SYSTEMS PLUS COLLEGE FOUNDATION

Angeles City
COLLEGE OF NURSING

CASE REPORT FORMAT

(Clinical special areas)

I. INTRODUCTION

Hemorrhage, one of the most important causes of maternal mortality associated with
childbearing, poses a possible threat throughout pregnancy and is a major potential danger in
the immediate postpartal period. Traditionally, postpartal hemorrhage has been defined as any
blood loss from the uterus greater than 500ml within 24-hour period. (St.John and Rouse,
2003). In specific agencies, the loss may not be considered hemorrhage until it reaches 1000ml.
hemorrhage may occur either early (i.e. within the first 24 hours), as in the case of my patient,
which happens during the operation, where in she already losses 1500ml of blood), or late
(anytime after 24 hours during the remaining days of the 6-week puerperium). The greatest
danger of hemorrhage is in the first 24 hours because of grossly denuded and unprotected area
left after detachment of the placenta.

As a way of remembering the causes of PPH, several sources have suggested using
the 4T’s as a mnemonic. Tone diminished (uterine atony), tissue (retained placenta, placenta
accrete), trauma (uterine inversion, uterine rapture, cervical laceration, vaginal hematoma) and
thrombin (disseminated intravascular coagulation) (Society of Obstetricians and Gynecologists
of Canada, 2002).

Types : 

1. Primary PPH : 

Hemorrhage occurs within 24 hours following the birth of the

baby. In the majority, hemorrhage occurs within2 hours following delivery.These are
of two types :

Third Stage Hemorrhage- Bleeding occurs before expulsion of the placenta. 

True Postpartum Hemorrhage-Bleeding occurs subsequent to expulsion of placenta(majority).

Causes :

*Uterine atony : Failure of the uterus to contract and retract following delivery of the baby

* Retained placenta 

* Failure to progress during second stage of labour 

* Placenta accreta 

* Lacerations 

* Instrumental delivery 

* Large for gestational newborn 

* Hypertensive disorders such as pre-eclampsia, eclampsia during pregnancy .
 To remember, causes of PPH, various sources suggested to remember 4T's.

4t's :

 Tone, Tissue, Trauma, and  Thrombosis

Tone

Uterine atony and failure of contraction and retraction of myometrial muscle fibres can lead to ra
pid & severe hemorrhage & hypovolemic shock. 

The main cause of atony of uterus is overdistension of uterus, which can occur due to 

*Multiple pregnancy 

*Fetal macrosomia

*Polyhydra-amnios

*Fetal abnormality such as severe hydrocephalus 

*Uterine structural abnormality 

*Failure to deliver placenta The other cause of poor tone of uterus ispoor myometrial contraction
s which can be due to 

*Prolonged labour 

*Rapid forceful labour

*Inhibition of contractions by drugs (halogenated anesthetic agents, nitrates, NSAIDs, MgSo4,

beta-sympathomimetic,nifedipin). 

*Implantation of placenta in lower uterine segment (placenta previa). 

2. Tissue 

Complete detachment and expulsion of the placenta permits continuedretraction and optimal

occlusion of blood vessels. If any part of placenta is left,
it will not allow continued retraction and occlusion of blood vessels due to which bleeding occur. 
Retained placenta occur mainly in : *Succenturiate placenta *Abnormal placenta *Placenta accr
eta – Failure of placenta to separate completely Retained placenta

-->Uterine distension -->Prevent effective contraction -->PPH 

3. Trauma 

Trauma to genital tract may occur spontaneously or through manipulations used to deliver the b
aby. Trauma may occur due to

*Prolonged or vigorus labour *Absolute or relative CPD 

*Extra uterine or intra-uterine manipulation of the fetus : internal version and extraction of a twin 
in twin pregnancy 
-While attempting to remove retained placenta manually or with instrumentation 

- Forceps delivery, vacuum delivery 

-Extension of episiotomy

4. Thrombosis 

In the postpartum period, disorders of the coagulation system and platelets do not usually result 
in excessive bleeding but emphasize the efficiency of uterine contraction and retraction for prev
ention hemorrhage .Fibrin diposition over the placental site and clots within the supplying vessel
s play a significant role in the hours and days following delivery and abnormalities in these can l
ead to late PPH. 

Pre-existant- Abnormalities may be pre-existant or acquired.

