8.2 Obstetric and Gynecologic Procedures

8.2 Obstetric and Gynecologic Procedures

Obstetric and gynecologic (OB/GYN) surgery encompasses life-saving reproductive interventions, fertility preservation, pelvic reconstructive surgery, and the surgical management of benign and malignant gynecological disorders. Operating across both clean and contaminated fields, the surgical technologist must command specialized instrumentation, understand precise pelvic anatomical relationships, master obstetric count protocols, and execute rapid actions during acute intraoperative hemorrhage.

For the Tech in Surgery - Certified (NCCT TS-C) examination, the Intraoperative Care and Preparation category (Surgeon Support) and the Essential Knowledge Base surgical-procedures concept test knowledge of obstetric delivery workflows, specialized clamps (Heaney, Kocher, Allis-Adair), uterine dynamic pharmacology, distention media dynamics, and pelvic ligamentous anatomy.

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1. Pelvic and Reproductive Anatomy

+-----------------------------------------------------------------------------+
|                        FEMALE INTERNAL REPRODUCTIVE ORGANS                  |
|                                                                             |
|                        [UTERINE FUNDUS]                                     |
|                      /        |        \                                    |
|      Fallopian Tube /         |         \ Fallopian Tube                    |
|     +--------------+     [MYOMETRIUM]    +--------------+                   |
|     | Ampulla/Fimb |          |          | Ampulla/Fimb |                   |
|     +-------+------+     [ENDOMETRIUM]   +-------+------+                   |
|             |                 |                  |                          |
|          (OVARY)       [CERVIX (Os)]          (OVARY)                       |
|                               |                                             |
|                           [VAGINA]                                          |
+-----------------------------------------------------------------------------+

Anatomical Structure and Layers

• Uterus: Inverted pear-shaped, thick-walled muscular organ situated in the lesser pelvis between the urinary bladder anteriorly and the rectum posteriorly. Anatomically divided into the Fundus (superior dome above fallopian tube insertion), Corpus / Body (central contractile portion), Isthmus (constricted lower segment), and Cervix (inferior cylindrical neck projecting into the vagina).
  • Endometrium: Inner mucosal lining, sheds during menses; site of blastocyst implantation.
  • Myometrium: Thick middle tunic of interlacing smooth muscle fibers; contracts powerfully during labor and postpartum hemostasis.
  • Perimetrium (Serosa): Outer peritoneal covering; folds anteriorly over the bladder to form the vesicouterine pouch (bladder flap) and posteriorly over the rectum to form the rectouterine pouch (Pouch of Douglas).
• Fallopian Tubes (Uterine Oviducts): Four distinct anatomical segments:
  1. Interstitial / Intramural: Embedded within the uterine muscular cornua.
  2. Isthmus: Narrow, thick-walled segment adjacent to the uterus.
  3. Ampulla: Wide, thin-walled tortuous segment; the primary site of normal biological fertilization and ectopic pregnancies.
  4. Infundibulum & Fimbriae: Funnel-shaped terminal opening fringed with finger-like fimbriae that sweep ovulated oocytes from the ovary.
• Ovaries: Almond-shaped paired female gonads suspended on the posterior leaf of the broad ligament. Secrete estrogen, progesterone, and release mature ova.

+-----------------------------------------------------------------------------+
|                   PELVIC LIGAMENTOUS SUPPORTS & VASCULARITY                 |
|                                                                             |
|   LIGAMENT NAME         ANATOMICAL ATTACHMENTS        VASCULAR CONTENT      |
|   --------------------  ----------------------------  -------------------   |
|   Broad Ligament        Lateral uterus to pelvic wall Uterine artery branch |
|   Round Ligament        Uterine cornu to labia majora Sampson's artery      |
|   Cardinal (Mackenrodt) Cervix to lateral pelvic wall UTERINE ARTERY (KEY!) |
|   Uterosacral           Posterior cervix to sacrum    Autonomic nerves      |
|   Infundibulopelvic     Ovary to lateral pelvic wall  OVARIAN ARTERY & VEIN |
|   (Suspensory)          (Crosses pelvic brim/ureter)                        |
|   Ovarian Ligament      Ovary to uterine cornu        Ovarian branch        |
+-----------------------------------------------------------------------------+

