In this article, you will Read about how to write a nursing report for a Caesarean Section
HOW TO WRITE A NURSING REPORT FOR A CAESAREAN SECTION
Caesarean delivery is a surgical procedure used to deliver a baby through incisions in the abdomen and uterus from the skin. The indications for caesarean section includes previous caesarean section (C/S), dystocia, foetal distress, non progressive labour, multiple gestation with abnormal lie and breach presentation, a concerned medical condition like chronic pre eclampsia and eclampsia etc, large fibroid and macrosomic foetus. Some of the risk factors are respiratory challenges i.e. tachypnoea, surgical injury infection, post partum hemorrhage etc. it is the ability of the scrub nurse to observe the procedure from beginning or inception to the conclusion paying apt attention to whatever that is being done in the theatre. The actions of the surgeons, anesthetist, the attendants, portals and the midwives are keenly observed by the scrub nurse. The scrub nurse is often times the owner of the theatre operating room. After the operation room (OR) is cleaned by the attendants, the patient is wheeled to the theatre “red cross line” where relatives can’t go further accompanied by a nurse from the ward.
The scrub nurse takes over to patient and dresses her up with theatre gown to the operating room. Meanwhile, before wheeling to the OR the scrub nurse checks to confirm if the name of the folder is consistent with the operation list and if it is same diagnosis. This is to confirm if the patient is the right patient. He or she makes sure the informed consent form is duly signed by the right patient’s relative. When this is done the nurse goes in to scrub i.e. washing hands, putting on sterile gloves and wearing protective and sterile garments as the surgeon and his assistant does that too the anesthetist prepares the patient for either regional or general anesthesia depending on the kind of surgery. Thereafter, the chief surgeon drapes the patient and cleans the abdomen with antiseptic povidone iodine or disinfectant eusol depending on which is available.
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The scrub nurse takes cognizance of these processes and the kind of incision that the surgeon makes either midline (pfanerstein) or horizontal incision, the different kinds of sutures used for the different layers of the abdomen, such as skin, subcutaneous layer, rectus muscle, peritoneal sheath, and the peritoneum including the uterus.
Most times the common inner sutures in Nigeria is vicryl which could be 2/0, 1/0, 0, 1, 2, 3 etc while the non absorbable outer suture is nylon. The scrub nurse also observes the time of delivery of the baby, the period in which the umbilical cord was cut, was the baby delivered dead or alive? He or she notes when the placenta was delivered and which mechanism of placenta delivery was done? Other observations include the Apgar score during the first 1, 5 and 10 minutes. One thing to watch out for also is the diagnosis of the mother her gravid/Para information i.e. her history of how many children she has and how many pregnancies she has had. The reason for this elaborate and detailed report writing is to exhibit professionalism as well as free oneself from legal litigation in case anything goes wrong during the operation. These are things that will form the content of your report writing.
Finally, after writing the report the scrub nurse is vindicated. The nurse puts his or her signature to confirm that the surgery was actually witnessed and written by him or her. A good caesarean report should be brief and concise summarizing the key things above in just 2 minutes.