Thrombocytopenia may be related to pre
existing disease such as idiopathic thrombocytopnia purpura, acquired secondary to HELLP syn
drome (hemolysis, elevated liver enzymes and low platelet count), abruptio placenta, disseminat
edintravascular coagulation (DIC) & sepsis.

 Acquired abnormalities- They are such as DIC related to placenta abruptio, HELLPsyndrome,
Intra uterine fetal demise.

2. Secondary PPH :

Hemorrhage occurs beyond 24 hours and within puerperium , also called delayed or late puerpe
ral hemorrhage.

Sign / Symptoms :

Sign / symptoms depend upon the severity of loss of blood and degree of shock.

Degree of shock in relation to loss of blood during PPH

Loss of blood Blood Sign / symptoms Degree of shock

volume pressure(systolic)

500-1000ml(10- Normal Palpitation,tachycardia,dizziness Componsated

15%)

1000-1500ml(15- Slight fall  Weakness,tachycardia,sweating Mild

25%)
 (80-100mmHg)

1500-2000ml (25 Moderate fall Restlessness,pallor,oliguria Moderate

-35%)
(70-80mHg)

2000-3000ml (35 Marked fall Collapse,air hunger,anuria Severe

-50%
(50-70mmHg)
 Genital Tract Trauma

 Laceration of  Extensions, lacerations,  Uterine rupture Uterine inversion

the cervix, vagina and cesarean section
or perineum

*Precipitate delivery *Previous uterine surgery * High parity

* Malposition
* Operative delivery * Fundalplacenta
* Deep engagement

Risk Factors for postpartum hemorrhage:

 Placental abruption. The early detachment of the placenta from the uterus.

 Placenta previa. The placenta covers or is near the cervical opening.

 Overdistended uterus. Excessive enlargement of the uterus due to too much amniotic fluid
or a large baby, especially with birthweight over 4,000 grams (8.8 pounds).

 Multiple pregnancy. More than one placenta and overdistention of the uterus.

 Gestational hypertension or preeclampsia. High blood pressure of pregnancy.

 Having many previous births

 Prolonged labor

 Infection

 Obesity

 Medications to induce labor

 Medications to stop contractions (for preterm labor)

 Use of forceps or vacuum-assisted delivery

 General anesthesia

INCIDENCE AND PREVALENCE

Postpartum Hemorrhage, 1993-2014*

This figure shows the rate of postpartum hemorrhage (PPH) per 10,000 delivery hospitalizations
from 1993 through 2014. Postpartum hemorrhage is when a woman has heavy bleeding after
delivery.

PPH with obstetric procedures to control hemorrhage include

 Surgical repair of a deep cut or tear of the uterus.

 Uterine artery ligation/embolization (tying off the vessel or identifying and injecting
material into the bleeding vessel).
 Obstetric tamponade of uterus or vagina (packing with gauze or using a medical device).
 Hysterectomy (surgery to remove the uterus).

PPH with blood transfusions is when a patient with PPH is given donated blood.

The rate of PPH with procedures to control hemorrhage increased from 4.3 in 1993 to 21.2 in
2014, with sharper increases in later years. The rate of PPH with blood transfusions also
increased noticeably over time, from 7.9 in 1993 to 39.7 in 2014.

*Obstetric procedures to control PPH and blood transfusion were coded hierarchically, meaning
that only blood transfusions were used to control PPH for the blood transfusion group, while
procedures with or without blood transfusion could be used for the obstetric procedure group.

