SUR 122

1. SUR 122 OBSTETRICAL & GYNECOLOGICAL SURGERY

2. OB-GYN Surgery • Female • From beginning of menses

3. OB-GYN Specialists • Obstetricians: pregnancy • Gynecologists: Breast Surgery (non-reconstructive) Bladder Tac related Surgeries: pubovaginal Sling, TVT (tension vaginal tape, A & P Repair, etc.) • Can be both or one or the other • Fertility Specialists • Oncology Gynecologist

4. Obstetrical & Gynecological Surgery • Reasons For: • Diagnose abnormalities • Treat abnormalities • Pain relief • Prevention of pregnancy • Aide in conception for infertile couples • Prevention of spontaneous abortion • Cesarian delivery (abdominal) when vaginal delivery not possible

5. The Female Reproductive System • Anatomy & Physiology • Pathology • Diagnostic & Pre-operative Testing • Anesthesia & Medications • Basic Supplies, Instrumentation, & Equipment • Positioning, Prep, & Draping • Dressings, Drains, & Post-operative Care

6. Pelvis • Pelvic girdle • Ilea • Ischia • Pubic bones • Vertebral column • Sacrum

7. Anatomy & Physiology • External Female Genitalia (Vulva) • Mons pubis • Labia majora • Labia minora • Urethral orifice • Vaginal orifice • Clitoris • Hymen • Perineum • Anus

8. External genitalia • Labia minora form the clitoris and contain sebaceous glands • Vestibule is the cavity between the labia minora • Contains urethral meatus and Bartholin’s (vestibular) glands • Perineum is the area between vaginal opening and anus • Can stretch with delivery however is frequently cut with an incision called episiotomy to prevent spontaneous tears during vaginal delivery

10. Vagina External Cervical Os Cervix Uterus Layers of: perimetrium myometrium endometrium Parts of: Body Fundus Adnexa Fallopian Tubes Ovaries Supporting Structures Internal Structures

11. Vagina • Receptacle to penis • Passageway for menstrual flow • Lower portion is the birth canal

13. Uterus • Function: • Site of menstruation • Or • Site of implantationif implantation occurs then is the site of fetal development

14. Uterus • Parts of: • Dome shaped portion=fundus • Central portion=body • Where narrows=cervix • Internal cervical os=where uterus and cervix meet • External os=where cervix meets vagina

15. Lining of: Perimetrium=outside of uterus covered in a this serous membrane lining Myometrium= -smooth muscle lining -middle layer -fetal support -during labor expels fetus with assistance of hormone oxytocin 3. Endometrium=inner lining2 parts: stratum basalis permanent layerthin Stratum functionalis -produced by s. basalis -temporary layer -shed w/menstruation -produces maternal portion of placenta Uterus

16. Uterus • Blood supply: • Uterine artery and uterine vein

19. Ovaries • Function: • Production and expulsion of oocytes (ova or eggs) • Release of hormones: estrogen and progesterone • Are both endocrine and exocrine glands • Exocrine produce eggs (ducts=fallopian tubes) • Endocrine portion produces estrogen and progesterone

20. Ligaments • Attachments: • Broad ligament -largest formed by a fold of peritoneum Attached uterus, ovaries and fallopian tubes to the pelvis -contains fallopian tube, blood vessels, lymphatics, nerves, suspensory (round) ligaments, and ovarian ligaments

21. Ligaments 2. Cardinal ligament • Continuation (base of) of broad ligament • Considered most important “cardinal” • Provides uterine and apical vaginal support • Also called utero-sacral ligament

22. Ovaries 3. Suspensory (round) ligament -small peritoneal fold -holds or “suspends” ovaries at upper end (laterally) anchoring it to pelvis -contains blood vessels and nerves 4. Ovarian ligament -anchors ovaries at their lower end medially to the uterus -is actually a thickening in the broad ligament

24. Fallopian tubes • Egg is caught by finger-like projections called the fimbrae after it is released from the ovary • Funnel shaped end prior to fimbrae=infundibulum

25. Fallopian tubes • 2 layers: 1.Mucous membrane innermost • Is lined with ciliated columnar epithelial tissue • Allows for movement of the egg • Scarring from STDs can damage or scar this lining rendering a female sterile

26. Fallopian tubes 2. Muscularis • Smooth muscle • Peristalsis or movement of the egg • So… • Egg movement through the fallopian tubes occurs by cilia and peristalsis • Fertilization must occur in the distal 1/3 of the fallopian tubes for successful implantation into the uterus

27. Physiology • Ovarian cycle caused by anterior pituitary gland which secretes: • LH “ovulation hormone” • FSH levels must be low to allow ovulation • Causes secretion of estrogen • Menses is caused by a sudden decrease in estrogen and progesterone triggered by no fertilization

28. Hormones • LH • Produced in anterior lobe pituitary gland • Ovulation hormone • Continues follicular development • Stimulates estrogen and progesterone production • Regulates ovulation and menstrual cycle (works with FSH to do this)

