Obstetric Surgery
Managing Complications in Pregnancy and Childbirth
Session Objectives
To describe general principles of obstetric
surgery
*
To describe common surgical procedures in
emergency obstetric care
Basic Principle
The woman is the primary focus of the doctor, midwife and nurse during
any operative procedure
Pre-Operative Care
Ensure that the operating room is fully
functional
Prepare the woman for surgery by explaining to
her the procedure to be done and its purpose.
Obtain her informed consent
Obtain her informed consent
Review her medical history for problems and
indication for surgery and do appropriate laboratory tests
Administer appropriate pre-anesthetic
medications
Intra-Operative Care
Place the woman in a position appropriate for
the procedure
Ensure sterile technique
Handle tissue gently—minimize tissue damage
Ensure hemostasis, adequate pain relief and hydration
Monitor her condition throughout the procedure
and initiate treatment if condition worsens
Intra-Operative Care
–
Place the woman in a position appropriate for
the procedure
–
Ensure sterile technique
–
Handle tissue gently—minimize tissue damage
–
Ensure hemostasis, adequate pain relief and
hydration
–
Monitor her condition throughout the procedure
and initiate treatment if condition worsens
Intra-Operative Care
- Place the woman in a position appropriate for the procedure
- Ensure sterile technique
- Handle tissue gently—minimize tissue damage
- Ensure hemostasis, adequate pain relief and hydration
- Monitor her condition throughout the procedure and initiate treatment if condition worsens
Postoperative Care
- Ensure clear airway, ventilation, hydration and pain relief
- Monitor vital signs and level of consciousness every 15 minutes until she is awake and her condition is stable
- Start on oral fluids as tolerated and change to normal meal
- Encourage ambulation
- Remove skin sutures when the wound has healed
Common Obstetric Surgery
Cesarean section
Salpingectomy for ectopic pregnancy
Laparotomy for ruptured uterus
Postpartum hysterectomy
Common Obstetric Surgery
–
Cesarean section
–
Salpingectomy for ectopic pregnancy
–
Laparotomy for ruptured uterus
–
Postpartum hysterectomy
Common Obstetric Surgery
l Cesarean
section
l Salpingectomy
for ectopic pregnancy
l Laparotomy
for ruptured uterus
l Postpartum
hysterectomy
Cesarean Section
l
May be done under local, spinal or general
anesthesia
l
Anticipate and prepare for problems during
childbirth (e.g., difficulty in delivering a head deep in the pelvis)
l
Vertical abdominal incision is preferred if
local anesthesia is used
l
Open the lower segment of the uterus
transversely and deliver the newborn, placenta and membranes
l
Give prophylactic antibiotic and oxytocin
l
Close the uterus and abdomen after ensuring
hemostasis
Problems Encountered During Cesarean Section
l
Difficulty in controlling bleeding
–
Oxytocics, massage, sutures
–
Uterine and utero-ovarian artery ligation,
hysterectomy
l
Difficulty in delivering malpresentation
–
Anticipate and perform appropriate manipulations
for childbirth
l
Placenta previa/Adherent placenta
–
Incise placenta and deliver
–
Hysterectomy if placenta cannot be removed or
uncontrollable bleeding
Cesarean Section: Post-Procedure Care
l
Watch for postpartum bleeding
–
Give oxytocin infusion after surgery
l
Give adequate analgesia and hydration
l
Encourage early feeding and ambulation
l
Explain what was done and its implications to
the woman
Salpingectomy for Ectopic Pregnancy
l
May be done under spinal or general anesthesia
l
Open the abdomen and identify the fallopian tube
with the ectopic pregnancy
l
Clamp the mesosalpinx to stop bleeding
l
Do a salpingectomy
l
Check the other tube, ovaries and other pelvic
organs for pathology
l
Close the abdomen after giving prophylactic
antibiotics
l
Give adequate analgesia and hydration
l
Encourage early feeding and ambulation
l
Explain what was done and its implications to
the woman
Laparotomy for Ruptured Uterus
l
May be done under spinal or general anesthesia
l
Open the abdomen and deliver the newborn and placenta
l
Lift the uterus out of the incision to visualize
the extent of the rupture. Suture together the edges of the rupture. If repair
is not possible, do hysterectomy
l
Examine the bladder for rupture and repair if
ruptured
l
Close the abdomen after giving prophylactic
antibiotics and oxytocin infusion
l
Leave drain if hemostasis is not satisfactory
l
Give adequate analgesia and hydration
l
Encourage early feeding and ambulation
l
Explain what was done and its implications to
the woman
Postpartum Hysterectomy
l
May be done under spinal or general anesthesia
l
Hysterectomy may be
–
Subtotal if cervix is left behind
–
Total if the cervix is removed
l
Lift the uterus out through the incision and
compress it to reduce bleeding
l
Clamp and divide round ligament, tubes and
ovarian ligaments but ligate pedicles after uterine artery has been tied
l
Separate the urinary bladder away from the lower
segment
l
WARNING: The ureters are close to the uterine
vessels
l
For sub-total hysterectomy: Ligate the uterine
arteries and amputate the uterus just above this level
l
For total hysterectomy: Divide cardinal
ligaments to remove cervix
l
Close the stump
l
Ensure hemostasis. Leave drain if hemostasis is
not satisfactory
l
Give adequate analgesia and hydration
l
Encourage early feeding and ambulation
l
Explain what was done and its implications to
the woman