxygen from the mother to the fetus and the transfer of waste products and carbon dioxide back from the fetus to the mother. Nutrient transfer to the fetus is both actively and passively mediated by proteins called nutrient transporters that are expressed within placental cells.

Adverse pregnancy situations, such as those involving maternal diabetes or obesity, can increase or decrease levels of nutrient transporters in the placenta resulting in overgrowth or restricted growth of the fetus.

b. Metabolic and endocrine activity

In addition to the transfer of gases and nutrients, the placenta also has metabolic and endocrine activity. It produces, among other hormones, progesterone, which is important in maintaining the pregnancy; somatomammotropin (also known as placental lactogen), which acts to increase the amount of glucose and lipids in the maternal blood; estrogen; relaxin, and beta human chorionic gonadotrophin (beta-hCG). This results in increased transfer of these nutrients to the fetus and is also the main cause of the increased blood sugar levels seen in pregnancy. This hormone (beta-hCG) ensures that progesterone and oestrogen are secreted; progesterone and oestrogen thicken and maintain the uterine lining as well as inhibit the production and release of more eggs. However after about 2 months the placenta takes on the role of producing progesterone and therefore beta-hCG is no longer needed. Beta-hCG is excreted in urine and this is what pregnancy tests detect. It also produces insulin-like growth factors (IGFs).

4. THE UMBILICAL CORD

The umbilical cord (also called the birth cord or funiculus umbilicalis) is the connecting cord from the developing embryo or fetus to the placenta. During prenatal development, the umbilical cord comes from the same zygote as the fetus and (in humans) normally contains two arteries (the umbilical arteries) and one vein (the umbilical vein), buried within Wharton's jelly. The umbilical vein

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supplies the fetus with oxygenated, nutrient-rich blood from the placenta. Conversely, the umbilical arteries return the deoxygenated, nutrient-depleted blood.

5. THE AMNIOTIC MEMBRANES

The villi on the medial surface of the trophoblast (those that are not involved in the implantation because they do not touch the endometrium) gradually thin, leaving the surface of the structure smooth (the smooth chorion). This eventually becomes the chorionic membrane, outermost fetal membrane. Once it becomes smooth, it offers support to the sac that contains amniotic fluid. A second membrane lining the chorionic membrane, the amniotic membrane or amnion, forms beneath the chorion. The amnion is a membrane building the amniotic sac that surrounds and protects an embryo.

Early in pregnancy, these membranes become so adherent that they seem as one at term. At birth they can be seen covering the fetal surface of the placenta, giving that surface its typically shiny appearance. Like the umbilical cord, they have no nerve supply. Therefore, when they spontaneously rupture at term or artificially ruptured, neither mother nor child experiences any pain.

The amniotic membrane produces amniotic fluid and phospholipids that initiate the formation of prostaglandins, which can cause uterine contractions and may be the trigger that initiates labor.

6. THE AMNIOTIC FLUID

Amniotic fluid or liquor amnii is the nourishing and protecting liquid contained by the amniotic sac of a pregnant woman. The amniotic sac grows and begins to fill, mainly with water, around two weeks after fertilization. After a further 10 weeks the liquid contains proteins, carbohydrates, lipids and phospholipids, urea and electrolytes, all of which aid in the growth of the fetus. In the late stages of gestation much of the amniotic fluid consists of fetal urine.

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The amniotic fluid increases in volume as the fetus grows. The amount of amniotic fluid is greatest at about 34 weeks after conception or 34 weeks ga (gestational age). At 34 weeks ga, the amount of amniotic fluid is about 800 ml. This amount reduces to about 600 ml at 40 weeks ga when the baby is born.

Amniotic fluid is continually being swallowed and "inhaled" and replaced through being "exhaled", as well as being urinated by the fetus. It is essential that the amniotic fluid be breathed into the lungs by the fetus in order for the lungs to develop normally. Swallowed amniotic fluid contributes to the formation of meconium. Amniotic fluid also protects the developing baby by cushioning against blows to the mother's abdomen, allows for easier fetal movement, promotes muscular/skeletal development, and helps protect the fetus from heat loss.

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b. Pathophysiology (Book-Based)

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b.1 Synthesis of the Disease

Chorioamnionitis is caused by a bacterial infection that usually starts in the mother’s urogenital tract. Abnormal bacterial colonization of the rectum and anus during pregnancy may create an abnormal vaginal and cervical microbial environment. Specifically, the infection can start in the vagina, anus, or rectum and move up into the uterus where the fetus is located. Chorioamnionitis occurs in up to 2 percent of births in the United States.

Chorioamnionitis is most often diagnosed by physical exam and the findings listed above. Other clues can be found by taking a blood sample from the mother and checking for bacteria. In addition, the doctor might take samples of the amniotic fluid to look for bacteria. The doctor might also use ultrasound to check on the health of the fetus.

Part of the reason for our failure to successfully treat premature delivery leading to IUFD is that its causes have been poorly understood. However, in the last ten years it has become apparent that a significant proportion of women with preterm labour and fetal death, perhaps up to 70%, have infections of the placenta or membranes that surround the fetus in the womb. It appears that in many such cases, the infection is not clinically obvious -- the mother does not have a fever or inflammation or tenderness in her womb or vagina. However, biochemically it has been shown that inflammatory reactions are established in the tissues that surround the fetus, and the chemical products of these reactions (cytokines) are thought to be the agents that cause the onset of premature labour.

To comprehend the process through which bacterial invasion can cause premature labour then intrauterine fetal death, one must first have a working knowledge of the organs that protect the fetus during pregnancy.

Throughout pregnancy the baby is immersed in a watery bath of amniotic fluid surrounded by a tough semi-transparent membranous sack. This fluid is composed principally of fetal urine, and is repeatedly swallowed and "breathed" by the baby as it grows and develops (distasteful as this may seem). The membranous sack is actually composed of three distinct layers: the inner membrane is called the amnion, the middle layer is called the chorion, and the outer layer is the decidua. This outer tissue is actually of maternal origin, originating from the cells that line the uterus before pregnancy, while the other two are derived from the fetus itself. Only the decidua is supplied with blood; the amnion and chorion are devoid of blood vessels and derive their oxygen and nutrients from the amniotic fluid or from the decidua by diffusion.

