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Surgery on a woman’s reproductive organs most commonly involves an adult patient; however, sometimes an adolescent or young girl requires surgery.1 The perianesthesia nurse may encounter a pediatric patient having surgery to correct a congenital anomaly or an adolescent patient undergoing laparoscopy for incapacitating pelvic pain.¹ The cause of severe pelvic pain in a young female may be various gynecopathologies, e.g., endometriosis, adhesions, infection, ovarian cyst, appendicitis, or occasionally a tortuous ovary or fallopian tube.^1,2 Typically, these surgeries are done laparoscopically. It is becoming increasingly common to see adolescents with severe pelvic pain, often due to endometriosis, causing them to miss school and extracurricular activities. There is mounting evidence that early diagnosis and treatment in this age group may prevent the disease from progressing. (See www.endowhat.org for a nonprofit group that educates school nurses and people of all ages with regards to endometriosis; it is especially focused on teenagers and early diagnosis.)

Surgery on a female may be divided into three major categories: obstetric, lower genital and vaginal, and abdominal gynecologic surgery (Figs. 42.1 and 42.2). Abdominal surgery is then subdivided into either more traditional surgery in the form of a laparotomy, mini laparotomy (could include hand-assisted surgery through a mini-type laparotomy incision), or into the category of operative laparoscopy (typically two to four small incisions or, if robotic-assisted, four to seven incisions). The area of operative laparoscopy in gynecologic surgery has greatly expanded and generally includes benign gynecologic surgery, although it can also include gynecologic cancer (see Evidence-Based Practice). Even though minimally invasive surgery is growing in popularity, there continue to be a great number of laparotomies performed. The use of the robot has increased the number of laparoscopic procedures being performed; however, the debate continues among gynecologists regarding pros and cons of the robot. The debate includes questions such as, “Is the cost of the robot warranted?” or “With proper training, can these same procedures be done just as effectively without the robot?” and “What procedures have the best outcomes with each method?³ The perianesthesia nurse must be aware of how the care of the patient differs with these various approaches.

Sagittal section of pelvis shows labels (clockwise) as follows: Suspensory ligament (of uterine tube), ovarian ligament, body of uterus, fundus of uterus, round ligament, vesicouterine pouch, parietal peritoneum, urinary bladder, pubic symphysis, urethra, clitoris, labium minus, labium majus, vagina, anus, coccyx, fornix of vagina, cervix, rectouterine pouch (of Douglas), uterosacral ligament, ureter, uterine tube, and sacral promontory.

Internal female reproductive system shows labels (clockwise) as follows: Isthmus of uterine tube, ovarian ligament, ampulla of uterine tube, infundibulum of uterine tube, fimbriae, ovary, ovarian fimbria, broad ligament, uterine artery and vein, vagina, external o s of vaginal cervix, fornix of vagina, cervix of uterus (internal o s of cervix, cervical canal), body of uterus (myometrium, endometrium, uterine body cavity, and fundus of uterus).

Definitions

OBSTETRIC SURGERY

Cervical Cerclage Procedure to treat cervical insufficiency. A cerclage can be done based on the patient’s history, ultrasound, or physical examination. The McDonald procedure involves the placement of a purse-string suture around the cervix at the level of the internal os. The Shirodkar procedure also requires dissection of the bladder and rectum and is less common.⁴

Cesarean Hysterectomy Incision into the abdomen, delivery of an infant through an incision made in the uterus (hysterotomy), extraction of the placenta, and removal of the uterus.

Cesarean Delivery (C-Section) Delivery of an infant through an incision made in the abdominal and uterine walls (hysterotomy).⁵

C-Section, Classic The hysterotomy is made through a vertical incision in the wall of the uterus.

C-Section, Low Segment The hysterotomy is a transverse incision in the lower part of the uterus made after a classic or low segment incision.⁵ This is the most common surgical method as there is less blood loss, the uterus is easier to repair, and there is a lower risk of uterine dehiscence (rupture) in future pregnancies.⁵

Ectopic Pregnancy Implantation of the fertilized ovum in any site other than the upper half of the uterus.

