Posted on 23rd Sep 2024 10:24:47 PM Medicine
1.1 Description about caesarean section
A caesarean section, or c-section, is an operation in which a baby is born through a cut made in the mother's abdominal wall and uterus. A caesarean section may be planned (elective) if there are signs that a vaginal birth is risky, or unplanned (emergency) if there are problems during labour.
A Caesarean section, (also C-section, Caesar, etc.) is a surgical procedure in which one or more incisions are made through a mother’s abdomen (laparotomy) and uterus (hysterectomy) to deliver one or more babies, or rarely, to remove a dead fetus. A late term abortion using Caesarean section procedures is termed a hysterectomy abortion and is very rarely performed. The first modern caesarean section was performed by Germen gynaecologist Ferdinand Adolf Kehrer in 1881. A Caesarean section is usually performed when a vaginal delivery would put the baby’s or mother’s life or health at risk, although in recent times it has been also performed upon request for child births that could otherwise have been natural. (Fear a factor in surgical births, 2007). In recent years the rate has risen to a record level of 46% in China and to levels of 25% and above in many Asian and European countries, Latin America, and the United States. (Finger, 2011).
Giving birth is a significant event in people lives. Women and men often refer to the birth of their children both in their thoughts and in discussions for many years after. For many women about to give birth for the first time, the event appears to be unfamiliar, uncontrollable and intimidating. The wish to avoid vaginal birth has during the last ten years resulted in an increased group of women approaching midwives and obstetricians to ask for an elective caesarean section. Healthcare personnel, midwives and particularly obstetricians sometime have difficulties meeting these demand. They might have medical concern about the negative effect of caesarean section. Traditionally caesarean section has also been associated with a higher maternal mortality and morbidity rate, both short and long term and with neonatal respiratory distress. (Anonymous, 2004). Lately attitudes toward health personnel have been changing. A growing awareness of consumer preferences among obstetricians and midwives could play an important role (Habiba et al., 2006). A significant proportion of obstetricians in the USA (46 percent) would favor for caesarean section for themselves, or for their partners in an uncomplicated pregnancy (Gabbe et al., 2001). Advances in medical have made caesarean delivery safer than it was 15 years ago (Anonymous 2004). At the same time vaginal birth has been linked for adverse outcome such as pelvic floor injury and rising rate of emergency caesarean section. During the last 30 years the rate of caesarean section in Sweden has risen 6 percent in 1974 to 17 percent in 2004 (Anonymous, 2005). Caesarean section performed on maternal request in the absence of a medical indication is a focus of considerable attention both for clinical and ethical reason and specific reason for the request should be evaluated (Schenker et al., 1999). Concern about the increasing the rates of caesarean section have led to discussion about possible causes behind this phenomenon. However, evaluation of factors associated with the increased caesarean section rate has been carried out in several countries. When women are delaying childbirth and having fewer children the average age of women giving birth will increased and also the proportion of primiparae, thus increase the rate of caesarean section (Anonymous, 2004).
1.1.1 Caesarean delivery in history
The year is 1537 and Jean Seymour the wife of third Henry is about to give birth to her first child. Edward is safely delivered but her mother was died 12 days after delivery due to puerperal infection (Weir, 2006). The caesarean delivery, a rescue and sometimes a shortcut to life has a short history. Not long ago women died into obstructed labour and complicated birth. One the earliest stories of performance of caesarean section is from 1411 when a German midwives is claimed to have performed seven caesarean section where both the mother and child survived (Trolle, 1980).The first reported caesarean section in Sweden was performed 1758 by an obstetrician, Schutzer. The mother died after three days of delivery but the child, a girl survived (Pleijel, 2006). In total three of are reports in 13 caesarean section are performed in Sweden 1758-1875, all womendied (Hogberg, 1985). Other methods than caesarean section developed such as forceps delivery, embryotomy, craniotomy etc. The author Professor Cederschiold states that “If there has been no progress of labour for 10-12 hours then the midwives has to call the doctors and the women in labour has to be delivered with forceps or other appropriate methods” . One of the reasons for high mortality in history was that the surgery was performed on exhausted who had been in labour for many days. The died due to puerperal infection, bleeding, postoperative ileus as well as eclampsia.When aseptic techniques came during the middle of 1800, this reduce septic mortality in hospital and in rural home deliveries. During the time 1926-1930 the caesarean section rate in Sweden was 0.25% and the mortality rate was 9.5%. Mortality rate decreased during the beginning of 1950. From (1951-1980) caesarean section rate was increased in (1.7-11) %. Still during the 1970’s the mortality rate was 9-12times higher than a vaginal delivery (Moldin et al., 1973-1979).
