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

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.

Care after specific procedures

Cesarean section

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.

Ectopic pregnancy

Faulty implantation of the ovum can take place in the fallopian tube (in approximately 98% of all ectopic pregnancies), in the ovary, in any part of the abdominal cavity, or in the uterine cervix (Fig. 42-1). Until recently, the treatment of choice for an ectopic pregnancy in the fallopian tube was laparoscopy (or laparotomy) with removal of the ectopic pregnancy and most often with preservation of the fallopian tube. In cases in which bleeding cannot be controlled or the physician believes that the fallopian tube poses too much of a risk for the patient, removal of the fallopian tube at the time of surgery may be necessary. Obviously the patient must give proper consent before surgery, and all these possibilities are thoroughly discussed between the surgeon and the patient. More recently, however, patients with the early diagnosis of an unruptured ectopic pregnancy can receive intravenous methotrexate and not undergo surgery. Regardless of the treatment, these patients must have proper follow-up with their physicians to ensure successful treatment, which involves follow-up quantitative human chorionic gonadotropin studies and possibly ultrasound scans as well.

FIG. 42-1 Sites of implantation of ectopic pregnancies. Order of frequency of occurrence is ampulla, isthmus, interstitium, fimbria, tubo-ovarian ligament, ovary, abdominal cavity, and cervix (external os).

(From Lowdermilk DL, et al: Maternity and women’s health care, ed 10, St. Louis, 2012, Mosby.)

If laparoscopy is performed, the ovary preferably is not resected or removed; however, this procedure may be necessary if the ovary is involved with the ectopic pregnancy. If implantation occurs in the cervix, a hysterectomy is usually indicated to control hemorrhage. If abdominal implantation has occurred, the fetus is removed and the placenta often is left within the cavity to be reabsorbed.

Laparoscopy (or laparotomy) is performed with general anesthesia. The perianesthesia nurse should be especially observant for signs of intraabdominal hemorrhage and shock because these are not uncommon complications of ectopic pregnancy, especially one that has ruptured before surgery. All patients with ectopic pregnancy should have complete typing and cross-matching for whole blood, which should be kept available in the laboratory for 24 hours. Women who are Rh-negative should receive Rhogam to prevent sensitization. As mentioned previously, many ectopic pregnancies are being successfully treated without surgery and only with medications.

Cerclage procedures

The McDonald or Shirodkar procedure is used to treat an incompetent cervix and is fairly successful in maintenance of pregnancy. The suture is usually placed between the fourteenth and eighteenth week of gestation. These procedures may be accomplished with general, spinal, or regional anesthesia.

On admission to the PACU, hospital guidelines are followed regarding patient admission to the PACU and care of the patient (see Chapters 27 and 28). Oxygen should be administered and weaned with pulse oximetry. Food and fluids can be resumed as soon as the patient is conscious and the laryngeal reflexes have returned. A perineal pad should be kept in place. Only a minimal amount of bloody spotting is normal. Pain should be minimal and easily controlled with a simple analgesic, such as acetaminophen. Any gross vaginal bleeding or abdominal cramping should be reported to the surgeon, because this procedure may induce labor and expulsion of the uterine contents. The surgeon may order an external fetal monitor to assess the presence of uterine contractions and fetal heart tones. If labor begins, the suture must be removed immediately.

Uterine aspiration

Uterine aspiration is used in the termination of early pregnancy (i.e., first trimester) or in treatment of incomplete spontaneous abortion. The procedure is a type of dilation of the cervix and curettage of the uterus (D&C). A general anesthetic can be used, but the trend has been toward the use of paracervical block and sedation only. Nursing care in the PACU is essentially the same as after D&C by conventional means. The woman who is Rh negative should receive Rhogam to prevent sensitization. Complications from this procedure include incomplete evacuation and hemorrhage, which may be treated with oxytocin. Uterine perforation can occur and must be treated surgically.

Gynecologic surgery

Certain problems are inherent in gynecologic disease processes and the surgical procedures that deal with them. Because of prolonged or heavy menstrual periods, the patient may be more chronically anemic than even the peripheral blood indices indicate. Moreover, large amounts of blood may have accumulated within the pelvic organs at the time of the operation and may not be reflected in the external blood loss. Although the procedures are elective, many gynecologic operations are associated with significant blood loss, depending on the approach taken. This can be affected by the patient’s age (more if she is premenopausal), a larger uterus, and large fibroids. One of the potential benefits of a well-trained laparoscopic team is a decrease in intraoperative complications and blood loss and a significant reduction in postoperative morbidity. For example, in the case of a hysterectomy or large fibroids in a premenopausal woman, the uterine vessels are large, vascular pedicles that need to be thoroughly coagulated to ensure hemostasis during surgery. For this reason, regardless of the approach (laparoscopy with or without a robot, vaginal, or laparotomy), these vessels must be identified and coagulated or ligated effectively. In addition, because of the proximity of the female organs to the urinary tract, great care must be taken during surgery to identify the ureters and bladder and provide proper follow-up during the observation period after surgery to ensure the integrity of this system. If there is any question of this, a cystoscopy should be done upon the conclusion of the surgery. In addition to overall assessment and general care of these patients, the perianesthesia nurse should direct specific attention toward the patient’s cardiovascular status, renal function, and fluid balance.³