The vagina contains a range of bacteria, the presence of which is normal and is usually harmless. They are prevented from ascending into the amniotic cavity by the cervix, which is not only constricted during pregnancy but is plugged with a thick mucus which is an effective barrier against microbial invasion. However, under some circumstances such as PROM, bacteria appear to gain access to the membranes or amniotic fluid. The

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normal response of tissues to the presence of bacteria is an inflammatory reaction, and this seems to occur during pregnancy following infection of the amniotic fluid, membranes or placenta.

All humans have a repertoire of defences -- the immune system -- which can be called upon to fight off an infection. One arm of the body's immunological armory involves the production of special targeting proteins called antibodies. Antibodies are produced by specific cells in the blood following activation by fragments of an invading microorganism or cell. They bind to a unique recognition sequence on the foreign cell, targeting it for destruction.

The other arm involves the release of chemical messengers which alert the body to the presence of an invader and cause the recruitment of special cells which are able to engulf and kill the foreigner with toxic chemicals. These cells, which include macrophages and neutrophils, are present in blood and also to a lesser extent in many tissues of the body, including the placenta and decidua. Since they can be recruited to the site of an infection, macrophages and neutrophils are often found in large numbers in infected tissues.

Infection is usually associated with inflammation, which involves vasodilation or widening of the blood vessels. This results in increased blood flow to the site of infection, swelling (fluid build-up) and tissue destruction. Vasodilation is caused by the local release of a variety of rapid-acting molecules, including lipid-like chemicals called prostaglandins. These inflammatory reactions are coordinated, in part, by a family of signalling proteins called cytokines.

The pro-inflammatory cytokines have powerful effects on the tissues surrounding the baby. They are capable of stimulating the production of prostaglandins from cells in the amnion, chorion, decidua and uterus; greatly elevated levels of prostaglandins are present in the amniotic fluid of women with infected pregnancies.

As mentioned above, inflammation is often associated with tissue destruction. Cytokines mediate this process through inducing the release of enzymes such as collagenase or elastase which dissolve the connective matrix which holds cells together. TNFa may also kill cells directly though the induction of a process known a apoptosis (programmed cell death).

If the membranes become too thin and weak due to these processes they may rupture prematurely, allowing the protective amniotic fluid to leak out and bacteria to get in. Premature rupture of the membranes is a common occurrence with infected pregnancies, and is a serious complication if it occurs more than a few weeks before term.

If the mother has a serious case of chorioamnionitis, or if it goes untreated, she might develop complications, including:

Infections in the pelvic region and abdomen

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Endometritis (an infection of the endometrium, the lining of the uterus) Blood clots in the pelvis and lungs

The newborn might also have complications from a bacterial infection, including sepsis (infection of the blood), meningitis (infection of the lining of the brain and the spinal cord), and respiratory problems.

b.2 Predisposing and Precipitating Factors

1. Premature rupture of membranes – The membranes that hold amniotic fluid (the water surrounding the baby) usually break at the end of the first stage of labor. With this, a portal of entry for the microorganism opens causing ascending infection from the rectum, going to the vagina up to the amniotic fluid which may then infects the fetl membranes leading to chorioamnionitis.

2. Prolonged rupture of membranes – If the membranes are ruptured beyond 12 hours prior to delivery, the fetus has an increased risk of fetal infection because of the exposed membranes to the outside environment. Without the amnion and the chorion which protects the fetus from infective bacteria and foreign substances, a greater risk for infection may be posed.

3. Pre existing infection of the lower genital tract – UTI or urinary tract infection can bathe the vagina with bacterial pathogens and is a recognized factor for causing chorioamnionitis and neonatal sepsis. Because of the altered host defenses, this allows ascending infection from the urogenital tract to placental tissues and amniotic fluid.

4. Internal fetal and uterine monitoring – Internal fetal heart rate monitoring uses an electronic transducer connected directly to the fetal skin. A wire electrode is attached to the fetal scalp or other body part through the cervical opening and is connected to the monitor. Entry of any foreign object carrying microorganisms such as streptococcus B or Escerichia coli to any orifce or opening in the body can possibly expose the fetal membranes to infection-causing organisms which may go through the membranes and further cause damage.

5. Multiple vaginal examinations during labor – Quick vaginal exam and other procedures done during labor inherently are invasive procedure that may be risky in certain situations and is a great risk factor for maternal or fetal infection. Entry of any foreign object carrying microorganisms such as streptococcus B or Escerichia coli to any orifce or opening in the body can possibly expose the fetal membranes to pathogens which may go through the membranes and further cause damage.

b.3 Signs and symptoms

Symptoms may include:

1. Fever - Fever happens when the immune system senses a threat such as infection caused by the presence of Escerichia Coli which is a bacteria, and pumps out

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chemicals called cytokines. They, in turn, set in motion a series of chemical reactions that turn up the body's thermostat. The goal of a fever is to raise body temperature - temporarily - to prompt infection-fighting white blood cells to fight harder and kill the pathogenic microorganism.

2. Significant maternal tachycardia - Inflammation induces various adaptive responses including tachycardia. Inflammation-associated tachycardia has been the result from increased sympathetic discharge caused by inflammatory signals of the immune system. The body tries to compensate to the said infection by sending more and more blood components especially the WBCs to fight off and phagocytize the Escerichia coli.

3. Fetal tachycardia – This symptom is a sign of fetal distress, meaning that the fetus is not receiving adequate nutrition and oxygen in his body. Thus, because of this, his heart pumps faster than normal to dispense oxygenated blood to the distal tissues in his body nearly experiencing ischemia.

4. Tender and painful uterus – Due to vasodilatation in the placenta as an immune response of the affected part to infection, swelling in the uterus occur which later results to congestion. This then causes obstruction to blood vessels leading to insufficient oxygen supply to tissues. Ischemia of the tissues in the uterus and near organs as fallout of decreased supply in oxygen happens and so consequently, ensuing pain in the uterus.

5. A foul odor of the amniotic fluid – After contamination of the amniotic fluid by the bacterium such as Escerichia coli, the fluid turns malodorous and smells like rotten.

