Operative procedures in postpartum period

1. Culdocentesis and Colpotomy
Prepared By:
Reena Bhagat
Senior Nursing Instructor
Maternal Health Nursing
BPKIHS

2. Culdocentesis
 Culdocentesis is a procedure in which peritoneal
fluid is obtained from the cul de sac of a female
patient.
 Cul de sac literally translated in French “ bottom
of sac “.
 In medical term it is called “ Retrouterus
peritoneal pouch” or “ Douglas pouch”.
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3. Anatomy
 The pouch of Douglas (recto-uterine pouch) is
formed by reflection of the peritoneum between
the rectum posteriorly and the posterior surface of
the uterus anteriorly.
 The pouch often contains small intestine and a
small amount of peritoneal fluid. It is the most
dependent intraperitoneal space in both the upright
and the supine position.
 Blood, pus, and other free fluids in the peritoneal
cavity pool in the pouch because of its dependent
location.
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4. Cul-de-sac:
In anatomy, a blindpouch or
cavity that is closedat one
end.
The term cul-de-sac is used
specifically to refer to the
rectouterinepouch (the
pouch of Douglas),an
extension of the peritoneal
cavity betweenthe rectum
and back wall of the uterus.
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6. Indications
In the current practice with easy access to
ultrasonography, culdocentesis is rarely performed
for most of the indications below.
Suspected ruptured ectopic pregnancy in the
following clinical situations:
 Hemodynamically unstable patients when
ultrasonography is not immediately available
 When ultrasonography or laparoscopy is not
available
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7. Contd..
 In place of diagnostic peritoneal lavage to detect
hemoperitoneum.
 To diagnose ruptured ovarian cysts in patients
with sudden onset of pelvic pain.
 To obtain fluid for culture to aid in the diagnosis
and treatment of pelvic inflammatory disease
(PID).
 For diagnosis and treatment of ascites.
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8. Contraindications
 Pelvic mass : ovarian tumors, tubo-ovarian
abscesses, appendiceal abscesses, and pelvic
kidney.
 Fixed retroverted uterus.
 Coagulopathy
 Prepubescence: procedure would be difficult to
perform through a small prepubertal vagina.
 Noncooperative patient.
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9. Anesthesia
Lidocaine (1-2%) with epinephrine is injected into
the vaginal mucosa of the posterior fornix in the
midline about 1 cm inferior to the point at which
the posterior vaginal wall joins the cervix.
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10. Equipments
 Bivalve vaginal speculum (Cusco’s speculum).
 Tenaculum or Allis clamp
 Ring forceps
 Spinal needle, 18 gauge (ga)
 Monsel solution (ferric subsulfate) for hemostasis
 Butterfly needle, 19 ga
 Needle, 25 ga, 1 inch
 Antiseptic (eg, povidone-iodine solution [Betadine])
 Lidocaine (1-2%) with epinephrine
 Specimen container
 Light source
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12. Positioning
• Allow the patient to walk
or sit up for a short time
prior to the procedure to
allow gravity to help
bring the peritoneal fluid
to the cul de sac.
• Place the patient in
dorsal lithotomy position
with the feet in stirrups.
• Elevating the head of the
bed helps the
intraperitoneal fluid
gravitate to the
retroperitoneal pouch for
easier aspiration.
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13. Contd..
Procedure:
1. Obtain informed consent prior to the procedure.
2. Premedicate with narcotics or sedatives as needed.
3. Radiographs, when indicated in stable patients, are
taken prior to culdocentesis to avoid possible
confusion if a pneumoperitoneum is detected
following the procedure.
4. Perform bimanual pelvic examination to rule out a
fixed pelvic mass and to assess the position of the
uterus prior to culdocentesis.
5. A bulging of the cul de sac into the posterior
fornix suggests pooling of intraperitoneal fluid.
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14. Contd..
• Prepare the vagina with povidone-iodine solution.
