1
Q
The Pelvis
A
- The pelvis is a bony ring that is supported by the lower extremities and in turn bears the weight of the upper body
- It is made up of right and left innominate bones (pubic bone, ilium and ischium); sacrum; and the coccyx. The innominate bones form the sides and front and the sacrum and coccyx forms the back.
- The ischial tuberosities bear the body’s weight when in the sitting position
- Protects reproductive tract
2
Q
Ischial Spine
A
- Ischial spine projects from the posterior border of the ischium
- The distance between the spines is the narrowest diameter of the pelvic cavity.
- Serves as a landmark to determine the degree of descent of the fetus during delivery.
3
Q
The pubis is located
A
- beneath the mons pubis. In the middle of the two pubic bones are strong ligaments and cartilage to form the symphysis pubis
- has a little bit of movement, can seperate during birth
4
Q
sacrum & coccyx
A
- The sacrum is formed by five (5) fused vertebrae. The upper anterior portion of the body of the first sacral vertebrae forms the posterior margin of the pelvic brim
- The coccyx is composed of 3 – 5 fused vertebrae and articulates with the sacrum. It projects downward and forward from the lower border of the sacrum
- can be broken during delivery
5
Q
False vs. True Pelvis
A
- The false basin lies above the linia terminalis (inlet) and varies in size with different women
- baby can easily fit here
- The true pelvis – the inlet and below, resembles an irregular curved canal.
- much narrower, can the baby fit? may need C-section
6
Q
Pelvic Diaphragm
A
- Made up of muscles and ligaments that stretch across the bones of the pelvic outlet.
- The openings that must exist for the urethra, vagina and rectum cause an inherent weakness in the pelvic diaphragm. Provides the main support for the pelvic viscera
- incontinence is common when these muscles stretch out
7
Q
Mons Pubis
(external Genitalia)
A
- a rounded, skin covered fat pad located anteriorly to the symphysis pubis
8
Q
vulva
A
- Consists of the labia majora, labia minora, clitoris, and the urinary meatus.
- If said in the OR, typically talking about only the majora and minora
9
Q
Labia majora
A
- lymphatic rich
- The outermost lips of the vulva; extend vertically from the mons pubis to the anus.
- protective
10
Q
Labia minora
A
- The inner most lips of the vulva; they lie between the labia majora and extend from the hood of the clitoris down to the base of the vagina
- They cover to prevent bacteria
11
Q
The fourchette
A
- a tense band of membrane, connecting the posterior ends of the labia minora
- This may rip during delivery or sometimes cut
12
Q
Clitoris & Urinary meatus
A
- Clitoris – approx 6 X 6 mm – unaroused. Located below the clitoral hood, which is formed by the joining of the two labia minora.
- full of nerve endings
- Urinary meatus – approx 2.5 cm below the clitoris. The opening to the urethra
13
Q
Skene’s glands
A
- situated posteriolaterally just inside the urethral opening at 5 and 7 O’clock. Produces a small and amount of mucus and is susceptible to gonorrhea.
- supposed to protect from bacteria
14
Q
Bartholin’s glands
A
- at the base of the labia, one on each side of the vaginal orifice at 5 and 7 o clock
- Secretes clear, viscid mucus (during sex)(lube for sex) and is supportive of sperm (it’s alkaline)-can change environment of vagina. normally acidic
- Vagina is acidic normally. sperm is fragile and cant survive in that acidity
15
Q
Vaginal orifice and Perineum
A
- Vaginal orifice – opening to the vaginal canal
- Perineum is the skin covered muscular area between the vaginal orifice and the anus
- Note: When they want perineal prep it usually means all of vagina
16
Q
Vagina
A
- Tubular structure in front of rectum and behind bladder and urethra that connects the internal and external genitalia
- Serves as a route for discharge of menses and other secretions
- Thin walled collapsible tube that is capable of great distention
- angled
- has rugae
17
Q
Recesses formed around the protruding cervix are called:
A
- fornixes:
- Anterior
- Posterior (the deepest)
- Right
- Left
- circufrential
18
Q
Vaginal Fluids
A
- Vaginal fluid is normal and cleanses the vaginal. May contain bacteria, parasites or neoplastic cells
- Usually the vaginal environment is acidic due to the normal flora.
- Change in the environment may cause it to be susceptible to infection
- ex: antibiotics and let yeast grow
- period
- pregnancy
- birth control pills
- diabetes
19
Q
Uterus
A
- A flattened, hollow, thick walled muscular organ. Never pregnant uterus is about 60g. (2oz)
- Three parts:
- Fundus = the portion above the insertion of the fallopian tubes.
- Body (Corpus) and Isthmus = the portion between the fundus and the cervix.