6. Maternal leukocytosis – White blood cells (WBCs), or, are cells of the immune system defending the body against both infectious disease and foreign materials. Increase in leukocytes or white blood cells happen in response to presence of infection such as Chorioamnionitis in which entry of E.coli into the amniotic cavity took place endangering the fetus life.

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b. Pathophysiology (Patient-Based)

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b.2 Predisposing and Precipitating Factors

1. Pre existing infection of the lower genital tract – UTI or urinary tract infection can bathe the vagina with bacterial pathogens and is a recognized factor for causing chorioamnionitis and neonatal sepsis. Because of the altered host defenses, this allows ascending infection from the urogenital tract to placental tissues and amniotic fluid. Pooh had experienced UTI even before she was a student. She does not void frequently and instead, holds her urine until her classes were done. At present, her OB-gyne had assessed her for the said infection and found positive through her urinalysis results. She was advised by her doctor to take Amoxicillin.

b.3 Signs and symptoms

1. Fever - Fever happens when the immune system senses a threat such as infection caused by the presence of Escerichia Coli which is a bacteria, and pumps out chemicals called cytokines. They, in turn, set in motion a series of chemical reactions that turn up the body's thermostat. The goal of a fever is to raise body temperature - temporarily - to prompt infection-fighting white blood cells to fight harder and kill the pathogenic microorganism. Pooh’s temperature by February 11, 2010 was 37.6C.

2. Significant maternal tachycardia - Inflammation induces various adaptive responses including tachycardia. Inflammation-associated tachycardia has been the result from increased sympathetic discharge caused by inflammatory signals of the immune system. The body tries to compensate to the said infection by sending more and more blood components especially the WBCs to fight off and phagocytize the Escerichia coli. Heart rate of Pooh was 121 beats per minute as of February 11, 2010.

3. Tender and painful uterus – Due to vasodilatation in the placenta as an immune response of the affected part to infection, swelling in the uterus occur which later results to congestion. This then causes obstruction to blood vessels leading to insufficient oxygen supply to tissues. Ischemia of the tissues in the uterus and near organs as fallout of decreased supply in oxygen happens and so consequently, ensuing pain in the uterus. This symptom was noted by February 11, 2010.

4. A foul odor of the amniotic fluid – After contamination of the amniotic fluid by the bacterium such as Escerichia coli, the fluid turns malodorous and smells like rotten. Foul smelling amniotic fluid was observed during induced labor by February 12, 2010.

5. Maternal leukocytosis – White blood cells (WBCs), or, are cells of the immune system defending the body against both infectious disease and foreign materials.

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Increase in leukocytes or white blood cells happen in response to presence of infection such as Chorioamnionitis in which entry of E.coli into the amniotic cavity took place endangering the fetus life. Pooh’s number of leukocytes was 18x10³/mm³ compared to 5-10x10³/mm³ which was the normal value.

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VI. MEDICAL MANAGEMENT:

Medical ManagementDate Ordered; Date

Performed; Date Changed/Discontinue

General Description Indication/ Purpose Client’s response to the treatment

D5LRS 1L + 10”u” oxytocin x 9-10 gtts/min + titrate

D5LRS 1L + 10”u” oxytocin 65gtts/min

D5LRS 1L + 10”u” oxytocin 65gtts/min

D5LRS 1L +10”u” oxytocin

DO: February 11, 2010DP: February 11, 2010Time Changed: 1:15am

DO: February 11, 2010DP: February 11, 2010Time Changed: 8:30am

DO: February 11, 2010DP: February 11, 2010Time Changed: 10:02am

A hypertonic solution that exerts less osmotic pressure than that of blood plasma. These solutions draw water from the intracellular compartment and cause cells to shrink. These solution is given cautiously and usually when the serum osmolarity has decreased to dangerously low level.

> access for Iv meds

>to replace fluid loss and electrolytes loss and maintain Pooh’s hydration and nutritional status.

>to compensate for the loss. There is the need to replenish, to prevent moisture loss and dryness of Pooh.

> Pooh tolerated IV infusion. Pooh did not complained any pain or irritation.

Humidified O2 inhalation @ 2-3 L/min

DO: February 11, 2010DP: February 11, 2010

Installation of oxygen to the patient

To alleviate difficulty of breathing of Pooh after the surgery (effect of anesthesia).

The group did not handle Pooh during the administration of Humidified O2 inhalation.

> IVF: D5 LRSBEFORE:

1 Check the doctor’s order2 Explain the procedure to the patient, whether in starting, changing, or removing the IVF.3 Always check for the correct type of IVF

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DURING: 4 Apply sterile to sterile technique5 Regulate IVF.

AFTER:1 Check/observe the puncture site for bleeding, edema, or thrombophlebitis.2 Always keep the IVF patent and properly regulated.3 Monitor electrolytes.

> HUMIDIFIED O2 INHALATIONBEFORE:

1 Check for the doctor’s order.2 Prepare the equipment needed.3 Explain to the pt. the procedure to be done.4 Place nasal cannula properly and check for the patency.5 Regulate as ordered

DURING:1 Attach delivery device to oxygen tubing.2 Attach appropriate flow meter to oxygen source and attach oxygen tubing.3 Check for the regulation and the amount of O2 in the tank.4 Adjust oxygen flow rate to prescribed dosage.5 Check for the patency every 2 hours.

AFTER:1 Document the O2 therapy on the chart.2 Monitor the response of the pt.

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DRUGS

Name of Drugs

Date orderedDate taken / givenDate change /

discontinue

Route of Administration, Dosage and Frequency of

Administration

General Action,Functional Classification,

Mechanism of Action

Indications or purposes

Client’s response to the medication with

actual side effect

Generic name: Ampicillin

Brand name:Omnipen, Polycillin, Principen

DO: February 11, 2010DP: February 11, 2010

500mg orally q6˚

Antibiotics that are used for preventing or treating

bacterial infections. They stop bacteria from

multiplying by preventing bacteria from forming the walls that surround them.

Ampicillin is indicated to Pooh for treatment of E.coli infection causing UTI.

The group was not able to handle the patient during the administration of the drug thus, not knowing the side effects of the drug

to Pooh.