• Place the patient in dorsal lithotomy position with the feet
in stirrups. Elevate the head of the bed.
• Insert a bivalve vaginal speculum into the vagina
• Grasp the posterior lip of cervix with a tenaculum or ring
forceps. In patients with retroverted uterus, anterior
tenaculum placement is preferred, as it helps straighten the
uterus.
• The patient should be forewarned that grasping the cervix
with the tenaculum will be painful. Some practitioners
inject the tenaculum site with local anesthetic.
• Open the speculum as wide as the patient can tolerate to
expose the posterior fornix and stretch the vaginal mucosa
taut, making the procedure easier.
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16. Contd..
• Attach an 18-ga spinal needle to a 20-mL syringe
with 2-3 mL normal saline and injecting 0.5-1 mL
of saline through the point of lidocaine infiltration
between the uterosacral ligaments in the posterior
fornix.
• If the puncture site is too high, the needle hits the
substance of the cervix or uterus. If it is placed too
low, the needle may enter the rectum or tunnel
beneath the posterior peritoneum of the cul de sac.
• The spinal needle is inserted parallel to the lower
blade of the speculum.
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17. contd..
• Free flow of saline confirms the correct placement of
the needle in the cul de sac. It may otherwise be
within the wall of the uterus or intestine.
• In that case, withdraw and redirect the tip of the
needle until saline flows freely upon injection.
• Apply negative pressure (pull back the syringe
plunger) while slowly withdrawing the needle.
• Avoid aspirating any blood that has accumulated in
the vagina from previous needle punctures or from
cervical bleeding because this may give the false
impression of a positive culdocentesis.
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18. • If no fluid is withdrawn, withdraw the needle and
reintroduce it, directing slightly to the left or right
of the midline.
• Avoid directing the needle too far laterally, which
can result in the puncture of a mesenteric or
pelvic vessel.
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19. Assessment
Normal culdocentesis result
• A normal culdocentesis result in the absence of
pathology should yield only 2-4 mL of clear to
straw-colored peritoneal fluid.
Nondiagnostic result
• A dry tap (return of no fluid) has no diagnostic
value; the needle may simply not have found the
pool of fluid.
• Aspiration of less than 2 mL of clotted blood is
nondiagnostic; this blood might have come from
the vessel at the puncture site of the vaginal wall.
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20. Contd..
Positive result
A positive tap is one in which more than 2 mL of
nonclotting blood is obtained. Absolute volume may be
related to the needle position or the rate of bleeding, so
larger amounts of blood have no particular
significance.
A positive culdocentesis result in the presence of
ectopic pregnancy does not necessary indicate tubal
rupture.
Intraperitoneal blood from a source other than ectopic
pregnancy (eg, ovarian cyst, ruptured spleen) may
remain unclotted after aspiration for days in the syringe
as a result of the defibrination activity of the
peritoneum.
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21. Contd..
• Hemoperitoneum has been noted to occur in
unruptured ectopic pregnancy proved at surgery.
• A positive culdocentesis result can also occur in
nonpregnant women (eg, retrograde
menstruation).
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22. Contd.
Negative result
 A culdocentesis is considered negative when the
aspirated fluid is pus, cystic, or straw-colored.
 Purulent fluid indicates infection. Pelvic
inflammatory disease is the most common
gynecological cause, but nongynecological causes
such as diverticulitis and appendicitis should also be
considered in the differential diagnosis.
 Rarely, greasy or fatty fluid is obtained during
culdocentesis. Such fluid is from a ruptured teratoma.
 A false-negative result is produced in 15% of ectopic
pregnancies; these pregnancies are generally
unruptured.
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23. Contd..
Culdocentesis Fluid Condition and Suggested
Differential Diagnosis
Clear, serous, straw-
colored (usually only a few
mL)
Normal peritoneal fluid
Large amount of clear fluid • Ruptured or large ovarian cyst
(fluid may be serosanguineous);
• pregnancy may coexist
• Ascites
• Carcinoma
Purulent fluid • Tubo-ovarian abscess with
rupture
• Appendicitis with rupture
• Diverticulitis with perforation
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24. Contd..
