I.

INTRODUCTION Placenta accreta refers to an abnormal placental implantation in which the anchoring placental villi attach to the myometrium, rather than being contained by decidual cells. This results in a placenta that is abnormally adherent to the uterus. In placenta accreta, the placenta attaches too firmily and deeply into the uterine wall but it does not penetrate the uterine muscle. Placenta accreta is the most common accounting for approximately 75% of all cases. In placenta increta, the attachment is much deeper into the uterine wall and does not penetrate into the uterine muscle, preventing easy separation after birth. It accounts for approximately 15% of all cases. In placenta percreta, the placenta attaches right through or beyond the uterus, invading sometimes to other internal organs, most commonly the bladder. It is the least common of the three conditions accounting for approximately 5% of all cases. These placental complications occur in about 1 of 2,500 pregnancies. Premature delivery and subsequent complication are primary concerns for the baby. Bleeding during the third trimester may be a warning sign that placenta accreta exist, and when placenta accreta occurs it commonly results in premature delivery. The incidence of placenta accreta ranged from 1 in 533 to 1 in 2510 deliveries in the United States during the 1980s and 1990s. By comparison, placenta accreta was a rare occurrence in 1950, occurring in 1 in 30,000 deliveries. The marked increase in incidence has been attributed to the increased prevalence of cesarean delivery in recent years. Combined results from two series involving a total of 138 histologically confirmed, abnormally implanted placentas from hysterectomy specimens showed that 79 percent were accretas, 14 percent were incretas, and 7 percent were percretas. The specific cause of placenta accreta is unknown, but it can be related to placenta previa and previous cesarean deliveries. The most important risk factor for placenta accreta is previous uterine surgery and the most common setting is placenta previa

after a prior pregnancy delivered by cesarean. The mechanism for the abnormal implantation is thought to be thin, poorly formed, or absent decidua basalis in the scarred area of the lower uterine segment that does not resist deep penetration by trophoblast. However, other pathophysiologic processes may be involved.Placenta accreta is present in 5% to 10% of women with placenta previa. A cesarean delivery increases the possibility of a future placenta accreta, and the more cesareabs, the greater the increase. In all cases, symptoms are similar to those of placenta previa and placental abruption, including late term vaginal bleeding and preterm delivery of the baby. The largest complication of these conditions is that the placenta does not readily detach from the uterine wall and will usually require surgical removal. This can lead to no other choice than hysterectomy, although increasingly other procedures are attempted to prevent the removal of the uterus. Diagnosis A diagnosis of accreta can be confirmed with tissue histology; however, medicalimaging can be an effective diagnostic tool. Ultrasound can detect the presence of accreta(80% sensitivity) and absence of accreta (95% specificity). Warshak et al. reported that incases with suspicious or inconclusive ultrasonography results, MRI accurately predicted placenta accreta with 88% sensitivity and 100% specificity. While MRIs specificity is enhanced when gadolinium is used, its effects on the fetus remain uncertain; many researchers believe benefits of its use outweigh risks associated with mis- or undiagnosed placenta accreta. Recent Stanford studies suggests that high-resolution sonography and results but are complimentary when one modality is inconclusive. Second trimester Maternal Serum Alpha-Fetoprotein (MSAFP) may also be helpful. In two recent studies of patients with placenta previa, MSAFP was elevated in 45% of those with accreta, and not in those without accreta. Providers caring for patients with

prenatally suspected placenta accreta should counsel patients extensively about potential risks and complications well in advance of their estimated due date. Patients with accreta are at increased risk for hemorrhage, blood transfusion, bladder/ureteral damage, infection, need for intubation, prolonged hospitalization, ICU admission, need for reoperation, thromboembolic events and death. Discussions should involve relative likelihood for hysterectomy and subsequent infertility. In patients with strong suspicion for placenta accreta, it is strongly advised to perform the delivery before labor begins or hemorrhaging occurs. Therefore, consideration should be given to performing the cesarean birth electively and prematurely, either after corticosteroids for fetal lung maturation or after documentation of fetal lung maturity. The committee could not reach consensus on the recommended gestational age for elective delivery; some tertiary referral centers recommended 32-34 weeks and others 35-36 weeks. All agreed that patients with repeated bleeding episodes or deeper invasion (e.g. placenta percreta) should be delivered early. Advance planning with anesthesia, blood bank, nursing (OB and OR) and advanced surgeons is an essential first step. Advanced surgeons are gynecology oncologists or experienced pelvic surgeons familiar with the operative management of complex pelvic surgeries. A Massive Transfusion Pack with 4-6 units PRBCs, FFP and Platelets should be available. At the time of cesarean, the hysterotomy should be made away from the location of the placenta. In all but those with focal accretas, a hysterotomy without disturbance of the placentais strongly advised. Blood salvage equipment should also be considered where available. The results of conservative surgery have been recently reviewed with many complications noted (e.g. infection, delayed hemorrhage, re-operation requiring hysterectomy, disseminated intravascular coagulation) and should only be considered in the most select situations. Consultation with experienced surgeons (e.g. gynecologic oncologist) or referral to

appropriate facilities is required when a provider lacks appropriate support services or surgical experience with managing placenta accreta. The use of prophylactic intravascular balloon catheters for cesarean hysterectomy for placenta accrete is controversial as a recent large case control study (UC Irvine/Long Beach Memorial) showed no benefit. If a focal placenta accreta is found (typically in the lower uterine segment at the delivery of a placenta previa) management options are broader and include over-sewing, fulguration and placement of an intrauterine compression balloon (with drainage through the cervix/vagina) for 24 hours.