29. Hormones 1. FSH • Produced in anterior lobe pituitary gland • Causes graafian follicular development • Causes estrogen secretion • Helps LH control ovulation and menstrual cycle

30. Hormones • Estrogen • Maintenance and development of reproductive organs and female sex characteristics

31. Hormones • Progesterone • Primary cause of endometrial changes & maintenance for pregnancy • Hormone of pregnancy • With Prolactin (hormone) influences mammary glands to develop and secrete milk • Milk secretion and labor is stimulated by oxytocin (hormone)

32. Physiology • In the ovary > the big 4 hormones are increasing which develops a follicle • Follicle becomes a graafian follicle • Graafian follicle rupture>egg released into fallopian tubes • Outer rind of graafian follicle becomes corpus luteum

33. Physiology • 2 possibilities: • No fertilization=corpus luteum degenerates and becomes corpus albicans and cycle starts over • Fertilization=corpus luteum maintained four months to suppress egg production and menstruation with estrogen and progesterone • Progesterone levels must be high enough to maintain endometrial lining to sustain pregnancy • Corpus luteum acts as a temporary endocrine gland • After four months placenta is developed and takes over

34. Obstetrics

35. Pregnancy (Obstetrics) Procedures • Cerlage (MacDonald or Shirodkar) • Deliveries: • Vaginal • Cesarian sections (C-sections) • Tubal ligations (sterilization procedures) • Emergent hysterectomy

36. Pregnancy Terminology • Labor • Four stages of: • True labor onset • Cervical dilation complete>birth • Birth>placental delivery • Placental delivery > stabilization of mother • Primapara • 6-18 hours • ½ - 3 hours (dilation 1 cm/hr) • 0-30 min • 6 hours • Multipara • 2-10 hours • 5-30 min (dilation 1.2cm/hr) • 0-30 min • 6 hours

37. Pregnancy Terminology • Braxton Hicks - “false labor” • Bloody show – onset of labor • Cervical dilation - cervical measurement (0 to 8cm) • Goes to 10cm, but at 10cm, your baby is through the cervix! • Cervical Effacement – thinning of cervix • Crowning - neonate head circumference at its largest point as it passes thru vulvar ring

38. Pregnancy Terminology • Descent – movement of fetus thru pelvis with contractions • Expulsion – delivery of infant • Gravida - how many times a woman has been pregnant • Parity – number of times a woman has given birth • Position – relationship between presenting infant part & pelvis of mother • Presentation – fetal part overlying pelvic inlet • Station – measurement of the descent of the infant’s presenting part thru the ischial spines

39. Presentation • Breech - buttocks first • Transverse – crosswise • Footling – feet • Vertex – upper back of head

40. More Terms • Dystocia- Difficult labor • Meconium-neonatal stool • DeeLee suction catheter-used to suction amniotic fluid tainted with meconium to prevent meconium aspiration syndrome

41. Gravita and Parity Clarification • Gravida-times pregnant • Parity-number of times given birth • Nulliparous-not given birth regardless of gravita • Primagravida-first pregnancy • Twins/Multiples count as G-1 P-1 • May hear GTPAL • G-gravity, T-term pregnancy, P-preterm pregnancy, A-abortion/miscarriage, L-live births

42. Obstetrical Complications • Placenta previa – placental implantation over cervix • Abruptio Placenta – premature placental separation

44. ABRUPTIO PLACENTA NORMAL PLACENTA

45. Obstetrical Complications • Abortions • Missed • Incomplete • Imminent • Spontaneous • Voluntary

46. Benign Cysts Polyps (pedunculated lesion) Fistulas Dysplasia Leiomyoma/Myoma/Fibroid Fibroma Malignant Vulvar Vaginal Cervical Uterine Ovarian Other Endometriosis Adenomyosis Cystocele Rectocele (posterior colporrhaphy) Enterocele Ectopic Pregnancy Incompetent Cervix (cerclage) PID (Pelvic Inflammatory Disease)-1° cause STDs Pathology

48. Colposcopy Hysteroscopy D & C D & E Laparoscopy Hysterectomy Oophorectomy Salpingectomy Abdominal Hysterectomy subtotal total radical (Wertheim) Vaginal LAVH A & P Repair Le Fort Bartholin’s Cyst (I & D) Gynecological Procedures

49. Patient symptoms: • Abnormal bleeding • Abdominal pain • Absence of menses (amenorrhea) • Excessive menses (menorrhagia) • Painful menses (dysmenorrhea) • Painful intercourse (dysparunia) • Painful defication (dyschezia)

50. Pre-Operative & Testing Diagnostic • Physical exam • UA, CBC, Blood Chemistry • Pelvic exam • Bi-manual exam • Colposcopy • PAP (papanicolaou smear) • Schiller Test • Biopsy • Ultrasound • MRI • X-ray • Laparoscopy • D & C