Culdocentesis
Fluid
Condition and Suggested Differential
Diagnosis
Bright red blood • Ruptured viscus or vascular injury
• Bleeding corpus luteum
• Intra-abdominal injury involving liver,
spleen, or other organs
• Ruptured aortic aneurysm
• Recently bleeding ectopic pregnancy
(ruptured or unruptured)
Old, brown,
nonclotting blood
• Ectopic pregnancy with intraperitoneal
bleeding over days or weeks Days-old
intra-abdominal injury (eg, delayed
splenic rupture)
• Ruptured viscus
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25. Colpotomy
• If pus is obtained on culdocentesis, keep the needle
in place and make a stab incision at the site of the
puncture:
• Remove the needle and insert blunt forceps or a
finger through the incision to break loculi in the
abscess cavity.
• Allow the pus to drain.
• Insert a high-level disinfected or sterile soft rubber
corrugated drain through the incision.
Note: A drain can be prepared by cutting off the
fingertips of a sterile examination glove.
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26. Contd..
• If required, use a stitch through the drain to
anchor it in the vagina.
• Remove the drain when there is no more drainage
of pus.
• If no pus is obtained, the abscess may be higher
than the pouch of Douglas. A laparotomy will be
required for peritoneal lavage (wash-out).
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27. Colpotomy
• A colpotomy, also known as a vaginotomy, is a
procedure by which an incision is made in the
vagina.
• A colpotomy is performed either to visualize
pelvic structures or to perform surgery on the
fallopian tubes or ovaries.
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28. Role of colpotomy in gynecologic
surgery
Several gynecologic surgery protocols require a
colpotomy as part of the overall surgical procedure. It
is performed whenever the surgeon needs to access
the vagina. Several of these surgeries include:
• Tubal sterilization: Sterilization is a procedure that
can be performed using either abdominal or vaginal
procedures. When a vaginal procedure is selected, a
colpotomy is performed and may also insert a
culdoscope to locate the tubes (culdoscopy), and
close them off.
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29. Contd..
• Removal of myomas: Myomas are fibroid tumors of
the muscle tissue of the uterus and they are
sometimes removed vaginally by colpotomy.
• Dysmenorrhea: Separation of the uterosacral
ligaments via colpotomy is an approach that has been
used for the relief of dysmenorrhea (painful
menstruation).
• Removal of pelvic cysts and masses: In one
treatment variant, patients may undergo a laparoscopy
followed by a colpotomy for the vaginal extraction of
the pelvic cyst or mass.
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30. Contd..
• Hysterectomy: One technique used to surgically
remove the uterus combines three steps, an initial
laparoscopic stage, followed by a vaginal stage, and
a final laparoscopic stage.
• The colpotomy is performed during the second step
to deliver the uterus into the vagina.
• Complications in pregnancy and childbirth.
Colpotomy may be used in the management of
difficult pregnancies and childbirths.
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31. Contd..
Aftercare
• Aftercare for colpotomy is associated with the overall
surgery that required the colpotomy.
• For example, if a colpotomy is performed for tubal
ligation (female sterilization), the procedure takes only
15-30 minutes and women usually go home the same day.
It may take a few days at home to recover.
• Sexual intercourse is usually postponed until the
colpotomy incision is completely healed, and as advised
by the doctor. The healing process usually requires
several weeks and there are no visible scars.
• In the case of a colpotomy performed for myoma
removal, aftercare is more elaborate with the patient’s
vital signs monitored in the recovery room until she
regains consciousness.
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32. Contd..
Risks
• Complications such as bleeding, infection, or
reaction to the anesthetic, may occur as with any
type of gynecological surgery.