Nurse centered objectives: After a week of accomplishing this case study, the researchers are expecting to have depth understanding with Placenta Accreta, Increta and Percreta will be able to: Cognitive: Familiarized with the disease condition: Understanding reasons behind the occurrence of risk factors. Pathophysiology, signs and symptoms and complication regarding the disease condition. Gain knowledge on how to formulate implementations with their corresponding nursing responsibilities. Affective: Emotionally relate with the client condition. Learn to use therapeutic skills.

Psychomotor : Promote usage of therapeutic communication skills of the student nurses in dealing with patients and with the other members of the healthcare team. Provide health teachings to the patient and significant others towards a better health. Obtain a cephalocaudal assessment of the patients condition. Collect the different laboratory and diagnostic procedures and findings. Able to relate the laboratory findings to the patient condition. Perform nursing responsibilities in the said procedures. Formulate nursing care plan. Implement the nursing interventions to alleviate the underlying signs and symptoms. Evaluate the nursing interventions performed.

II.DIAGNOSTIC TEST Ultrasound and MRI High-frequency sound waves. Ultrasound waves can be bounced off soft tissues using special devices. The echoes are then converted into a picture called a sonogram. Ultrasound imaging, referred to as ultrasonography, allows physicians and patients to get an inside view of soft tissues and body cavities, without using invasive techniques. Ultrasound is often used to examine a fetus during pregnancy. There is no convincing evidence for any danger from ultrasound during pregnancy. MRI (or magnetic resonance imaging) scan is a radiology technique that uses magnetism, radio waves, and a computer to produce images of body structures. The MRI scanner is a tube surrounded by a giant circular magnet. The patient is placed on a moveable bed that is inserted into the magnet. The magnet creates a strong magnetic field that aligns the protons of hydrogen atoms, which are then exposed to a beam of radio

waves. This spins the various protons of the body, and they produce a faint signal that is detected by the receiver portion of the MRI scanner. The receiver information is processed by a computer, and an image is produced. The image and resolution produced by MRI is quite detailed and can detect tiny changes of structures within the body. For some procedures, contrast agents, such as gadolinium, are used to increase the accuracy of the images. MRI scan can be used as an extremely accurate method of disease detection throughout the body. In the head, trauma to the brain can be seen as bleeding or swelling. Other abnormalities often found include brain aneurysms, stroke, tumors of the brain, as well as tumors or inflammation of the spine. It provides valuable information on glands and organs within the abdomen, and accurate information about the structure of the joints, soft tissues, and bones of the body. Often, surgery can be deferred or more accurately directed after knowing the results of an MRI scan. Degree of invasion of chorionic villi Occurs when the decidua basalis is partially or totally Accreta Attach superficially tomyometrium(80%) absent in conjunction with an imperfect development of the Nitabuchmembrane, a fibrinoid layer that separates the decidua basalisfrom the placental villi. Increta Deep intomyometrium(15%) Results when placental villi invade the myometrium. Represents the greatest degree of severity. Defined as the Percreta Through themyometriumand intoserosa (5%) penetration of the trophoblast through the myometrium and into or through the peritoneum, it sometimes extends to adjacent structures such as the bladder Pathology

Nursing Responsibilities: Before:

1. Check doctors orders 2. Ask for the patients identification 3. Explain the procedure properly to the SO. 4. Instruct the client not to void prior the procedure. During:
1.

The patient lies on an examining table with the part of the body to be examined exposed. A conductive gel is applied to the skin over the area under examination. You lie quietly as the person performing the examination moves the transducer over the skin surface while watching the monitor. You may be asked to shift positions to obtain other views of the organ(s) under study.

2. 3.

4.

After: 1. Wait for the further results. 2. The patient can void. 3. Wait for the physician to interpret the results.

III. ANATOMY AND PHYSIOLOGY Uterus, the pear-shaped hollow muscular organ, houses the fetus until delivery. This structure has three layers namely: the perimetrium, myometrium and endometrium.