Generic name: Nubain

Brand name: Nalbuphine- Injection

DO: February 11, 2010DP: February 11, 2010

5mg SIVP q8˚ PRN

It is for preoperative and postoperative analgesia, and

for obstetrical analgesia during labor and delivery.

Indicated to treat moderate to severe pain of Pooh and

to boost the effects of anesthesia.

The group was not able to handle the patient during the administration of the drug thus, not knowing the side effects of the drug

to Pooh.

Generic name:Diazepam

Brand name:Valium, Diastat

DO: February 11, 2010DP: February 11, 2010

10 mg IM Benzodiazepines are sedative-hypnotic drugs that help to relieve nervousness, tension, and other anxiety symptoms by slowing the

This drug is indicated to Pooh to relieve anxiety and tension prior

to surgery.

The group was not able to handle the patient during the administration of the drug thus, not

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central nervous system. To do this, they block the

effects of a specific chemical involved in the

transmission of nerve impulses in the brain ,

decreasing the excitement level of the nerve cells. All benzodiazepines, including diazepam, cause sedation, drowsiness, and reduced

mental and physical alertness.

knowing the side effects of the drug

to Pooh.

Generic name:Promethazine

Brand name: Phenergan, Phenadoz, Promethegan

DO: February 11, 2010DP: February 11, 2010

50 mg oral q8˚ Is not used as an anti-psychotic. They prevent

histamine from binding and stimulating the cells.

Promethazine also blocks the action of acetylcholine

(anticholinergic effect), and this may explain its benefit in reducing the nausea of

motion sickness.

Promethazine and treats nausea and vomiting or pain after surgery of Pooh. It is also

used as a sedative or sleep aid.

The group was not able to handle the patient during the administration of the drug thus, not knowing the side effects of the drug

to Pooh.

Generic name:Oxytocin

Brand name;Pitocin

DO: February 11, 2010DP: February 11, 2010

10 units by IV infusion in 100ml of intravenous fluid.

It is often used to induce labor in difficult

pregnancies or pregnancies at risk for complications

(e.g., preeclampsia,

Indicated only in pregnancies that have a medical

reason for inducing labor like

The group was not able to handle the patient during the administration of the drug thus, not

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eclampsia, diabetes). This drug may also be used

during pregnancy to test the heartbeat of the fetus; and to

remove the afterbirth (placenta) and control bleeding of the womb

(uterus) after childbirth.

Pooh’s. knowing the side effects of the drug

to Pooh.

Generic name:Metoclopramide

Brand name: metoclopramide, Reglan, Reglan ODT, Metozol ODT, Octamide,

DO: 02-11-10DP: 02-11-10

10mg oral q12˚ Stimulates motility of upper GI tract without stimulating gastric, biliary, or pancreatic

secretions, appears to sensitize tissues to action of

acetylcholine; relaxes pyloric, which, when

combined with effects on motility, accelerate gastric emptying and intestinal transit; little effect on gallbladder or colon

motility; increase lower esophageal sphincter pressure; has sedative

properties; induces release of prolactin.

Prophylaxis of post operative

nausea and vomiting when

nasogastric suction is undesireable. Metoclopramide interacts with the

dopamine receptors in the brain and can be

effective in treating nausea of

Pooh.

The group was not able to handle the patient during the administration of the drug thus, not knowing the side effects of the drug

to Pooh.

Generic name: Diclofenac

DO: February 12, 2010

2 doses ANST(-) 75 mg IM

q12˚

Diclofenac belongs to a class of drugs called non-

steroidal anti-inflammatory

Indicated primarily for the Pooh’s treatment

The group was not able to handle the patient during the

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Brand name: Voltaren, Cataflam, Voltaren-XR

DP: February 12, 2010

drugs, that are used for the treatment of mild to

moderate pain, fever, and inflammation.

of inflammation and pain.

administration of the drug thus, not knowing the side effects of the drug

to Pooh.

Nursing Responsibilities:

*AMPICILLINBEFORE:

1. Check the doctor’s order.2. Explain the procedure to the patient the importance of the drug, its uses, and effects.3. Determine hypersensitivity to the drug.4. Explain the procedure to the patient, the importance of the drug, it’s uses and effects.5. Prepare the right medication at the right time and with the right dosage.

DURING:1. Adhere to standard precautions.2. Administer at the right route.

AFTER:1. Monitor for hypersensitivity and adverse reactions such as erythematous maculopapular rash, urticaria, and anaphylaxis.2. Check the IV site carefully for signs of thrombosis or drug reaction.

*NUBAIN BEFORE:

1. Check doctor’s order.2. Determine hypersensitivity to the drug.3. Ask the patient if he/she has asthma, gallbladder disease or a history of drug or alcohol addiction.4. Assess for the BP, PR, RR prior to admission.5. Explain the procedure to the patient, the importance of the drug, it’s uses and effects.6. Prepare the right medication at the right time with the right dosage.

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DURING:1. Adhere to standard precautions.2. Administer on the right route.3. Nalbuphine (Nubain) is usually given every 3 to 6 hours.

AFTER:1. Reassure patient about addiction liability: most patients who receive opiates for medical reasons do not develop

dependence syndrome.2. Discuss to the patient the side effects of the drug.

*DIAZEPAM BEFORE:

1. Check doctor’s order.2. Assess for hypersensitivity and other contraindications.3. Explain the procedure to the patient, the importance of the drug, it’s uses and effects.4. Prepare the right medication at the right time with the right dosage.

DURING:1. Adhere to standard precautions.2. Administer at the right route.

AFTER:1. Monitor BP, PR,RR prior to periodically throughout therapy and frequently during IV therapy.2. Assess IV site frequently during administration, diazepam may cause phlebitis and venous thrombosis.3. Prolonged high-dose therapy may lead to psychological or physical dependence. Restrict amount of drug available to patient. Observe depressed patients closely for suicidal tendencies.4. Observe and record intensity, duration and location of seizure activity. The initial dose of diazepam offers seizure control for 15-20 min after administration.5. IM injections are painful and erratically absorbed. If IM route is used, inject deeply into deltoid muscle for maximum absorption.6. Caution patient to avoid taking alcohol or other CNS depressants concurrently with this medication.7. Effectiveness of therapy can be demonstrated by decrease anxiety level; control of seizures; decreased tremulousness.