Normal results
• Colpotomy results are considered normal when
the incision performed allows the surgeon to
meet the goal of the overall surgical protocol.
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33. Dilatation and Curettage(D & C)
 The preferred method of evacuation of the uterus is
manual vacuum aspiration. Dilatation and curettage
should be used only if manual vacuum aspiration is
not available.
 Dilation and curettage (D&C) is a procedure in
which material from the inside of the uterus is
removed.
 The "dilation" refers to dilation of the cervix, the
lower part of the uterus that opens into the vagina.
 "Curettage" refers to the scraping or removal of
tissue lining the uterine cavity (endometrium) with a
surgical instrument called a curette.
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34. Purposes of D & C
 To determine the reason for heavy bleeding during or
between your menstrual periods
 To remove noncancerous tumors, or fibroids
 To remove and examine potentially cancerous tumors
 To remove infected tissue, which is often caused by a
sexually transmitted disease called pelvic
inflammatory disease (PID)
 To remove tissue left behind in the womb after
miscarriage or childbirth.
 To perform an elective abortion.
 To remove an intrauterine device (IUD), which is a
form of birth control.
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35. Indications
 Abnormal uterine bleeding
 Irregular bleeding
 Menorrhagia,
 Suspected malignant or premalignant condition.
 Retained material in the endometrial cavity.
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36. Contraindications
• Viable desired intrauterine pregnancy.
• Inability to visualize the cervical os.
• Obstructed vagina.
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37. Procedure
D & C TRAY:-
• Sponge holding-2
• Sims vaginal speculum.
• Sims vaginal wall retractor.
• Cusco`s vaginal speculum.
• Vulsellum forceps 2
• Cervical dilator(Hegar`s dilator).
• Sims uterine curette
• Ayre`s spatula.
• Uterine sounds.
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39. Contd..
Pre-Operative:- Instructions to be given to the
patient before the procedure:-
Limiting food and drink prior 48 hours of the
procedure.
Arrange for someone to help the patient get home
because she may be drowsy after the anesthesia
wears off.
Clear the schedule to allow enough time for the
procedure and recovery afterward.
The patient would be spending a few hours in
recovery after the procedure.
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40. Contd..
Intra-operative
• During a D&C, the patient lie on her back and place
her legs in stirrups like during a pelvic exam. Then
the doctor inserts a speculum into the vagina and
holds the cervix in place with a clamp.
• Although the D&C involves no stitches or cuts, the
doctor cleanses the cervix with an antiseptic
solution.
• D&C involves two main steps:-
oDilation involves widening the opening of the lower
part of the cervix to allow insertion of an instrument.
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41. Dilatation and Curettage( D & C)
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42. Contd..
oThe doctor may insert a slender rod( laminaria) into the
opening beforehand or use a medication before the
procedure to soften the cervix and cause it to widen.
oCurettage involves scraping the lining and removing
uterine contents with a long, spoon-shaped instrument
(a curette). The doctor may also use a cannula to
suction any remaining contents from the uterus. This
can cause some cramping. A tissue sample then goes to
a lab for examination.
 Sometimes other procedures are performed along
with a D&C. For example, The doctor may insert a
hysteroscope to view the inside of the uterus
(called hysteroscopy). He/she may remove a polyp
or fibroid.
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44. Contd..
Post-operative
 The patient is sent to recovery room after the
D&C for few hours so that the doctor can
monitor heavy bleeding or other complications.
 This also gives the patient time to recover from
the effects of anesthesia.
 If the patient had general anesthesia, she may
become nauseated or vomit, or might have a sore
throat if a tube was placed in the windpipe to
help in breathing. With general anesthesia or light
sedation, she may also feel drowsy for several
hours.
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45. Contd..
Side Effects
 Cramping
 Spotting or light bleeding
 Heavy or prolonged bleeding or blood clots
 Fever
 Pain
•
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46. Contd..
