Chapter 15 Flashcards
OBGYN
1
Q
What are some oxytocic drugs?
A
-Synthetic oxytocin (Pitocin and Syntocinon)
-Carboprost Tromethamine (Hemabate)
-Methylergonovine Maleate (Methergine)
2
Q
What do oxytocic drugs do?
A
Stimulate smooth muscle including:
-Inducing/continuing labor
-Contracts uterus postpartum to prevent hemorrhage
-Dilate the cervix
-Stimulate lactation (milk let-down)
-Treat/cause abortion (spontaneous or elective)
3
Q
What are some side effects of oxytocic drugs?
A
-Risk of uterine rupture
-Irregular maternal heartbeat
-Increase in postpartum bleeding
-Jaundice in neonate
-Methergine can pass into breast milk causing vomiting, decreased circulation to extremities, diarrhea, weak pulse, unstable BP, and convulsions in the neonate
4
Q
What is Vasopressin (Pitressin)
A
A vasoconstrictor that increases BP and decreases bleeding. Can be injected into the cervix/uterine myometrium to decrease interop bleeding.
5
Q
What is Monsel’s Solution?
A
Is a Chemical mixture of ferrous sulfate, sulfuric acid, nitric acid, and water. A topical hemostatic agent post cervical biopsy. Is brown in color and differentiated from Lugol’s by its sticky, honey consistency.
6
Q
What is RhoGam?
A
Immunization that prevents erythroblastosis fetalis (hemolytic disease in newborns) in an Rh negative mother with an Rh positive fetus.
7
Q
What are dyes used for in OBGYN procedures?
A
Used to mark skin, tattooing, or following a tract
8
Q
What color dyes are usually used in OBGYN procedures?
A
-Brilliant green
-Gentian Violet
-Indigo carmine
-Methylene blue
9
Q
What is a cervical stain?
A
Stains the cervical mucosa during conization. Solutions that are used include Schiller’s, Lugol’s (more diluted solution of Schiller’s), and Acetic Acid.
10
Q
What is Schiller’s Solution?
A
Contains iodine and potassium which turns normal tissue brown. Since normal tissue does not have glycogen and will not uptake the stain.
11
Q
How does an Acetic Acid cervical stain work? (3%)
A
Vinegar solution that cause abnormal cells to fill with water so that light can’t pass through. The cervix is illuminated with light and white areas indicate abnormal cells. A green filter can be used to aid in visulization.
12
Q
What is gravida?
A
Number of times a woman has been pregnant.
13
Q
What is parity?
A
Number of times a woman has given birth
14
Q
What is lightening?
A
Settling of the fetal head into the pelvis or “dropped”
15
Q
What is Hyskon? (D5W)
A
A distention media. Dextran in glucose. High viscosity that reduces distortion of the image from intrauterine bleeding. Should be rinsed off of instruments to prevent hardening and damage. Used in open procedures such as an anti-thrombolytic and reduction of adhesions
16
Q
What is Sorbitol/Glycine?
A
Isotonic, non-electrolytic, non-hemolytic irrigation
17
Q
What is some equipment unique to OBGYN?
A
-Table with a foot end that drops.
-Stirrups, candy-canes, Allens, Fins
-Fetal monitors
-Warming beds for baby
-Laparotomy instruments
-Laparoscopy instruments
-Lasers
18
Q
What are common positions for OBGYN procedures?
A
-Lithotomy (pt on back and legs are in stirrups or candy canes)
-Trendelenburg
-Supine
19
Q
What are Braxton Hicks?
A
Muscular action of the uterus that does
not progress cervical dilation. AKA False Labor
20
Q
What are contractions?
A
Muscular action of uterus to
dilate the cervix and expel the
fetus
21
Q
What does Lie mean?
A
Relationship between the long axis of the fetus and mother. Includes longitudinal and transverse.
22
Q
What is Position?
A
Relationship between presenting
fetal part and the maternal body
pelvis
23
Q
What is Presentation?
