DILATION & CURETTAGE (D&C)

DILATION & CURETTAGE (D&C)

Dilation and curettage is a surgical abortion procedure performed during the first 12 to 15 weeks gestation.

Indication

·       Curatine

·       Diagnostic

·       As preliminary to other operations

Diagnostic

·       Sterility

·       To determine whether the cycle is ovulatory

·       Dysfunctional uterine bleeding

·       Secondary haemorrhage and amenorrhoea

·       Carcinoma

·       Uterine polyps

·       Postnatal bleeding

Curatine

·       Dysfunctional uterine bleeding

·       Endometrial thickness reduced

·       Habitual abortion and relative infertility

·       Post obstetrical bleeding

·       To correct or arrest bleeding

·       Spasmodic dysmenorrhoea

As preliminary to the other operations

·       For any plastic operation of the cervix

·       Vacuum aspiration for MTP

·       As preliminary to an intra activity radium insertion

Articles

·       Vulsellam forceps

·       Posterior vaginal speculum

·       Uterine sound

·       Dilator

·       Curette

Procedure

Ø  Patient is asked to empty the bladder before being put to the table in lithotomy position.

Ø  The operation field should be cleaned with antiseptic solution and sterile drapes are put on.

Ø  Vaginal examination is done to confirm the size and position of the uterus.

Ø  Anterior tip of cervix is caught by the vulsellum and the cervix is cleaned again with antiseptic solution.

Ø  Gentle traction is applied to the vulsellum to pull on the cervix as the uterine sound is inserted to find out the length and direction of uterine cavity.

Ø  Dilatation of the cervix is done with cervical dilators. The tip of the dilator is dipped in savlon. The cervix is sufficient to admit a sharp endometrial curette.

Ø  Curette is then introduced and the endometrium is scraped. The cervix is swabbed with sterile swab.

Ø  Specimen is collected in a vial containing 10% formaline solution and sent to the lab.

Ø  Dilation and curettage is similar to suction aspiration but with the introduction into the cervix of a curette. A curette is a long, lopped shaped knife that scrapes the lining, placenta and fetus away from the uterus. A cannula may be inserted for a final suctioning. This procedure usually lasts 10 minutes with a possible stay of up to 5 hours.

Side effects and/or complications

The side effects and possible complications of dilation and curettage are the same as suction aspiration as noted above with the exception that there is a slight increased chance for perforation of the uterus.

Additionally, dilation and curettage or D&C may be necessary after a vacuum aspiration. In this procedure, a separate curette (a spoon-shaped instrument) may be used to help remove any remaining tissue that may be lining the uterus. A vacuum aspiration abortion procedure (by itself or followed by a dilation and curettage) can be performed in one visit and is an option for women until 14 weeks have passed since their last menstrual period. It is nearly 100% effective.

Nurses Responsibility

Preparation

Ø  The patient is instructed to refrain from eating and drinking for at least eight hours before the procedure, if general anaesthesia will be used.

Ø  Prepare the patient when the doctor order blood and/ or urine tests to scan for certain abnormalities.

Ø  Sedatives may be given before the procedure begins as doctors orders because opening the cervix can be painful.

After Care 

Ø  The nurse usually looks for any abnormalities and sends home from the hospital on the same day or the next day.

Ø  The nurse observes women experiencing backache and mild cramps after the procedure, and pass small blood clots for a day or so. Vaginal staining or bleeding may continue for several weeks.

Ø  Nurse educates the women that they can resume normal activities almost immediately and should avoid sexual intercourse, douching and tampon use for at least two weeks to prevent infection while the cervix is closing and to allow the endometrium to heal completely.

Ø  As the procedure is infectious, the woman is educated to report immediately to her doctor, who can treat the infection with antibiotics, if a woman experiences any of the following symptoms.

·       Fever

·       Heavy bleeding

·       Severe cramps

Foul-smelling vaginal discharge

M’C DONALD’S OPERATION

M’C DONALD’S OPERATION

It is known by different names like as tightening, cervical suture, cervical encirclage, nylon wiring.

Indication

1.     Incompetent cervical os.

2.     Prophylatically in cases with history of repeated second trimester abortions or history of premature labours with obvious case.

