3-102
uterus can then be returned to the abdomen. Irrigate the pelvis and lower abdomen with at least 1 L
of sterile fluid. Make sure that all sponges (bandages) and needle counts are correct or have been
accounted for prior to closing the abdomen.
- There is no need to reapproximate the peritoneum. Using 0 Vicryl (not chromic due to its inability to
maintain tensile strength) begin closing the fascia. The initial suture should be placed inferior to the
lower margin of the vertical incision and in a running fashion, close the fascia. Irrigate and inspect the
subcutaneous tissue for bleeding. If there is significant fat tissue, reapproximate the subcutaneous tissue
with several interrupted stitches with 3-0 or 4-0 Vicryl. Close the skin using staples (if applicable) or 2-0
non-absorbable sutures in an interrupted fashion. Apply a sterile dressing and leave it in place for
approximately 24 hrs. - If the bladder is inadvertently lacerated, use a two-layer technique to close it (running layers like the
fascia) as well as leaving the Foley in for 7-10 days. Put the patient on a prophylactic antibiotic
(Macrobid or Zithromax) while the Foley catheter is in place. - Counsel the patient that she will not be a future candidate for a trial of labor. SHE WILL ALWAYS HAVE
TO HAVE A CESAREAN SECTION FOR EACH SUBSEQUENT PREGNANCY, or risk uterine rupture and
death for both mother and fetus.
Post-Operative Orders:
- Diet: NPO except sips of water. May begin clear liquids 24 hrs after surgery if have bowel sounds, then
advance diet as tolerated. - List Allergies to Medications
- Initial vital signs (BP, P, RR) every 15 minutes for the first hr., then VS every 2 hrs X 2 then every
4 hrs X 72 hrs. - Bedrest for 8 hrs, then out of bed with assistance.
- Turn, cough and deep breath every 2 hrs while awake.
- Ice pack to the incision every 4-6 hrs for 30-45 minutes
- Strict monitoring and recording of intake and output (fluids).
- Leave the Foley catheter in place for 24 hrs to monitor urine output. A patient should make at least
30 cc/hr. - Demerol 25-50 mg IM every 3-4 hrs for pain
- Phenergan 25 mg IM every 8 hrs for nausea and vomiting
- Once patient tolerating clear liquid diet well, remove IV, change IM pain management to oral, and remove
Foley catheter. - Motrin 800 mg po q 8 hrs with food
- Hydromorphine or equivalent 1-2 tabs po every 3-4 hrs for pain.
- CBC 6-8 hrs post op and again at 24 hrs post-op to check for bleeding (low HCT), infection (increased
WBC, bands). - Remove stitches at 7 days
What Not To Do:
Do not get too excited. It will impede decision-making.
Do not cut into the intestines, bladder or baby.
Do not forget to always retract the bladder once you have developed your flap so as not to injure it.
Do not expose the uterus or other intraperitoneal structures to any non-sterile objects if at all possible.
Do not operate too slowly. Once the uterus is entered the baby must be delivered and the uterus closed
quickly to achieve control of bleeding before significant hemorrhage endangers the mother’s survival.
Symptom: OB Problems: Episiotomy and Repair
MAJ Marvin Williams, MC, USAWhat: Incision of the perineum to enlarge the vaginal opening, and subsequent repair.
When: At the time of delivery, perform an episiotomy when 3-4 cm of fetal scalp is visible at the vaginal