Laparoscopy

Operative laparoscopy commonly is performed as outpatient surgery for treatment of benign gynecologic problems and may involve advanced operative laparoscopic procedures for more significant problems that involve the pelvic organs. A small incision (approximately 1 cm) is made at the subumbilical site for insertion of the primary trocar (typically 10 to 12 mm in diameter), which houses the laparoscope with attached video camera for visualization of the pelvis (Fig. 42-2). The entry into the pelvic cavity can be done various ways; one of which includes open laparoscopy, particularly for patients who have had multiple previous surgeries to protect against injuring the bowel. When a patient has had multiple previous surgeries, the bowel is more likely to be adhered to the abdominal wall and oftentimes thought to be a safer way to enter. After pneumoperitoneum is established, the surgeon can visualize the organs within the peritoneum. The video camera enables the surgeon, first assistant, scrub technician, and entire team to view the procedure on the video monitor (Fig. 42-3). The video camera provides excellent resolution and visualization of the pelvis.

FIG. 42-2 Placement of trocars during advanced operative laparoscopy. Trocar in upper left quadrant is optional and only recommended in cases in which primary trocar is not sufficient because of severe adhesions. Laparoscope needs to be placed off to one side for taking down adhesions.

FIG. 42-3 The surgeon and registered nurse first assistant (RNFA) and the rest of the team are able to benefit from improved resolution attainable with high-definition cameras and monitors.

(Courtesy Wendy Winer.)

Advances in digital technology with high-definition (HD) cameras and monitors provide better resolution than ever before (Fig. 42-4). The surgeon is able to operate from HD monitors with instruments that are typically 5 mm in diameter (sometimes the instruments are as small as 3 mm in diameter or as large as 12 mm in diameter, depending on the procedure). In addition, an angled laparoscope can be used for improved visualization in the case of a large uterus. If the robot is to be used, it is connected after the trocars have been placed. The robot offers three-dimensional visualization that some find appealing. The surgeon sits at a console and is able to maneuver the instrumentation from that location while the surgical assistant is at the patient’s side and using instrumentation such as suction and irrigation. In addition, a surgical technologist is typically present between the patient’s legs (similar to laparoscopy without the robot) to manipulate the uterus with a uterine manipulator. In addition to the expense of the robot, there can be a significant amount of time required for the robot to be connected and disconnected. This includes the sterile draping of the arms of the robot. If an emergency arises with bleeding that cannot be controlled, the robot has to quickly be disengaged so that traditional surgery can quickly be initiated. For teaching purposes in particular, it is now possible to get a robot with two consoles so that the surgeon may have the student surgeon (resident or fellow) at the secondary console to work and receive instruction.

FIG. 42-4 High-definition cameras and monitors used for laparoscopic surgery at Northside Hospital in Atlanta, Georgia.

(Courtesy Wendy Winer.)