- Cervix = the lower, narrowed part
20
Q
Uterine Canals
A
- Two cavities:
- Uterine
- Cervical
21
Q
Uterine wall is composed of three layers
A
- Endometrium
- innermost layer
- has 2 layers
- basal layer- regenerates superficial layer
- superficial layer-sloughed off during period
- Myometrium
- muscular layer with
- oblique fibers
- circular fibers
- longitudinal fibers
- helps push baby out and contracts to help with bleeding after.
- muscular layer with
- Perimetrium (Parietal peritoneum)
22
Q
Cervix
A
- The lowermost portion of the uterus, divided into the supravaginal portion and the vaginal portion
- External Os (mouth)
- Internal Os
- Most significant characteristic is its ability to stretch
- dirty
- fibrous tissue, white
23
Q
Cervical Epithelium
A
- Exocervix – stratified squamous epithelium
- Endocervix – columnar epithelium- just past inside openings
- Hormones and acid in vagina – transforms columnar epithelium to squamous epithelium – Transformation zone cells are more likely to become cancerous
24
Q
Uterine Location and Position
A
- Uterine location – in the true pelvis behind the symphysis pubis and bladder and in front of rectum
- Position – Anteverted and anteflexed
25
Uterine anteversion and anteflexion
* Anteverted and anteflexed (tipped and bent forward). Corpus lying over posterior wall of bladder. Cervix is directed downward and backward toward sacrum, so cervix is approx at a right angle to vagina.
26
Alterations in Position (Uterus)
* abnormal anatomy
* problem getting pregnant or keeping the baby
27
Uterine Ligaments
* Broad ligaments
* Round ligaments
* Cardinal ligaments
* Uterosacral ligaments
28
Paired Broad Ligaments
* are **double folds of peritoneum** that extend winglike from the
* sides of the uterus to the pelvic walls. It is further divided into the
* Mesosalpinx (immediately below the fallopian tube);
* Mesoovarium (immediately above the ovary); and the
* Mesometrium (below the ovary).
29
Paired round ligaments
* smooth muscle and connective tissue between the layers of the broad ligament. They extend from the upper outer angles formed where the fallopian tube join the uterine corpus, **through the inguinal canals** and ending in the labia majora.
30
Cardinal Ligaments
* The denser connective tissue of the lower portion of the broad ligament is known as the cardinal (transverse or Mackenrodt’s) ligament
* wrap around bladder
31
Uterosacral Ligaments
* Two uterosacral ligaments are cordlike folds of peritoneum extending from the supravaginal cervix to the fascia over the 2nd and 3rd sacral vertebrae passing on each side of the rectum.
* Maintains traction of the cervix
32
Cul-de-sac (of Douglas)
* The cul-de-sac is the lowest part of the abdominal cavity and collects blood, pus, or other drainage and can be reached through the posterior fornix
33
uterine artery
* Vaginal branch
* Uterine body branch
* Fallopian tube branch
* Ovarian branch
34
Functions of uterus
* Rejuvenation of endometrium
* Pregnancy
* Labor
(all about reproduction)
35
Fallopian Tubes
* Pair of slender, cylindrical structures attached to the uterus at the cornua
* Muscles
* Inner = circular
* Outer = longitudinal
* Mucosa
* **Ciliated** and secretory columnar cells.--to push egg towards uterus
* just a transport tube
* fertilization occurs here
36
Fallopian Segments
* Four distinctive segments:
* infundibulum
* ampulla
* isthmus
* interstitial part
37
Infundibulum
* the most distal portion. It’s funnel shaped opening is encircled with **fimbriae**. Fimbriae become swollen and erectile at ovulation and “sweep” up the ovum after ovulation
38
Ampulla
* distal and middle segment – this is where fertilization occurs
39
Isthmus
* proximal to ampulla, small and firm, similar to round ligament
40
Interstitial
* portion passes through myometrium between the fundus and body of uterus and has the smallest lumen -- less than 1mm
41
Ovaries
* The gonads (female sex organs) One located on each side of the uterus, below and behind the fallopian tubes
* **Large almond size** and shape. **Whitish**, rounded but flattened – approx 3g (usually easily identifiable)
* The ovaries store the ova and also produce the female sex **hormones estrogen and progesterone**.
42
Function of Ovaries
* Ovulation and hormone production
* At birth ovaries contain thousands of primordial ova.
* you are born with all the eggs you're going to have
43
Corpus Albicans
* associsted with higher incidence of ovarian cancer if you have a higher number of these scars
44
Structure of the Ovary
* Composed of two layers around a central zone
* Inner medulla – highly vascular with supporting connective tissue
* Outer cortex – the location of the epithelial follicles which contains the oocytes (immature ova)
45
Supporting Structures of Ovary
* Ovarian Ligament- to ovary
* Suspensory Ligament- attavhes ovary to side wall
* ovaries are on the posterior side of the broad ligament
46
Bladder and Urethra
* The urethra and its orifice lie in close proximity to the external reproductive anatomy
* The bladder lies **anterior** and “lies” on top of the cervix and vagina.