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*PROMETHAZINE BEFORE:

1. Check doctor’s order.2. Assess for hypersensitivity and other contraindications.3. Reduce dosage for patients with hepatic impairment.4. Reduce dosage of barbiturates given a concurrently with promethazine by at least a half.5. Arrange for dosage reduction of opoid analgesics given concomitanly by one-fourt to one-half.

DURING:1. Adhere to standard precautions.2. Administer at the right route.3. Do not give tablets or rectal suppositories to children younger than 2 yrs.4. Give IM injection deep into muscle.5. Do not administer intratertially; arteriospasm and gangrene of the limb may result.6. Instruct to take drug exactly as prescribed.

AFTER:1. Instruct to avoid alcohol2. Instruct to avoid driving or engaging in other dangerous activities of dizziness, drowsiness or vision changes occur.3. Educate about avoiding prolonged exposure to the sun, or using of sunscreen or covering garments.4. Maintain fluid intake, use precautions against heatstroke in hot weather.5. Report sore throat, fever, unusual bleeding or brushing, rash, fever, urine, pale stools, yellowing of the skin or eyes.

*OXYTOCIN BEFORE:

1. Assess for significant cephalopelvic disproportion, unfavorable fetal positions or presentations, severe toxemia, uterine inertia, hypertonic uterine patterns,previous cesarean section

2. Assess fetal heart rate, uterine tone3. Ensure fetal position and size and absence of complications.4. Explain the procedure to the patient, the importance of the drug, it’s uses and effects.5. Prepare the right medication at the right time with the right dosage.

DURING:

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1. Adhere to standard precautions.2. Administer at the right route.3. Infuse via constant infusion pump to ensure accurate control of rate; rate determined by uterine response; begin with

1-2mL/min and increase at 16- to 60-min intervals4. Do not combine in solution with fibrinolysin or heparin5. Monitor maternal BP6. Monitor neonate for jaundice7. Discontinue drug and notify physician at any sign of hypertensive emergency

AFTER:1. Educate client on the side effects of the medication and what to expect.2. Document that drug has been given.

*METOCLOPRAMIDE BEFORE:

1. Check doctor’s order.2. Assess for hypersensitivity and other contraindications.3. Explain the procedure to the patient, the importance of the drug, it’s uses and effects.4. Prepare the right medication at the right time with the right dosage.

DURING:1. Adhere to standard precautions.2. Administer at the right route.3. Take the medicine with full glass of water.4. The drug metoclopramide can be mixed with another liquid, such as water, fruit juice, soda, or soft foods.5. Metoclopramide is usually taken before meals and at bedtime.

AFTER:1. Assess the patient for N/V, abdominal distension, bowel sounds before and after, extrapyramidal side effects, tardive

dyskinesia, and for signs of depression.2. Give motoclopramide exactly as directed by the doctor.3. Give the missed dose as soon as you remember4. Observed the patient for severe side effects.

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*DICLOFENACBEFORE:

1. Check doctor’s order.2. Determine hypersensitivity to the drug.3. Before taking the drug, ask the patient if he/she has a history of heart or kidney disease, stomach ulcers and asthma.4. Explain the procedure to the patient, the importance of the drug, it’s uses and effects.

5. Prepare the right medication at the right time and with the right dosage.DURING:

1. Adhere to standard precautions.2. Administer at the right route.3. Instruct patient to take Diclofenac with a full glass of water and to remain in an upright position for 15-30 minutes after

administration.4. Instruct the patient to swallow the drug whole. Do not crush or chew.

AFTER:1. Caution the patient that the drug may cause drowsiness or dizziness. Caution patient to avoid any kind of activities that

requires alertness until response to medication is known. 2. Instruct patient to take missed dose as soon as possible within 1-2 hours if taking once o twice a day or unless almost most

of the time for the next dose if taking more than 2x a day. 3. Advise to the patient to avoid prolonged exposure to sunlight. Diclofenac may increase the sensitivity of the skin to

sunlight.

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C. DIET

Type of DietDate OrderedDate Started

Date Changed

General description

Indications or Purposes Specific food taken

Client’s reaction and/or response to

the diet

Nothing Per Orem D.O: February 12, 2010

D.S: February 12, 2010

No foods or drinks is allowed to be

given to the patient, also a type of diet modification and fluid restriction

This was ordered in order to prevent

aspiration of Pooh.

Nothing Pooh was able to comply with the diet

regimen.

Nursing Responsibilities:

Check doctor’s order. Explain the reason of such diet to the patient, as well as with he patient’s significant other. Remove all foods bedside. If the client eats or drinks, the physician should be notified at once.

D. ACTIVITY/EXERCISE

Type of ExerciseDate OrderedDate Started

Date ChangedGeneral description Indications or

Purposes

Client’s reaction and/or response to the

activity / exercise

Flat on bed D.O : February 12, 2010

D.S. February 12, 2010

This is the usual position ordered for post-op.

patient like Pooh and is positioned flat on bed,

To prevent spinal headache of Pooh.

Pooh maintained a flat-on-bed position

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the head is erect or slightly flexed.

Nursing Responsibilities:

Check doctor’s order. Explain the procedure and the reason to the patient. Assist the patient in assuming the position ordered. Observe if the patient can tolerate it.

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Surgical Management

a) HYSTEROTOMY

A hysterotomy is an incision in the uterus, commonly combined with a laparotomy during a cesarean section. Hysterotomies are also performed during fetal surgery.

DESCRIPTION OF PROCEDURE

A general anesthesia is used. An incision is made in the abdomen and then in the uterus. Fetal tissue and

placenta are removed. The uterus wall is sewed back together and the abdominal opening closed.

*POST PROCEDURE CARE

GENERAL MEASURES

Use sanitary pads for bleeding, which may last for several days. If bleeding continues 10-14 days after surgery, you may then use tampons.

If you have pain, place a heating pad or hot-water bottle on the abdomen or back. Hot baths frequently promote muscle relaxation and relieve discomfort. Repeat the baths as often as they provide comfort.

If contraception is desired, it can often be initiated shortly after the procedure. If you wish to take birth control pills, begin taking them either on the night you return from surgery or the next day. If you prefer an IUD, diaphragm or cervical cap, the fitting can be made during you next clinical appointment.