The surgeon examines the ovaries, fallopian tubes, pelvic side walls, uterosacral ligaments, bowel, appendix, peritoneum, anterior and posterior cul de sacs, and uterus after placement of the second and third incisions suprapubically in the right and left lower quadrants of the abdomen (this houses the ancillary instrumentation). If additional instrumentation is needed, a fourth incision may be made along the midsuprapubic area as well. During operative laparoscopy, the surgeon may differentially diagnose pelvic inflammatory disease or perform relatively simple procedures, such as aspiration of an ovarian cyst, lysis of adhesions, tissue biopsy, and tubal ligation. In addition, more advanced laparoscopic procedures may be done, including extensive lysis of adhesions, excision of mild, moderate or severe endometriosis, myomectomy, hysterectomy (laparoscopic total hysterectomy or laparoscopic supracervical hysterectomy), salpingectomy, salpingo-oophorectomy, removal of an ovarian remnant, ureterolysis, paravaginal repair or Burch procedures, repair of pelvic floor relaxation including laparoscopic sacral colpopexy with nonabsorbable mesh appendectomy, fibrinolysis, and tubal reanastomosis (Fig. 42-5). Various types of laparoscopic hysterectomy include laparoscopic supracervical hysterectomy, in which the cervix is preserved, laparoscopic-assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy. It is important to note that not all energy sources can be used with the robot, such as certain types of lasers and electrosurgery devices. In cases of severe endometriosis in which there is significant bowel involvement, a general surgeon may be called to do a laparoscopic bowel resection with the gynecologist. These surgeries may occur in patients with severe endometriosis and bowel symptoms and who have had a complete bowel preparation before surgery. The general surgeon, who is part of the endometriosis team, is on standby for that type of procedure. PACU needs to be aware of any special needs postoperatively for patients undergoing either a laparoscopic bowel resection or a laparoscopic cystotomy and repair of the bladder for extensive invasion of these tissues with endometriosis. In regard to any type of bladder repair, it is common for the urinary catheter to be left in place for at least 7 to 10 days. With bowel surgery, the patients are generally kept inpatient for 3 to 4 days until bowel function returns. The diet generally is very limited, beginning with ice chips, followed by clear liquids, clear fluids, and then advance to a soft diet. In most cases, these patients no longer require a colostomy or a suprapubic urinary catheter. Always notify the surgeon if there is a significant amount of bleeding from any orifice. It is common for patients to have a pinkish urine output after cystoscopy. Often these patients have at least a mild form of interstitial cystitis. If there is any blood in the urine when the patient is brought to the PACU, the circulating nurse should communicate that information in the report.

FIG. 42-5 Laparoscopic anatomy as seen through laparoscope. Figure shows bipolar instrument used for uterine occlusion.

(Courtesy Center for Women’s Care and Reproductive Surgery, Atlanta, Georgia.)

Closure of the skin wound involves a few absorbable type sutures. It is important to close the fascia at the subumbilical site as well as any other incision sites that are 7 mm or larger to prevent the development of a hernia. Depending on the type of trocar used, some manufacturers recommend only closing the fascia for trocars 10 or 12 mm in size. The ancillary sites that are 5 mm can be sutured subcutaneously or a liquid glue can be used followed with liquid adhesive and Steri-Strips to approximate the edges of the skin incision. It is common for larger patients in whom the fascia of 7-mm trocar incisions or larger must be closed to be more tender the first couple of weeks postoperatively. If there is any oozing from an incision site, it is usually coagulated or an additional stitch is placed before the patient waking up. In addition, if there is any question about the amount of oozing, a pressure dressing can be place and the perianesthesia nurse can reinforce it with a 1-pound sandbag during the first hour postoperatively in the PACU. Dressings may include an eye pad or a 2 × 2-inch pad at the subumbilical site with clear adhesive type bandages over the other sites to allow the patients to shower. If patients have an allergy to adhesive, then use paper tape or Steri-Strips depending on the patient history. Initial pain in the PACU should be minimal to moderate and is generally successfully controlled with antiinflammatory agents or mild opioids. Severe pain may indicate a more severe condition, and the surgeon should be notified immediately. A firm abdomen could indicate abdominal bleeding that is not normal. Severe pain, nausea, or vomiting could indicate a bowel perforation. Generally these types of occurrences may show up in the first 24 hours, but also may not occur for 10 to 14 days postoperatively. For that reason, it is crucial that all this information is reinforced in writing to give the patient when they are discharged. If any of these conditions occur or anything is out of the ordinary, the surgeon should be notified immediately. Postoperative care instructions, including an explanation of the possibility of referred chest or shoulder pain, should be discussed with the patient and a significant other. Again, instructions should always be written and given to the patient preoperatively and reviewed prior to discharge.

A follow-up phone call to the patient within 24 to 48 hours is recommended. Special care for the patient who undergoes outpatient surgery is outlined in Chapter 46.

Lower genital and vaginal surgery

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). The conditions that require this type of surgery occur most often in women who have had multiple births, do frequent lifting in their occupation, are smokers, or frequently cough; they also occur as women age. Often this is seen in young women after they have had two or more children. These conditions are caused most commonly by exaggeration of the normal relaxation of the pelvic ligaments and support that occurs during childbirth and also after menopause. A number of specific procedures, named after their developers, may be encountered and include the following:

Evidence-Based Practice

A study was conducted to determine long-term outcomes after complete laparoscopic excision in a teen-aged population, who were not specifically advised to take postoperative hormonal suppression. The design used was a prospective observational case series. All patients underwent diagnostic laparoscopy and complete excision of all areas of abnormal peritoneum with typical and atypical endometriosis. Patients were not specifically advised to take postoperative hormonal suppression. Complete laparoscopic excision of endometriosis in teenagers has the potential to eradicate the disease, and the results do not depend on postoperative hormonal suppression.