1.1.2 Caesarean delivery today
Caesarean section rates are progressively increasing many part of the world. The caesarean section rate in Sweden has increased 60% from 1990-2001 and the rate in Stockholm was 19% of all deliveries in 2003. Increased age among childbearing women and increased BMI is one of the explanation for this as well as fetal indication and previous caesarean section (Kallen et al., 2005). Breach presentation has become an indication of caesarean section. Caesarean section performed on maternal request in the absence of an obstetrics indication also probably contributes to this increase. Since serious complications during childbirth cannot always be predicted, many caesarean sections are unanticipated. In Sweden about 60% of abdominal deliveries are carried out as emergency caesarean section (Anonymous, 2005).
Emergency caesarean section is associated with a greater risk of complication both during surgery and postpartum period compared to elective caesarean section. Still today the morbidity of caesarean delivery is higher than during a planned vaginal delivery. Overall rate of severe morbidity were 27.3 and 9.0 respectively per 1000 deliveries. The planned caesarean section group had increased risk of cardiac arrest, hysterectomy, major puerperal infection, anesthetic complication, venous thrombo-embolism, and hemorrhage requiring hysterectomy (Liu et al. 2007). In Sweden there are nearly 100000 deliveries annually. Today maternal mortality during delivery in Sweden is very low. The register of cause of deaths in Sweden 1989-2004 reported 1-7 per year in complication during pregnancy, birth and postpartum period (Socialstyrelsen, 2007). During the last three years the focused therefore changed toward perinatal mortality which in Sweden 2003 was 5.0 per 1000 birth in 2003 (Anonymous, 2005). From psychological perspective emergency caesarean section has found to significant adverse psychological effect. Fisher and co- worker found that significant adverse psychological effect were associated with mode of delivery and those who had spontaneous deliveries were most likely to experiences a marked improvement in mood and elevation in self-esteem across to the late pregnancy to early postpartum interval. In contrast, women submitted to caesarean section were significantly more likely to experience deterioration in mood and self- esteem (Fisher et al., 1997).
Bangladesh has made great achievement in key health indicators, which are important to achieve maternal child health related MDGs 4 and 5. Maternal mortality ratio decline from 650 to 290 per 1000000 live births, and under five chilled mortality rate (U5MR) dropped from 133 to 65 per 1000 live births, from 1989 to 2007. However MMR in Bangladesh is still remarkably high and Bangladesh is still far away from achieving the MDG target of reducing MMR to 143 per 100000 by the year 2015. Encouragingly, Bangladesh is considered to be on track in reducing child mortality rate but sustaining this rate will demand cautious and continued effort. Inequalities in terms of socio economic status and geographic location are major challenges in achieving equitable development in maternal and child health. Rapid Urbanization makes women highly vulnerable because of poor hygiene, over-crowding, lack of basic amenities such as water and sanitation, low availability and use of formal health services including maternity care. (UN: WUP, 2000). The burden of maternal mortality is especially heavy in urban slums of developing countries. (Zahar, 2007). In developing countries, the urban poor exhibit poorer pregnancy outcome compared to those in rural areas. (Fosto et al., 2008).
1.2 Types of caesarean sections
The only difference between caesareans is where the cuts (incisions) are made to the uterus. After your caesarean, ask the obstetrician what kinds of cuts were made. This will be useful information when you are making decisions about future births. The two types of cuts that can be used when you have a caesarean sectionare:
1.2.1 A lower segment incision:
will be used wherever possible. This is a horizontal (across) cut through the abdomen (stomach) and a horizontal cut through the lower part of the uterus, sometimes known as a ‘bikini line’ incision. These cuts heal better, are less visible and are less likely to cause problems in future pregnancies.
1.2.2 A classical incision:
refers to a vertical cut on the uterus. The cut on the abdomen may be horizontal or vertical. This type of incision is usually only used for extreme emergencies or in specific situations, such as if the placenta is lying very low, if the baby is lying sideways or if the baby is very small. It can increase the chance of having problems in later pregnancies and births.
1.3 Indication of caesarean section
One of the most common indications for cesarean section is prior cesarean section. (Williams Obstetricians, 2005).