* most of the time we need to drain the bladder
47
Ureters
* Pass just behind the ovarian blood vessels close to fallopian tubes and **in front of the uterine blood vessels**. Ureters must be identified and preserved during pelvic surgery
* travels through broad ligament
* need to watch it paristalse
* artery will pulsate
* vein will do nothing
48
Menstrual Cycle
* Normal control of the cycle results from interactions among the CNS, hypothalamus, anterior pituitary, ovaries, and associated target tissues
* Estrogen
* Progesterone
* FSH
* LH
49
Estrogens
* Sexual maturation, skeletal growth, fat distribution
* **Ovulation, implantation, pregnancy, parturition**
* Development, maintenance of female accessory organs
* Cell division in the breasts and endometrium
* Maintain skin and blood vessels
* Decrease bone resorption
* Increase HDL, triglycerides; decrease LDL, cholesterol
* Sodium and water retention
50
Progesterones
* **Maintain pregnancy**
* **Breast and endometrium development**
* Decrease sodium reabsorption
* **Increase body temperature**
* Smooth muscle relaxation
51
The Menstrual cycle and hormones
* Gonadotropin-releasing hormone (GnRH) from the hypothalamus begins the cycle
* GnRH stimulates the anterior pituitary to release follicle-stimulating hormone (FSH) and luteinizing hormone (LH)
* FSH stimulates development of follicle cell layers
* This is the follicular phase of the menstrual cycle
* the developing follicle produces estrogen
* Estrogen decreases FSH release; LH increases
* Only the strongest follicles survive the drop in FSH
* Follicles continue to make estrogen
* Estrogen now stimulates LH release from the anterior pituitary
* LH stimulates the mature follicle to burst
* LH surge causes release of the egg = ovulation
* Follicle cells become corpus luteum, producing progesterone
* This is called the luteal phase of the cycle
* Progesterone prepares the body for pregnancy
* If pregnancy does not occur, the corpus luteum replaced by corpus albicans
* The drop in progesterone tells the hypothalamus to secrete GnRH and begin a new cycle.
52
Pap Smear Classifications
53
True or False? The suspensory ligament supports the uterus in place.
* False The suspensory ligament (infundibulopelvic ligament) supports the ovary.
54
True or False? The myometrial layer has a basal layer and a superficial layer.
False
The endometrial layer has a basal and superficial layer
55
True or False? The ovary continues to produce eggs as we mature.
* False
* The ovary matures eggs that are already in the ovary at birth.
56
Which of the following glands produces lubricant to aid in sexual activity and reproduction? A. Skene’s gland B. Bartholin’s gland
B. Bartholin’s gland
The gland produces lubricant that aids in intercourse and creating an alkaline environment for sperm
57
True or False? The uterus has two separate canals?
* True
* The uterus has the uterine canal and the cervical canal
58
Which ligament supports the uterine body by securing it to the abdominal side wall?
A. Round ligament
B. Broad ligament
C. Cardinal ligament
D.Uterosacral ligament
* B. Broad ligament
59
Which ligament supports the uterine body by travelling through the inguinal canal and attaching to the labia majora?
Round ligament
Broad ligament
Cardinal ligament
Uterosacral ligament
* A. Round Ligament
60
What structure runs through the broad ligament and must be protected whenever we are working in the pelvis?
* Ureter
61
Which hormone slows the release of FSH?
A. LH
B. Estrogen
C. Progesterone
D.GnRH
* B. Estrogen
* Rationale: Estrogen, produced by the developing follicle, decreased FSH release (which only the strongest follicles will be able to survive). The remaining follicles continue to produce estrogen, which will stimulate the pituitary gland to release LH
62
Progesterone maintains pregnancy but also has many of the following local effects on the body. Which is NOT true?
A. Increase in basal body temperature
B. Decrease in absorption of sodium
C. Increase in secretion of aldosterone by the adrenal cortex
D. Relaxation of smooth muscle
* B. Decrease in absorption of sodium
63
64
65
Uterine Artery
66
PREGNANCY
* Definition--The condition of carrying an embryo in the uterus.\
* Duration in humans
* approx 282 days, according to Taber’s which is approx. 9.3 months
* 38 weeks = Term, and 39-40 weeks is not unusual.....
