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Breech Presentation, Medical Examination, Theory : Cesarean section, Lab …

- - - - support data
        
        S: Mother said "Milk is not flowing."
        
        O: maternal postpartum Day 1 Milk is not flowing.
        
        Implementation
        
        1.Evaluate the flow of milk
        
        2.Help to position the baby into the breast.
        
        3.Encourage the baby to suckle every 2 hours.
        
        4.Stimulate the suction of the baby
        
        Evaluation
        
        Baby well Active Good suckling Not regurgitation V/S BT 36.8 c PR 144 bpm RR 42 bpm
    - - support data
        
        S : -
        
        O : maternal postpartum have abdominal tear low transverse cesarean section,
        Total blood loss 500 cc
        
        Implementation
        
        Evaluate uterine contractions and measure high of fundus its should usually be no more than 6 inches above the pubis.
        
        wear a pad for observe bleeding per vagina and record. If the amount of bleeding during the first 2 hours is greater than 100 ml, there may be postpartum hemorrhage.
        
        Evaluate tissue for swelling, redness, and bleeding. May represent a separate wound and hematoma.
        
        Observe v/s q 4 hr
        
        Evaluate the signs and symptoms of shock in mother,The expression was pale and cold, the level of consciousness decreased.
        
        On 5%DN/2 1000 ml + syntocinon 20 U IV drip 120 cc/hr
        
        Retain foley cath
        
        Obs. maternal postpartum mild fatigu
        
        Evaluation
        
        maternal postpartum mild fatigue, no bleeding, The uterus is contracted, round, solid. No bladder full, V/S stable T= 37°C,P= 86/min, R= 20/min, BP= 132/86 mmHg
    - - support data
        
        S: Mother said "Pain the lesion cesarean section"
        
        O: maternal postpartum tired expression have Abdominal tear from low transverse cesarean section
        Pain score 3
        
        Implementation
        
        Giving nursing care softly and quickly and encouraging.
        
        Give the mother an opportunity to speak and express pain.
        
        Recommended to reduce the tension of the wound. such as careful movement.
        
        Recommended to avoid abrasion of the abdominal, pressure on the wound, abdominal and adjacent tissues and bed rest.
        
        Make sure to sleep in a comfortable position, such as lying on your side or with your head high.
        
        Observe and record the pain area. The nature, intensity and frequency of pain If the pain is very painful, report the carpool boss.To provide analgesic Paracetamol 1 tabs oral pm for pain q 4-6 hrs.
        
        1.Evaluate of pain by observing facial expressions, behavior, and asking pain scale.
        
        Care and assistance in doing various activities.
        
        Evaluation
        
        Maternal postpartum mild fatigue, said " Pain in the cesarean section region" Pain score 3 can rest, cesarean section incisions stick together well, no bleeding, no hematoma, has not received any pain medication
  - - - OR for C/S due to breech presentation
      - perineal shaving 14.30
      - NPO
      - CBC
      - Acetar 1000 ml v 100 ml/hr
      - PRC 1 u
      - Cefazolin 2 g v
      - retain foley cath No. 14
    - - Order for one day
        
        Record V/S q 15 min 4 times q 30 min 2 times q 1 hr Until stable
        
        5%DN/2 1000 ml + synto 20 u v 120 ml/hr
        
        5%DN/2 1000 ml v 120 ml/hr
      - Order for continuation
        
        NPO
        
        Record I/O
        
        off cath
        
        cefotaxim 1 g v q 6 hr × 3
        
        Medication
        
        re admit 1 month
        
        paracetamol 1 tab for pain
        
        cephalexin 1×3 oral hs
        
        ferrous fumarate 1×3 oral pc
- - - - Birth asphyxia
      - Fractures
      - Intracerebral Hemorrhage
    - - Obstetric Perineal Laceration
      - Postpartum Hemorrhage,