Transcript Procedures - Northwest Florida State College

Procedures
Basic Format
Cesarean Section
Objectives
• Assess the anatomy, physiology, and
pathophysiology of the Cesarean Section.
• Analyze the diagnostic and surgical interventions
for a patient undergoing a Cesarean Section.
• Plan the intraoperative course for a patient
undergoing Cesarean Section.
• Assemble supplies, equipment, and
instrumentation needed for the procedure.
Objectives
• Choose the appropriate patient position
• Identify the incision used for the procedure
• Analyze the procedural steps for Cesarean
Section.
• Describe the care of the specimen
• Discuss the postoperative considerations for a
patient undergoing Cesarean Section .
Terms and Definitions
• Obstetrics
• See Indications
• Same as for L & D Terms STST p. 486
Definition/Purpose of Procedure
• Surgical delivery of an infant through the abdominal and
uterine wall. Often performed as an emergency for
abruptio placentae, placenta previa, or cephalopelvic
disproportion. May be scheduled for “previous c-section.”
• Performed when safe vaginal delivery is questionable or
immediate delivery is crucial because the well-being of the
mother or fetus is threatened
Indications
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Abnormal presentations (breech, transverse, etc.)
Abruptio Placenta
Carcinoma of the Cervix
Cephalopelvic Disporportion (CPD)
Cervix will not dilate
Fetal distress** Most common reason
Habitual death of the fetus during the course of labor
Placenta Previa
Preeclamptic toxemia in pts where difficult labor is anticipated
Presence of STDs such as genital herpes
Previous cesarean section
Prolapse of the umbilical cord
Relevant A & P
• Physiology of pregnancy
• Female anatomy (covered last week)
Blood supply to internal
reproductive organs
Blood supply to vagina, ovary, uterus,
& fallopian tube
Pelvic Bones
Midsagittal view in supine position
with some ligaments
Pathophysiology
• Dependent on type of Indication
Female Pelvis: True Pelvis
Inlet, Cavity (midpelvis), and Outlet
Caldwell-Maloy Pelvic Types
Diagnostics
• Exams
– Multiple methods depending on problem
– Standard Assessments: Client history, determining
gestational age (EDB); uterine assessment, fetal
development, pelvic adequacy
• Preoperative Testing: typical for any surgery (CBC, blood
chemistries, U/A)
External Cephalic Version
Surgical Intervention:
Special Considerations
• Patient Factors
– Psychological status
– Significant other present or not
• Room Set-up: all preparations are made before the
anesthetic is administered. If regional anesthesia is
planned, the set-up, counts, and preliminary routines can
be performed simultaneously w/anesthesia procedures. If
general, the set-up, prep, catheterization, gowning &
gloving of all personnel and draping are performed before
anesthesia induction. Why?
Surgical Intervention: Anesthesia
• Method: Regional (Epidural preferred or Spinal) or Local
or General
• Equipment: spinal or epidural tray
• Other meds: Oxytocin (Pitocin) 10-20 u per liter of IV
fluids once infant is delivered to minimize blood loss
– Oxytocin may be used to induce or continue labor,
contract the uterus post delivery; stimulate lactation
– Carbopost (Hemabate) parenteral oxytocic used to
control uterine hemorrhage following childbirth
– Ergonovine, Methylergononvine (Ergotrate,
Methergine) causes uterine muscle contraction
Surgical Intervention: Positioning
• Position during procedure
– Supine with roll at Rt hip to displace the uterus
& prevent aortocaval compression
• Supplies and equipment: rolled sheet for hip roll,
safety belt
• Special considerations: high risk areas: bony
prominences; assistance PRN –awkward and in
pain/between contractions
Surgical Intervention: Skin Prep
• Method of hair removal: wet prep or clippers
• Anatomic perimeters: Similar to laparotomy—
table side to table side; to xiphoid process
extending down to mid thigh: NO Vaginal prep
• Solution options: Betadine or Duraprep or
Hibiclens
• Insert foley before prep
Surgical Intervention: Draping/Incision
• Types of drapes: C-Section pack includes laparotomy
drape, which may sticky clear plastic around fenestration
and fluid-catching channels
• Order of draping: 4 towels, abd drape
• Special considerations
• State/Describe incision
– Skin: Low transverse Pfannenstiel (Most common) or
low midline vertical; length depends on estimated size
of fetus
– Uterus: type depends on the need for the c-section
Uterine Incisions
Kerr Incision vs Sellheim Incision vs Classical
Surgical Intervention: Supplies
• General: prep set, C-Section pack, basin set,
gloves
• Specific
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Bulb syringe for infant suction
Cord clamps, 2 per infant
Delee suction device
Cord blood tubes (2)
Blood gas tubes on standby
Suture/dressings of choice
Medications on field (name & purpose)
Catheters & Drains: Foley catheter is placed
preoperatively
Surgical Intervention: Instruments
• General: those for a major GYN laparotomy plus
(below) or C-Section tray (facility specific)
• Specific
– Delivery forceps (in room), a cord clamp, mucus
aspiration bulb, possible Delee suction trap, Lister
bandage scissors, Foerster ring forceps, Pennington
forceps, Delee retractor, (2) lab tubes for cord blood
Surgical Intervention: Equipment
• General: ESU, Suction
• Specific:
– Infant radiant warmer mobile unit and possibly
additional transport device depending on location of
procedure (OR vs L & D)
– Fetal monitor
Procedure Overview
• The pelvis & uterus are entered.