67
Risk Factors- pregnancy
* High risk pregnancy
* Teenage pregnancy
* might have no prenatal care
* no family support
* body not muture fully
* Pregnancy after menopause
* sometimes the body goes haywire and releases an egg. need hormone replacement if this happens
68
Labor
* The process by which the fetus is expelled from the uterus into the vagina and then outside the body.
* It is characterized by uterine contractions that occur at decreasing intervals with increasing intensity, causing dilation of the cervix.
* Three Stages
69
First Stage “Stage of Dilatation”
* Lasts from the onset of regular uterine contractions to full dilation and effacement of the cervix
* Effacement - dilation of the cervix, during labor, to the extent that only the cervical Os remains. The cervical canal has been obliterated--cervix thinning out, measured by %
* Dilation of the cervix: the gradual widening of the cervical Os. Completely dilated -- Big enough for the fetus’ head to pass, or about 10 cm. opening of cervix--measured by cm.s
70
Second Stage of Labor “Stage of Expulsion”
* Lasts from complete dilatation of the cervix to the birth of the fetus.
* Rupture of the membranes (BOW) -- Usually occurs during the early part of this stage
* The decision whether to make an episiotomy is made during this stage.
71
Third Stage of Labor “Placental Stage”
* Begins with delivery of the infant and ends with delivery of the placenta
* There is usually some bleeding (200 – 500 cc) after deliver of the placenta
* It is important that the placenta separates completely from the uterus
* if placenta stays in, the body will act pregnant ans send blood to where that placenta is. Could bleed to death
* Oxytocin -- “Pit” is given to strengthen uterine contractions
* pitocin is syntheic version
72
False Labor
* Pain in the lower abdomen and groin that may precede True Labor by 3-4 weeks.
* brakston hicks
* Characteristics
* Irregular pains that do not increase in frequency with time, and are not made more intense by walking
* False labor does not cause effacement and dilation of the cervix
73
Presentation
* The position of the fetus presenting itself to the examining finger in the vagina
* Occiput: back of the head
* Face -- The head is sharply extended so that the face is “presented”
* Breech -- buttocks first
* Placental -- (placenta previa) Placenta that is implanted in the lower uterine segment
* Shoulder -- shoulder first
74
Breech position
* Frank Breech – hips flexed, knees extended
* Complete Breech – hips flexed, one or both knees flexed.
* Incomplete Breech – one or both hips not flexed, one or both feet lie below breech.
75
The Seven Cardinal Movements
* A process of positional adaptation of the fetal head to the various segments of the pelvis is required for the completion of childbirth
76
Vaginal Delivery – ST role
* General Information:
* The L&D Tech should watch the “Board” - - the tech must know the terminology and abbreviations to be able to predict where the next delivery will occur
* Delivery Carts - - AKA “Cluster Carts”
* an instrument set-up is kept ready for vaginal deliveries on a rolling cart.
* The L & D tech must be able to “Read the Board” in order to keep the proper number of carts ready
77
“Reading the Board”
* Want to know gravida/para & Station/Dilation/Effacement
* gravida-- how many pregnancies
* para- how many deliveries
* if Pit given, means induced labor
* station--if baby at ishial spines= 0
* 1cm away= -1
* underneath= +
78
Vaginal Birth Procedure
* Drape the patient with lithotomy drapes
* Lubricant -- most doctors use either betadine paint or mineral oil to massage and help to dilate the vulvular ring (Forchette).
* Episiotomy
* The doctor will use bandage scissors or straight mayos
* You may need to provide local anesthetic....
* Suction: The doctor uses it to clear the baby’s airway as soon as the head is accessible and again immediately after delivery. The bulb syringe ALWAYS goes with the baby.
* Umbilical cord: May be wrapped around the neck. You will need two kelly clamps per wrap around the neck, then heavy scissors. Time to stay focused.
* The plastic cord clamp is placed on the umbilical cord, on the “going side” (it goes with the baby).
* A short kelly clamp is placed on the cord, placenta side. Bandage scissors are used to cut between them Bulb syringe goes with the baby (& sometimes scissors).
* Blood Samples
* Cord Blood - - unclamp the kelly clamp and drain some cord blood into a test tube.
* Arterial Blood Gas -- somebody has to stick an umbilical artery, & draw up some arterial blood; ice it.
* Suture the episiotomy.
* Placenta -- bring up a basin for the placenta
* Clean up, Cover up mom, get her out of stirrups, and get the mess out of the LDR; do this quickly and compassionately (her family is there).
79
Lacerations of the Birth Canal
* First Degree lacerations - - Involve the fourchette, the skin of the perineum, and the vaginal mucosa, but NOT the fascia and muscle.
* Second Degree lacerations - - Skin, mucosa, fascia, and muscles of the perineum, but NOT the anal sphincter
* Third Degree lacerations - - extend through the skin, mucosa, perineal body, and involve the anal sphincter.