Perimetrium the outermost layer that covers the uterus. (Peri means outside) Myometrium located at the middle part of uterus. Myo denotes muscle, thus, this layer contains thick muscular layers. Endometrium the innermost layer that responds to hormonal variations (estrogen and progesterone) during the menstrual cycle. The chorionic villi (finger-like projections

that attaches to the uterine wall) penetrates into this portion of the uterus during implantation. (Endo means inside) In a female reproductive cycle, the uterine endometrium normally sloughs off the thickened vascular surface that precedes the actual secretion of blood flow. With fertilization, it continues to be crammed with blood to accommodate and nourish the embryo. Following this condition, uterine endometrium is now called decidua, which has three separate areas:

Decidua Basalis point of attachment between the maternal vessels and trophoblast (structure that forms the placenta and membrane). Lies under the embryo. (To remember easily Basalis comes the word base meaning under/below)

Decidua Capsularis part of endometrium that expands and encapsulates the implanted trophoblast. .(To remember easily Capsularis comes the word capsule meaning to enclose/above)

Decidua Vera (Parietalis) remaining portion of the uterine endometrium. (To remember easily Parietalis comes the word parietal meaning wall of a hollow organ

IV.PATHOPHYSIOLOGY of PLACENTA ACCRETA(BOOK-BASED)

Predisposing factors: NON-MODIFIABLE
Age (more than 35 years old) Scarring of tissues from previous infection Increased parity (number of pregnancies beyond 20 weeks gestation) Previous uterine surgery (Dilation and Curettage, Cesarean Section, Myomectomy) Asherman syndrome Thin decidua or absent deciduas basalis Presence of tumor

Precipitating factors: MODIFIABLE

Smoking

Invasive placental implantation occurs when there is a defect or absence of the decidua basalis, which is replaced by loose connective tissue

This allows the chorionic villi of the placenta to directly attach to the myometrium.

3 forms of abnormal placental invasion

Placenta Accreta chorionic villi attaches deeply into the uterine wall but does not penetrate the myometrium.

Placenta Increta chorionic villi invades or infiltrates the muscular layer

Placenta Percreta Chorionic villi penetrates beyond the myometrium into the entire uterine wall and possibly to other adjacent organs such as the bladder.

SIGNS & SYMPTOMS Abnormal elevations in [beta]-hCG and maternal alpha-fetoprotein may be measured in the second trimester Third trimester bleeding

COMPLICATIONS Hemorrhage during delivery because the placenta has difficulty separating from the uterine wall Uterine rupture in cases of placenta increta and percreta

Synthesis of the disease b.1. Definition of Disease Placenta accreta, increta and percreta is a severe obstetric complication involving an abnormally deep attachment of the placenta, through the endometrium and into the myometrium (the middle layer of the uterine wall). There are three forms of placenta accreta, distinguishable by the depth of penetration. The placenta usually detaches from the uterine wall relatively easily, but women who encounter placenta accreta during childbirth are at great risk of hemorrhage during its removal. This commonly requires surgery to stem the bleeding and fully remove the placenta, and in severe forms can often lead to a hysterectomy or be fatal.

b.2. Predisposing and Precipitating Placenta Accreta, Increta and Percreta affect around 10% of cases of placenta previa . Placenta previa occurs when the placenta implants low in the uterus, partially or completely covering the internal cervical os. It can occur if the placenta implants over a submucosal fibroid located in the lower uterine segment, near the rudimentary uterine horn or near the uterine cornu. These conditions also increased in incidence by the presence of scar tissue i.e. Asherman's syndrome (a disease that causes intrauterine adhesions) usually from past uterine surgery, especially from a past Dilation and curettage (which is used for many indications including miscarriage, termination, and postpartum hemorrhaging), myomectomy, or caesarean section. Grand multiparity or increased parity (number of pregnancies beyond 20 weeks gestation) is also considered as

a major risk factor. A thin decidua basalis can also be a contributing factor to such trophoblastic invasion. Some studies suggest that the rate of incidence is higher when the fetus is female. Furthermore, additional risk factors including smoking (smoking or being exposed to tobacco smoke, either before or during pregnancy is associated with a range of poor pregnancy outcomes due to various possible diseases) and a maternal age older than 35 years are known to predispose and precipitate a pregnant women for having such condition.

b.3. S/sx with Rationale

Abnormal elevations in [beta]-hCG and maternal alpha-fetoprotein may

be measured in the second trimester - the human fetus has the highest amount of AFP levels found in humans. At the end of the first trimester, fetal AFP levels decrease. This is a protein found in the blood, at highest concentrations in the fetus. The defect in the layer normally separating the placenta and uterus allows leakage of fetal alpha-fetoprotein into the mother's circulation. Up to 45% of women with placenta accreta have elevated MSAFP levels in the absence of an obvious cause.AFP is measured in pregnant women through the analysis of maternal blood or amniotic fluid, as a screening test for a subset of developmental abnormalities.

 Third trimester bleeding and massive bleeding during labor and delivery,

it usually occurs when deciduas basalis is absent, the placenta will not loosen and fails to be delivered. Decidua Basalis point of attachment between the maternal vessels and trophoblast (structure that forms the placenta and membrane).