Your next menstrual period should begin 4 to 6 weeks after the procedure. If you take birth control pills, your first period will begin after you complete the first cycle of pills.

MEDICATION

Prescription pain medication should generally be required for only 2 to 7 days following the procedure.

You may use non-prescription drugs, such as acetaminophen, for minor pain. Antibiotics may be prescribed to reduce risk of infection. Stool softener laxative, if needed to prevent constipation.

ACTIVITY Have someone drive you home from surgery. Resume normal activities slowly. Avoid sexual relations for 4 to 6 weeks after the surgery.

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b) CESAREAN SECTION

Cesarean sections, also called c-sections or cesarean deliveries, are performed whenever abnormal conditions complicate labor and vaginal delivery, threatening the life or health of the mother or the baby. Dystocia, or difficult labor, is the other common cause of c-sections. Regional anesthesia, either a spinal or epidural, is the preferred method of pain relief during a c-section. The benefits of regional anesthesia include allowing the mother to be awake during the surgery, avoiding the risks of general anesthesia, and allowing early contact between mother and child. Spinal anesthesia involves inserting a needle into a region between the vertebrae of the lower back and injecting numbing medications. An epidural is similar to a spinal except that a catheter is inserted so that numbing medications may be administered continuously.

The most common reason that a cesarean section is performed (in 35% of all cases, according to the United States Public Health Service) is the woman has had a previous c-section. The "once a cesarean, always a cesarean" rule originated when the uterine incision was made vertically (termed a "classical incision"); the resulting scar was weak and had a risk of rupturing in subsequent deliveries. Today, the incision is almost always made horizontally across the lower end of the uterus (called a low transverse incision), resulting in reduced blood loss and a decreased chance of rupture. This kind of incision allows many women to have a vaginal birth after a cesarean (VBAC).

The second most common reason that a c-section is performed (in 30% of all cases) is difficult childbirth due to non-progressive labor (dystocia). Difficult labor is commonly caused by one of the three following conditions: abnormalities in the mother's birth canal; abnormalities in the position of the fetus; or abnormalities in the labor, including weak or infrequent contractions. The mother's pelvic structure may not allow adequate passage for birth. When the baby's head is too large to fit through the pelvis, the condition is called cephalopelvic disproportion (CPD).

There are a number of reasons why a woman might choose a c-section in the absence of the usual indications. These include:

Convenience. A scheduled c-section would allow a woman to choose the time and date of delivery to avoid conflicting with work or family obligations.

Fear of childbirth. A woman might fear the pain of labor and delivery and feel that a scheduled c-section would allow her to circumvent it.

Avoiding risks of vaginal delivery. Certain risks inherent to vaginal delivery (urinary or rectal incontinence, sexual dysfunction, dystocia) are avoided in a c-section.

To remove a baby by cesarean section, an incision is made into the abdomen, usually just above the pubic hairline (A). The uterus is located and divided (B), allowing for delivery of the baby (C). After all the contents of the uterus are removed, the uterus is repaired, and the rest of the layers of the abdominal wall are closed.

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Once the uterus is opened, the amniotic sac is ruptured and the baby is delivered. The time from the initial incision to birth is typically five minutes. The umbilical cord is clamped and cut, and the newborn is evaluated. The placenta is removed from the mother, and her uterus and abdomen are stitched closed (surgical staples may be used instead in closing the outermost layer of the abdominal incision). From birth through suturing may take 30–40 minutes; the entire

surgical procedure may be performed in less than one hour.

The mother is at risk for increased bleeding (a c-section may result in twice the blood loss of a vaginal delivery) from the two incisions, the placental attachment site, and possible damage to a uterine artery. The mother may develop infection of the incision, the urinary tract, or the tissue lining the uterus (endometritis); infections occur in approximately 7% of women after having a c-section. Less commonly, she may receive injury to the surrounding organs such as the bladder and bowel. When a general anesthesia is used, she may experience complications from the anesthesia. Very rarely, she may develop a wound hematoma at the site of either incision or other blood clots leading to pelvic thrombophlebitis (inflammation of the major vein running from the pelvis into the leg) or a pulmonary embolus (a blood clot lodging in the lung).

Procedures for Cesarean

What is the procedure for a cesarean?

Some of these may go in a different order, and a few left out, but these are the basics:

A catheter inserted to collect urine An intravenous line inserted An antacid for your stomach acids Monitoring leads (heart monitor, blood pressure) Anesthesia Anti-bacterial wash of the abdomen, and partial

shaving of the pubic hair Skin Incision (vertical or midline(most

common)) Uterine Incision Breaking the Bag of Waters Disengage the baby from the pelvis

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Birth Cord Clamping and cutting Newborn Evaluation Placenta removed and the uterus repaired Skin Sutured (Usually the top layers will be stapled and removed within 2 weeks.) You will be moved to the Recovery Room (If the baby is able s/he can go with

you.

Preoperative Interventionsa. Check vital signs as indicated (depending on severity).b. Check amount of vaginal bleeding.     c. Check for signs of shock such as tachycardia, drop in blood pressure, and cool

clammy skin. (During pregnancy, signs of shock are not manifested until there has been at least a 40 % blood volume loss.

d. Check state of mental acuity/level of consciousness.e. Keep an accurate record of intake and output. f. Urinary output during pregnancy is the best noninvasive indicator of circulatory

volume. Diminished cardiac output causes a shunting of blood away from the skin, kidneys, and skeletal muscles in order to ensure blood delivery to heart and brain.

g. Start an intravenous infusion with an 18-gauge intracatheter and maintain as ordered.

h. Fluid replacement may reverse impending shock by increasing capillary blood flow and thereby cardiac output increases. (Normal saline or Ringer’

i. Obtain blood as ordered for a complete blood count, prothrombin time, partial thromboplastin time, Rh antibody screen, and type and cross match for 2 to 4 units of blood.

j. Administer oxygen at 8 to 10 L by mask as needed.k. Carry out such preoperative protocol as giving the patient nothing by mouth, l. Giving no enemas or cathartics since they could stimulate a tubal ectopic

pregnancy to rupture, being prepared to insert a Foley catheter as ordered, and get the permit signed for surgery.

m. Notify the attending physician of any changes in vital signs, decreasing urinary output, blood pressure that falls 10 mmHg or more, or a change in mental acuity.

n. If the patient presents in shock, be prepared to assist with central line placement. The internal jugular and subclavian veins are less likely to collapsed.

o. Be prepared to administer blood replacement therapy if the hemoglobin level is below 7 g/dl or   the patient is manifested signs of shock.

