42 Care of the obstetric and gynecologic surgical patient
Cerclage Procedure: Procedure for the treatment of incompetent cervix. The McDonald procedure involves the placement of a pursestring suture on the cervix at the level of the internal os. The Shirodkar’s procedure involves placement of a fascia lata (from the thigh) or a surgical band at the level of the internal os.
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 cystoscope is inserted for the purpose of visualization of the pelvic structures, including the uterus, fallopian tubes, broad ligaments, uterosacral ligaments, rectal wall, sigmoid colon, and sometimes the small intestine. A newer technique for this procedure is transvaginal hydrolaparoscopy, which uses normal saline solution and a camera attached to a small-diameter rigid endoscope.
Dilation of the Cervix and Curettage of the Uterus (D&C): Introduction of instruments (dilators) through the vagina into the cervical canal and scraping of the uterus with a curette for removal of substances, including blood. This procedure is used for diagnostic purposes and for treatment of conditions such as incomplete abortion, abnormal uterine bleeding, and primary dysmenorrhea.
Prolapse of the Uterus: Downward displacement of the uterus. Vaginal hysterectomy is often recommended for a prolapsed uterus when childbearing is no longer desired or when marked prolapse is present.
Vaginal Plastic Operation (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. Used to correct a cystocele or rectocele, restore the bladder to its normal position, and strengthen the vagina and the pelvic floor.
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, usually at the umbilicus after the establishment of a pneumoperitoneum. A video camera is attached to the eye piece of the laparoscope so that the surgeon and team can visualize the procedure while watching a video monitor; this provides a magnified view of the pelvis. If the robot is used, it is often set up after the umbilical trocar is in position.
Radical Hysterectomy: Removal of the uterus, the uterosacral and uterovesical ligaments, the upper third of the vagina, and all the peritoneum. This may or may not include removal of the fallopian tubes and ovaries.
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. Because the success rates of in vitro fertilization are so good, this procedure is seldom done anymore.
Total Abdominal Hysterectomy: Removal of the uterus, including the cervix (with or without the adnexa which refers to the tube and/or ovary), through an abdominal incision. Various types of hysterectomy include the following if done laparoscopically:
LSH: Laparoscopic supracervical hysterectomy; 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.
NOTE: If a robot is used, the robot must be disconnected for any tissue to be removed. One of the main reasons some physicians choose to use the robot is because they find suturing laparoscopically much easier with the robot.
Tubal Ligation: Interruption of fallopian tube continuity, which results in sterilization; this is most commonly done laparoscopically. The fallopian tube is cauterized or ligated, a clip is placed, or the tube is partially excised. Reversal procedures can be attempted with tubal reanastomosis using microsurgery; however, this is seldom done because the success rate of IVF is so high.
Traditionally, surgery on organs of reproduction usually involved an adult patient. However, in most recent years as girls reach puberty at earlier ages, it is becoming more frequent for young girls in their teens to have laparoscopic surgery for conditions such as endometriosis.1 In addition, the perianesthesia nurse may encounter pediatric or adolescent female patients who undergo gynecologic surgery for repair or correction of congenital or traumatic deformities or incapacitating pelvic pain from causes such as endometriosis, ovarian cyst, or appendicitis. Surgery on the female genitalia may be conveniently divided into three major categories: obstetric, lower genital and vaginal, and abdominal gynecologic surgery. Abdominal surgery is then subdivided into either what used to be referred to as 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 or three small incisions or robotic surgery, which may include four to seven incisions). The area of operative laparoscopy in gynecologic surgery has expanded and includes the majority of benign gynecologic surgery. However, there are still a great number of laparotomies currently performed. Many surgeons who previously have not felt comfortable performing laparoscopic procedures are now doing so with the aid of the robot. There is much debate among gynecologists as to whether the learning curve is shorter with the use of the robot. Whether or not that is the case, the bigger questions are “Is the cost of the robot warranted?” and “With proper training, can these same procedures be done just as effectively without the robot?” The perianesthesia nurse must be aware of how the care of the patient differs with these various approaches.
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 for reasons of fetal or maternal well being, and to interrupt pregnancy.
Cesarean sections are performed on both an emergency and an elective basis. These patients have special physical and psychological needs. A selection of articles is included in the bibliography at the end of this chapter to assist the reader who provides care for families who experience cesarean birth.
Cesarean sections are indicated for dystocia (usually caused by cephalopelvic disproportion); antepartum bleeding; some toxemic conditions; certain medical complications, especially diabetes mellitus; and previous cesarean section. The low-segment cesarean section is usually the procedure of choice. Anesthesia may be general inhalation, spinal, or local infiltration of the operative field. Postoperative care after cesarean section includes all care rendered to a patient who undergoes abdominal surgery and postpartum care.
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 condition permits, the patient can assume any position of comfort. Oxygen should be delivered and monitored with the use of pulse oximetry.2
Parenteral fluids are usually administered during the first 24 hours after surgery, but oral fluids can usually be resumed as soon as bowel sounds are audible and the patient desires. Intravenous fluids often contain oxytocin to increase uterine muscle tone and stop excessive blood flow. Usually 10 to 20 units of oxytocin are added to 1000 mL of lactated Ringer solution and infused at 125 mL/h. Side effects with oxytocin are not common. Serious side effects include an allergic reaction (shortness of breath; closing of the throat; hives; swelling of the lips, face, or tongue; rash; or fainting), difficulty in urination, chest pain or irregular heart beat, difficulty in breathing, confusion, sudden weight gain or excessive swelling, severe headache, rash, excessive vaginal bleeding, 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. A progressive diet is advised, pending the return of bowel sounds.
The patient has an abdominal dressing and a perineal pad; both 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. Checking 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 firmly contracted, it need not be massaged, and in fact should not be massaged, because massage may cause uterine muscle fatigue and subsequent relaxation and bleeding. 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. Oxytocin often is administered intravenously and titrated to maintain the uterus in a state of contraction. If oxytocin is used, the uterus should be checked for firmness, but usually does not need frequent massage.
A full bladder is one cause of uterine atony. An indwelling urethral catheter commonly is left in place for the first 12 postoperative hours. 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. Many hospitals have separate PACUs for postpartum patients; therefore the special considerations for the cesarean section patient pose no significant problems. The nurse who cares for the cesarean section 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. 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.