V.MEDICAL MANAGEMENT a. Intravenous Fluid

Placenta Accreta

Medical Management 1L

General Description 5% Dextrose in Lactated Ringers Solution contains sodium, chloride, potassium, calcium and lactate which is needed to maintain electrolyte balance. Isotonic Table Salt (Sodium Chloride)

Indications To correct electrolyte imbalances To correct hydration

chorionic villi attaches deeply D5LRS into the uterine wall but does not penetrate the myometrium.

31-32gtts/min

PNSS 1L 31-32gtts/min

NS can be used to replace fluids in dehydration

Nursing Responsibilities:

BEFORE: Check the physicians order. Check the type and amount of solution to be infused. Check the rate of flow or time over which the infusion is to be completed. Explain to the patient or to the significant other the purpose of the IV fluid to be administered.

DURING: Instruct the patient to relax especially the hands where the needle is to be inserted. Maintain IV patency and check on it time and again. Check for backflow by lowering the IV bottle. The bottle should be lower than the IV site. Check the IV site for edema or redness.

AFTER: Advise the patient to avoid scratching the site and less movement of the hand where the needle was inserted. Instruct patient or significant others to inform the nurse on duty if bulging on the site is visible and if there is back flow of blood or IVF is not infusing well. IVF regulation should be checked and monitored. Always check if the IVF is infusing well and intact. Monitor for signs of hypervolemia.

b. Drugs

Name of Drugs

Route Administration, Dosage, Frequency

General Action, Classification, Mechanism of Action

Generic: Methotrexate Brand: Folex Trexall Amethoptertin, Nursing Responsibilities: BEFORE:

15 to 30 mg IM or orally daily for 5 days. Repeat courses 3 to 5 times with a rest period of greater than or equal to 1 week between courses, until any manifesting toxic symptoms subside.

Anti-metabolite Anti-folate It acts by inhibiting the metabolism of folic acid.

Assess patients condition before starting therapy and regularly thereafter to monitor the drugs effectiveness. Prepare medication on the exact time as prescribed. DURING: Women taking Methotrexate should be monitored for:

WBC and platelet count (thrombocytopenia and leucopenia may occur 7-14 days after the initiation of treatment) Blood Urea Nitrogen (BUN), Creatinine, and urine pH (should be above 7.0) Presence of dry and nonproductive cough may be an early sign of pulmonary toxicity Symptoms of gout must be assessed frequently (increased uric acid, joint pain, edema). Methotrexate causes increase serum uric acid. Allopurinol may be given to decrease uric acid levels.

AFTER: Document the administration properly.

Name of Drugs

Route Administration, Dosage, Frequency

General Action, Classification, Mechanism of Action

Generic: Cefazolin Brand: Ancef

1gm IV ANST(-) q8 500mg IV q8

Antibiotic

Interferes with bacterial cellwall synthesis, causing cell to rupture and die.

Nursing Responsibilities: BEFORE: Assess patient for infection (vital signs, appearance of surgical site, urine, WBC) at beginning and during therapy. Before initiating therapy, obtain a history to determine previous use of and reaction to penicillins or cephalosporins. Persons with negative history of penicillin sensitivity may still have an allergic response.

DURING: Observe patient for signs and symptoms of anaphylaxis (rash, edema, wheezing, pruritus). Discontinue drug and notify physician on other health care professionals immediately of these problems occur.

AFTER: Instruct patient to notify health care professionals of fever and diarrhea develop, especially if diarrhea contains blood, mucus and pus. Advise not to treat diarrhea without consulting health care professionals.

Name of Drugs

Route Administration, Dosage, Frequency

General Action, Classification, Mechanism of

Action Generic: Ciprofloxacin Brand: Cipro Oral: 250-750 mg (immediate Antibiotic release tablets) every 12 hours Interferes with bacterial cellwall synthesis, causing cell to rupture and die.

Nursing Responsibilities: BEFORE: Assess patients condition before starting therapy and regularly thereafter to monitor the drugs effectiveness. Prepare medication on the exact time as prescribed. DURING: Check doctors order for route, dosage and frequency.

AFTER: Document the administration properly.

Name of Drugs

Route Administration, Dosage, Frequency It is available in sterile ampules of 1 mL, containing 0.2 mg for intramuscular or intravenous injection and in tablets for oral ingestion containing 0.2 mg

Generic: Methylergonovine Maleate Brand: Methergine

General Action, Classification, Mechanism of Action It is a semisynthetic ergot alkaloid used for the prevention and control of postpartum hemorrhage.

Nursing Responsibilities: BEFORE: Assess patients condition before starting therapy and regularly thereafter to monitor the drugs effectiveness. Prepare medication on the exact time as prescribed.
Before initiating therapy, obtain a history to determine if the patient is allergic to ergot

alkaloids. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Before using this medication, tell your doctor or pharmacist your medical history, especially of: kidney disease, liver disease, high blood pressure, heart disease (such as venoatrial shunts, mitral valve stenosis), blood vessel disease (such as Raynaud's disease), complications during pregnancy (such as preeclampsia, eclampsia). DURING: Check doctors order for route, dosage and frequency.