A
Fetal part overlying the pelvic inlet. Normally should be the head. Buttocks is breach and compound are other parts.
24
Q
What is Station?
A
Measurement of the descent of the
presenting part of the fetus in relation
to the ischial spines
25
What is Cervical Effacement?
Cervix softens and thins and is taken
up into the lower uterine segment
26
What is Cervical Dilation?
Opening in the cervix for passage of
uterine contents
27
What is Bloody Show?
Blood tinged mucous that may herald
onset of labor
28
What is Crowning?
Largest diameter of fetal head is
encircled by the vulvar ring
29
What is Vernix Caseosa
Natural, protective and waterproof
coating. Has a white and creamy appearance and develops in the 3rd trimester.
30
What is Meconium?
Newborn feces within the amniotic
fluid. Can caused aspiration syndrome when breathed in during delivery
31
What is descent?
Movement of fetus through pelvic canal via contractions
32
What is flexion?
Bringing of the fetal head to the chest
33
What is internal rotation?
Rotation as fetal head meets pelvic floor
muscles
34
What is Extension Rotation?
Rotation as fetal head passes over
peritoneum
35
What is expulsion?
Delivery of shoulders and body of the fetus
36
What is Labor?
Process by which a fetus is moved from the uterine cavity to the external world.
37
What are the stages of labor?
Stage 1- Contractions (decent of fetus through the pelvic canal; goes from true labor to full dilation)
Stage 2- Delivery of the fetus (Fully dilated to birth)
Stage 3- Delivery of the placenta (Birth to delivery of placenta)
Stage 4- Recovery (Placenta delivery until mother's condition has stabilized)
38
What is obstetrics and gynecology?
A field specializing in females after the beginning of menstruation.
Obstetrics - The pregnant pt and fertility issues
Gynecology - Female reproductive system and problems outside of pregnancy
39
What set is used for gynecologic laparotomy?
Major abdominal set
40
What is included in a typical vaginal prep set?
-Graves vaginal speculum
-16 Fr urethral catheter
-Dressing forceps
-Sponge forceps
-Solution cups
41
What is included in a typical vaginal delivery set?
-Kelly hemostats
-Medium needle holder
-Tissue forceps with teeth
-Russian tissue forceps
-Straight Mayo scissors
-Curved Mayo scissors
-Placenta basin
-Cord clamps
-Cord blood tube
42
What is included in a typical D&C set?
-Knife handles, #3 and #4 long
-Dressing forceps, 8 in.
-Russian tissue forceps
-Towel clamp(s)
-Sponge forceps, 9.5 in.
-Bozeman dressing forceps, 10.5 in.
-Heaney needle holder
-Graves vaginal speculum
-Auvard weighted speculum
-Jackson vaginal retractor
-Hegar uterine dilator set
-Sims uterine sound
-Tenaculum forceps
-Sims uterine curette set
43
What is included in a vaginal set?
-Knife handles, #3 and #4
-Mayo scissors, several lengths
-Metzenbaum scissors, 7 in.
-Dressing forceps
-Tissue forceps, different lengths
-Kelly hemostats
-Rochester-Pean clamps
-Heaney clamps
-Kocher clamps
-Towel clamps
-Sponge forceps
-Vaginal retractors
-Deaver retractors
-Allis tissue forceps
-Auvard weighted speculum
-Tenaculum forceps
44
What is included in a gynecological abdominal set?
Basic laparotomy set plus:
-Mayo scissors, different lengths
-Jorgensen scissors
-Long and short tissue forceps with and without teeth
-Long and short Russian tissue forceps
-Rochester-Ochsner clamps
-Heaney needle holders
-O’Sullivan-O’Connor retractor
-Tenaculum, triple toothed
-Heaney hysterectomy clamps
-Heaney-Ballantine hysterectomy clamps
45
What is included in a set for a c-section?