CURRENT TRENDS

Bleeding after birth, also known as postpartum haemorrhage, is the most common
reason why mothers die in childbirth worldwide. Although most healthy women can cope well
with some bleeding at childbirth, others do not, and this can pose a serious risk to their health
and even life. To reduce excessive bleeding at childbirth, the routine administration of a
uterotonic drug called Oxytocin which contracts the uterus has become standard practice across
the world.
In this study, researchers from the Cochrane Pregnancy and Childbirth Group have
reviewed the data of the births of 88,000 women who took part in 140 randomised trials, with the
aim of identifying which uterotonics (including oxytocin, as well as misoprostol, ergometrine,
carbetocin or combinations of these) are most effective in preventing excessive bleeding after
childbirth and have the least side-effects.
The Cochrane Review found that ergometrine plus oxytocin; misoprostol plus oxytocin;
and carbetocin on its own, were more effective drugs for reducing excessive bleeding at
childbirth rather than the current standard use of oxytocin on its own. The team analysed all the
available evidence to compare all of the drugs and calculated a ranking among them, providing
robust effectiveness and side-effect profiles for each drug. Side-effects can include vomiting,
high blood pressure and fever.
University of Birmingham Clinician Scientist Dr Ioannis Gallos, of the Cochrane
Pregnancy and Childbirth Group and Review Author, said: "Whilst death from postpartum
haemorrhage is a rare complication, it is the most common reason why mothers die in childbirth
worldwide and happens because a woman's womb has not contracted strongly enough after
birth and results in excessive bleeding.
"Currently, to reduce excessive bleeding at childbirth, the standard practice across the
world is to administer to women after childbirth a drug called oxytocin -- a uterotonic which
contracts the uterus and stimulates contractions to help push out the placenta."However, there
are a number of other uterotonics and combinations of these drugs that can be given that may
be more effective.
This Cochrane review is expected to be updated later this year to incorporate the results
of some key ongoing studies which will report their findings in coming months, including a large
study involving around 30,000 women across 10 different countries comparing the effectiveness
of carbetocin versus oxytocin for preventing bleeding in women having a vaginal birth, and a
UK-based trial involving more than 6,000 women comparing carbetocin, oxytocin and
ergometrine plus oxytocin combination.

II. ANATOMY AND PHYSIOLOGY

Anatomy and physiology of postpartum haemorrhage due to placental causes and uterine
atony. As these are the most common forms of postpartum haemorrhage, it is worthwhile
recalling the following facts. Postpartum hemorrhage due to other than trauma arises from the
placental bed which is obviously inside the uterus. The blood supply comes from outside the
uterus and traverses the myometrium. Primary haemostasis from the placental bed is due to
compression of the uterine vessels as they pass through the myometrium. The degree of
compression of these vessels depends on the force acting on the vessels. This force obeys the
Young-Laplace relationship (F= 2T / r ), where F equals the compressive force acting on the
blood vessels, T is the wall tension (generated by the uterine contraction), and r is the radius of
the uterus. It is apparent that the force compressing the vessels cannot be very high if r is large.
Therefore, it is essential that the radius of the uterus be made small by emptying the uterus from
any blood or placental tissue and increasing the wall tension of the uterus (T) by giving ecbolics.

Placental bed
The term placental bed was coined to describe the maternal-fetal interface (ie, the area in which
the placenta attaches itself to the uterus). Appropriate vascularization of this area is of vital
importance for the development of the fetus.

Myometrium

It is the middle layer of the uterine wall, consisting mainly of uterine smooth muscle cells (also
called uterine myocytes) but also of supporting stromal and vascular tissue. Its main function is
to induce uterine contractions.

Uterus

The uterus has three layers, which together form the uterine wall.From innermost to outermost,
these layers are the endometrium, myometrium, and perimetrium.. The endometrium is the
inner epithelial layer, along with its mucous membrane, of the mammalian uterus.

Placenta

The placenta is a temporary fetal organ that begins developing from the blastocyst shortly after
implantation. It plays critical roles in facilitating nutrient, gas and waste exchange between the
physically separate maternal and fetal circulations, and is an important endocrine organ
producing hormones that regulate both maternal and fetal physiology during pregnancy.

What causes postpartum hemorrhage?

Once a baby is delivered, the uterus normally contracts and pushes out the placenta. After the
placenta is delivered, these contractions help put pressure on the bleeding vessels in the area
where the placenta was attached. If the uterus does not contract strongly enough, these blood
vessels bleed freely. This is the most common cause of postpartum hemorrhage. If small pieces
of the placenta stay attached, bleeding is also likely. 
Postpartum hemorrhage may also be caused by:

 Tear in the cervix or tissues of the vagina

 Tear in a blood vessel in the uterus

 Bleeding into a hidden tissue area or space in the pelvis. This mass of blood is called a
hematoma. It is usually in the vulva or vagina.