AFTER: Document the administration properly. Instruct the patient that this drug will make him dizzy. Do not drive, use machinery, or do any activity that requires alertness until you are sure you can.

Name of Drugs

Route Administration, Dosage, Frequency 500mg q6 orally

Generic: Ampicillin Brand: Omnipen

General Action, Classification, Mechanism of Action Antibiotic It is used for treating bacterial infections. They stop bacteria from multiplying by preventing bacteria from forming the walls that surround them. The walls are necessary to protect bacteria from their environment and to keep the contents of the bacterial cell together.

Nursing Responsibilities: BEFORE: Determine history of hypersensitivity reactions and history of other drug allergies before therapy is initiated.

DURING: Check doctors order for route, dosage and frequency.

AFTER: Keep physician informed if adverse reactions appear.

c. diet Type of Diet Nothing per orem General description Any kinds of food and drinks are not allowed to be given to the patient. Clear liquid diet a temporary diet used to help treat specific health conditions or in preparation for or following medical procedures. Juices are transparent. It is used to keep the body hydrated and is easy to digest. It doesn't leave much residue in the stomach and intestines and helps the body get used to food again after long periods without food. Also used to prepare the patient in surgery. Full liquid diet The full liquid diet is low in iron, vitamin B12, vitamin A, and thiamine. It should not be used for a long period The full liquid diet is used as a step between a clear liquid diet and a regular diet. Since patient undergone an invasive Fruit juices like orange juice or nectars Fruit juices without pulp like apple juice. Broth foods and Water Indications or Purposes Tgis was ordered to prevent aspiration. Specific food taken Nothing

of time unless vitamins, iron, or liquid nutritional supplements are added. This diet has 1800 mg of calcium, so extra calcium is not needed.

procedure, full liquid diet is prescribed.

Soft Diet

Foods that easly chewed ad digested and swallowed

To prepare the body to assume regular diet.

Noodles and Bread

Diet as Tolerated

Kinds of Diet that the client tolerates what he/she wants to eat.

To meet the needed daily requirements of the nutrition of the patient and to sustain the body with vitamins and nutrients to resume the ADL of the patient.

Rice

Nursing Responsibilities > NPO (NOTHING PER OREM)

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

>CLEAR LIQUID DIET

 Check doctors order. Explain the reason of such diet to the patient, as well as with he patients significant other. Instruct the patient on what specific foods she can take. No nectars allowed. Fruit juices must be transparent such as apple juice. Offer alternatives in terms the client cannot or will not eat.

>FULL LIQUID DIET Check doctors order. Explain the reason of such diet to the patient, as well as with he patients significant other. Instruct the patient on what specific foods she can take. Instruct client she can eat nectars and fruit juices. Offer alternatives in terms the client cannot or will not eat. > SOFT DIET Check doctors order. Explain the reason of such diet to the patient, as well as with he patients significant other. Instruct the patient on what specific foods she can take. Serve small, frequent meals to avoid overwhelming the client with large amount of foods. Offer alternatives in terms the client cannot or will not eat. > DAT (DIET AS TOLERATED) Check doctors order. Explain the reason of such diet to the patient, as well as with he patients significant other. Instruct the patient on what specific foods she can take. Serve small, frequent meals to avoid overwhelming the client with large amount of foods. Offer alternatives in terms the client cannot or will not eat.

d. exercise Type of Exercise General description This is the usual position ordered for post-op. patient is positioned flat on bed, the head is erect or slightly flexed. Patient may change position periodically and gradually A patient can do the things she can like standing and sitting Indications or Purposes

Flat on bed

To prevent spinal headache

Turn side to side Ambulate

To promote peristalsis and mobilize secretions. To have adequate muscle strength and promote circulation

Nursing Responsibilities:

Check doctors 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.

> AMBULATION Explain to the client how you are going to assist, why ambulation is necessary, Ensure the client is appropriately dressed to walk and he wears slippers.

and how he can cooperate.

Prepare the client for ambulation. Ensure safety while assisting client to ambulate. Encourage client to ambulate independently if he is able. Remain physically close to the client in case assistance is needed at any point.

VI.SURGICAL MANAGEMENT A. Caesarean Section a. Brief Description

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 (D).

