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Estimated B lood Loss (E BL): 800 cc; no bl ood repl aced
(normalbl oodl ossi s500-1000cc).
Specimens: P lacenta,cordpH ,cordbl oodspeci mens.
Drains:F oleytogravity .
Fluids:I nput-2000ccLR ;Output-300cccl earuri ne.
Complications: None.
Disposition: T he pati ent was tak en to the recovery room
thenpostpartum w ardi nstabl econdi tion.
Postoperative M anagement after
CesareanSection
I. PostC esareanS ectionOr ders
A. Transfer:topostpartum w ardw henstabl e.
B. Vitalsigns: q4hx 24hours,I andO.
C. Activity:B edrestx 6-8hours, then ambulate; if given
spinal, k eep pati ent fl at on back x 8h. I ncentive
spirometerq1hw hileaw ake.
D. Diet: N PO x 8h, then si ps of w ater. Advance to cl ear
liquids,thentoregul ardi etastol erated.
E. IVFl uids:I VD 5 LR or D5 ½ NSat125cc/h.Fol eyto
gravity;di scontinueafter12hours.I and O catheterize
prn.
F. Medications
1. Cefazolin ( Ancef) 1 gm IVPB x one dose at tim e of
cesareansecti on.
2. Nalbuphine(N ubain)5to10 mgS CorI Vq2-3h OR
3. Meperidine(D emerol) 50-75m gI Mq3-4hprnpai n.
4. Hydroxyzine (Vistaril) 25-50 m g I M q3-4h prn nau
sea.
5. Prochlorperazine (C ompazine) 10 m g I V q4-6h prn
nausea OR
6. Promethazine (P henergan) 25-50 m g I V q3-4h prn
nausea
G. Labs: CBCin AM .
II. PostoperativeD ay#1
A. Assess p ain, l ungs, ca rdiac st atus, f undal hei ght,
lochia,passi ngoffl atus, bowelm ovement,di stension,
tenderness,bow elsounds,i ncision.
B. DiscontinueI Vw hentak ingadequateP Ofl uids.
C. DiscontinueFol ey,andI andOcatheteri zeprn.
D. Ambulateti dw ithassi stance;i ncentivespi rometerq1h
whileaw ake.
E. Checkhem atocrit,hem oglobin,R h,and rubellastatus.
F. Medications
1. Acetaminophen/codeine (Tylenol#3)1-2P Oq4-6h
prnpai n OR
2. Oxycodone/acetaminophen(P ercocet)1 t ab q6hprn
pain.
3. FeSO4325m gP Obi d-tid.
4. MultivitaminP Oqd, Colace 100 mgP Obi d.M ylicon
80m gP Oqi dprnbl oating.
III. PostoperativeDay #2
A. If passi ng gas and/or bow el m ovement, advance to
regulardi et.
B. Laxatives:D ulcolaxsuppprn or Milk of magnesia30cc
POti dprn.M ylicon80m gP Oqi dprnbl oating.
IV. PostoperativeD ay#3
A. If transverse i ncision, rem ove stapl es and pl ace steri
stripsonday 3.I faverti cali ncision,rem ovestapl eson
postopday 5.
B. Dischargehom eonappropri atem edications; follow up
in2and6w eeks.
LaparoscopicB ilateralT ubalLigation
OperativeR eport
Preoperative D iagnosis: Mul tiparous fem ale desi ring
permanentsteriliz ation.
PostoperativeD iagnosis:S ameasabove
TitleofOper ation:Laparoscopi cbi lateraltubal l igationw ith
Faloperi ngs
Surgeon:
Assistant:
Anesthesia:General endotracheal
FindingsA tS urgery:N ormaluterus,tubes,andovari es.
DescriptionofOper ativeP rocedure
After i nformed consent, the pati ent was tak en to the
operating room wheregeneral anesthesi aw asadm inistered.
The pati ent w as ex amined under anesthesia and found to
havea n ormalu terusw ithn ormal adnexa.S hew as p laced
in the dorsal l ithotomy posi tion and prepped and dr aped i n
sterile fashion.A bi valvespecul umw aspl aced in the vagina,
and the anteri or lip of the cervi x w as grasped w ith a si ngle
toothedtenacul um. Auteri nem anipulatorw aspl acedi ntothe
endocervical canal and arti culated w ith the tenacul um. T he
speculumw asrem ovedfrom thevagi na.
An infraum bilical incision w as m ade w ith a scalpel, then
while tenti ng up on the abdom en, a V erres needl e was
admitted i nto the i ntraabdominal cavi ty. A sal ine drop test
was perform ed and noted to be w ithin norm al l imits.