 Blood clotting disorders

 Placenta problems

III. MEDICAL MANAGEMENT

a. DIAGNOSTIC AND LABORATORY PROCEDURES

DIAGNOSTI GENERAL INDICATION NORMAL ANALYSIS NURSING

C/ DESCRIPTI OR PURPOSE VALUES AND RESPONSIBIL
LABORAT ON INTERPRETA ITIES
ORY TION
PROCEDU
RES

Hematolog -the study of Indication: -Red blood 1st test: Explain to

blood in cell count decrease level client the
y *CBC
relation to Female: 3.92- of hgb, procedure to
health and This blood test 5.13 million hct,pt,ptt be done.
disease. evaluates cells/mcL indicates
-Blood plays blood loss, bleeding, Observe sterile
essential -Hemoglobin decrease techniques
anemia, blood
roles in Female: 116- blood volume. when taking
human replacement 150 grams/L) 2nd test: low specimen.
health, therapy and level of hgb
including: fluid balance -White blood hct. Indicates -Submit
and screens cell count decrease level specimen
-transporting red blood cell 3,400 to of blood immediately to
vital status. 9,600 volume. the laboratory.
substances, cells/mcL 3rd test (post
*PTT & PT
such as BT): hgb and -Explain to
oxygen and This test -Platelet hct are within client the
nutrients, evaluates count normal value. findings.
around the coagulation Female: Compensated
body ability of blood. 157,000 to from blood
helping to 371,000/mcL loss.
control the
body’s
 balance of
water and
acidity
helping to
fight off
disease
-Problems
with the
blood can
affect several
of the body’s
systems,
such as the
lymphatic
system, a
network of
tissues and
organs that
clear waste.

-Blood typing -Postpartum Blood Types -Involves -Explain to

is a test that hemorrhage -O mixing of client the
*BLOOD determines a indicates -A. maternal procedure to
TYPING person’s requiring blood -B serum with be done.
blood type. transfusion due -AB standard
The test is to the reagent red -Observe
essential if possibility of Blood types cells that sterile
the patient significant are further contain the techniques
needs a blood loss to a organized by antigens with when taking
blood patient. Rh factor: which most of specimen.
transfusion the common
or is planning -It is also one Rh-positive clinical -Submit
to donate of the significant specimen
blood. Not all requirements Rh-negative antibodies will immediately to
blood types for a patient react, thus, the laboratory.
are undergoing administration -Explain to
compatible, surgery like a of unscreened client the
so it’s Hysterectomy. blood may findings.
necessary to res8ult to
know your adverse
blood group. reaction.
Receiving
blood that’s
incompatible
with your
blood type
could trigger
a dangerous
immune
response.
 -A dedicated -vaginal -It can detect - -Prepare
pelvic bleeding and 250-500 mL Ultrasonograp patient for the
ultrasonogra decreasing red of fluid in the hy cannot procedure.
phy blood cell peritoneum, reliably
(transabdomi counts in the but it is a poor differentiate -Explained why
nal and/or postpartum study for between blood, procedure is
transvaginal) patient identifying urine, or necessary.
is helpful in retroperitonea ascites;
identifying l or however, in the -Instruct client
Ultrasonog to empty the
large paravaginal setting of
raphy retained hemorrhage suspected bladder before
placental (extra- hemorrhage, the procedure.
fragments, peritoneal any fluid in the
hematomas, bleeding). abdomen
or other should prompt
intrauterine further
abnormalities investigation.
.

b. IVF, O2 THERAPY, NEBULIZATION, NGT

TYPE OF GENERAL INDICATION OR NURSING

MEDICAL DESCRIPTION PURPOSE RESPONSIBILITIES
MANAGEMENT

 Determine what
type of IVF to
infuse.
Isotonic Solution This was indicatede to
Intravenous Fluid
– have the same the patient as an  Always check for
concentration as access for IV patency.
D5LRS 1L x 31-
blood and medications and to
32 gtts/min Check for IVF’s
plasma. Used to restore vascular 
restore vascular volumes since she will proper regulation.
volumes. undergo surgery
 Check for fluids to
follow.

Blood  Determine what

Transfusion blood products to
4 “u” FWB To replace blood loss infuse in the
during the surgery Doctor’s Order
- RBC and and to prevent sheet.
plasma. WBC and hypovolemia.
platelet not viable  Check for vital
after 24 hrs. As a compensation to signs of the client
maintain adequate before, 15 mins.
supply of hemoglobin after starting BT
in the body. and after BT.

 Monitor BT
regulation strictly.

 Monitor patient for

any allergic
 reactions.

 Stop BT if
untoward
reactions happen
such as fever,
rashes, etc.

 Maintain a KVO
regulation for the
IVF.

As an assistive way to  Determine the

help clients with amount of oxygen
compromised oxygen to be given in
status. Doctor’s Order
sheet.

 Check for the

For patients with patency of the
breathing and airway cannula to be
problems. used.

 Maintain regulated
amount of oxygen
given to patient.
2-3 LPM via nasal
Oxygen Therapy  Humidify the
cannula
oxygen to be
given to patient.