Uterine Aspiration (Suction Curettage) Dilation of the cervix and vacuum removal of the uterine contents.

LOWER GENITAL SURGERY AND VAGINAL SURGERY

Anterior and Posterior Repair Reconstruction of the vaginal walls (colporrhaphy), the pelvic floor, and the muscles and fascia of the rectum, urethra, bladder, and perineum (perineorrhaphy). Used to correct a cystocele, enterocele, paravaginal repair, and rectocele; restore the bladder to its normal position; and strengthen the vagina and the pelvic floor.

Bartholin’s Duct Cyst A cyst that results from blockage and inflammation of one of the major vestibular glands at the vaginal introitus.

Bartholinectomy Removal of a Bartholin duct cyst.

Cervical Conization Removal of abnormal cervical tissue via scalpel or electrosurgical current (loop electrosurgical excision procedure [LEEP]). A cold knife cone is a more aggressive excision that weakens the cervix. Cervical conization is important to consider in future fertility and may increase the necessity of a cervical cerclage early in a pregnancy to prevent miscarriage. The risk of bleeding during and after the procedure may be greater when electrosurgery is not used. For these reasons, LEEP is the most common of these techniques.^6,7

Colporrhaphy Repair of the vaginal wall. May be anterior, as in cystocele repair, or posterior, as in rectocele repair or enterocele repair specifically for vaginal prolapse.

Culdoscopy An operative diagnostic procedure in which an incision is made into the posterior vaginal cul-de-sac through which a tubular instrument, similar to a hysteroscope or cystoscope (transvaginal endoscopy), is inserted for the purpose of visualization of the pelvic structures.⁸

Cystocele Prolapse of the bladder into the anterior vaginal wall.

Dilation and Curettage (D&C) Introduction of instruments (dilators) through the vagina to dilate the cervical canal and scraping of the endometrium or lining of the uterus with a curette for removal of tissue including blood. This procedure is used for diagnosis and/or treatment of conditions such as incomplete abortion, abnormal uterine bleeding, primary dysmenorrhea, therapeutic abortion, endometrial polyps, and endometrial cancer.

Enterocele Prolapse of the small intestine into the upper portion of the vagina.

Hysteroscopy Direct visualization of the canal of the uterine cervix and cavity of the uterus with an endoscope called a hysteroscope.

Prolapse of the Uterus Downward displacement and/or protrusion of the uterus into the vagina. Vaginal hysterectomy is often recommended for a prolapsed uterus when childbearing is no longer desired or when marked prolapse is present. Procidentia is complete prolapse of the uterus beyond the introitus.

Rectocele Prolapse of the rectum into the posterior vaginal wall.

Trachelorrhaphy Removal of torn surfaces of the anterior and posterior cervical lips and reconstruction of the cervical canal.

Trachelectomy Removal of the cervix (patients who have previously had a supracervical hysterectomy may need removal of their cervix at a later date due to prolapse, bleeding, pain, adenomyosis, or cervical cancer).

Urethrocele Prolapse of the urethra into the anterior vaginal wall.

ABDOMINAL GYNECOLOGIC SURGERY (LAPAROTOMY, MINI LAPAROTOMY, OR LAPAROSCOPY WITH OR WITHOUT THE ASSISTANCE OF A ROBOT)

Abdominal Myomectomy Removal of leiomyomas (fibroids) through a large or small incision; if this is done laparoscopically, then the abdominal cavity is visualized through a small incision (5, 10, or 12 mm), usually at the umbilicus after the establishment of a pneumoperitoneum. Because most types of mechanical morcellation have been removed from the market, laparoscopic removal of fibroids must be done either by extending the umbilical incision, doing a mini laparotomy, or doing a colpotomy.⁹

FALLOPIAN TUBE TORSION

Hysterectomy Removal of the uterus; can be vaginal, laparoscopic (with or without the assistance of the robot), or abdominal laparotomy.