1. Maternal/FetalIndications: Dystocia
The most common indication for cesarean section in primiparous women, accounting for 68% of cesarean sections in one series, is failure to progress in labour or dystocia (Williams Obstetricians, 2005).Dystocia, literally meaning “difficult labour”, refers to a disproportion between the fetal presenting part and the maternal pelvis. Dystocia is typically accompanied by slower than usual progress in labour (dilation at less than 1cm/hour in a primiparous patient) or crossing of lines on the partogram, indicating slow progress in labour. Dystocia can be caused by poor forces of expulsion – either poor contraction forces (in the first or second stages of labour) or insufficient maternal expulsive effort (in the second stage of labour).It can also be caused by fetal malpresentation or malposition, such as transverse, posterior presentations of the fetal occiput, breech or transverse position.
2. Malpresentation can be a common cause of dystocia. Accurate vaginal assessment of the presenting part is required in order to make a diagnosis of malpresentation; consultation between the consultant physician and midwives is recommended. Although face presentation is rare (0.17%), it should be remembered that mentum anterior presentations can deliver vaginally, although mentum posterior can not. Manual attempts to convert a face presentation can be dangerous and are not indicated. Cesarean delivery may often be indicated as pelvic contraction may be the cause for the face presentation. Brow presentation is the rarest of presentations; it may spontaneously convert to mentum or vertex, but so long as a brow presentation persists, vaginal delivery is not possible and cesarean section is indicated (Williams 2005).
3. Breech Presentation: At term approximately 3-4% of infants are in the breech presentation. A breech presentation has been associated with a higher incidence of morbidity for both the mother and the fetus. In general, complete or footling breech presentation is considered an indication for cesarean section, due to the increased risk of cord prolapse.
4. Failure to progress
In order to properly diagnose failure to progress, the mother should be in active labour, that is, at least 3-4cm dilated. Prior to that, it is not possible to make a diagnosis of dystocia as the active first stage of labour has not begun and there has not been an adequate trial of labour.
1. Fetal Indications: Fetal Distress:
Normal baseline fetal heart rate is between 110 and 160 beats per minute; above 160 beats per minute, is considered tachycardic and below 110 beats per minute is considered bradycardic. Nonreassuring fetal heart rates include late decelerations, repetitive prolonged variable decelerations (to less than 60beats per minute or for more than 60 seconds), sinusoidal patterns, tachycardia, prolonged bradycardia (greater than 4-6 minutes) and, where possible to determine, a no reactive fetal heart rate accompanied by a scalp pH of less than 7.20. Timing to caesarean section will be discussed in an upcoming section.
2. Placental Indications:
In placenta praevia, the placenta lies over the cervix and below the fetus. This would lead to detachment of the placenta and maternal hemorrhage in labour as the cervix opens. Placenta praevia must therefore be delivered by cesarean section.
3. Other Indications:
Additional indications for cesarean section include, but are not limited to, major antepartum hemorrhage such as with significant abruption, severe Pregnancy Induced Hypertension (PIH) remote from term, high order multiple gestations (triplets or higher), twins with twin A in a noncephalic presentation, cervical cancer and active herpes infections .
1.4 Post Operative Care
Expect a hospital stay of 3 to 5 days.
Fluids will be given via an intravenous line after the surgery to maintain nourishment and hydration. Sips of water will be allowed gradually over the first few hours. If you feel well and not nauseous, you will be given nourishing fluids such as a cup of tea/coffee/milo. The drip will be stopped when you are drinking normally again. This may take a little longer if you have had a general anesthetic. Your doctor will review periodically to decide when to start soft diet.
Antibiotics may be prescribed for those at risk of infection.
Pain relief medication should generally be required for only 2 to 7 days following the procedure.
Move and elevate your legs often while resting in bed to improve circulation and decrease the likelihood of deep-vein clots.
It is important to mobilize as soon as possible, since it helps to prevent complications, such as blood clots and pneumonia.
Frequent uterine cramps will be present and will response to simple pain relief medications.
There will be fresh vaginal bleeding for 1 to 2 weeks and will usually reduce in amount and change in colour with time. It may last from 4 to 6 weeks. Use sanitary napkins—not tampons—to absorb blood or drainage.
Wound dressing will be removed before discharge and the operation area sprayed with a dressing. The wound will be kept exposed.
A firm ridge may form along the incision. As it heals, the ridge will gradually recede.
Non absorbable sutures are usually removed from the skin incision on the seventh day. If absorbable suture is used, then the suture need not be removed. It will dissolve by itself after a few weeks.
Once home, someone should be available to help care for you for the first few days.
Shower as usual. Dry the incision site with dry, clean towel after each shower.
Do not douche.