The Critical Hazard: "Water Under the Bridge"

The ureter enters the pelvis by crossing over the common or external iliac vessels at the pelvic brim. Deep in the pelvis, the ureter courses forward and medially toward the bladder base, passing directly underneath the uterine artery approximately 1.5–2.0 cm lateral to the cervix at the internal os. This anatomical crossing is universally memorized in surgery as "water (ureter) under the bridge (uterine artery)". Clamping the uterine artery during a hysterectomy without mobilizing the bladder flap and visualizing the ureter risks accidental ureteral transection, ligation, or ischemic thermal injury.

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2. Obstetric Surgical Procedures

1. Cesarean Section (C-Section)

• Indications: Cephalopelvic disproportion (CPD), failed labor progression/dystocia, acute fetal distress, malpresentation (breech, transverse lie), placenta previa (placenta covers internal os), placental abruption, umbilical cord prolapse, active maternal genital herpes, or previous classical hysterotomy.
• Positioning & Table Setup: Patient positioned supine on the operating table with a firm wedge placed under the right lumbar/hip region (left lateral tilt). This tilts the gravid uterus to the left, decompressing the inferior vena cava and descending aorta to prevent supine hypotensive syndrome and optimize uteroplacental perfusion.
• Skin Incision: Pfannenstiel incision (curved transverse lower abdominal skin incision 2–3 cm above pubic symphysis) or midline vertical if catastrophic emergency.
• Uterine Incisions (Hysterotomy):
  • Low Transverse (Kerr incision): Standard incision placed across the non-contractile lower uterine segment after dissecting and retracting the bladder peritoneum downward with a DeLee bladder retractor. Associated with minimal blood loss and lowest risk of rupture during subsequent labors (allowing VBAC - Vaginal Birth After Cesarean).
  • Low Vertical (Kronig incision): Vertical incision in lower segment; used for breech or transverse lie.
  • Classical Vertical: Incision placed vertically through the active, thick, vascular upper uterine corpus. Reserved for extreme prematurity, anterior placenta previa, or impacted transverse lie. High risk of catastrophic rupture in future pregnancies; mandates all future deliveries be via scheduled Cesarean.

+-----------------------------------------------------------------------------+
|                   CESAREAN DELIVERY INTRAOPERATIVE SEQUENCE                 |
|                                                                             |
|   1. Pfannenstiel Skin Incision (#10 blade) -> Fascia split & divided       |
|   2. Rectus muscles split -> Parietal peritoneum opened                     |
|   3. Bladder blade placed -> Peritoneum nicked to create Bladder Flap       |
|   4. Hysterotomy initiated with #10 scalpel -> Extended with Bandage/Mayo   |
|   5. Amniotic sac ruptured -> Amniotic fluid SUCTIONED with Poole tip       |
|   6. Fetal head elevated -> IMMEDIATE SUCTIONING (Mouth, then Nose)        |
|   7. Body delivered -> Umbilical cord DOUBLE-CLAMPED (Rochester-Pean/Kelly) |
|   8. Cord cut with Curved Mayo -> Cord blood collected in tubes             |
|   9. Baby handed to Neonatal Team -> Oxytocin (Pitocin) infused IV/IM       |
|   10. Placenta extracted manually -> Uterine cavity wiped with dry lap sponge|
|   11. Uterine hysterotomy closed in 2 layers (#0 or #1 absorbable suture)   |
|   12. Mandatory Count Protocol executed across each closed layer            |
+-----------------------------------------------------------------------------+

The Mandatory 4-Stage Count Protocol in Cesarean Section

Because the surgical field transitions rapidly from emergency fetal delivery to multi-layer visceral closure, sponge, needle, and instrument counts must be strictly executed at four defined stages:

1. Initial Baseline Count: Prior to initial skin incision.
2. First Closing Count (Uterine Closure): Performed immediately before the surgeon places the first suture in the uterine hysterotomy incision.
3. Second Closing Count (Peritoneal Closure): Performed immediately before closing the parietal peritoneum / abdominal cavity.
4. Final Closing Count (Skin Closure): Performed during skin or subcutaneous closure.