Hysterectomy, Radical Removal of the uterus, the uterosacral and uterovesical ligaments, the upper third of the vagina, and all of the peritoneum. This may or may not include removal of the fallopian tubes and/or ovaries. If there is suspected malignancy, a gynecologic oncologist may be doing the surgery or consulted. In cases of malignancy, the lymph nodes may be removed at this time (lymphadenectomy).

Hysterectomy, Supracervical Removal of the uterus without removing the cervix (most commonly done laparoscopically). Umbilical incision must be extended to remove the uterus as most mechanical morcellators are no longer available.⁹

Hysterectomy, Total Abdominal Removal of the uterus, including the cervix (with or without the adnexa, which refers to the tube and/or ovary), through an abdominal incision. Types of laparoscopic hysterectomy include: (1) Laparoscopic total hysterectomy (LTH) or total laparoscopic hysterectomy (TLH); the uterus is removed laparoscopically, and the vaginal cuff is sutured laparoscopically. (2) Laparoscopic-assisted vaginal hysterectomy (LAVH); the uterus is reached laparoscopically and removed vaginally. The vaginal cuff is sutured vaginally. (3) Laparoscopic supracervical hysterectomy (LSH); the uterus is removed laparoscopically and the cervix remains. This is thought to be the hysterectomy with the least morbidity and the quickest recovery for the patient postoperatively because there is no vaginal incision. The umbilical incision is extended to remove the uterus.⁹

Oophorectomy Removal of an ovary.

Oophorocystectomy Removal of an ovarian cyst.

Salpingectomy Removal of the fallopian tube. If a woman is undergoing hysterectomy and wants to preserve her ovaries, bilateral salpingectomy is done at the time of hysterectomy to help prevent future ovarian cancer (research shows significant evidence that the fallopian tube is the origin for most pelvic serous carcinomas that have traditionally been assumed to be ovarian in origin).¹⁰

Salpingo-Oophorectomy Removal of the fallopian tube and the associated ovary.

Salpingostomy (Tubal Plasty) Repair and opening of the fallopian tube to establish patency. This is often done in the case of a hydrosalpinx. Tubal plasty or tubal reanastomosis is used for removal of an obstructed portion of the tube and reconnection of each normal end of the tube after the obstruction has been removed to establish patency. Tubal reanastomosis increases the risk of ectopic pregnancy.^11,12

Tubal Sterilization (Ligation) Interruption of fallopian tube continuity, which results in sterilization; this may be done laparoscopically. The fallopian tube is cauterized or ligated, a clip is placed, or the tube is partially excised. NOTE: There are currently tubal sterilization techniques that are being done hysteroscopically with the use of a material that occludes each fallopian tube. Further research needs to be done to compare the efficacy and safety of these techniques compared with laparoscopic tubal sterilization.¹³

Obstetric surgery

Obstetric surgery involves procedures on pregnant women to promote full-term pregnancy, to provide an alternative means of delivery when normal vaginal delivery is not feasible, and for reasons of fetal or maternal well-being.

Care after Specific Procedures

Cesarean Delivery

Cesarean deliveries are performed on both an emergency and an elective basis. These patients have special physical and psychological needs. Cesarean deliveries are indicated for nonreasurring fetal heart patterns, labor dystocia malpresentation (breech or transverse lie), and placenta previa; some hypertensive disorders of pregnancy; certain medical complications; and previous cesarean delivery.^14,15 The lower segment cesarean delivery is usually the procedure of choice.⁵ Regional anesthesia is most common and safest for both mother and fetus, but, in indicated circumstances, general inhalation may be needed usually for emergency delivery or severe thrombocytopenia. Postoperative care after cesarean delivery includes all care rendered to a patient who undergoes abdominal surgery and postdelivery.^15–17

On admission to the postanesthesia care unit (PACU), a report is given by the circulating nurse who transports the patient with the anesthesia provider to the PACU area. The patient’s vital signs should be monitored regularly in keeping with the PACU guidelines in the facility. As soon as the patient’s condition permits, the patient can assume any position of comfort. Oxygen should be delivered as indicated by pulse oximetry monitoring.