Implications for practice

Perianesthesia nurses can be actively involved in projects and studies that determine best practice for teenage patients following laparoscopic excision of endometriosis. Many of these patients have been suffering with severe dysmenorrhea since they began menarche. This is becoming more common in teenagers, particularly since the age of menarche is before they reach their teenage years. By the time they reach their teens, they have been taking a variety of pain medications, with the cause of their pain often diagnosed incorrectly, and taking numerous hormones in an attempt to alleviate their symptoms. As a result of short- and long-term follow-up, results show that thorough excision of endometriosis improves a patient’s quality of life postoperatively. Additional studies postoperatively are being done to further evaluate the use of hormonal suppression in these patients.

From Yeung P, et al: Complete laparoscopic excision of endometriosis in teenagers: is postoperative hormonal suppression necessary? Fertil Steril 95:6:1909−1912, 2011.

• Baldy-Webster procedure: Shortening of the round ligaments and changing of the direction of their pull by attaching them to the back of the uterus

• Fothergill-Hunter procedure: Complete repair of the vaginal wall (enterocele defect), from above downward toward the vulva, to correct faulty supportive structures of the pelvic floor; various defects commonly referred to as vaginal defect (enterocele repair), protrusion of the bladder (cystocele repair), or protrusion of the rectum (rectocele repair) and prolapse of the vaginal walls (paravaginal repair); generally a combination and not an isolated repair, which is why a urogynecologist is often the best person to most thoroughly make these repairs because there is so much overlap and it is important to evaluate the woman’s entire pelvic floor for optimal success with the repairs

• Gilliam procedure: Shortening of the round ligaments by attaching them to the abdominal wall

• Le Fort operation (colpocleisis): Closure of the vagina with approximation of the anterior and posterior vaginal walls with or without attendant vaginal hysterectomy

• Radical vulvectomy: Abdominal and perineal dissection of the superficial and deep inguinal nodes and portions of the saphenous veins, reconstruction of the vaginal walls and pelvic floor, and closure of the abdominal wounds

• Vulvectomy: Removal of the labia majora, labia minora, and possibly the clitoris and perianal area, with a Z-plasty closure; used in treatment of leukoplakia vulva, carcinoma in situ of the vulva, and Paget disease of the vulva

The specialty of gynecologic oncologists typically perform procedures such as radical hysterectomy, vulvectomy, and lymphoidectomy, because they are usually performed on women with a form of gynecologic cancer.

Other vaginal surgical procedures include fistula repairs, correction of urinary stress incontinence (various sling procedures with nonabsorbable transobturator tape), and vaginal reconstruction to repair congenital or acquired defects developed during childbirth. Many of the pelvic floor repair procedures can be done laparoscopically if the surgeon is comfortable with laparoscopic suturing and is a well-trained laparoscopist. Currently there is a great amount of debate over the types of mesh being used in the body. In particular, mesh that is used for gynecologic pelvic organ prolapse procedures is under investigation because of infections and mesh erosion, which can cause subsequent pain months or years after surgery. In the past it was thought that the type of mesh and the pore size were the key factors; however, this is being discussed again. Patients with severe prolapse need some type of graft, and it is unclear what the eventual reality will be on this issue. Most importantly, patients must be sure to stay abreast of the research on this topic. Regardless of the type of graft that is used, a well-trained laparoscopist is required to do these procedures. Many gynecologists use the robot because they are not comfortable suturing laparoscopically. Other surgeons believe that the time and expense is unnecessary if the surgeon takes the time for proper training. In addition, many gynecologists believe that they can do the surgery more effectively and efficiently without the robot. Operative laparoscopy typically requires three to four incision sites, and the robotic laparoscopy may require four to seven incisions. In addition, there are single puncture devices that may be used at the umbilicus without the robot, and those are also being developed to be used with the robot. The debate continues about whether the surgery can be done effectively with one larger single site incision at the umbilicus. During a time when health costs are out of control, cost of instrumentation and equipment and length of surgery are important, and the question remains, does the robot offer advantages over advanced operative laparoscopy by a well trained, experienced laparoscopist and team?

There are several sides to this argument and debate. It appears that the robot is necessary for certain procedures in surgery, and there needs to be more follow-up and research to determine what procedures those will be and more specifically which ones those might include in the area of gynecology. It is important, however, to examine this data and to ascertain that comparisons of the robot are made to laparoscopy and that outcomes from robotic surgery are not compared to open surgeries. The pelvic floor procedures are performed with nonabsorbable sutures and mesh for optimal long-term results. The role of the operative team in these procedures cannot be overemphasized in enabling the surgeon to focus on the surgery. The entire team can play an integral part in large part because of the video cameras and monitors being used during laparoscopic surgery.