3.     Twin pregnancy to prevent preterm labour. Not scientifically proved.

      Time of operation

During pregnancy around 12-14 weeks is ideal time. It can be done as early as 10 weeks and is indicated cases up to as late as 32 weeks. Reasons for doing operation at 14 weeks

a.      After 14 weeks risk of abortion increases as the time passes.

b.     Before 14 weeks i.e in first trimester the abortion is commonly due to defect in the fertilized ovum or defect in the placenta.

c.      Even in proved cases there is very little risk of abortion before 14 weeks because only at the end of 12 weeks uterine cavity is completely filled up by the growing fetus so as to exert strain on the cervix at internal os.

Anaesthesia

It is performed under short GA ( IV/ pentothal). It can be performed in local anaesthesia and sedation. Pre anaesthetic medication in the form of Inj. Atropine 0.6 mg. Half an hour before operation is given.

Steps of operation

¨     Emptying of bladder. Lithotomy position. Painting and drapping.

¨     Anaesthesia is given. Per vaginal examination is done.

¨     Per speculum examination is done to see that there is no bleeding or leaking or herniation of membranes.

¨     Cervix is swabbed with dry sterile swabs.

¨     Anterior and posterior lips are held with swab holders. Instead 4 allis forceps are commonly used as they give better grip.

¨     Double strands of No.2 braided silk on round body half circle curved needle is used for suture. Persestring suture is taken as high as possible on the cervix without incising the epithelium. Suture is started anteriorly and minimum 4 bites are taken i.e at 1-2, 10-11, 7-8 and 4-5’O clock position anticlockwise. Bites should be deep in the cervical substance but avoiding endocervix.

¨     Post operative treatment: patient is kept in the hospital for 1 to 2 days. Antibiotics uterine relaxants and sedatives are given. P/S examination is done before discharge.

¨     Patient is adviced for weekly antenatal check up and should report immediately if she develops pains, bleeding p/v or leaking.

Removal of stitch

Suture is removed in 38^th week. But if the patient is not sure of her LMP it may be removed immediately after the onset of labour.

Long ends of the ligature are caught with an artery forceps and ligature is cut with the scissors beyond the knot close to the cervix and then pulled out.

Contraindications

Ø  Local infection

Ø  Bleeding p/v rupture of membrane

Ø  Irritable tissues

Ø  Cervical dilatation more than 3cm

Ø  Intrauterine fetal death

Ø  Fetal abnormalities

Ø  Suspected intrauterine infection

Complication

« Bleeding

« Accidental injury to membranes leading to rupture or ascending infection (amnionitis) or abortion

« During labour cervical dystocia (due to fibrosis)

« Cervical tears or rarely rupture uterus if stitch is not removed immediately after labour pains have started.

CERVICAL CAUTERIZATION

CERVICAL CAUTERIZATION

Introduction

            This is performed by electric cautery. In electrocautery there is simple burning of diseased tissue while with diathermy cautery there is electrocoagulation (i.e, both incision and coagulation) of diseased tissue. Electrocoagulatio (with high frequency monopolar electrode) is better than electrocautery because the penetration of heat and destruction of diseased gland tissue are uniform and controllable. As electrocautery is quite cheaper than diathermy cautery it is widely used.

Definition

Cervical cauterization is a procedure that is used to destroy abnormal (noncancerous or precancerous) cells on the opening to the womb (cervix). Cauterization is carried out through the use of heat, electricity, cold, corrosive chemicals or laser. The most common methods involve high frequency electric current (electrocoagulation) or freezing (cryocauterization, cryosurgery).

Indication

Cervical cauterization is commonly used ti treat inflammation of the cervix (cervicitis), liquid-filled sacs (cysts) and precancerous lesions of the cervix, such as small areas of  abnormal tissue (cervical dysplasia). Cauterization is used to treat cervical lesions caused by human papilloma virus (HPV) AS 80% of cervical cancers are associated with HPV. It may also be used to stop bleeding that is occurring either spontaneously or following a cervical procedure such as cervical biopsy, cervical polypectomy or cervical conization. Cervical cancer itself is not treated with cauterization but by more aggressive means including surgery and radiation therapy.

Contraindications

Acute cervicitis, vaginitis, pregnancy, acute pelvic inflammatory disease and suspected early invasion carcinoma of cervix under evaluation.