• The head of the infant is delivered & the
infant’s airways are cleared
• The infant’s body is delivered
• The placenta is removed
• The uterus is closed.
• The abdomen is closed.
Surgical Intervention: Procedure Steps
• Incision is made (#10 blade) and tissues of abdomen are
divided w/usual fashion: have goulet or army-navy ready
for muscle separation at midline & fascial incision and
dissection
• Peritoneal covering over bladder is palpated (to ensure no
inclusion of bladder, bowel, or omentum) and incised
(exposing distended uterus). 2 crile hemostats are used to
elevate the peritoneum about 2 cm apart.
• Bleeding sites will be clamped but not ligated until later
(typically)
• The uterus is quickly palpated to determine fetal placement
& position
• STSR: Be ready with dry lap sponges, bulb syringe, and
suction
Step 6: Creation of bladder flap at
vesicouterine fold
Step 7: Bladder flap retracted & transverse
incision made in lower uterine segment
Surgical Intervention: Procedure Steps
• Amniotic fluid is quickly evacuated from field
• Assistant retracts the bladder downward with the bladder
blade or other similar retractor
• Surgeon nicks the uterus w/deep knife and extends the
incision w/bandage scissors (blunt tips prevent injury to
fetus)
• STSR may be asked to remove bladder retractor &
simultaneously assistant pushes firmly on upper abd while
surgeon grasps infant’s head & rotates upward
• Head is delivered from wound & airways immediately
suctioned with bulb (poss Delee)
Step 10: Delivery of infant w/umbilical
cord clamped
Surgical Intervention: Procedure Steps
• STSR: Once the head is controlled, all sharp and metal
objects are removed prior to elevating the infant’s head
• The umbilical cord is clamped and cut. Cord blood sample
is collected (surgeon may milk the cord)
• The infant is passed off to the pediatrician and into the
warmed crib for assessment and possible emergency
resuscitation measures
• STSR: Protect your sterile field
• The placenta is delivered, inspected, & removed to back
table (usually in a basin)
Step 12: Dissection of the placenta
from the uterine wall
Surgical Intervention: Procedure Steps
• The uterine interior may be cleaned w/a
moist lap sponge. Oxytocin MAY be
injected into the uterus to help with
hemostasis
• The surgeon closes the uterus in 2 layers
with 2-0 or 0 absorbable suture (chromic
catgut, Vicryl, or Dexon)—running stitch
Step 14: Uterus is closed in 2 layers
Surgical Intervention: Procedure Steps
• The bladder flap may be approximated or not—if so, a 2-0
or 3-0 absorbable suture w/fine taper needle is often used
• The abdominal cavity is examined for bleeding, sponges,
etc and is irrigated.
• Surgeon closes abd wall and skin for low transverse
incision; subcuticular stitch or staples are used for closure.
• Blood clots are expressed from the uterus (STSR may be
asked for basin at perineum).
• Wound and vaginal area are cleaned
• Dressing & perineal pad applied
Counts
• Initial: Before case begins: sponges, sharps, instruments,
bovie tip cleaner
• First closing: Closure of uterus
• Second count: beginning closure of abd cavity
• Final closing
– Sponges
– Sharps & sm items
– Instruments
Dressing, Casting, Immobilizers, Etc.
• Types & sizes
– Abdominal dressing and perineal pad
• Type of tape or method of securing
– Silk, paper, foam tape. Elastoplast for
compression dressing as ordered.
Specimen & Care
• Identified as: Placenta is sent per surgeon
request for evaluation
– Cord blood tubes x 2 filled
– Blood gasses of cord may be ordered and
drawn by circulator or peds from the artery
within the umbilical cord
• Handled: Placenta is usually sent in
formalin, if sent
Postoperative Care
• Destination
– Allow for bonding time with infant if possible
– PACU
• Expected prognosis (Good, Depends on Indication
and any anesthetic complications) * mortality is 46 times that assoc w/vaginal delivery
– Maternal: healing & care of surgical wound
increased risk of future C-section
Infant: prognosis depends on reason for C-section and
extent of oxygen deprivation
Postoperative Care
• Potential complications
– Hemorrhage: Fundus must be massaged just
after delivery and become firm to help stop
bleeding
– Infection
– Other: Injury to surrounding structures
• Surgical wound classification: II
References
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Alexander Ch 14, pp. 513-517
www.Allrefer.com
Berry & Kohn Ch 34, pp. 694-697
Fuller pp. 362-363
MAVCC Unit 5
Vaginal Delivery
Procedure 15-1
Delivery Presentation
Labor & Delivery Terminology
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Stage one: onset of labor
Stage two: complete dilatation of cervix
Stage three: birth of the infant
Stage four: after placenta is delivered
What is an episiotomy?
Intentional incision at perineum to ease
birth process or to protect mother from
uncontrolled perineal lacerations.
Perineal Lacerations & Incisions
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First degree
Second degree
Third degree
Fourth degree
Episiotomies:
Midline & Rt Mediolateral