 Observe
precautionary
measures while
giving the therapy
like avoiding
smoking,
preventing static
electricity/
removing
combustible and
igniting materials.

Indwelling Foley Indwelling  Determine

Catheter Catheter, French Doctor’s order for
18 the insertion of the
catheter.

 Explain the
procedure and the
purpose of IFC
insertion to the
client.

 Prepare all the

 necessary
equipments.
To prevent bladder
distention and injury  Maintain the
during surgery sterility of the
catheter and apply
KY gel to lubricate
catheter before
insertion.

 Insert the catheter

with the dominant
hand while
opening the labia
with less dominant
hand.

 Inject 5-10 cc of
NSS to keep the
catheter
anchored, observe
for backflow of
urine.

 Monitor the
amount of urine in
the urine bag.

c. MEDICATIONS

NAME OF ROUTE OF
THE DRUG GENERAL INDICATION ADMINISTRA SIDE NURSING
GENERIC DESCRIPTI OR PURPOSE TION, EFFECTS RESPONSIBIL
NAME ON/ DOSAGE AND ITIES
BRAND CLASSIFIC AND ADVERSE
NAME ATION FREQUENCY REACTIONS
OF
ADMINISTRA
TION

Generic -Oxytocic -To reduce -Adult: 10 to -Subarachnoid -Monitor fluid

Name: postpartum 40 units in 1 hemorrhage, intake and
Oxytocin bleeding after liter of LR or seizure, coma output. Anti-
the expulsion NSS IV -Arrythmias, diuretic effect
Brand of the placenta infused at a HTN, may lead to
Name: rate to sustain Hypotension, fluid overload,
Pitocin uterine Tachycardia seizure, and
contraction -Abruptio coma from
and control Placenta, water
uterine atony. tetanic uterine intoxication,
contractions, -Monitor and
-10 units IM, uterine rupture, record uterine
after delivery increase contractions,
of placenta. uterine motility HR, BP,
-Pelvic Interauterine
Hematoma pressure, fetal
-Anaphylaxis, HR, and blood
 Death from loss atleast
oxytocin- Q15mins.
induced water -Observe
intoxication, patient
hypersensitivit receiving
y reaction oxytocin
continuously

Generic -Oxytocic, -To prevent -Adult: 0.2 mg -Nausea, -Determine

Name: Uterine hemorrhage IM or IV after uterine baseline serum
Methylergon Stimulant caused by delivery of the cramping, calcium level,
ovine uterine atony or anterior vomiting BP, Pulse.
Malleate subinvolution shoulder, -Abdominal -Check for
placenta, or pain, diarrhea, evidence of
Brand during the dizziness, bleeding
Name: puerperium. diaphoresis, before
Methergine tinnitus, administration.
-Repeat Q2-4 bradycardia, -Monitor
hrs as chest pain. uterine tone,
needed. -Allergic Bleeding, BP,
-During life- Reaction, P Q15 mins
threatening (Rash, until stable
emergencies, pruritus), (about 1-2
0.2 mg IV Dyspnea, hrs).
over atleast 1 severe or -Assess
min while sudden extremities for
monitoring for hypertension color, warmth,
BP and -CVA due to movement for
uterine severe HTN color, warmth,
contraction. -serious movement,
-After First IM arrythmias, pain.
or IV dose, seizure -Report chest
0.2 mg PO pain promptly.
Q6-8 hrs for
up to 7 days.
Decrease
dosage if
severe
cramping
occurs.

Generic Prostaglandi -Use in cervical -Postpartum -Abdominal -assess for

Name: n ripening, labor Hemorrhage( pain, Diarrhea possibility of
Misoprostol induction, Prevention) -Nausea, pregnancy
treatment of 600mcg as Flatulence, before initiating
Brand postpartum single dose Dyspepsia, therapy
Name: hemorrhage, immediately Headache -Allergy to
Cytotec treatment of after delivery Vomiting,Const prostaglandin
incomplete or ipation -Renal
missed -Treatment -Overdosing Impairment
abortion. 600-1,000 may produce -Ulcer
mcg as a sedation, -Perform
single dose. tremor, abdominal
seizures, exam, check
dyspnea, for bowel
palpitations, function,
hypotension, urinary output.
bradycardia