Procedure

Cauterization is performed in outpatient surgery centers and hospital. The woman lies on the exam table in lithotomy position. A speculum is inserted into vagina to hold it open to allow visualization of the cervix. The cervix is cleaned using a vaginal swab that is soaked in a salt solution (saline). Using a lighted, magnifying instrument (colposcope), the vagina and cervix are carefully examined for signs of inflammation or abnormal surface patterns. To allow visualization of abnormal surfaces, a solution of acetic acid is applied to the cervix. The acetic acid turns precancerous and cancerous regions of the cervix white (acetowhitening). A surface anesthetic or cervical nerve block may be administered a few minutes prior to cauterization. Cauterization is performed on any abnormal-appearing regions of the cervix. The method chosen depends on the experience of the physician, availability of necessary equipment and extent and location of lesion.

Electrocoagulation diatherapy uses electric current to destroy tissue. The current is delivered to the tissue through needle or ball electrodes. Electrocoagulation diathermy of deep cervical tissue requires general anesthesia. The most common office procedure for these conditions is Loop Electrical Excision Procedure (LEEP). The excision is done with an electrical wire so that precise control of the excision and electrocoagulation for hemostasis are accomplished. Injection of local anesthesia is necessary for this to be done in the office setting. Sometimes general anesthesia is required.

Chemical cautherization is used to treat cervical cysts, precancerous erosions of the cervix and cervicitis. The area to be cauterized must be dried using a cotton swab to prevent the chemical from trickling onto normal tissue. A cotton swab that has been moistened with the chemical cauterant (e.g biochloracetic acid) is touched to the cervical lesion. Cervical cysts would be punctured before application of the cauterant. After a few minutes the cauterized area is wiped with a dry swab to remove any residual chemical. Laser cauterization (laser vaporization) is an effective treatment of all cervical dysplasias including those that are too large for cryocauterizatiuonand those that slightly extend into the cervical canal (endocervix). Because of the expense of laser cautery equipment, most laser cauterizations are performed in outpatient surgery centers and hospitals and frequently involve general anesthesia. Laser cauterization is carried out by aiming a carbon dioxide laser beam at the cervical dysplasia. Because of the fine degree of control over the depth and width of tissue destruction, the laser can precisely vaporize the dysplasia while leaving adjacent normal tissue intact. A smoke evacuator is utilized to remove smoke from the vagina. Antibiotics and analgesics are prescribed as needed.

After-treatment

            Inform the patient that there will be excessive vaginal discharge for about 3 weeks. Abstinence from sexual intercourse for 3 weeks. Vaginal pessary or antiseptic cream is usually not necessary. Only if the discharge becomes infective they are indicated. Follow-up after 6 weeks: (1) If erosion has not healed completely repeat cauterization is indicated. (2) Pass a uterine sound to check that cervix is not stenosed.

Prognosis

            Electrocoagulation has a high success rate and is associated with a recurrence rate of 3% to 14%. Chemical cauterization has a high success rate for mild dysplasias. Laser cauterization has a high success rate and a recurrence rate of 4% to 23%.

Complications

            Complications associated with cervical cauterization include uterine cramping, lightheadedness, hot flashes and headaches (vasomotor reactions), profuse watery vaginal discharge, bleeding (hemorrhage), upwardly spreading (ascending) infection and narrowing (stenosis) of the cervical canal.  

HYSTEROTOMY

HYSTEROTOMY

DESCRIPTION

            The hysterotomy is a technique of electively terminating a pregnancy after 20 weeks of gestation or when vaginal route is not possible. In this method, a surgical procedure similar to cesarean section is performed with all the same risks and complications associated with a cesarean delivery. It is reserved for special circumstances, such as when other abortion methods have failed, and usually is not the primary abortion method chosen.

            The fetus is usually killed prior to or at the time of the delivery, usually by cutting the umbilical cord to prevent the fetus from getting oxygen. Occasionally a fetus will survive and may have to be killed after delivery by the health care provider or allowed to die on its own through neglect. Many countries have laws in place to cover any fetus that is born during an abortion and survives the procedure, but cases have been documented of such babies being left to die.

REASONS FOR PROCEDURE

·       Personal concerns about the social or economic aspects that involve an uplanned pregnancy.

·       Continuing with the pregnancy may pose a threat to the life of the mother.

·       Pregnancy resulted from a rape.

·       Fetus is affected with a major disorder such as chromosomal abnormality or birth defects.

·       Fear that the fetus has been harmed by medications or other conditions.