Uterotonic Pharmacology for Postpartum Hemorrhage

Uterine atony (failure of myometrium to contract following placental separation) is the leading cause of postpartum hemorrhage. The surgical team utilizes specific uterotonic agents:

• Oxytocin (Pitocin): Synthetic peptide hormone; administered as an IV drip (20–40 units/L) or injected directly into the myometrium to induce rhythmic contractions.
• Methylergonovine (Methergine): Ergot alkaloid; administered IM (0.2 mg). Contraindicated in hypertensive patients and pre-eclampsia (causes severe vasoconstrictive blood pressure spikes).
• Carboprost Tromethamine (Hemabate / PGF2-alpha): Prostaglandin analogue; administered deep IM or intramyometrially (250 mcg). Contraindicated in patients with active asthma (induces potent bronchoconstriction).
• Misoprostol (Cytotec): Synthetic PGE1 analogue; administered buccally or rectally (800–1000 mcg).

2. Cervical Cerclage

• Indication: Cervical insufficiency / incompetence (painless dilation and effacement of the cervix during the second trimester, causing recurrent mid-trimester spontaneous abortions).
• McDonald Procedure: A heavy non-absorbable purse-string suture (e.g., #1 or #2 braided polyester, Mersilene, or nylon) on a blunt needle is placed circumferentially around the body of the cervix near the level of the internal os without dissecting the vaginal mucosa, and tied tightly anteriorly.
• Shirodkar Procedure: Submucosal placement of a 5 mm Mersilene tape at the internal os after incising and dissecting the anterior and posterior vaginal mucosa and advancing the bladder reflection superiorly.

3. Ectopic Pregnancy Management

• Pathology: Implantation of the conceptus outside the uterine cavity (95% in fallopian tube ampulla).
• Linear Salpingostomy: Laparoscopic or open longitudinal incision along the antimesenteric border of the fallopian tube over the ectopic gestational sac. The products of conception are evacuated using gentle suction and irrigation, and the tubal incision is left open to heal by secondary intention or closed with fine 5-0/6-0 absorbable suture.
• Total Salpingectomy: Complete excision of the involved fallopian tube when ruptured, severely damaged, or when childbearing is complete. Hemostasis secured with bipolar cautery, Endoloops, or vascular staplers.

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3. Diagnostic and Minor Gynecologic Procedures

+-----------------------------------------------------------------------------+
|                        D&C INSTRUMENTATION TRAJECTORY                       |
|                                                                             |
|   [EXPOSURE]            [STABILIZATION]       [DEPTH SOUNDING]              |
|   Auvard Weighted Spec  Schroeder Single-Tooth Sims Uterine Sound           |
|   + Graves Vaginal Spec Tenaculum on Cervix   (Measures in cm)              |
|            |                    |                     |                     |
|            v                    v                     v                     |
|   [CERVICAL DILATION]                     [ENDOMETRIAL SAMPLING]            |
|   Hegar / Pratt / Hank Dilators           Sims Sharp Curettes (Uterine cavity|
|   (Graduated sizes, lubricated)           Kevorkian Curette (Endocervix)    |
+-----------------------------------------------------------------------------+