Generic -Hemostatic -Decrease -1g -Pale skin, -Monitor blood

Name: -Antifrinolytic blood loss after intravenously trouble pressure,
Tranexamic - delivery during over 10 breathing with pulse, and
Acid Antihemophil C-section and minutes, exertion respiratory
ic Vaginal may be -unusual status as
Brand delivery. repeated after bleeding or indicated by
Name: 30 bruising, severity of
Cyklokapron -Prevention minutes tiredness or bleeding.
and Mgmt of weakness -Monitor for
bleeding during -Following -Anxiety, overt bleeding
pregnancy Surgery: 10 change in every 15–30
mg/kg IV vision, chest min.
TID/QID for 2- pain -Monitor
8 days. -Confusion, neurologic
cough status (pupils,
-Difficulty level of
swallowing consciousness
-Dizziness, , motor activity)
lightheadednes in patients with
s, fainting subarachnoid
-Tachycardia hemorrhage.
-Skin, rash, -Assess for
hives, itching thromboemboli
c
complications.
(especially in
patients with
history). Notify
physician of
positive
Homans’ sign,
leg pain
hemorrhage,
edema,
hemoptysis,
dyspnea, or
chest pain.
-Monitor
platelet count
and clotting
factors prior to
and
periodically
throughout
therapy in
patients with
systemic
fibrinolysis.
-Stabilize IV
catheter to
minimize
thrombophlebit
is. Monitor site
closely.
-Instruct
patient to notify
the nurse
immediately if
bleeding
recurs or if
thromboemboli
c symptoms
develop.
-Caution
 patient to
make position
changes slowly
to avoid
orthostatic
hypotension.

d. DIET

GENERAL
TYPE OF DIET DESCRIPTION INDICATION OR NURSING
PURPOSE RESPONSIBILITIES

NPO  Indicated to the  Determine

patient pre and patient’s diet in the
post op to avoid Doctor’s Order
vomiting during sheet.
surgery and to
prevent  Instruct client of
aspiration after the appropriate
surgery and to diet.
avoid  Enumerate
abdominal different foods
discomforts. suited for the diet.

DAT if (+) BM Is ordered when  When normal

the client’s intestinal
appetite, ability to motility has
eat, and tolerance returned.
for certain foods
may change.

Soft diet Low residue diet  To prepare the

containing very stomach for
few uncooked solid foods.
foods. Is easily
chewed and
digested

Sips of water Pure water  Indicated to

patient to
prepare the
stomach for soft
diet and to
avoid
abdominal
discomforts

e. ACTIVITY
 GENERAL
TYPE OF DESCRIPTION INDICATION OR NURSING
ACTIVITY PURPOSE RESPONSIBILITIES

Passive Exercise Movements with Pre-operative & Determine patient’s

assistance. post-operative type of exercise in the
assistance for Doctor’s Order sheet.
patient
Passive ROM: assist
client in every activity
to prevent him/her
from fall.

Flat on Bed Person remains To remove effects of Assist client in

on bed without spinal anesthesia to stretching- flexing and
pillow prevent spinal extending of
extremities.
headache and
prevents opening of FOB: do not use
the surgical wound. pillows

Advice client to dangle

feet when sitting on
bed

SURGICAL MANAGEMENT (applicable to patients who had surgery)

i. Definition of the operation
ii. Procedure (preoperative, intraoperative and postoperative period)
iii. Instruments / equipment and machines / materials needed (provide
pictures/illustration)
iv. Responsibilities of the Nurse
- Before the procedure
**special physical preparation
- During the procedure
- After the procedure

f. SURGICAL MANAGEMENT

I. Definition of the operation

Hysterectomy  - is the surgical removal of the uterus. It ends

menstruation and the ability to become pregnant. Depending on the
reason for the surgery, a hysterectomy may also involve the removal of
other organs and tissues, such as the ovaries and/or fallopian tubes.

II. Procedure (preoperative, intraoperative and postoperative period)

A. Preoperative

i. Blood and urine tests are taken.

ii. Hair in the abdominal and pelvic areas may be clipped.

iii. An intravenous (IV) line is placed in a vein in your arm to

deliver medications and fluids.
B. Intraoperative

i. Laparotomy and development of the visual field

a. The operator is on the patient's left side with the

assistant on the patient's right side.

b. If the surgeon is right-handed, standing on the patient's

left side makes it easier to manipulate tissues and
instruments in the pelvis.

c. The author usually makes a midline abdominal incision

for the required length according to the size of the
uterus.