Postoperative Interventionsa. Check blood pressure, pulse, and respiration

every 15 minutes, eight times; every 30 minutes two times; every hour, two times; every 4 hours, two times; and then routinely.

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b. Assess vaginal bleeding by pad count.c. Check dressing

every hour four times and then every shift for bleeding

d. Refer to laboratory work, such as hemoglobin and hematocrit.e. Keep an accurate intake and output records.f. Assess for cyanosis.g. Reinforce or change dressing as needed.h. Carefully administer IV fluids as ordered.i. Once the gastrointestinal tract resumes normal function, instruct regarding the

importance of a high protein, high-iron diet for body repair and replacement of blood loss.

j. Notify physician if   blood pressure drops to less than 90 systolic,   pulse rises to greater than 120 bpm, or  anemia develops.

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VII. NURSING CARE PLAN

PROBLEM # 1: Acute PAIN

ASSESSMENTNURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATIONOBJECTIVES INTERVENTION RATIONALE

EXPECTED

OUTCOME

S: “masakit yung tahi ko,kumikirot siya” as verbalized by the patient.

O: -pain scale of 8 out of 10-facial grimace when moving-guarding behavior observed

Acute pain r/t stimulation of nerve endings secondary to

surgical procedure

Depending on the depth of injury, nerve endings either become

exposed, resulting in pain and

discomfort until wound closure are damaged leaving

the innervated area insensate, with

potential for permanent

impairment of ability to sense, touch, pressure

and pain.

Short Term:After 8 hours of nursing interventions, Pooh’s pain will be decreased from 8 to 6 out of 10.

Long Term:After two days of nursing intervention, the patient will demonstrate relaxation skills as indicated for individual situation AEB doing her ADL independently.

-Monitor v/s esp. BP

-Perform a comprehensive assessment of pain to include location, characteristics, onset and duration, frequency, quality, intensity or severity of pain and precipitating factors -assess pt’s perception of pain-observe non-verbal cues-Provide comfort measures like repositioning

-To have base line data-To know the precipitating factors of pain and to have necessary information about the case of the Pooh.

-Pain is a subjective cue.-To confirm pt’s pain.-To provide a non pharmacological pain management such as administering

Short term: Pooh’s pain will be decrease from 8 to 6 out of 10.

Long Term: Pooh will demonstrate relaxation skills as indicated for individual situation AEB doing her ADL independently.

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-Encourage adequate rest period

-Encourage deep breathing exercise

-Encourage diversional activities like listening to a music and watching TV

-Administer analgesics as ordered

pain relievers.-To alleviate pain

-To reduce pain by breathing exercise.-To divert the pain by listening to a music and watching t.v.

-To treat underlying cause.

PROBLEM # 2: INEFFECTIVE TISSUE PERFUSION

ASSESSMENT NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION OBJECTIVES INTERVENTION RATIONALE EXPECTED

OUTCOMES: Ø

O: Patient manifested:- Pallor- Capillary refill

Ineffective Tissue

Perfusion r/t decreased

hemoglobin

Due to the CS surgery, there is a

massive blood loss. This will lead to the decrease in

Short Term:After 8 hours of nursing intervention, Pooh will demonstrate

-Monitor v/s esp. PR

-Assess Pooh’s condition especially signs and symptoms

-To have base line data-To have base line data

Short term:Pooh will be able to demonstrate increased in perfusion AEB

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of 3 secs- Weak pulse- Hgb: 110g/dl

concentration in the blood

the concentration of hemoglobin in

the blood and alteration in tissue

perfusion.

increased in perfusion AEB strong peripheral pulse and capillary refill of 1-2 secs.

Long Term:After one day of nurse patient interaction, Pooh will be able to understand the condition and treatment regimen to improve tissue perfusion.

of disease such as pulse rate and capillary refill-Review laboratory studies-Identify changes related to systemic and/or peripheral alterations in circulation-Encourage early ambulation-Encourage quiet, restful atmosphere

-Provide comfort measures such as repositioning -Monitor signs of bleeding-Transfuse blood as ordered

-To provide comparison -To assess the extent of involvement

-To promote venous return-To conserve energy and lowers tissue oxygen demands.-To help patient to relax

-To prevent further injury- To replace

blood loss

strong peripheral pulse and capillary refill of 1-2 secs.

Long Term:Pooh will verbalize understanding of the condition and treatment regimen to improve tissue perfusion.

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PROBLEM # 3: IMPAIRED SKIN INTEGRITY

ASSESSMENT NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION OBJECTIVES INTERVENTION RATIONALE EXPECTED

OUTCOMES: Ø

O: Patient manifest:- Presence of

surgical incision in the abdomen

- Intact and dry dressing

- (+) pain

Impaired skin integrity r/t abdominal incision 2˚

surgery

Due to the incision done during

surgery, there will be disruption of the skin surface that will lead to

the impairment of the skin integrity.

Short Term:After 4 hours of nursing interventions, Pooh will be able to understand on how to promote wound healing and prevent further complications.

Long Term:After 2 days of NPI, Pooh will be able to participate in prevention measures and treatment program such as eating nutritious foods rich in protein and Vit. C such as citrus fruits.

- Assess pt’s condition

- Assess skin noted color, turgor, sensation, and signs of infection

- Described and measured wounds and observed changes.

- Determine the depth of damage

- Keep the area clean and dry

- Remove wet linens promptly.

- Change dressing everyday as ordered

- Encourage early ambulation

- Instruct to eat

- To have base line data

- To know for the presence of infection

- Establishes comparative baseline providing opportunity for timely intervention.