1. Dilation and Curettage (D&C)

• Indications: Diagnostic evaluation of abnormal uterine bleeding (AUB), postmenopausal bleeding, endometrial hyperplasia, incomplete spontaneous abortion (retained products of conception), or endometrial polyps.
• Positioning: Dorsal Lithotomy position utilizing candy-cane or Allen stirrups. The patient's buttocks must extend slightly beyond the break edge of the lower table bed to allow full downward deflection of the weighted speculum.
• Procedural Sequence & Instrumentation:
  1. Vaginal Retraction: An Auvard weighted vaginal speculum is placed into the posterior vaginal vault; an anterior Sims or deaver retractor elevates the anterior vaginal wall.
  2. Cervical Grasping: The anterior lip of the cervix is grasped and stabilized with a single-tooth Schroeder tenaculum (or Jacobs vulsellum).
  3. Uterine Sounding: A malleable Sims uterine sound is gently introduced through the cervical os to the uterine fundus to determine the exact depth and angle (anteverted vs. retroverted) of the uterine cavity, preventing accidental uterine perforation.
  4. Cervical Dilation: The cervical canal is systematically dilated using graduated Hegar, Pratt, or Hank dilators, lubricated with water-soluble sterile jelly and passed sequentially from smallest to largest diameter.
  5. Fractional Curettage (Specimen Integrity):
     • First specimen: The endocervical canal is curetted with a fine Kevorkian curette prior to full dilation, placed on a Telfa pad, and labeled "Endocervical Curettings" (ECC).
     • Second specimen: Sharp Sims uterine curettes scrape the entire endometrial lining of the fundus and corpus; tissue is collected on a moist gauze sponge or Telfa pad and labeled "Endometrial Curettings" (EMC).
     • Critical Rule: Endocervical and endometrial curettings must NEVER be mixed; they are processed as separate specimens.

2. Cervical Biopsy, LEEP, and Cold Knife Cone

• Schiller's Test: Diagnostic staining of the ectocervix with Lugol's solution (strong iodine). Normal cervical squamous epithelium contains high glycogen reserves and stains a uniform dark mahogany brown. Dysplastic, malignant, or abnormal cells lack glycogen and fail to take up the stain, appearing uncolored, pale yellow, or white, guiding targeted biopsy.
• Acetic Acid Test (3–5% Vinegar): Applied to the cervix to produce an acetowhite reaction on areas of abnormal cervical intraepithelial neoplasia (CIN).
• LEEP (Loop Electrosurgical Excision Procedure): A fine tungsten wire loop electrode energized with high-frequency electrosurgical cutting-coagulation current excises the cervical transformation zone. Hemostasis achieved with ball electrode cautery or topical Monsel's solution (ferric subsulfate).
• Cold Knife Conization (CKC): Scalpel excision (using a pointed #11 blade on a long #7 handle) of a cone-shaped wedge of the cervix containing the squamocolumnar junction. Avoids thermal artifact on specimen margins. Hemostasis secured with lateral cervical stay sutures (e.g., 0 Vicryl) or Sturmdorf inverted tracheloplasty sutures.

3. Bartholin Duct Cyst Marsupialization

• Pathology: Obstruction of the Bartholin gland excretory duct at the 4 o'clock or 8 o'clock position of the introitus, resulting in cyst formation or acute abscess.
• Procedure: Longitudinal incision over the fluctuant cyst wall. Purulent contents evacuated (specimen sent for aerobic/anaerobic Gram stain and culture). The interior lining of the cyst wall is grasped with fine Allis clamps, everted, and sutured directly to the adjacent vestibular mucosa with interrupted 2-0 or 3-0 absorbable sutures (Chromic or Vicryl) to create a permanent open drainage stoma.

4. Hysteroscopy and Distention Media Hazards

• Technique: Visualization of the endometrial cavity via a rigid hysteroscope introduced through the dilated cervix. Continuous fluid distention is required to separate the anterior and posterior uterine walls.
• Distention Media Selection & Fluid Balance:

+-----------------------------------------------------------------------------+
|                        HYSTEROSCOPY DISTENTION MEDIA                        |
|                                                                             |
|   [ISOTONIC CONDUCTIVE FLUIDS]         [NON-CONDUCTIVE NONELECTROLYTIC]     |
|   - 0.9% Normal Saline                 - 1.5% Glycine                       |
|   - Lactated Ringer's                  - 3% Sorbitol / 5% Mannitol          |
|   * Used for DIAGNOSTIC hysteroscopy   * MANDATORY for MONOPOLAR Resecting  |
|     and BIPOLAR resecting devices        devices (prevents energy dispersion)|
|   * Safest electrolyte profile         * HIGH RISK of Dilutional            |
|                                          Hyponatremia & Fluid Overload      |
+-----------------------------------------------------------------------------+

[!WARNING] Hysteroscopic Fluid Overload and Dilutional Hyponatremia: When non-conductive fluids (1.5% Glycine or 3% Sorbitol) are infused under pressure, fluid is absorbed into the systemic circulation via severed endometrial venous channels. Excessive absorption leads to hypervolemic hemodilution, severe hyponatremia (<120 mEq/L), hypoosmolality, pulmonary edema, cerebral edema, intractable seizures, and cardiac arrest. The surgical technologist and circulating nurse must maintain a strict, real-time log of fluid instilled versus fluid recovered. An absorption deficit exceeding 1,000 mL (or 2,500 mL for isotonic saline) mandates immediate termination of the procedure.