d. Next, the intestinal tract is pushed into the upper

abdomen with two towels moistened with physiological
saline, and a retractor is applied to expand the visual
field.

e. A pair of long, straight Pean's forceps are applied across

each uterine cornu, including the Fallopian tube and
ovarian ligament. If a myoma is firm and large, use a
myoma borer.

ii. Ligate and divide the

round ligament

a. Place a ligature in the

round ligament
using 1-0
absorbable suture
approximately 1.5 to
2 cm away from the
uterus and hold
with a Kocher's
forceps.

b. The uterine side is clamped with a Kocher's forceps and

the round ligament is cut

c. Expand the incision slightly upward and downward, then

cut the anterior leaf of the broad ligament across the
vesicouterine peritoneal reflection.

iii. Clamp, cut, and ligate the ovarian ligament and Fallopian
tubes (or infundibulopelvic
ligament)

a. The ovarian ligament and

the Fallopian tubes (or
infundibulopelvic
 ligament) are clamped with Heaney's forceps and
Kocher's forceps and cut.

b. The edge of the pelvic side is ligated again.

iv. Mobilization of the bladder

a. With strong upward traction on the uterus and lifting the

incised bladder
peritoneal stump with
smooth forceps
increasing tension.

b. First, mobilize the

bladder with Cooper's
scissors at the center of
the cervix.

c. Then, proceed with lateral blunt dissection with the

Cooper's scissors to expose the vesicouterine ligament.

d. It is important to avoid drifting laterally into the bladder

pillars, where troublesome bleeding may be
encountered.

e. At each stage, small vessels may require hemostasis

with a bipolar coagulator.

f. The bladder should be mobilized at approximately 1 cm

below the cervicovaginal junction.

g. If there is bleeding, the bleeding point is coagulated with

bipolar coagulator.

v. Clamp, cut, and ligate the uterine artery and vein/cardinal

ligament (first step of
parametrial tissue cutting)

a. In preparation for this step,

grasp the posterior
broad ligament with
forceps, scrape off the
tissues at the back of the
posterior broad ligament with
Cooper's scissors, and
when the posterior
broad ligament is
thinned cut down toward the sacrouterine ligament.

b. This procedure is important to keep the ureter away from

the uterine cervix, especially when there is inflammation
or endometriotic adhesions near the sacrouterine
ligament.
 c. Next, the loose
connective tissue
around the cardinal
ligaments is scraped off until
the uterine artery can be
visualized.

d. Then, clamp the uterine

vessels and cardinal
ligament slightly below the
internal os of the uterus with
Heaney's forceps so that
the uterine side can be
sandwiched with a short
Kocher's forceps to
control back-bleeding from the uterine side uterine artery,
then divide .

e. A absorbable suture is placed and the ligature is gripped

and pulled with a short Kocher's forceps.

f. The transected stump is double-ligated because the

uterine artery is included.

vi. Push down the stump of the uterine artery and upper part of
the cardinal ligament

a. Retract the uterus

strongly upwards to the
opposite side,
compress the cut
stump of the
cardinal ligament and
uterine vessels with
gauze as shown
in picture , and push
down slowly 1.5 to 2 cm along the cervix to the level of
the sacrouterine ligament and the vesicouterine ligament.

b. Using this method, the ureter is further away from the

uterine cervix,
and the same
effect is
obtained when
clamping and
cutting the 1.5 to 2
cm lower part of
the internal os 
vii. Clamp, cut, and ligate the sacrouterine ligament and
posterior half of the cardinal ligament (second step of
parametrial tissue cutting)

a. When the cardinal ligament stump, the vesicouterine

ligament and the sacrouterine ligaments are aligned at
the same level using the push-down procedure in step 6,
move to manipulating the sacrouterine ligament and
posterior half of the cardinal ligament.

b. As shown in picture , one

arm of the Heaney's
forceps is placed inside
the sacrouterine
ligament, and the other
arm is clamped against
the posterior half of the
cardinal ligament as
shown in picture.

c. Following the roundness

of the uterine cervix, the
convex surface of the Heaney's forceps is clamped such
that it faces diagonally behind the uterus with the
sacrouterine ligament. The sacrouterine ligament is cut
and ligated, and the ligature is gripped and retracted.

viii. Clamp, cut, and ligate the vesicouterine ligament and the
anterior half of the cardinal ligament (third step of parametrial
tissue cutting)

a. The remaining
ligaments adhering to
the uterus are the
vesicouterine ligament
and anterior half of the
cardinal ligament.