- To asses the injury

- To promote healing

- To prevent skin breakdown

- To prevent infection

- To promote circulation

- To aid in

Short term:Pooh will be able to verbalize understanding on how to promote wound healing and prevent further complications

Long Term:Pooh will be able to participate in prevention measures and treatment program such as eating nutritious foods rich in protein and Vit. C. such as citrus

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nutritious food rich in protein and Vit. C.

- Review importance of measures to maintain skin function.

healing

- To promote wellness

fruits.

PROBLEM # 4: ACTIVITY INTOLERANCE

ASSESSMENT NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION OBJECTIVES INTERVENTION RATIONALE EXPECTED

OUTCOMES: “hindi ako gaano makagalaw, nanghihina pa kasi ako saka nag-aalala ako sa na-opera ko” as verbalized by Pooh.

O: The group observed that Pooh is:

- irritable- uncomfortable

Activity intolerance

related to generalized

weakness and presence of

pain secondary to surgical procedure

Inadequate oxygen in the circulation

can develop weakness in our

muscles. Muscles need oxygen to

move and to do its function. If the patient cannot tolerate any

activities because of the low

oxygenation caused by the

Short term:After 8 hours of nursing intervention, Pooh will report activity intolerance with enhanced energy, and she will participate willingly in desired activities.

Long term:

- monitor the vital signs

- provide health teaching to Pooh regarding the organization and time management technique to prevent while on activity

- adjust activities, reduce intensity level or

- to obtain baseline data

- to provide adequate knowledge to Pooh.

- to prevent overexertion

Short term:Pooh will report activity intolerance with enhanced energy, and she will participate willingly in desired activities.

Long term:

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- worried- immobility

weakness

ventilation-perfusion

imbalance caused by the pathological

minimized lung expansion.

After one day of NPI, Pooh will identify techniques to enhance activity tolerance AEB doing her ADL independently.

discontinue activities that cause undesired physiologic changes

- suggest use of relaxation techniques

- assist Pooh to learn and demonstrate appropriate safety measures

- To enhance sense of well-being

- To prevent or protect Pooh from injuries

Pooh will identify techniques to enhance activity tolerance AEB doing her ADL independently.

PROBLEM # 5: Risk for Infection

ASSESSMENT NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION OBJECTIVES INTERVENTION RATIONALE EXPECTED

OUTCOMES: Ø

O: Patient may manifest:- Increased

environmental exposure, tissue destruction

- Inadequate primary

Risk for infection related to

inadequate primary

defenses due to tissue trauma

caused by surgery.

A surgical incision is prone

to pathogenic bacteria that will cause infection to the broken skin. The bacteria will be able to enter the incision and

Short Term:After two hours of nursing interventions, Pooh will be able to identify interventions to prevent the risk for infection like hand washing.

- Monitor v/s esp. PR , RR and temperature

- Assess Pooh’s condition

- Assess the

- To have base line data, fever maybe secondary to infection- To have

base line data

- To know for

Short term:Pooh will identify interventions to prevent the risk for infection like hand washing after 2 hrs of nursing

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defenses due to abdominal incision and trauma brought about by surgery

- (+) pain

may infect the wound. Long Term:

After one day of nursing interventions, Pooh will demonstrate techniques to decrease risk for infection such as frequent changing of dressing.

surgical incision for signs of infection

- Stress proper hand washing when the patient is going to have in contact to the wound

- Encourage early ambulation, deep breathing, coughing exercises, and position changes

- Changed dressing as ordered

- Administer antibiotics as ordered.

the presence of infection

- To prevent cross contamination

- To mobilize respiratory secretions

- To prevent infection

- For prophylaxis

interventions.

Long Term:Pooh will be able to demonstrate techniques to decrease risk for infection such as frequent changing of dressing.

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VIII. LEARNING DERIVED FROM THE STUDY

In a few women, for some reasons, there are unusual and unexpected deviations

or complications from the course of normal pregnancy. When this happens, it can place a

severe burden on a woman and her family. All families benefit from the support and skill

of a professional nurse who helps them work through the task of pregnancy and prepare

to become parents. It is our duty to provide our patients as well as their significant other

with adequate knowledge to prevent the occurrence of the possible complications of the

disease entity. That is why, as much as possible, nurses must guide their patients and their

family in identifying ways o how to manage the situation in order to prevent further

impediments and its progress to a more complicated one. This case study can help to

ensure that women are well-informed about the normal course of pregnancy so they can

recognize it when a complication is occurring. This is why prenatal check-ups are very

important for mothers and mothers-to-be.

Moreover, this case study thought the group how to stand on their own and by not

depending on others work. This provides us, students, indeed a big learning regarding

how to take care of our patients in the real clinical setting. Nursing really demands a

tender loving caring attitude. It also demands patience and its calling is not merely taken

for granted.

As future nurses, we must have competent skills, adequate knowledge and

acquaintance plus a compassionate heart. The nurse is not the sole determinant of the

failure or effectiveness of any treatment The patients themselves are the prime factors for

achieving the best possible results of interventions made, yet the nurse who spends

greater time with the patient functions not only to perform health assessments, a

administer medications, provide health teachings, but helping the patient process both the

physiological and psychological impact of the treatment.

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IX. REFRENCES

Black, Joyce and Hawk, Jane Hokanson (2005). Medical-Surgery Nursing:

Clinical Management for Positive Outcome 7th Edition. WB Saunder.

Doenges M and Moorhouse M.F. Nurses Pocket Guide 7th edition; 2000 F.A.

Davis Company, Thailand

Kozier B. et al. Fundamentals of Nursing 7th edition; 2004 Pearson Education;

South Asia PTE LTD.

Nursing Drug Guide 2006 . Pennsylvania, Springhouse Cooperation

Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and

Childbearing Family. Volume 1, 4th edition. Lippincott Williams and Wilkins.

2003.

http://en.wikipedia.org/wiki/stillbirth

http://en.wikipedia.org/wiki/placenta

http://en.wikipedia.org/wiki/Hysterectomy

http://www.medicinenet.com/hysterectomy/article.htm

http://www.hysterectomyresources.com/blog.php/hysterectomy-surgical-procedure

http://www.surgeryencyclopedia.com/Ce-Fi/Cesarean-Section.html

http://www.childbirth.org/section/CSFAQ.html

http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/

Hysterectomy_surgical_procedures

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