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4. Major Gynecological and Reconstructive Procedures

1. Hysterectomy Classifications and Approaches

+-----------------------------------------------------------------------------+
|                   TAH SYSTEMATIC PEDICLE CLAMPING SEQUENCE                  |
|                                                                             |
|   1. ROUND LIGAMENT: Clamped (Heaney/Kocher), transected, ligated (0 Vicryl)|
|   2. INFUNDIBULOPELVIC (IP) LIGAMENT (if BSO) or OVARIAN LIGAMENT (if keep) |
|      --> Clamped doubly with Heaney clamps, cut, doubly ligated             |
|   3. BLADDER FLAP: Peritoneum incised, bladder mobilized inferiorly         |
|   4. UTERINE ARTERY PEDICLE: Skeletonized, clamped with curved Heaney       |
|      at the internal os ("water under the bridge"), cut, transfixed         |
|   5. CARDINAL (Mackenrodt's) LIGAMENT: Clamped close to cervix, cut, tied   |
|   6. UTEROSACRAL LIGAMENT: Clamped, transected, ligated                     |
|   7. VAGINAL VAULT: Cross-clamped below cervix with right-angle Heaney,     |
|      incised with curved Mayo/long scalpel -> Specimen handed off           |
|   8. VAGINAL CUFF CLOSURE: Running or figure-of-eight #0 Vicryl or PDS      |
+-----------------------------------------------------------------------------+

2. Pelvic Support Defects & Colporrhaphy (A&P Repair)

• Pathophysiology: Weakness and attenuation of the pelvic floor endopelvic fascia and levator ani musculature secondary to multiparity, chronic straining, and estrogen deficiency:
  • Cystocele: Herniation of the urinary bladder through the anterior vaginal wall.
  • Rectocele: Herniation of the rectum forward through the posterior vaginal wall.
  • Enterocele: Herniation of the peritoneal sac (containing loops of small intestine) through the apex of the vaginal vault between the uterosacral ligaments.
• Anterior Colporrhaphy (Cystocele Repair): The anterior vaginal wall is grasped with Allis-Adair clamps, incised longitudinally, and the vaginal mucosa dissected off the pubocervical fascia. The weakened fascial defect is plicated over the bladder base with interrupted figure-of-eight 2-0 or 0 absorbable sutures (Vicryl), redundant vaginal mucosa is trimmed, and the mucosal edges are approximated.
• Posterior Colporrhaphy (Rectocele Repair): Longitudinal midline incision of the posterior vaginal wall from the perineal body to the apex. Rectovaginal fascia and levator ani muscles are plicated in the midline to reinforce the posterior floor. Perineorrhaphy reconstructs the perineal body.
• Postoperative Packing: At the conclusion of vaginal repairs, the surgeon packs the vaginal vault tightly with iodoform or plain packing gauze saturated with antibiotic ointment or lubricant, and places a Foley catheter to prevent urinary retention.

3. Pelvic Exenteration

• Definition: Radical, multi-visceral salvage operation performed for central, recurrent, or locally advanced pelvic carcinomas (cervical, vaginal, or vulvar) that have failed radiation therapy.
• Classifications:
  • Anterior Exenteration: En bloc removal of the reproductive organs (uterus, cervix, vagina, adnexa) and the urinary bladder and urethra, necessitating an ileal conduit urinary diversion.
  • Posterior Exenteration: En bloc removal of the reproductive organs, rectum, and anal canal, necessitating a permanent end colostomy.
  • Total Pelvic Exenteration: Complete pelvic clearance—removal of uterus, cervix, vagina, ovaries, bladder, urethra, rectum, anus, and pelvic lymph nodes, requiring both an ileal conduit and an end colostomy.