-Knife handles, #3
-Needle holders
-Tissue forceps, short and long
-Russian, with teeth, and Adson’s
-Kelly hemostats, short and medium
-Rochester-Pean clamps
-Rochester-Ochsner clamps
-Mayo scissors
-Metzenbaum scissors
-Bandage scissors
-De Lee universal retractor or bladder blade from Balfour
-Richardson retractors
-Goulet retractors
-Cord clamps
-Cord blood tubes
-Bulb syringe
46
What is a typical monitoring board for delivery?
May be used to alert team about changing conditions, developing problems, deliveries, and cesarean sections. Usually contains:
-gravida/parity
-dilation
-effacement
-station
47
What are the roles of the CST during vaginal birth?
-Clamping/cutting umbilical cord (family member may choose to do this or might be a lotus birth which is delayed detachment)
-Collecting blood for cord gases
-Assisting OB as needed
-Prepared for emergency situations with mother/fetus (know fetal monitoring equipment)
48
What is the difference between and episiotomy and a perineal laceration?
A perineal laceration is an uncontrolled laceration of the vulva.
An episiotomy is an intentional surgical incision in the vulva to ease the birth process or to protect the mother from an uncontrolled perineal laceration. Is the most common surgical intervention in vaginal births.
49
How are perineal lacerations classified?
-First Degree: The vaginal mucosa or perineal skin
-Second Degree: Vaginal submucosa or perineum with or without perineal musculature
-Third Degree: Extends to the anal sphincter
-Fourth Degree: Extends to the rectal mucosa
50
How are perineal lacerations closed?
Absorbable suture. Layers of closure depends on degree of tear
51
What is a cervical cerclage?
Procedure performed in the late second or early third trimester to correct an incompetent cervix due to cervical weakness. A large diameter Dacron or Marcelene tape is placed around the cervix at the level of internal os to prevent spontaneous abortion. Includes the Shirodkar's and McDonalds procedure (uses suture instead of tape)
52
What is a Cesarean Section?
Surgical response to failure of the normal birthing process.
G.T.T: Remember the R hip bolster to get the baby off of the vena cava.
G.T.T: Tech might be asked to put pressure on the fundus of the uterus
53
What are the risks of a cesarean section?
-Mortality is 4-6 times that of vaginal delivery
-Epidural is the preferred anesthesia.
54
What are the indications of a Cesarean Section?
-Eclampsia or severe preeclampsia
-Cardiac disease
-DM
-Cervical C
-STD's like Herpes or AIDs
-Previous Sx
-Obstructions
-Fetal Distress
-Malpresentation (Breach, Transverse, etc)
-Cephalopelvic disproportion
-Placenta previa
55
What is Tubal Sterilization (Tubal occlusion/ligation)?
Done mini-laparotomy, laparoscopic, and colpotomy. Lumen may be interrupted by harmonic division, clips, ESU, and silastic bands.
56
What is a tuboplasty?
Microscopic resection and anastomosis of the fallopian tube. Reverses a tubal ligation or for ectopic pregnancy. Clipped or banded ligation reversal show the most success rate. They are classified according to anatomical classification:
-Isthmic-isthmic (midsegment)
-Ampullary-ampullary
-Isthmic-ampullary
G.T.T: you need a microscopes and loupes. treat it like a PV case
57
What is the standard procedure for a tuboplasty?
A Pfannenstiel incision is used.
-Damaged ends of fallopian tubes are isolated
-Tube is freed from attachments
-Tube is transected with an 11 blade against a tongue blade or iris scissor.
-Lacrimal duct probe and injection of dye demonstrates patency of lumens (18g angio or peds catheter can be used)
-Mesosalpinx is approximated
-2-0 monofilament is passed through to stent the lumen
-8-0 synthetic absorbable suture is used to make interrupted stiches at 3, 6, and 9 o'clock in the muscularis only (no mucosa to not compromise patency)
-2-0 stent is removed
-A 12 o'clock stitch is placed
-8-0/9-0 absorbable suture to stitch a second layer (only serosa and outer muscle layer)
-Patency is tested
-Lumen is irrigated
-Abdomen is closed
58
What is a laparoscopic resection of an unruptured tubal pregnancy?