Complications
• Damaged cervix
• Perforated uterus or bladder and blood vessels
• Abdominal tenderness
• Foul-smelling discharge from the vagina
• In very rare cases, scar tissue (adhesions) may
form inside the uterus called Asherman's
syndrome, this may cause infertility and changes in
menstrual flow. Surgery can repair this problem, so
report any abnormal menstrual changes after a
D&C.
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47. Asherman’s syndrome
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48. Uterine and Utero-ovarianArtery
Ligation
 Review for indications: generally done for
management of bleeding in PPH. ( it can decrease
uterine bleeding by reducing perfusion pressure in
myometrium.
 Follow general care principles and operative care
principles and start an IV infusion.
 Give a single dose of prophylactic antibiotics:-
oampicillin 2 g IV; OR
ocefazolin 1 g IV.
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50. Contd..
• Open the abdomen:
Make a midline vertical incision below the
umbilicus to the pubic hair, through the skin and to
the level of the fascia.
Make a 2–3 cm vertical incision in the fascia.
Hold the fascial edge with forceps and lengthen the
incision up and down using scissors.
Use fingers or scissors to separate the rectus
muscles (abdominal wall muscles).
Use fingers to make an opening in the peritoneum
near the umbilicus.
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51. Contd..
Use scissors to lengthen the incision up and down
in order to see the entire uterus. Carefully, to
prevent bladder injury, use scissors to separate
layers and open the lower part of the peritoneum.
Place a bladder retractor over the pubic bone and
place self-retaining abdominal retractors.
• Pull on the uterus to expose the lower part of the
broad ligament.
• Feel for pulsations of the uterine artery near the
junction of the uterus and cervix.
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52. Contd..
• Using 0 chromic catgut (or polyglycolic) suture
on a large needle, pass the needle around the
artery and through 2–3 cm of myometrium
(uterine muscle) at the level where a transverse
lower uterine segment incision would be made.
Tie the suture securely.
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53. Contd..
• Place the sutures as close to the uterus as possible,
as the ureter is generally only 1 cm lateral to the
uterine artery.
Repeat on the other side.
If the artery has been torn, clamp and tie the
bleeding ends.
Ligate the utero-ovarian artery just below the point
where the ovarian suspensory ligament joins the
uterus.
Repeat on the other side.
Observe for continued bleeding or formation of
hematoma.
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55. Contd..
• Close the abdomen:
Ensure that there is no bleeding. Remove clots
using a sponge.
Examine carefully for injuries to the bladder and
repair any found.
Close the fascia with continuous 0 chromic catgut
(or polyglycolic) suture.
.
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56. Contd..
• If there are signs of infection, pack the
subcutaneous tissue with gauze and place loose 0
catgut (or polyglycolic) sutures. Close the skin
with a delayed closure after the infection has
cleared.
• If there are no signs of infection, close the skin
with vertical mattress sutures of 3-0 nylon (or
silk) and apply a sterile dressing.
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57. Contd.
• Post-procedure Care
Follow postoperative and general care principles.
Monitor urine output. If there is blood in the urine
or the woman has loin pain (pain in the sides
between the lower ribs and pelvis, and/or in the
lower part of the back), refer the woman to a tertiary
care centre, if possible, for treatment of an
obstructed ureter.
If there are signs of infection or the woman
currently has fever, give a combination of antibiotics
until she is fever-free for 48 hours:
• clindamycin phosphate 600 mg IV every eight hours;
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58. Contd..
• PLUS gentamicin 5 mg/kg body weight IV every 24
hours.
• Give appropriate analgesic drugs.
• If there are no signs of infection, remove the
abdominal drain after 48 hours.
• Offer other health services, if possible.
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59. Postpartum Hysterectomy
• This is an operation to remove the womb. It is
usually performed as an emergency to save the life
of a woman with persistent bleeding after childbirth.
Less frequently, it is a planned operation at the same
time as a caesarean birth.