RISKS INCREASES WITH

« Obesity

« Smoking

« Poor nutrition

« Recent or chronic illness

« Use of drugs such as anti-hypertensive; muscle relaxants; tranquilizers; sleep inducers; insulin; sedatives; narcotics; beta-adrenergic blockers; or cortisone.

« Use of mind- altering drugs including narcotics; psychedelics; hallucinogens; marijuana; sedative; hypotics; cocane.

ARTICLES REQUIRED

v Kidney tray-2

v Sponge holder-2

v Gauze swabs

v Sponges

v Basin

v Green armitage-6

v Long artery forceps-4

v Short artery forceps-4

v Mosquito forceps-4

v Doyins retractor

v Devers retractor

v Cord clamps-2

v Curved scissor-1

v Straight scissor-1

v Betadine solution

v Suction tube and catheters

Sutures

R 1 vicryl

R Catgut

R Vicryl rapid

DESCRIPTION OF PROCEDURE

ª A general anesthesia is used.

ª An incision is made in the abdomen and then in the uterus. Fetal tissue and placenta are removed.

ª The uterus wall is sewed back together and the abdominal opening closed.

EXPECTED OUTCOME

R Termination of the pregnancy.

R Complete healing without complications.

POSSIBLE COMPLICATIONS

1.     Immediate

2.     Remote

IMMEDIATE

à Excessive bleeding

à Surgical-wound infection

à Depending upon the type of uterine scare, there is often an increased risk of uterine rupture in a future pregnancy.

§  Peritinitis

§  Intestinal Obstruction

§  Anesthetic hazards, all these lead to increased morbidity and occasional death.

REMOTE

     Menstrual abnormality-menorrhagia or irregular periods.

     Scar endometriosis (1%).

     Scar rupture in subsequent pregnancy.

POST OPERATIVE CARE

GENERAL MEASURES

§      Use of sanitary pads for bleeding, which may last for several days. If bleeding continues 10-14 days after surgery, tampons can be used.

§      If pain is present place a heating pad or hot-water bottle on the abdomen or back. Hot baths frequently promote muscule relaxation and relieve discomfort. Repeat the baths as often as they provide comfort.

§      If contraception is desired, it can often be initiated shortly after the procedure. If the client wishes to take birth controlling pills, begin taking them either on the night she returns from surgery or the next day. If the client prefers an IUD, diaphragm or cervical cap, the fitting can be made during clinical appointment.

§      The next menstrual period should begin 4-6 weeks after the procedure. If the client is on birth controlling pills, the first period will began after the completion of the first cycles of pills.

MEDICATIONS

ü  Prescription pain medication should generally be required for only 2-7 days following the procedure.

ü  Non-prescription drugs, such as acetaminophen, for pain can be used.

ü  Antibiotics may be prescribed to reduce risk of infection.

ü  Stool softener, laxative, if needed to prevent constipation.

ACTIVITY

Ø  Resuming normal activities normally.

Ø  Avoiding sexual relations for 4-6 weeks after surgery.

DIET

No special diet. The client has to notify the clinician if any of the following occurs:

o   Pain, swelling, redness or drainage increases in the surgical area.

o   Signs of infection; headache; muscle aches; dizziness or general ill feeling and a temperature of over 100⁰ orally.

o   New, unexplained symptoms develop. Drugs used in treatment may produce side effects.

NEONATAL CARE: ADMINISTRATION OF FLUIDS AND MEDICATION

NEONATAL CARE: ADMINISTRATION OF FLUIDS AND MEDICATION

Administration of oral medication

Adherence to the following principles in your professional and legal responsibility and will assist in safe practice (Griffith et al, 2003)

The Five Cs/Rs:

·        Correct/ Right Patient/ Child

·        Correct/ Right Medicine

·        Correct/ Right Dose

·        Correct/ Right Time

·        Correct/ Right Route

Double Checking

If double checking is required, all aspects of preparation, administration and documentation must be carried out from start to finish by both practitioners

Basic principles when administering oral medication

Child development considerations are important in the administration of medicines. Some basic principles include (Rationale 17).

·       Be confident

·       Approach the child/family with a positive attitude

·       Be honest and understanding

·       Allow the child to have control where appropriate.

·       Use appropriate language that the child understands.

·       Discuss with the child what they might taste/ smell/see/hear/feel.