-Done for an ectopic pregnancy (most common in the fallopian tube)
-Unruptured cases are commonly treated laparoscopically
-Ruptured is emergent and are commonly open.
59
What are the percentages of ectopic pregnancies that happen per area?
Ampullary-80%
Isthmic- 12%
Fimbrial- 5%
Intestinal- 2%
Abdominal- <1%
Ovarian-<1%
Cervical- <1%
60
What are the risk factors of an ectopic pregnancy?
-Hx or pelvic inflammatory disease
-Previous ectopic pregnancy
-Pregnancy following sterilization procedure
-Prior tubal reconstructive surgery
-IUD usage
-Prolonged infertility
-Exposure to diethylstilbestrol
61
What is a Salpingostomy?
Incision into the fallopian tube
62
What is a Salpingectomy?
Removal of affect tubal segment
63
What is an incompetent cervix and what are some risk factors?
A cervix that is prone to dilating and effacing which can lead to premature labor or miscarriage
-Previous premature delivery
-Prior trauma to cervix
-Congenital weakness of cervix
-Abnormalities of the uterus or cervix
64
What may low molecular weight Dextran be used for?
Poured in the pelvic area like irrigation fluid but is left in place to keep tissues separate which reduces adhesions and scar tissue formation
65
What are some gynecological conditions commonly operated on ?
-Genital anomalies
-Benign lesions of the vagina, cervix, uterus, ovaries and fallopian tubes
-Endometriosis
-GU Dysfunction (prolapsed bladder, uterus, rectum)
-Uterine, cervical, ovarian, vulvar, and vaginal tumors
-Dysfunctional uterine bleeding (DUB)
66
What are some incisions that are used in GYN and what are their disadvantages and advantages?
Oblique: less vascular and nerve damage and less likely to herniate but limits access
Vertical: best exposure and fast access but increased chance of herniation
Transverse: 30x stronger than vertical and better cosmesis but time consuming, hemorrhagic, compromises nerve and limits upper abdominal access.
67
What are some transverse incisions for GYN procedures?
Cherney: Rectus abdominus is dissected from the pubic symphysis.
-better exposure (pts w cancer)
-increased blood loss and pain
-faster access but weaker tissue postop
-common in urology
Maylard: muscle is dissected horizontally
-better exposure (pts w cancer)
-slow access
-increased blood loss and pain
Pfannenstiel: Muscle is dissected vertically.
-less exposure but faster access
Prep and drape is all the same
68
What are some components of a basic laparoscopy?
Used for diagnostic purposes to look for abnormalities and when labs can't explain symptoms. There is a dirty and clean area of the procedure:
Dirty- instruments needed for placement of uterine manipulator
Clean- include laparoscopic instruments
69
What are some components of a vaginal laparoscopy?
Handheld vaginal retractor is placed and tenaculum is used to grab the end of the cervix. A uterine manipulator is placed and covered w a sterile drape
70
What are some components of an abdominal laparoscopy?
Abdomen is insufflated, trocars are placed, and camera is inserted. Additional trocars and instruments may be used depending on findings.
71
What is a cervical biopsy?
Acetic acid and Lugol's solution are used as indicators of abnormal tissue. Punch biopsy forceps are then used take a bite of abnormal tissue such as small lesions.
72
What are some structures which should be identified and protected during a TAH?
-Bladder
-Ureters
-Rectum
-Iliac Vessels
73
What is removed in a total abdominal hysterectomy?
Uterus and the cervix
74
What is removed in a total abdominal hysterectomy bilateral salpingectomy oophorectomy
Uterus, cervix, fallopian tubes, ovaries
75
What is a hysteroscopy?