Parenteral fluids are usually administered during the first 24 hours after surgery, but oral fluids can be resumed as the patient desires and tolerates unless otherwise indicated.^17,18 Intravenous (IV) fluids often contain oxytocin to increase uterine muscle tone and stop excessive blood flow.¹⁹ Usually 10 to 20 units of oxytocin are added to 1000 mL of lactated Ringer’s solution and infused at 125 mL/h. Side effects with oxytocin are not common. Serious side effects are rare but include allergic reaction, water intoxication, difficulty in urination, chest pain or irregular heartbeat, difficulty in breathing, confusion, sudden weight gain or excessive swelling, severe headache, rash, or seizures. Other less serious side effects may be more likely to occur and include redness or irritation at the injection site, loss of appetite, and nausea or vomiting. The physician should be notified if any side effects occur. Perianesthesia nurses should be familiar with potential side effects. Intake and output should always be monitored appropriately in the PACU regardless of what medications are given.^15,17,18

The patient’s abdominal dressing and perineal pad should be inspected for drainage. The abdominal dressing should remain dry and intact. A moderate amount of lochia rubra is normal, but saturation of two or more perineal pads with blood during the first hour is considered excessive. The area underneath the buttocks should be checked for pooling of blood.

The fundus should be checked frequently to ensure that it is firmly contracted. Assessment of the fundus is an uncomfortable procedure for the patient; therefore, careful explanation should be provided before it is performed. The patient should be encouraged to relax the abdominal muscles as much as possible. Slow, deep breathing with an open mouth facilitates relaxation of those muscles. If the uterus is soft and “boggy,” it should be gently but firmly massaged through the abdominal wall to stimulate contraction. The patient may be instructed to do this herself with supervision, which may allay anxiety and be more comfortable. Prophylactic oxytocin is administered for the third stage of labor to prevent postpartum hemorrhage.¹⁹ A provider should be notified of persistent heavy lochia or a boggy uterus. One less common cause of uterine atony in the PACU may be a full bladder, although unlikely as an indwelling urethral catheter commonly is left in place for the first 6 to 8 postoperative hours or until regional anesthesia has worn off. A fundus palpated above the umbilicus or to the side of the abdomen (usually the right side) may indicate a nonfunctioning catheter. The catheter should be positioned for gravitational drainage and avoidance of kinks. The urine should be monitored for volume and color.

Many patients have transient trembling or shivering after delivery. Several theories have been proposed regarding this sense of chilling, although the actual cause remains unknown. This trembling is generally not associated with an elevation of temperature. Warmed blankets or warm-air therapy should be available as a comfort measure.¹⁷ Many hospitals have separate PACUs for postpartum patients; therefore, the special considerations for the cesarean delivery patient pose no significant problems. The nurse who cares for the cesarean delivery patient within the general PACU must be judicious and often innovative to meet the needs of the mother and the new family. The mother, the neonate, and the father should be together as soon as possible to allow for the bonding experience. This experience can be accomplished using a quiet corner of the unit (if such a place exists), drawing curtains around the family, or expediting the discharge process to transfer the patient to the postpartum unit.

Skin-to-skin care for the first hour (or more) after delivery is rapidly becoming the standard of care. Skin-to-skin care improves thermoregulation of the newborn and is important for the initiation of breastfeeding.^20,21 The mother and father are anxious to review the details of the birth together, and the perianesthesia nurse should be prepared to answer questions. Consistent communication between the surgical nurse and the perianesthesia nursing staff makes answering these questions much easier.¹⁷

Ectopic Pregnancy

Faulty implantation of the ovum occurs in approximately 2% of pregnancies and can take place in the fallopian tube (in approximately 98% of all ectopic pregnancies), in the ovary, in any part of the abdominal cavity, or in the uterine cervix (Fig. 42.3).^22,23 Traditionally, the treatment of choice for an ectopic pregnancy in the fallopian tube was laparoscopy (or laparotomy) with removal of the ectopic pregnancy and most often with preservation of the fallopian tube. However, patients with the early diagnosis of an unruptured ectopic pregnancy who meet selection criteria can receive intramuscular methotrexate and avoid surgery.^22,23 Regardless of the treatment, these patients must have proper follow-up with their physicians to ensure successful treatment, which involves follow-up quantitative human chorionic gonadotropin (HCG) studies and possibly ultrasound scans as well.