• The most common reason is severe bleeding from
the womb which cannot be controlled by other
measures. This may be due to uterine atony (when
the womb doesn’t contract properly after the birth),
rupture of the womb, fibroids, blood clotting
problems or injury to a blood vessel.
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60. Contd..
• It can also become necessary due to a condition
called placenta praevia. This is where the placenta
(afterbirth) lies over the cervix (neck of the
womb) or where the placenta has grown
abnormally deeply into the muscle of the uterus
(placenta accreta).
• The rate of post-partum hysterectomy is less than
one in a 1000 of all births and one in 200
caesarean births. Although rare, its occurrence is
increasing. This is partly due to the increasing
number of births following caesarean deliveries in
previous pregnancies.
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61. Contd..
 Postpartum hysterectomy can be subtotal
(supracervical) unless the cervix and lower uterine
segment are involved.
 Total hysterectomy may be necessary in the case of a
tear of the lower segment that extends into the cervix
or bleeding after placenta praevia.
 Review for indications.
 Follow general care principles and operative care
principles, and start an IV infusion.
 Give a single dose of prophylactic antibiotics:
oampicillin 2 g IV; OR
ocefazolin 1 g IV.
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62. Contd..
 If there is uncontrollable hemorrhage following
vaginal birth, keep in mind that speed is essential.
To open the abdomen:
Make a midline vertical incision below the
umbilicus to the pubic hair, through the skin and to
the level of the fascia.
Make a 2–3 cm vertical incision in the fascia.
Hold the fascial edge with forceps and lengthen the
incision up and down using scissors.
Use fingers or scissors to separate the rectus
muscles (abdominal wall muscles).
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63. Use fingers to make an opening in the
peritoneum near the umbilicus.
Use scissors to lengthen the incision up and
down in order to see the entire uterus. Carefully,
to prevent bladder injury, use scissors to separate
layers and open the lower part of the peritoneum.
Place a bladder retractor over the pubic bone and
place self-retaining abdominal retractors.
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64. Contd..
• If the birth was by caesarean, clamp the sites of
bleeding along the uterine incision:
• In case of massive bleeding, have an assistant
press fingers over the aorta in the lower
abdomen. This will reduce intraperitoneal
bleeding.
• Extend the skin incision, if needed.
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66. Contd..
Subtotal (Supracervical) Hysterectomy
• Lift the uterus out of the abdomen and gently pull to
maintain traction.
• Doubly clamp the round ligaments and cut with
scissors. Clamp and cut the pedicles, but ligate after
the uterine arteries are secured to save time.
• From the edge of the cut round ligament, open the
anterior leaf of the broad ligament. Incise to:
the point where the bladder peritoneum is reflected
onto the lower uterine surface in the midline; or
the point where the peritoneal incision was made for
the current or a previous caesarean.
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67. Contd..
• Use two fingers to push the posterior leaf of the
broad ligament forward, just under the fallopian
tube and ovary, near the uterine edge.
• Make a hole the size of a finger in the broad
ligament, using scissors. Double clamp and cut the
tube, the ovarian ligament and the broad ligament
through the hole in the broad ligament.
• The ureters are close to the uterine vessels. The
ureter must be identified and exposed to avoid
injuring it during surgery or including it in a stitch.
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68. Contd..
• Divide the posterior leaf of the broad ligament
downwards towards the uterosacral ligaments,
using scissors.
• Grasp the edge of the bladder flap with forceps or
a small clamp. Using fingers or scissors, dissect
the bladder downwards off of the lower uterine
segment. Direct the pressure downwards but
inwards towards the cervix and the lower uterine
segment.
• Reposition the bladder retractor and retract the
bladder inferiorly.
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69. Contd..
• Locate the uterine artery and vein on each side of
the uterus. Feel for the junction of the uterus and
cervix.
• Doubly clamp across the uterine vessels at a 90
degree angle on each side of the cervix. Cut and
doubly ligate with 0 chromic catgut (or
polyglycolic) suture.