Abdominal incision One option is to use a midline infraumbilical incision to enter the peritoneal cavity. This incision provides quicker access to the uterus. In pregnancy, entry commonly is enhanced by diastasis of the rectus muscles. This incision is associated with less blood loss, easier examination of the upper abdomen, and easy extension cephalad around the umbilicus. If a patient is anticipated to have significant intra-abdominal adhesions from prior surgeries, a vertical incision may provide easier access into the abdomen, with better visualization. Upon reaching the rectus sheath, either the rectus sheath can be incised with a scalpel for the entire length of the incision or a small incision in the fascia can be made with a scalpel and then extended superiorly and inferiorly with scissors. Then, the rectus muscles (and pyramidalis muscles) are separated in the midline by sharp and blunt dissection. This act exposes the transversalis fascia and the peritoneum. The peritoneum is identified and entered at the superior aspect of the incision to avoid bladder injury. Prior to entering the peritoneum, care is taken to avoid incising adjacent bowel or omentum. Once the peritoneal cavity is entered, the peritoneal incision is extended sharply to the upper aspect of the incision superiorly and to the reflection over the bladder inferiorly. Most commonly, a transverse incision through the lower abdomen is made. The incision is either a Maylard or, more commonly, a Pfannenstiel incision. Transverse incisions take slightly longer to enter the peritoneal cavity, usually are less painful, have been associated with a smaller risk of

developing an incisional hernia, are preferred cosmetically, and can provide excellent visualization of the pelvis. The Pfannenstiel incision is curved slightly cephalad at the level of the pubic hairline. The incision extends slightly beyond the lateral borders of the rectus muscle bilaterally and is carried to the fascia. Then, the fascia is incised bilaterally for the full length of the incision. Then, the underlying rectus muscle is separated from the fascia both superiorly and inferiorly with blunt and sharp dissection. Clamp and ligate any blood vessels encountered. The rectus muscles are separated in the midline, and the peritoneum is entered. A Maylard incision is made approximately 2-3 cm above the symphysis and is quicker than a Pfannenstiel incision. It involves a transverse incision of the anterior rectus sheath and rectus muscle bilaterally. Identify and possibly ligate the superficial inferior epigastric vessels (located in the lateral third of each rectus). For most cesarean deliveries, only the medial two thirds of each rectus muscle usually needs to be divided. If more than two thirds of the rectus muscle is divided, identify and ligate the deep inferior epigastric vessels. The transversalis fascia and peritoneum are identified and incised transversely. Uterine incision Upon entering the peritoneal cavity, inspect the lower abdomen. The uterus is palpated and commonly is found to be dextrorotated such that the left round ligament is more anterior and closer to the midline. Dissect the bladder free of the lower uterine segment. Grasp the loose uterovesical peritoneum with forceps, and incise it with Metzenbaum scissors. The incision is extended bilaterally in an upward curvilinear fashion. The lower flap is grasped gently, and the bladder is separated from the lower uterus with blunt and sharp dissection. A bladder blade is placed to both displace and protect the bladder inferiorly and to provide exposure for the lower uterine segment (the acontractile portion of the uterus). One of essentially 2 incisions can be made on the uterus, either a transverse or vertical incision. The decision for the type of incision is based on several factors, including fetal presentation, gestational age, placental location, and presence of a well-developed lower uterine segment. The choice of incision must allow enough room to deliver the fetus without risking injury (either

tearing or cutting) to the uterine arteries and veins that are located at the lateral margins of the uterus. In more than 90% of cesarean deliveries, a low transverse (Monroe-Kerr) incision is made. The incision is made 1-2 cm above the original upper margin of the bladder with a scalpel. The initial incision is small and is continued into the uterine wall until either the fetal membranes are visualized or the cavity is entered (take care to not injure the underlying fetus). The incision is extended bilaterally and slightly cephalad. The incision can be extended with either sharp dissection or blunt dissection (usually with the index fingers of the surgeon). Blunt dissection has the potential for unpredictable extension, and care should be taken to avoid injury to the uterine vessels. The presenting part of the fetus is identified, and the fetus is delivered either as a vertex presentation or as a breech. With a low transverse incision, the risk for uterine rupture in subsequent pregnancies is approximately 1%, and patients can be counseled about the safety of an attempted trial of labor and vaginal birth. In some instances, a vertical incision is used. A vertical incision may be used if the lower segment is not well developed (ie, narrow), if an anterior placenta previa is present, or if the fetus is in a transverse lie or in a preterm nonvertex presentation. Again, the bladder has been dissected inferiorly to expose the lower segment, and the bladder blade has been placed. The vertical incision again is initiated with a scalpel in the inferior portion of the lower uterine segment. Care is taken to avoid injury to the underlying fetus, and the incision is carried into the uterus until the cavity is entered. When the cavity is entered, the incision is extended superiorly with sharp dissection. The fetus is identified and delivered. Note the extent of the superior portion of the uterine incision. If the incision is confined to the lower acontractile portion, it is considered a low vertical incision and patients can be counseled for a trial of labor and vaginal delivery in subsequent pregnancies. With a true low vertical incision, the risk of uterine rupture with a trial of labor is approximately 1-4%, with most recent reports finding a risk for uterine rupture of less than 2%. If the incision should be either extended into the contractile portion of the uterus or is made almost completely