* Fourth Degree lacerations - - Extension of a third degree laceration through rectal mucosa, exposing the lumen of the rectum.
80
Episiotomy
* An incision in the perineum that is performed to substitute
a straight, clean, surgical incision for a ragged laceration
that may otherwise occur.
* It is easier to repair and heals better.
* It shortens the second stage of labor and spares the infant’s head from prolonged pounding against the perineum.
* It was the most commonly-performed operation in obstetrics.
* This is controversial…
* 2-0 or 3-0 chromic
or monocryl is
used to close the
vaginal mucosa
and submucosa
* Interrupted sutures
(2-0 or 3-0
chromic or
monocryl) are used
to close fascia and
muscle of the
incised perineum.
* Continuous suture
is carried
downward to to
unite the
superficial fascia
* Continuous suture
is carried upward
as a subcuticular
stitch
81
Difficult Delivery
* Umbilical cord around the neck
* Can be very serious -- pay attention to the doctor’s needs; have some kelly clamps READY
* Be mentally prepared to cut the cord in a fashion that is different from the norm.
82
Large baby, small birth canal
* Mother may need assistance in expelling the fetus:
* Be familiar with assistive devices:
* Forceps : There are MANY different types; look at the doctor’s preference card.
* Vacuum Extractor (“Mighty Vac”): May be used instead of forceps (suction cup is put on the baby’s head; used to “pull ‘em out”.There are different types of cups; see doctor’s card.
83
Forceps
84
Forcep Delivery
* The left handle of the Simpson forceps is held in the left hand and is introduced into the left side of the pelvis
* Left blade in place; introduction of right blade by right hand.
* Forceps have been locked. Vertex is rotated (arrow) from left occiput anterior to occiput anterior
* Forceps in place. Midline episiotomy performed
* Horizontal traction provided
* Upward traction is applied as head is delivered
* Forceps may be disarticulated after delivery of head.
85
Vacuum Delivery
* Suction cup placed on skull
* Placement depends on position of fetal head
86
Twins
* Twins are ALWAYS cause for concern; many things can go wrong.
* Delivery in the C-section room: Be prepared to convert from a vaginal delivery to a Csection
* Anything above twins= C-section
87
Indications for Cesarean Section
* Cephalopelvic Disproportion
* Fetal Distress--relates to umbilical cord
* Abnormal Presentation
* Placenta Previa
* Abruptio placenta
* Multiple Pregnancy
* Prior C-section
* Prolapsed umbilical cord
* Failure to progress
* active herpes outbreak
* preeclampsia
* dcells- deceleration of heartrate--bad
* Note: Emergency C-section
88
Cesarean Section
* Major abdominal surgery
* Anesthesia: Spinal, epidural or general
* Scheduled: Spinal
* Emergency: General, rapid induction, 30 seconds from cutting, might have to intubate baby because of the anesthesia. Scary for mom
* Position: Supine with roll under right hip--takes pressure off vena cava & aorta
* Foley catheter placement (usually prior to arriving in OR)
* Nursery personnel available
89
Mobius Elastic Abdominal Retractor
90
Cervical Cerclage
* A procedure whereby the cervix is sutured shut, using a very heavy suture (usually a 5mm Mersilene) in a pursestring fashion. It is done for **“Incompetent Cervix”**.
* Incompetent Cervix -- def -- painless dilatation of the cervix, usually leading to second trimester spontaneous abortion. It occurs secondary to insufficiency of the internal cervical Os.
* This procedure is done in the operating room
91
Cerclage Techniques (2)
1. Shirodkar technique -- The suture is almost completely buried beneath the cervical mucosa. It can be left in place for subsequent pregnancies IF a Csection is performed.
2. McDonald technique -- A simple purse-string suture that is removed for vaginal birth.
92
VBAC
* “Vaginal Birth After Cesarean”
* In the “old days”, there was a saying: “Once a C-section, always a C-section”.
* A few VBACs will experience uterine rupture:
* This is a life-threatening emergency!
* STAT C-section is required to save the baby, and total hysterectomy may be necessary to save the mother
93
Abortions
* Abortion is a termination of pregnancy, miscaraige is an abortion
* non viable pregnancies, can't stay in due to bleeding or infection
94
Suction Curettage
95
Ectopic Pregnancy
* Implantation of fertilized egg someplace other than the endometrium
* A ruptured extopic pregnancy can be a life threatening emergency
96
Sterilization Methods
* Ligation (possible partial salpingectomy)
* Fallope-rings
* Hulka Clips
* Essure
97
Bartholin Cyst
* Cyst -- a fluidfilled sac; results from occlusion of the duct system. The obstruction usually follows some type of infection
* Abscess -- if the cyst becomes infected, it can form an abscess.
