Obstetric Surgery

1
Obstetric Surgery

• Managing Complications in Pregnancy and Childbirth

2
Session Objectives

• To describe general principles of obstetric
  surgery
• To describe common surgical procedures in
  emergency obstetric care

3
Basic Principle

• The woman is the primary focus of the doctor,
  midwife and nurse during any operative procedure

4
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
• Review her medical history for problems and
  indication for surgery and do appropriate
  laboratory tests
• Administer appropriate pre-anesthetic medications

5
Intra-Operative Care

• Place the woman in a position appropriate for the
  procedure
• Ensure sterile technique
• Handle tissue gentlyminimize tissue damage
• Ensure hemostasis, adequate pain relief and
  hydration
• Monitor her condition throughout the procedure
  and initiate treatment if condition worsens

6
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

7
Common Obstetric Surgery

• Cesarean section
• Salpingectomy for ectopic pregnancy
• Laparotomy for ruptured uterus
• Postpartum hysterectomy

8
Cesarean Section

• May be done under local, spinal or general
  anesthesia
• Anticipate and prepare for problems during
  childbirth (e.g., difficulty in delivering a
  head deep in the pelvis)
• Vertical abdominal incision is preferred if local
  anesthesia is used
• Open the lower segment of the uterus transversely
  and deliver the newborn, placenta and membranes
• Give prophylactic antibiotic and oxytocin
• Close the uterus and abdomen after ensuring
  hemostasis

9
Problems Encountered during Cesarean Section

• Difficulty in controlling bleeding
• Oxytocics, massage, sutures
• Uterine and utero-ovarian artery ligation,
  hysterectomy
• Difficulty in delivering malpresentation
• Anticipate and perform appropriate manipulations
  for childbirth
• Placenta previa/Adherent placenta
• Incise placenta and deliver
• Hysterectomy if placenta cannot be removed or
  uncontrollable bleeding

10
Cesarean Section Post-Procedure Care

• Watch for postpartum bleeding
• Give oxytocin infusion after surgery
• Give adequate analgesia and hydration
• Encourage early feeding and ambulation
• Explain what was done and its implications to the
  woman

11
Salpingectomy for Ectopic Pregnancy

• May be done under spinal or general anesthesia
• Open the abdomen and identify the fallopian tube
  with the ectopic pregnancy
• Clamp the mesosalpinx to stop bleeding
• Do a salpingectomy
• Check the other tube, ovaries and other pelvic
  organs for pathology
• Close the abdomen after giving prophylactic
  antibiotics
• Give adequate analgesia and hydration
• Encourage early feeding and ambulation
• Explain what was done and its implications to the
  woman

12
Laparotomy for Ruptured Uterus

• May be done under spinal or general anesthesia
• Open the abdomen and deliver the newborn and
  placenta
• 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
• Examine the bladder for rupture and repair if
  ruptured

13
Laparotomy for Ruptured Uterus (contd)

• Close the abdomen after giving prophylactic
  antibiotics and oxytocin infusion
• Leave drain if hemostasis is not satisfactory
• Give adequate analgesia and hydration
• Encourage early feeding and ambulation
• Explain what was done and its implications to the
  woman

14
Postpartum Hysterectomy

• May be done under spinal or general anesthesia
• Hysterectomy may be
• Subtotal if cervix is left behind
• Total if the cervix is removed
• Lift the uterus out through the incision and
  compress it to reduce bleeding
• Clamp and divide round ligament, tubes and
  ovarian ligaments but ligate pedicles after
  uterine artery has been tied
• Separate the urinary bladder away from the lower
  segment

15
Postpartum Hysterectomy (contd)

• WARNING The ureters are close to the uterine
  vessels
• For sub-total hysterectomy Ligate the uterine
  arteries and amputate the uterus just above this
  level
• For total hysterectomy Divide cardinal ligaments
  to remove cervix
• Close the stump
• Ensure hemostasis leave drain if hemostasis is
  not satisfactory
• Give adequate analgesia and hydration
• Encourage early feeding and ambulation
• Explain what was done and its implications to the
  woman