in the upper contractile portion, the risk of uterine rupture in future pregnancies is 4-10% and patients are counseled to undergo a repeat cesarean delivery with all subsequent pregnancies. A vertical incision also may be considered in those cases where a hysterectomy may be planned in the setting of a placenta accreta or if the patient has a coexisting cervical cancer for which a hysterectomy would be the appropriate treatment. A vertical incision is associated with increased blood loss and longer operating time (takes longer to close) with less risk of injury to the uterine vessels than a low transverse incision. Delivery When the fetus is delivered, the umbilical cord is doubly clamped and cut. Blood is obtained from the cord for fetal blood typing, and a segment of cord is placed aside for attaining blood gas results if a concern exists regarding fetal status. Following delivery, oxytocin (20 U) is placed in the intravenous fluid to increase contractions of the uterus. The placenta usually is delivered manually. Awaiting spontaneous delivery of the placenta with gentle traction is more time consuming but is associated with decreased blood loss, lower risk of endometritis, and lower maternal exposure to fetal red blood cells, which can be important to Rh-negative mothers delivering an Rh-positive fetus. After delivery of the baby, administer prophylactic antibiotics. A single dose of ampicillin or a first-generation or second-generation cephalosporin is appropriate. If the surgery is prolonged, a second dose can be administered later. If the patient has chorioamnionitis, broader-spectrum antibiotics, such as gentamicin and clindamycin or Unasyn, are indicated and should be continued in the postoperative period until the patient is afebrile. Repair of the uterine incision Repair of the uterus can be facilitated by manual delivery of the uterine fundus through the abdominal incision. Externalizing the uterine fundus facilitates uterine massage, the ability to assess whether the uterus is atonic, and the examination of the adnexa.

The uterine cavity usually is wiped clean of all membranes with a dry laparotomy sponge, and the cervix can be dilated with an instrument, such as a Kelly clamp, if the patient underwent delivery with a previously undilated cervix. Typically, an Allis clamp is placed at the angles of the uterine incision. The incision is inspected for other bleeding vessels, and any extensions of the incision are evaluated. Inspect the bladder and lower segment inferior to the incision. Repair of a low transverse uterine incision can be performed in either a 1-layer or 2-layer fashion with zero or double-zero chromic or Vicryl suture. The first layer should include stitches placed lateral to each angle, with prior palpation of the location of the lateral uterine vessels. Most physicians use a continuous locking stitch. If the first layer is hemostatic, a second layer (Lembert stitch), which is used to imbricate the incision, does not need to be placed. A large prospective study has shown no increase in postoperative complications with a 1-layer versus 2layer closure. Although the risk of uterine rupture with subsequent trials of labor appears to not be increased with a 1-layer closure, the authors await follow-up data from this trial. Closure of a vertical incision usually requires several layers because the incision is through a thicker portion of the uterus. Again, a heavy suture material is used, and usually the first layer closes the inner half of the incision, with a second and possible third layer used to close the outer half and serosal edges. Again, note the extent of a vertical uterine incision because it impacts how a patient should be counseled regarding future pregnancies. When the uterus is closed, attention must be paid to its overall tone. An atonic uterus can be encountered in a patient with a multiple gestation, polyhydramnios, or a failed attempt at a vaginal delivery in which the patient was on Pitocin augmentation for a prolonged period. If the uterus does not feel firm and contracted with massage and intravenous oxytocin, consider intramuscular injections of prostaglandin (15-methyl-prostaglandin, Hemabate) or methylergonovine and repeat as appropriate. Continued closure If the uterine incision is hemostatic, the uterine fundus is replaced into the abdominal cavity (unless a concurrent tubal ligation is to be performed). The incision is reinspected for hemostasis, and the bladder flap also is inspected. The paracolic gutters are visualized, and any blood clots

are removed with dry laparotomy sponges. The vesicouterine peritoneum and parietal peritoneum can be reapproximated with a running chromic stitch. Many physicians prefer to not close the peritoneum because these surfaces reapproximate within 24-48 hours and can heal without scar formation. Furthermore, the rectus muscles to do not need to be reapproximated. The subfascial tissue is inspected for bleeding, and, if hemostatic, the fascia is closed. The fascia can be closed with a running stitch, and synthetic braided sutures are preferred over chromic sutures. Chromic sutures do not maintain their tensile strength as long or as predictably as synthetic braided material. If the patient is at risk for poor wound healing (eg, those with chronic steroid use), then a delayed absorbable or permanent suture can be used. Place stitches at approximately 1-cm intervals and more than 1 cm away from the incision line. The subcutaneous tissue should be inspected for hemostasis and can be irrigated according to physician preference. The subcutaneous tissue does not have to be reapproximated, but in patients who are obese (subcutaneous depth >2 cm), a drain may be placed and connected to an external bulb suction apparatus. The skin edges can be closed either with a subcuticular stitch or with staples (removed 3 or 4 d postoperatively). b. Nursing Responsibilities A catheter is inserted into her bladder and an intravenous (IV) line is inserted into her arm. Leads for monitoring the mother's heart rate, rhythm, and blood pressure are attached. In the operating room, the mother is given anesthesia, usually a regional anesthetic (epidural or spinal), making her numb from below her breasts to her toes. In some cases, a general anesthetic will be administered. Surgical drapes are placed over the body, except the head; these drapes block the direct view of the procedure. A woman who undergoes a c-section requires both the care given to any new mother and the care given to any patient recovering from major surgery. She should be offered pain medication that does not interfere with breastfeeding. She should be encouraged to get out of bed and walk around eight to 24 hours after surgery to stimulate circulation (thus avoiding the formation of blood clots) and bowel movement. She should limit climbing stairs to once a day, and avoid lifting anything heavier than the baby. She should nap as often as the baby sleeps, and