98
Marsupialization of Bartholin Cyst
* The labia are retracted with interrupted 3-0 sutures, and the introitus of the vagina is exposed. An incision is made over the mucosa of the vagina at its junction with the introitus down to the wall of the gland
* The wall of the gland is incised. The contents of the abscess are evacuated.
* The wall of the abscess is sutured with interrupted 3- 0 synthetic absorbable suture to the skin of the introitus laterally and to the vaginal mucosa medially.
* The marsupialization is complete. Generally, no packing or drain is necessary
99
Cervix problems
* May see patients for cervicitis – biopsies, cryosurgery, cauterization or laser treatments may be done in the OR
100
Cervical Polyp
* Usually benign
* Symptoms
* Abnormally heavy periods
* Abnormal uterine bleeding
* After douching
* After intercourse
* After menopause
* Between periods –
* White or yellow mucus (leukorrhea)
* May interfere with becoming pregnant
101
HPV
* human papillomavirus
* a sexually transmitted virus. It is passed on through genital contact. It is also passed on by skin-to-skin contact. At least 50% of people who have had sex will have HPV at some time in their lives.
* Approx 40 strains of HPV – only a few may lead to cervical cancer
* All women should get regular Pap tests
* Genital warts do not lead to cancer, but the virus remains even after treatment to remove the wart
* also linked to vulvular cancer
102
True or false?
HPV is a contributing factor to both vulvular and cervical cancer
* True
* In young women, HPV has been linked to vulvular cancer; it also causes 70% of cervical cancers
103
Cervical Punch Biopsy
* Punch biopsy forceps used to retrieve specimen for pathology
104
Cone Biopsy
* “Cone” shaped biopsy of cervix, including the transformation zone, is removed.
* “Cold knife”
105
LEEP
* Loop Electrode Excision Procedure
* LLETZ – Large Loop Electrodiathermy of the Transformation Zone
106
Invasive Cervical Cancer
* Cervical cancer is treated in several ways. It depends on the kind of cervical cancer and how far it has spread.
* Treatments include
* Surgery
* Chemotherapy
* Radiation
107
Cervical Cancer Staging
* Staged according to the extend of spread
* Stage 0
* Carcinoma-in-situ
* Stage Ia
* Microinvasive cancer not extending more than 5mm beyond the basement membrane and of a width less than 7mm
108
Cervical Cancer Stage Ib
* The growth is confined to the cervix
109
Cervical Cancer Stage IIa
* Extension to the vagina not beyond the upper two thirds
110
Cervical Cancer Stage IIb
* Extension into the parametrium but not as far as the pelvic walls
111
Cervical Cancer Stage IIIa
* Carcinoma involving the lower third of the vagina
112
Cervical Cancer Stage IIIb
* Carcinoma extending to the pelvic side wall and/or hydronephrosis due to tumor
113
Cervical Cancer Stage IVa
* Carcinoma involving the bladder, rectum or outside the pelvis
* Treatment? Exseneration removing everything from bellybutton down, take everything
* only pallitive
114
Cervical Cancer Stage IVb
* Carcinoma extending to distant organs
115
True or False?
The only treatment for cervical cancer is surgery
* False
* Treatment for cervical cancer include:
* Radiation
* Chemotherapy
* Surgery
116
Your patient receives a PAP smear result that shows she is positive for HPV. She will need to continue with follow up since HPV is directly associated with:
A. Uterine cancer
B. Cervical dysplasia
C. Genital herpes lesions
D.Urinary tract infections
* B. Cervical dysplasia
117
Abnormal Menstrual Bleeding
* many reasons
* biggest sign of endometrial cancer is post menopausal bleeding
118
Ablate
To remove or destroy tissue
119
Adnexa
a collective term for the ovaries and fallopian tubes and their connective and vascular attachments.