Diagnostic procedure where
-weighted speculum is placed in vagina
-cervix is grabbed with a tenaculum
-uterine sound is placed to determine the direction and depth of uterus
-cervix is dilated
-uterus is dilated (could be done w CO2, sorbitol, glycine, and dextran solution)
-visual exploration (Bx or operative action can be done atp)
76
What is the standard procedure for a Total Abdominal Hysterectomy (TAH)?
-self retaining retractor is placed
-bowel is packed cephalad w moist laps
-Lahey is placed on fundus of uterus to control
-stick tie around the round ligament (could also do GIA, harmonic scalpel, plasma seal coagulator) to create anterior and posterior leaves of broad ligament
-broad ligament is separated from peritoneum anterior and posteriorly
-ureters and iliac vessels are identified and protected
-bladder is bluntly dissected from uterus and cervix
-ovarian ligament, fallopian tube, and uterine artery are ligated
-paracervical fascia is dissected
-cardinal ligaments are transected and suture is tagged for cuff closure
-rectum is dissected from uterus and cervix
-uterosacral ligaments are transected and tagged
-colpotomy is performed
-uterus is removed
-vaginal cuff is closed
77
What is the difference between an abdominal and vaginal hysterectomy?
78
What is marsupialization of Bartholin's Gland Cyst?
Done for obstruction of bartholin's gland (can be caused by infection/trauma) which manifests as a cyst. Most are asymptomatic but can become large.
-Incision and drainage bring immediate relief
-May be performed under local anesthesia
-Marsupialization may be required for permanent healing to occur
79
What is the standard procedure for marsupialization of Bartholin's Gland Cyst?
-elliptical incision is made in vaginal mucosa
-cyst dissected from surrounding tissue
-cyst is opened and drained
-cyst wall is everted and sutured to vaginal mucosa.
80
What is a simple vulvectomy (skinning)?
Performed for benign or malignant conditions of the vulva. Is the last recourse when other treatments have failed. Treatment for genital condylomas and Padget's.
81
What is the standard procedure for a simple vulvectomy?
-area is marked
-local is administered
-vaginal incision is made
-epithelium is undermined
-minor bleeders are coagulated
-outer incision is made
-dissection of adipose layer only is completed
-hemostasis is achieved
-tissue is approximated with absorbable suture
-skin edges are approximated
-small drain may be placed
-vaginal epithelium is everted over perineum to level of anal orifice to allow for satisfactory coitus
-dressing is firm packed applied to entire area
82
What are ablations for condylomas?
-CO2 layer ablation is done on areas that could be compromised. OR
-A wide local lesion excision with 5mm margin (preferred prior to vulvectomy)
83
What is a labiaplasty?
Done to correct the labia minora hypertrophy. (is a congenital abnormality or torn/stretched due to trauma, age)
Laser or sharp dissection of epithelium and then wound is closed
84
What is the preop diagnosis for a Dilation and Curettage (D&C)?
-Dysmenorrhea
-Rule out endometrial disease
-R/o pregnancy prior to sterilization
-Determine the cause of infertility
-Removal of suspected pathology
-Tx of postpartum bleeding
-Vacuum out retained placenta
-Retrieval of lost IUD
-Placement of radioactive carriers for management of cervical/uterine malignancies
-Tx of incomplete abortion (D&E at 13 wks)
85
What is the standard procedure for a D&C (dilation and curettage)
86
What are some indications for a myomectomy?
-Anemia
-Chronic, severe pelvic pain
-Chronic secondary dysmenorrhea
-Fibroid is preventing the evaluation of adnexa
-UTI S&Sx
-Infertility
-Rapid increase in size
87
What is a myomectomy?
Excision of uterine fibroids
88
What are some considerations for a myomectomy?
89
What is the standard procedure for a myomectomy (abdominal approach)?
-Pfannenstiel or vertical midline incision is made
-self retaining retractor is placed (bowel is packed cephalad w moist laps)
-vertical incision is made over myoma
-incise pseudocapsule
-expose tissue planes
-blunt dissection, cut, cauterize, laser, and peel the myoma from the capsule
-incision is closed, abdomen is closed
90