Pneumoperitoneum w as attai ned w ith 4 l iters of carbon
dioxide. T he V erres needl e w as rem oved, and a 1 0 m m
trocar and sl eeve were advanced i nto the i ntraabdominal
cavity w hile tenti ng up on the abdom en. T he l aparoscope
was i nserted and proper l ocation w as confi rmed. A second
incision w as m ade 2 cm abo ve the sy mphysis pubi s, and a
5 m m trocar and sl eeve w ere i nserted i nto the abdom en
underl aparoscopicvi sualizationw ithoutcom plication.
Asurvey reveal ed normalpel vicandabdom inalanatom y.
A Fal ope ri ng appl icator w as advanced through the second
trocar sl eeve, and the l eft Fal lopian tube w as i dentified,
followed out to the fi mbriated end, and grasped 4 cm from
thecornual regi on.T heFal operi ngw as applied to ak nuckle
oftubeandgoodbl anchingw asnotedatthesi teofappl ica
tion. N o bl eeding w as observe d from the m esosalpinx. T he
Faloperi ngappl icatorw asrel oaded,andaFal operi ngw as
applied i n a similar fashi on to the opposi te tube. C arbon
dioxidew asal lowedtoescapefrom theabdom en.
The i nstruments w ere rem oved, and the sk in i ncisions
were cl osed w ith #3-O V icryl i n a subcuti cular fashi on. T he
instruments w ere rem oved from t he vagi na, and ex cellent
hemostasis w as noted. T he pati ent tol erated the procedure
well,andsponge,l ap and needle counts werecorrectti mes
two. T he pati ent w as tak en to the recovery room i n stabl e
condition.
EstimatedB loodLoss(E BL):
Specimens: N one
Drains:F oleytogravity
Fluids:1500ccLR
Complications: None
Disposition:T hepati ent wastak entotherecovery room i n
stablecondi tion.
PostpartumT ubal LigationO perative
Report
Preoperative D iagnosis: M ultiparous female after vagi nal
delivery,desiringperm anentsteriliz ation.
PostoperativeD iagnosis: Sameasabove
TitleofOper ation:M odifiedP omeroybi lateral tubal ligation
Surgeon:
Assistant:
Anesthesia:E pidural
FindingsA tS urgery:N ormalfal lopiantubesbi laterally
DescriptionofOper ativeP rocedure:
After assuringi nformedconsent, the pati ent w as tak en
totheoperati ngroom and spinal anesthesiaadm inistered.A
small,transverse, infraumbilicalsk inincisionw asm adew ith
a s calpel, and the i ncision w as carri ed dow n through the
underlying fasci a unti l the peri toneum w as i dentified a nd
entered. T he l eft fal lopian tube w as i dentified, brought i nto
the i ncision and gra sped w ith a B abcock cl amp. T he tube
wasthenfol lowedouttothefi mbria.A n avascular midsection
of the fallopian tubew asgraspedw ithaB abcockcl ampand
broughti ntoak nuckle.T hetubew asdoubl yl igated with an
O-plain suture and transected. T he speci men w as sent to
pathology. E xcellent hem ostasis w as noted, and the tube
was returned to the abdo men. The sam e procedure w as
performedontheopposi tefal lopiantube.
The fasci a was then cl osed w ith O-V icryl i n a si ngle
layer. T he sk in w as cl osed with 3-O V icryl i n a subcuti cular
fashion.T hepati enttol eratedthe procedure well.N eedleand
spongecountsw erecorrectti mes2.
EstimatedB loodLoss(E BL):
Specimens: S egmentsofri ghtandl efttubes
Drains:F oleytogravity
Fluids:I nput-500ccLR ;output-300cccl earuri ne
Complications: None
Disposition: Thepati entw astak entotherecovery room i n
stablecondi tion.
PreventionofD Isoimmuniz ation
The morbidityandm ortalityofR hhem olyticdi seasecanbe
significantly reduced by i dentification of w omen at ri sk for
isoimmunizationandby adm inistration of Di mmunoglobulin.
Administration of D i mmunoglobulin [R hoGAM, R ho(D)
immunoglobulin, R hIg] i s very effecti ve i n the preventi ng
isoimmunizationtotheD anti gen.
I. Prenataltesting
A. Routine prenatal l aboratory eval uation i ncludes A BO
andD bl oodty pedeterm inationandanti bodyscreen.
B. At28-29w eeksofgestati onw omanw hoareD nega
tive but not D i soimmunized shoul d be retested for D
antibody. I f the test reveal s that no D anti body i s
present, prophy lactic D i mmunoglobulin [R hoGAM,
Rho(D)i mmunoglobulin,R hIg]i si ndicated.
C. IfDantibody ispresent,Dim munoglobulinw illnotbe
beneficial, and speci alized m anagement of the D
isoimmunized pregnancy i s undertak en to m anage
hemolyticdi seaseofthefetusandhy dropsfetal is.
II. Routinead ministrationo fDim munoglobulin
A. Abortion. Dsensi tization may becausedby aborti on.
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