If laparoscopy is performed, the ovary is not resected or removed unless the ovary is involved with the ectopic pregnancy. If implantation occurs in the cervix or cesarean scar, a hysterectomy may be indicated to control hemorrhage.²⁴ A call for conservative treatment without a hysterectomy is growing backed by multiple case studies and commentaries in the literature.²⁴ If abdominal implantation has occurred, the fetus is removed and the placenta often is left within the cavity to be reabsorbed. Methotrexate may also be recommended.^25,26

Laparoscopy (or laparotomy) is performed with general anesthesia. Postanesthesia care is standard care as for any postlaparoscopy procedure including assessment of vaginal drainage.¹⁷ The perianesthesia nurse should be especially observant for signs of intra-abdominal hemorrhage and shock because these are not uncommon complications of ectopic pregnancy, especially one that has ruptured before surgery. All patients with an ectopic pregnancy should be typed and screened unless the patient is already hemodynamically unstable. In case of hemorrhage, packed red blood cells are generally used for transfusions (good for 3 days).²⁴ Women who are Rh negative must receive alloimmunization to prevent sensitization.²⁷ As mentioned previously, many ectopic pregnancies are successfully treated without surgery and only with medications.^25,26 Nurses caring for these patients should remember that the patient may perceive this as a pregnancy loss and need appropriate supportive comfort care. The greatest factor in perinatal grief is not the length of gestation but the woman’s perception of the pregnancy.²⁸

Cervical Cerclage

The McDonald or Shirodkar procedure is used to treat cervical insufficiency (the cervix dilates and thins out too early) and is fairly successful in reducing preterm birth in singleton pregnancies. The suture is usually placed between the 14th and 18th weeks of gestation. These procedures may be accomplished with general, spinal, or regional anesthesia.4^,29–31

On admission to the PACU, hospital guidelines are followed on patient admission to the PACU and care of the patient (see Chapters 27 and 28).^17,32 Pain should be minimal and easily controlled with a simple analgesic such as acetaminophen. Any gross vaginal bleeding or abdominal cramping should be reported to the surgeon because this procedure may indicate labor and expulsion of the uterine contents. The obstetrician may also order indomethacin, a prostaglandin synthetase inhibitor, to reduce uterine contractions, with a dosage of 25 or 50 mg administered orally.³³ If labor begins, the suture must be removed immediately, as there is risk that the cerclage suture will tear, resulting in significant cervical bleeding.

Dilation and Curettage

Dilation of the cervix and curettage of the uterus (D&C) is used for the termination of early pregnancy (i.e., first trimester) or in treatment of incomplete spontaneous abortion as well as diagnostic purposes. A general anesthetic can be used, but the trend has been toward the use of paracervical block and IV moderate sedation. Nursing care in the PACU is essentially the same as after D&C by conventional means, with attention to the amount of cramping, discomfort, and vaginal bleeding, which should be minimal. Complications from this procedure include incomplete evacuation and hemorrhage, which may be treated with misoprostol, methylergonovine, or oxytocin.34 Uterine perforation can occur and must be treated surgically. The woman who is Rh negative should receive treatment to prevent sensitization.²⁷

Gynecologic surgery

Gynecologic surgery has changed considerably for several reasons. The first reason is that more young females are requiring gynecologic surgery for treatment of pelvic pain and less frequently for congenital anomalies. More young females are being seen for incapacitating pelvic pain that may be caused by endometriosis in particular to the extent that surgical intervention is required. Parents, school nurses, teachers, coaches, pediatricians, and other health care providers need to be aware of this. Generally, pelvic pain is associated with the menstrual cycle.1