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70. Contd..
• Observe carefully for any further bleeding. If the
uterine arteries are ligated correctly, bleeding
should stop and the uterus should look pale.
• Return to the clamped pedicles of the round
ligaments and tubo-ovarian ligaments and ligate
them with 0 chromic catgut (or polyglycolic)
suture.
• Amputate the uterus above the level where the
uterine arteries are ligated, using scissors.
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71. contd…
• Close the cervical stump with interrupted 2-0 or
3-0 chromic catgut (or polyglycolic) sutures.
• Carefully inspect the cervical stump, leaves of
the broad ligament and other pelvic floor
structures for any bleeding.
• If slight bleeding persists or a clotting disorder is
suspected, place a drain through the abdominal
wall. Do not place a drain through the cervical
stump, as this can cause postoperative infection.
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72. Contd..
• Close the abdomen:
Ensure that there is no bleeding. Remove clots
using a sponge.
In all cases, check for injury to the bladder. If a
bladder injury is identified, repair the injury.
Close the fascia with continuous 0 chromic catgut
(or polyglycolic) suture.
• Note: There is no need to close the bladder
peritoneum or the abdominal peritoneum.
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73. Contd..
If there are signs of infection, pack the
subcutaneous tissue with gauze and place loose 0
catgut (or polyglycolic) sutures.
Close the skin with a delayed closure after the
infection has cleared.
If there are no signs of infection, close the skin
with vertical mattress sutures of 3-0 nylon (or silk)
and apply a sterile dressing.
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74. Contd..
• Total Hysterectomy The following additional
steps are required for total hysterectomy:
• Push the bladder down to free the top 2 cm of the
vagina.
• Open the posterior leaf of the broad ligament.
• Clamp, ligate and cut the uterosacral ligaments.
• Clamp, ligate and cut the cardinal ligaments,
which contain the descending branches of the
uterine vessels.
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75. Contd..
• This is the critical step in the operation:
- Grasp the ligament vertically with a large-toothed
clamp (e.g. Kocher). Place the clamp 5 mm lateral
to the cervix and cut the ligament close to the
cervix, leaving a stump medial to the clamp for
safety.
- If the cervix is long, repeat the above step two or
three times as needed.
- The upper 2 cm of the vagina should now be free
of attachments.
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76. Contd..
• Clamp and transect the vagina as near to the
cervix as possible, clamping bleeding points as
they appear.
• Place hemostatic angle sutures, to include
round, cardinal and uterosacral ligaments.
• Place continuous sutures on the vaginal cuff to
stop hemorrhage.
• Close the abdomen (as above) after placing a
drain in the extraperitoneal space near the stump
of the cervix.
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77. Contd..
• Post-procedure Care
• Review postoperative care principles.
• Monitor urine output. If there is blood in the urine
or the woman has loin pain (pain in the sides
between the lower ribs and pelvis and/or in the
lower part of the back), refer the woman to a tertiary
care centre, if possible, for treatment of an
obstructed ureter.
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78. Contd..
• If there are signs of infection or the woman
currently has fever, give a combination of
antibiotics until she is fever-free for 48 hours:
• clindamycin phosphate 600 mg IV every eight
hours; Postpartum hysterectomy
• PLUS gentamicin 5 mg/kg body weight IV every
24 hours.
• Give appropriate analgesic drugs.
• If there are no signs of infection, remove the
abdominal drain after 48 hours.
• Offer other health services, if possible.
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79. Complications
 As with any surgery, there are a number of
complications which can occur. The commonest is
heavy bleeding during or after the procedure. This
may require transfusion of blood or blood products.
 Other complications include damage to the bladder or
ureter (tube from kidney to bladder), damage to the
bowel, returning to theatre to manage bleeding or
wound problems, pelvic abscess or infection or blood
clot in the leg or lung.
 Each of these complications affects less than 8 in 1000
women.
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