·       Listen to all involved.

·       Explain the benefits of compliance with the medicine taking.

Age –appropriate considerations should always be taken into account during drug administration.

Drug Calculations

Paediatric dose calculation is usually based on either body surface area (mg/m²) or body weight (mg/ kg) of the child. Body weight is used more frequently for the case of calculation.

The calculation of body surface area (BSA) used to require body weight and height.

To calculate drug doses, use the following formula:

Dose required/ Present Standard Quantity of Drug  X  Present Quantity of Liquid in which Standard Quantity of Drug is Dissolved

In other words:

What you want/ What you have X What it is in (dilation)

For example: A child is prescribed 90mg of Paracetamol and the medication supplied is 120mg of Paracetamol in 5mls:

90 / 120 X 5 = 3.75mls

CONTRAINDICATIONS

o   Unconscious child

o   Absent gag reflex

o   Inability to swallow

o   Vomiting

CAUTIONS

R Digestive tract trauma/ illness

R Post gastro-intestinal surgery

R Nil-by-mouth

R Nausea

R Diarrhoea

IV CANNULAE INSERTION

Before cannula insertion, use aseptic techniques by doing the following:

     Wash hands aseptically

     Wear sterile gloves

     Disinfect the skin

     Use no-touch technique

IV THERAPY

Each NICU should designate persons to be trained in the preparation of IV fluids, peripheral additional fluids. They should establish a dedicated area for preparation of medications and IV fluids. This area should not be used to store/ place any biologic material (eg. tubes of blood, formula and others). Preparation of IV fluids, preparation of IV medications or drugs and administration of medications or drugs are important activities that have to be performed safely to prevent infections inside NICUs. Therefore, task analysis was performed where all steps required are described in details to avoid any contamination. Three main critical activities will be described:

A.    Preparation of IV fluids

B.    Preparation of IV medications or drugs

C.    Administration of IV medications or drugs

A.    Critical Steps in Preparation of IV fluids

1.     Perform routine/ hygienic hand wash.

2.     Prepare and clean working area with a disinfection

3.     Gather necessary materials (IV fluids, drugs, syringes, needles, disinfecting materials, etc) and place them in the clean area of possible on a clean cloth/ towel.

4.     Inspect IV fluid containers for expiry date, cracks, leaks, cloudy/turbid etc.

5.     Wash hands with an antiseptic for 2-3 minutes. Dry hands with paper towel or fresh cloth towel or perform alcohol hand rub.

6.     Disinfect the port of IV bottles/bags with appropriate disinfectant (70% alcohol) immediately before removing/adding fluids.

7.     Wear sterile gloves.

8.     Use a sterile base needle/syringe for each IV fluids (the container that has the largest volume of the mixture wanted i.e. adding the smaller amount of fluids to the larger amount which will be the base)

B.    Critical Steps in Preparation of IV medications or drugs

1.     Use single-dose ampoules rather than multi-dose vials. If multi-dose vials must be used, always pierce the septum with a sterile needle. Never enter multi-dose vials with a needle or syringe that has been used on a patient. Use a new needle every time you stick into the multi-dose vial.

2.     If a multi-dose vial needs to be resolved, the used needle/syringe must be disposed. For each draw from the vial a new sterile needle and syringe must be used.

3.     Before filling a syringe from an ampoule or multi-dose vial, inspect for any contamination, turbidity, cracks, leaks and expiry date.

4.     Between each draw the top of the vial should be wiped once with alcohol and a cotton pad.

5.     Use for each vial/ampoule a new sterile needle and syringe.

6.     Any medication left in the vital should be kept in a fridge for no more than 24 hours or less if the manufacturing instruction doesn’t allow 24 hours storage.

7.     Aseptic hand washing or alcohol rub should be performed before each use of a multi-dose vial/ampoule.

C.    Critical Steps in Administration of IV medications or drugs

A.    Every step must follow strict aseptic techniques.

B.    Maintain a closed system at all times.

C.    Do not mix medications together.

D.    If medications are not compatible with IV fluids, the IV line needs to be stopped and flushed before administration as follows:

a.      Stop the IV fluid first.

b.     Flush the cannula with saline solution.

c.      Infuse the medication.

d.     Flush again.

e.      If needed infuse the second medication and flush again.

f.      Restart the routine IV fluid.

BIBILIOGRAPHY

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