In general, women may have incapacitating pelvic pain requiring surgery.^35–38 This is usually due to severe menstrual cramps and bleeding often associated with endometriosis, fibroids, ovarian cysts, adhesions, or infection. Another common reason for gynecologic surgery is pelvic floor prolapse. Patients with prolonged or heavy menstrual periods may be more chronically anemic. Large amounts of blood may have accumulated within the pelvic organs at the time of surgery. Although the procedure may be elective, many gynecologic operations are associated with significant blood loss, depending on the approach taken. This can be affected by a larger uterus with multiple fibroids. A well-trained laparoscopic surgeon and team should increase efficiency intraoperatively, reduce blood loss, limit complications, and decrease postoperative morbidity.

In the case of a premenopausal woman undergoing a hysterectomy where the uterus is large or a myomectomy, the uterine vessels may be significantly larger than usual. Regardless of the approach (laparoscopy with or without the robot, vaginal, or laparotomy), all vessels and pedicles must be identified and coagulated or ligated effectively. In addition, because of the proximity of the female organs to the urinary tract, great care must be taken during surgery to identify the ureters and bladder. Also, the bowel must be safely out of the way to prevent injury. Proper postoperative observation and follow-up of all systems must be done. If there is any question regarding the urinary tract during surgery, a cystoscopy should be done near the conclusion of the surgery.^39,40

Gynecologic surgery is increasingly being performed with a minimally invasive approach.⁴¹ These procedures are often done laparoscopically, and the robot may or may not be used. The perianesthesia nurse needs to know how to care for the patient regardless of the approach taken.^17,42,43 In addition to overall assessment and general care of these patients, the perianesthesia nurse should direct specific attention toward the patient’s cardiovascular status, renal function, and fluid balance.¹⁷

Laparoscopy

Operative laparoscopy commonly is performed as outpatient surgery (23-hour overnight stay) for treatment of benign gynecologic problems and may involve advanced operative laparoscopic procedures for more significant problems that involve the pelvic organs. A small incision (approximately 1 cm) is made at the subumbilical site for insertion of the primary trocar (typically 5, 10, or 12 mm in diameter), which houses the laparoscope with attached video camera for visualization of the pelvis (Fig. 42.4). The entry into the pelvic cavity can be done in various ways, one of which includes open laparoscopy, particularly for patients who have had multiple previous surgeries to protect against injuring the bowel.⁴¹ When a patient has had multiple previous surgeries, the bowel is more likely to be adhered to the abdominal wall. After pneumoperitoneum is established, the surgeon can visualize the organs within the peritoneum. The video camera enables the surgeon, first assistant, scrub technician, and entire team to view the procedure on the video monitor (Fig. 42.5). A high-definition video camera attached to the laparoscope provides visualization of the pelvis. Continued advances in digital technology increase the resolution and lighting dramatically. Visualization of the abdomen and pelvis continues to improve (Fig. 42.6). The surgeon generally uses a laparoscope that is 5, 10, or 12 mm in diameter. Ancillary instruments are typically 5 to 12 mm in diameter. An angled laparoscope may be used for difficult cases when there is a large uterus to improve visualization. If the robot is used, it is connected after the trocars have been placed. The robot offers three-dimensional visualization that some find appealing. The surgeon sits at a console and is able to maneuver the instrumentation from that location while the surgical assistant is at the patient’s side and using instrumentation such as suction and irrigation. In addition, a surgical technologist is typically present between the patient’s legs (similar to laparoscopy without the robot) to manipulate the uterus with a uterine manipulator. If an emergency arises with bleeding that cannot be controlled, the robot is quickly disengaged so that a laparotomy can quickly be initiated. Newer robots may have two consoles so that the surgeon may have a student surgeon (resident or fellow) at the secondary console to work and receive instruction.^44–46

Female torso shows five trocar sites of either 5 or 12 millimeters. One 12 millimeters trocar site in the middle of upper quadrant, second 5 millimeters site to the left in-between upper and lower quadrant, two 5 millimeters and one 12 millimeters trocar site in lower quadrant. 12 millimeters trocar site in the lower quadrant is 12 centimeters away from vagina.

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