There is no specific dietary restriction. Eat a healthy and balanced diet.
Resume daily activities and work as soon as you are able. Full recovery normally takes about 4 to 6 weeks.
You should start postnatal exercise once you are pain-free and comfortable. Specific exercises are available for women who had a C-section. Discuss this with your nurse or doctor. Avoid heavy lifting or strenuous activity for 6 weeks.
You can resume driving after 4 weeks, provided full mobility has returns and pain-killers medications are no longer required. Please ask your doctor if you are not
Avoid sexual intercourse for 6 weeks or as directed by your doctor.
Do not skip your postnatal visit, which is usually 6 weeks after the delivery. Discuss family planning choices with your doctor during this visit. t is advisable to avoid the next pregnancy for at least one year.
1.5 Possible Complications
Excessive bleeding or surgical-wound infection.
Post operative anemia.
Endo-myometritis (inflammation of lining and muscle of the uterus).
Excessive scar formation (called keloid scars).
Complications of anesthesia.
Higher possibility of caesarean section in next pregnancy, depending on how the uterine (not skin) incision was done.
Blood clots in calf veins, which can travel to the lung, causing lung damage.
In rare situations, there can be injury to the bladder, intestine or other structures.
1.6 Justification of the study
The purpose of the study is explore current knowledge regarding care of a patient after caesarean section among nurses in Rajshahi Medical College Hospital, which might provide a comprehensive picture about the current situation and thus help to carry out further in depth study to increase the knowledge regarding post operative care of caesarean section. It will be helpful to decrease maternal mortality rate during the post natal period.
1.7 Objectives
1.7.1 General objectives:
The study was done with a view to assess the nurse’s knowledge regarding care of a patient after caesarean section in Rajshahi Medical College Hospital.
1.7.2 Specific objectives:
The specific objective of the study were-
- To assess the knowledge about care of a patient after caesarean section. Assess the knowledge of nurses about prevention of infection after caesarean section.
- To assess the knowledge of nurses about puerperium and its abnormality.
- To assess knowledge about postpartum hemorrhage and its management.
1.8 Research Question
Q.1. What is the knowledge level of nurses regarding care of patient after caesarean section.
1.9 Variable used in study
1.9.1 Independent variable:
Age, sex, marital status, religion, academic qualification, length of service etc.
1.9.2 Dependent variable:
Knowledge of nurses regarding care of a patient after caesarean section.
CONTENTS
Abstract
CHAPTER – 1: INTRODUCTION
1.1 Description about caesarean section
1.1.1 Caesarean delivery in history
1.1.2 Caesarean delivery today
1.2 Type of caesarean section
1.3 Indication of caesarean section
1.4 Post operative care of caesarean section
1.5 Possible Complication
1.6 Justification of study
1.7 Objectives
1.8 Research questions
1.9 Variables
CHAPTER – 2: REVIEW OF LITERATURE
2.1 Methodology of literature review
2.2.1 History of caesarean section
2.2.2 Improvements in the technique
2.3 Caesarean section, Current trends
2.4 Indication of caesarean section
2.5 Torture evidence
2.6 Risk of caesarean section
CHAPTER – 3: MATERIALS AND METHODS
3.1 Design of the study
3.2 Study population
3.3 Sample place
3.4 Study duration
3.5 Sample size
3.6 Sample technique
3.7 Research instrument
3.8 data collection procedure
3.9 Data analysis
3.10 Ethical consideration
CHAPTER – 4: RESULTS
4.1 Demographic information of the nurses
4.2 Knowledge related question to the nurse
CHAPTER – 5: DISCUSSION
5.1 Discussion
CHAPTER – 6: CONCLUSION
6.1 Conclusion
CHAPTER – 7: REFERENCES
7.1 References
CHAPTER – 8: APPENDIX
8.1 Appendix
LIST OF TABLES
Table 1: Demographic information of the participated nurses
Table 2: Information regarding knowledge of the participated nurses
LIST OF FIGURES
Figure 1: Distribution of nurses by their age
Figure 2: Distribution of nurses by their knowledge level regarding patient care after caesarean section
Thesis, Assessment, Nurses, Knowledge, Regarding, Patient, Care, Caesarean, Section, Rajshahi, Nursing, College, Medical, Hospital, Operation, Baby, Born, Cut, Made, Mothers, Abdominal, Abdomen, Laparotomy, Hysterectomy, Babies, Vaginal, Birth, Risky, Unplanned, Emergency, Labour, Abortion, Hysterectomy, Germen, Gynaecologist, Ferdin
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