120
Amennorhea
The absence of menstrual bleeding
121
Bladder flap
a peritoneal fold between the bladder and uterus
122
Colposcopy
microscopic examination of the cervix
123
Cystocele
a herniation of the bladder into the vaginal wall
124
Debulking
Removal of a major portion of the material that composes a lesion, such as the surgical removal of most of a tumor so that therre is less tumor load for subsequent treatment
125
Electrolytic fluid
fluid that contains electrolytes and therefore can transmit electrical current
126
En bloc
a term meaning "in one peice" The term is used in surgery to describe the technique of removing tissue
127
Hysteroscopy
* Technique using lighted fiberoptic endoscope for diagnostic and operative procedures
* inside uterus, transvaginally
* saline is the insufflation medium
* Resectoscope used for therapeutic hysteroscopy. Note cutting coagulation loop on distal end
* Fluid distension system for use with resectoscope. **Note that fluid pressure is regulated to prevent extravasation and subsequent fluid overload in vascular system, which may cause serious patient injury**
128
Laser and electrosurgery during hysteroscopy
* Nd:YAG (neodymium:yttrium aluminum garnet) and argon lasers commonly used
* Argon laser transmits through aqueous solution
* Coagulation with laser is achieved on lower power settings
* KTP-532 and tunable dye lasers also effective
* Safety considerations primary
129
Endometrial Ablation
* Endometrial ablation destroys a thin layer of the lining of the uterus
* damaging the basal layer
* treatment for abnormal uterine bleeding
* there is still a tiny chance you could get pregnant so not considered a sterilization procedure it's just a side effect
130
Hysteroscopic endometrial ablation
* Coagulation of the endometrium of the uterus to treat uterine bleeding
* Hysteroscope is inserted into sheath before insertion in uterine cavity
* Main operating channel receives telescope; side channels accept accessory instruments
* Main channel fitted with rubber gaskets that prevent backflow of distension media
* Allows surgeon to flush fluid and debris from the uterus while operating
131
True or False?
Endometrial ablation is considered an elective sterilization procedure.
* False
* Endometrial ablation is done to treat abnormal uterine bleeding. However, sterilization should be expected after the destruction of the endometrial lining.
132
Leiomyofibroma
* Uterine Fibroids
* “Fireballs”
* Myomectomy done to preserve ability to become pregnant
* balling up of smooth muscle formation
* benign--rare they become cancerous
* very common
* start out painless and pt. has heavy periods
* no treatment unless they start causing problems
133
Uterine Fibroid Treatments
* Myomectomy
* Removal of benign leiomyoma of the myometrium to control bleeding and prevent pressure on other structures in the pelvis
* **Done if patient wishes to preserve fertility**
134
Endometrial Cancer/ Uterine Cancer
* Age.
* Endometrial hyperplasia-overgrowth
* Hormone Replacement Therapy (HRT)- need estrogen & progesterone
* Obesity and related conditions- adipose tissue increases estrogen
* tamoxifen (oral chemo for breast cancer)
* Race- white women
* Colorectal cancer
* Other risk factors
* Leading cancer of female tract
* postmenopausal bleeding
* easy to diagnose and treat
135
True or False?
Abnormal menstrual bleeding may be caused by fibroids
* True
* Multiple causes can be attributed to abnormal bleeding, including:
* Fibroids
* Polyps
* Adenomyosis
* Uterine cancer
* endometriosis
136
Endometriosis
* 20% of females in reproductive age group. Very common in 30-40 year old women
* Retrograde menses thought to be cause
* Bluish or black lesion that will bleed with the womans cycle
* Endometrial tissue outside uterus
* Retrograde menstruation
* Metastasis through lymphatics or vascular system
* Activation of dormant cells that were always there
* Ectopic implants respond to hormones
* Go through menstrual cycle
* During menstrual period, tissue dies and bleeds
* Pain and adhesions result
* causes dysmehorrhia, syspurnia (painful sex), infertility
137
Endometriosis – Stage I
* Severity – Mild
* Implants – Shallow on Ovaries
* Adhesions – None
Note: # of implants does not = pain. Even one can be very painful
138
Endometriosis – Stage II
* Severity – Minimal
* Implants – Deep on pelvic lining
* Adhesions – Light
139
Endometriosis – Stage III
* Severity – Moderate
* Implants – Deep on ovaries and pelvic lining
* Adhesions – Dense
140
Endometriosis – Stage IV
* Severity – Severe
* Implants – Deep on ovaries and pelvic lining
* Adhesions – Dense on ovaries, fallopian tubes, and bowel
141
Endometrial Cyst
* Chocolate cyst
* typically on ovary body, tries to wall off and forms cyst wall, blood accumulates and gets old
142
True or false?
Endometrium that grows inside the uterus is called endometriosis.
* False
* Endometriosis is a condition in which endometrial tissue develops anywhere outside the uterus—most commonly on abdominal viscera. Surgery may be necessary to remove endometrial tissue
143
A post-menopausal patient c/o several vague signs and symptoms. Which of the following raises a red flag indicating the client may have developed endometrial cancer?
