Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
Emergency Obstectric Care
Hypertension in Pregnancy
Hypertension
Assessment and management
Delivery
Postpartum care
Chronic hypertension
Complications
Management of Slow Progress of Labour
General principles
Slow progress of labour
Progress of labour
Operative procedures
Bleeding in Pregnancy and Childbirth
Bleeding
Diagnosis and initial management
Specific management
Procedures
Aftercare and follow-up
Procedures
 


> MANUAL VACUUM ASPIRATION
> DILATATION AND CURETTAGE
> CULDOCENTESIS
> COLPOTOMY
> SALPINGECTOMY FOR ECTOPIC PREGNANCY
> REPAIR OF RUPTURED UTERUS
> MANUAL REPAIR OR PLACENTA
> REPAIR OF CERVICAL TEARS
> REPAIR OF VAGINAL AND PERINEAL TEARS
>

UTERINE INVERSION
> UTERINE AND UTERO-OVARIAN ARTERY LIGATION
> POSTPARTUM HYSTERECTOMY


SALPINGECTOMY FOR ECTOPIC PREGNANCY

1 Give a single dose of prophylactic antibiotics (ampicillin 2 g IV or cefazolin
1 g IV).
2

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 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.


3 Identify and bring to view the fallopian tube with the ectopic gestation
and its ovary.
4 Apply traction forceps (e.g. Babcock) to increase exposure and clamp the
mesosalpinx to stop haemorrhage.
5 Aspirate blood from the lower abdomen and remove blood clots.
6 Apply gauze moistened with warm saline to pack off the bowel and
omentum from the operative field.
7 Divide the mesosalpinx using a series of clamps (Figure 12.12). Apply
each clamp close to the tubes to preserve ovarian vasculature.
8 Transfix and tie the divided mesosalpinx with 2-0 chromic non absorbable
(or polyglycolic) suture before releasing the clamps.
9 Place a proximal suture around the tube at its isthmic end and excise the
tube.
10

Close the abdomen:

• Ensure that there is no bleeding; remove clots using a sponge
• In all cases, check for injury to the bladder and repair it, if found
• Close the fascia with continuous 0 chromic non absorbable (or polyglycolic) suture; there is no need to close the bladder peritoneum or the abdominal peritoneum
• Use fingers or scissors to separate the rectus muscles (abdominal wall muscles)
• 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
• If there are signs of infection, pack the subcutaneous tissue with gauze and place loose 0 non absorbable (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.



Salpingostomy

Rarely, when there is little damage to the tube, the gestational sac can be removed and the tube conserved. This should be done only in cases where the conservation of fertility is very important to the woman since she is at risk for
another ectopic pregnancy.

1 Open the abdomen and expose the appropriate ovary and fallopian tube.
2

Apply traction forceps (e.g. Babcock) on either side of the unruptured tubal pregnancy and lift to view.
3 Use a scalpel to make a linear incision through the serosa on the side opposite to the mesentery and along the axis of the tube, but do not cut the gestational sac.
4 Use the scalpel handle to slide the gestational sac out of the tube.
5 Ligate bleeding points.
6 Return the ovary and fallopian tube to the pelvic cavity.
7 Close the abdomen.


Post-procedure care

1 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:
•
Ampicillin 2 g IV every 6 hour plus gentamicin 5 mg/kg body weight IV every 24 hours plus metronidazole 500 mg IV every 8 hours.
 
2

Give appropriate analgesic drugs.
3 If salpingostomy was performed, advise the woman of the risk for another ectopic pregnancy and offer family planning.


> MANUAL VACUUM ASPIRATION
> DILATATION AND CURETTAGE
> CULDOCENTESIS
> COLPOTOMY
> SALPINGECTOMY FOR ECTOPIC PREGNANCY
> REPAIR OF RUPTURED UTERUS
> MANUAL REPAIR OR PLACENTA
> REPAIR OF CERVICAL TEARS
> REPAIR OF VAGINAL AND PERINEAL TEARS
>

UTERINE INVERSION
> UTERINE AND UTERO-OVARIAN ARTERY LIGATION
> POSTPARTUM HYSTERECTOMY



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