arrange for help with the housework, meals, and care of other children. She may resume driving after two weeks, although some doctors recommend waiting for six weeks, the typical recovery period from major surgery.

B. Hysterectomy

a.Brief description A hysterectomy is surgery to remove a womans uterus, or womb. The womb is the area where a baby grows when a woman is pregnant. During a hysterectomy, your doctor may remove the entire uterus or just part of it. The fallopian tubes (the tubes that connect the ovaries to the uterus) and ovaries may also be removed. Types of hysterectomy:

Partial (or supracervical) hysterectomy: The upper part of the uterus is removed. The cervix is left in place. Total hysterectomy: The entire uterus and cervix are removed. Radical hysterectomy: The uterus, upper part of the vagina, and tissue on both sides of the cervix are removed. This is most often done if you have cancer.

There are many different ways to perform a hysterectomy. It may be done through a surgical cut in either the belly (abdomen) or vagina.

Your doctor will help you decide which type of hysterectomy is best for you. The specific procedure depends on your medical history and reason for the surgery.

Abdominal hysterectomy: The surgeon makes a 5- to 7-inch surgical cut in the lower part of your belly. The cut may go either up and down, or it may go across your belly, just above your pubic hair. This is called a "bikini cut."

Vaginal hysterectomy: The surgeon makes a cut in your vagina and removes the uterus through this opening. The wound is be closed with stitches. Laparoscopic hysterectomy: A laparoscope is a narrow tube with a tiny camera on the end. Your surgeon will make 3 to 4 small cuts in your belly. The laparoscope and other surgical instruments will be inserted through the openings. The surgeon cuts the uterus into small pieces that can be removed through these openings.

Laparoscopy-assisted vaginal hysterectomy: The surgeon removes the uterus through a cut that is made inside your vagina. A laparoscope is used to guide the procedure. Robotic hysterectomy: This procedure is like laparoscopic surgery, but a special machine (robot) is used. Robotic surgery is most often used to perform a hysterectomy when a patient has cancer or is very overweight and vaginal surgery is not safe.

Procedure The hysterectomy surgical procedure can be performed several ways, vaginally, laparoscopically assisted, or open through the abdomen (abdominal hysterectomy). Regardless of the approach, a hysterectomy is an inpatient procedure that is done using general anesthesia. Generally speaking, laparoscopic patients heal the quickest, with a return to work and activity as quickly as two weeks, while open hysterectomy patients required six to nine weeks to return to normal activity. The approach varies with surgeon preference and the reason for the hysterectomy. A uterus with large tumors may not be able to be removed through the vagina or tiny laparoscopic incisions, but must be removed through the larger open incision. In most cases, the open approach is the least favored by surgeons, as blood loss is greater, recovery is longer and the risk of infection is higher.

Regardless of the approach used for the surgery, the procedure consists of separating the uterus from the ligaments and tissue that hold it in place and any scar tissue that may be present. It is then removed through the vagina or the abdominal incision. Once the surgeon has inspected the tissue for any tumors or bleeding and determines that the surgery is complete, the instruments are withdrawn and any incisions are closed. Abdominal laparoscopic incisions may be closed with absorbable sutures and sterile tape while open incisions will be held closed with staples or sutures that are removed weeks later by the surgeon. b. Nursing Responsibilities Before:

Obtain a informed consent, make sure that the patient truly understand the procedure and the reason for doing it. Instruct the patient to stop taking aspirin, ibuprofen (Advil, Motrin), clopidogrel (Plavix), warfarin (Coumadin), and any other drugs like these. If patient is smoking, ask her to stop it before the surgery Instruct the patient not to drink or eat anything for 8 hours before the surgery.

During: Assist in the procedure, make sure that aseptic principles are being followed.

After:

Give pain medication as ordered. Ask the patient to move or to do little exercise. This helps prevent blood clotsfrom forming in your legs and speeds up recovery. Instruct the diet that was ordered by the physician.

REFERENCES

Sources: www.americanpregnancy.org www.marchofdimes.com www.babymed.com/placenta-creta-accreta-increta-percreta www.medicinenet.com/pregnancy_placenta.../article.htm (http://www.scribd.com/doc/45777180/GREGORIO#fullscreen:on)