A. Lumps palpated in her breasts
B. Small, atrophied ovaries
C. Painless abnormal bleeding
D.Difficulty emptying her bladder
* C. Painless abnormal bleeding
144
Ovarian Cyst
* Corpus luteum cyst
* leftover spot where egg left
* secretes progesterone
145
Ovarian Tumor
* Benign Cystadenoma
* Serous fluid, mucinous fluid
146
Laparoscopic Management of an Ovarian Mass
* The cyst wall is dissected using a hydro dissector
* Dissection of the cyst wall is nearly completed
* The body of the cyst is grasped and removed from the ovary
147
Ovarian Cancer
* Frequently does not result in symptoms until the cancer has spread extensively (stage 4)
* Risk Factors:
* Family history of cancer
* Personal history of cancer
* Age over 55
* Never pregnant
* Menopausal (estrogen alone)
* Debulking
* Wertheim procedure (radical hysterectomy)
* Risk Reduction Bilateral Salpingectomy
* Ovulatory age – most significant risk factor
* BRCA1 and BRCA2 increase susceptibility (gene mutation)
* High-fat diet and genital talc powders linked
* Causes vague GI symptoms
* No good screening tests available
* exzenoration
148
True or false?
Early detection through screening tests has improved the prognosis of ovarian cancer
* False
* Rationale: Because the signs and symptoms of ovarian cancer are so vague, the majority of patients do not seek medical attention until the disease is advanced (the cancer has usually metastasized by then). There are currently no good screening tests available to detect ovarian cancer
149
Benign Cystic Teratoma
* dermoid cyst
* Benign tumor that contains derivatives of all three germ layers
* Examples include hair, teeth, fat, skin, muscle, and endocrine tissue
150
Pelvic Inflammatory Disease
* Infection ascends through uterus to fallopian tubes and ovary
* 1.5 million cases a year
* Sexually active females
* 1.under 20 years old
* 2.multiple sex partners
* 3.nulliparity
* previous PID
* Most common organism
* gonorrhea and chlamydia
* treated with antibiotics
151
P.I.D. symptoms and complications
* Symptoms
* Lower abdominal pain -- especially adnexal(tube and ovary) pain, with exquisitely painful cervix
* Fever
* elevated white blood count and
* purulent vaginal discharge
* Complications--we may see in the OR because of complications
* Peritonitis
* Chronic abdominal pain
* Tubo-ovarian abscess
* Pelvic adhesions
* Infertility
* Ectopic pregnancy
152
Adhesions
* Pain
* Infertility
* Obstruction
153
Tubal Patency
* Chromotubation
* May be done with laparoscopy to check patency of tubes
* Indigo carmine or methylene blue with saline injected into uterus through a uterine manipulator---through uterus, fallopian tube to abdomen
154
Uterine Prolapse
* Due to weakening of support structures
* May use pessary
155
Types of Genital Fistulae
* Due to trauma or weakened tissue (radiation)
* Fitula= abnormal connection between 2 structures
156
Peritoneum
* Note peritoneal fold between bladder and uterus
157
Dilators
*
158
Tuttle Tissue Forceps
159
Hysterectomy types – normal anatomy
160
Total Hysterectomy
uterus and cervix
161
Total Hysterectomy-BSO
* uterus, cervix, tubes, ovaries
162
Supracervical
* uterus without cervix
* why? holds vagina in place, save uterosacral ligamennts
163
Radical hysterectomy – Also called Wertheim procedure
* A Wertheim procedure is the dissection and wide removal of
* Uterus
* Tubes
* Ovaries
* Supporting ligaments
* Upper vagina
* Lymph nodes in the pelvis
164
Pelvic exenteration
* A pelvic exenteration procedure is the dissection and wide removal of
* Uterus
* Tubes
* Ovaries
* Supporting ligaments, iliac vessels, and lateral branches
* Upper vagina
* Lymph nodes in the pelvis
* Rectum
* Distal sigmoid colon
* Bladder and ureters
165
True or False?
A TLH is a removal of the uterus, bilateral fallopian tubes and ovaries
* False
* A TLH (total laparoscopic hysterectomy) is the removal of the uterus and cervix using laparoscopic methods only.
166
Basic GYN Laparoscopy Notes
* Always place an intrauterine manipulator. If the patient has had a hysterectomy, many surgeons will still place a sponge stick vaginally
* Most GYN’s will use the verres needle (blind) method for insufflation
* Always have the blunt probe available for diagnostic GYN laparoscopies.
167
Surgical Technologist Considerations
* Planned procedures
* Instrumentation
* Approach
* Sterile, clean, dirty, or combination • Anatomic structures involved
* Primary and secondary diagnosis
* Surgeon and patient preferences
* Availability of institutional resources
168
Which of the following procedures is the patient placed in the supine position?
A. TAH
B. TVH
C. LAVH
D.TLH
E. LSH
* A. TAH
169
Which procedures require the use of a uterine manipulator?
A. TAH
B. TVH
C. LAVH
D.TLH
E. LSH
* C. LAVH
* D. TLH
* E. LSH
170
Which procedures require the use of a RUMI uterine manipulator with a Culpo cup?
A. TAH
B. TVH
C. LAVH
D.TLH
E. LSH
* D. TLH
Surgical Procedures I
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