b. Place the right hand

against the back of the
cervix, check the
cervicovaginal
junction, and if the
bladder is not
mobilized sufficiently,
push down on the
bladder again with the
left hand and gauze to
approximately 1 cm below the cervicovaginal junction.
 c. Then, the vesicouterine ligament and anterior part of the
cardinal ligament are clamped such that the convex
surface of the Heaney's forceps faces diagonally in front
of the uterus .

d. Then, the ligaments are cut and ligated, and the ligature
is gripped and retracted.

e. If the Heaney's forceps are used correctly, at the end of

these three steps, the
ligated stumps will
line up at the same
level to surround the
cervix .

f. If the stumps are

arranged this way, the
ligaments are cut
along the
roundness of the
uterine cervix, so there is little risk of ureteral damage.

g. However, if the divided stumps are aligned along the

longitudinal axis of the uterus, ligament cutting has not
been performed along the roundness of the cervix, which
avoids the ureter, results in ureteral injury in a high
percentage in the locations shown by the arrow.

ix. Clamp the vaginal wall at the cervicovaginal junction

a. Palpate the uterine cervix

again from the front
and back to identify
the boundary, and clamp
the vaginal wall with
right-angle forceps or
Heaney's forceps .

b. If the rectum
adheres to the
posterior wall of the
cervix and is raised when
the cervix is also raised,
incise the adhesion at the border with an electric knife and
push down slightly, then clamp the vaginal wall.

xi. Opening the vagina

a. Step 9 is repeated on the

contralateral side.

b. A large gauze is placed

on the posterior side of the
uterus, the bladder is
 elevated with the bladder spatula, and the anterior wall of the
cervix is incised with an electric knife

c. When the vaginal spase is partially opened, grasp the vaginal

wall with a long, straight Kocher's forceps.

d. Use another long, straight Kocher's forceps to grip and retract

the uterine cervix, incise the vaginal wall around the entire
circumference, and remove the uterus.

e. Hold the vaginal wall with long, straight Kocher's forceps at

three to four points, and remove vaginal secretions and
disinfect.

xii. Closing the vaginal vault

a. First, the bilateral ends of

the vaginal stump are
sutured with 1–0
absorbable suture, and the
remaining part is
sutured continuously.

b. Suturing the vaginal

stump must be
completed with
absorbable suture to
prevent postoperative
vaginal stump
granulation.

c. After confirming hemostasis, the detached end of the

bladder, vaginal stump, and Douglas' peritoneum are
interruptedly sutured at three points.

xiii.  Hemostasis and closing the retroperitoneum

a. Grip the broad ligament incision end with a Pean's forceps,

check the surgical field, and stop bleeding.

b. Suture the pelvic peritoneum with 3–0 synthetic absorbable

suture.

xiv. Lavaging the abdominal cavity and closing the abdominal wall

a. After confirming the physiological gauze count, lavage the

abdominal cavity with warm saline, return the intestines to
their original position, and close the abdominal wall.

b. After closing, ensure that there is no bleeding from the

vaginal stump, using a vaginal speculum. Postoperatively,
perform abdominal X-rays and confirm again that there are
no gauze remnants.
 Notes to Avoid Complications

 Bleeding from behind the

bladder : suction well and
identify the specific
bleeding points to be
coagulated with the
bipolar coagulator. If
bleeding does not stop after
2 to 3 attempts, do not
repeat coagulation
hemostasis; use Z
sutures with 3–0
absorbable suture. Repeated coagulation with a bipolar
coagulator causes urinary fistula.

 Bleeding from the pelvic floor : This is likely to occur, for

example, when removing retroperitoneal myomas. Gauze
packing is useful for a small amount of bleeding. If the
bleeding point is clear, coagulate and stop bleeding using
bipolar coagulation. However, if you cannot stop bleeding
after 2 to 3 attempts, do not repeat coagulation hemostasis;
instead, place Z sutures with 2–0 or 3–0 absorbable suture. If
the suture area is close to the vascular plexus of the pelvic
floor and dangerous, or with oozing, attach a fibrinogen
compound (Tacosil), then apply gauze pressure for 2 to 3
minutes to stop bleeding. In either case, insert a drain if there
is concern about postoperative bleeding.

 Confirming the location of the ureters : with strong adhesions,

cervical fibroids, or retroperitoneal myomas, it is necessary to
separate the ureters before performing other surgery. A safe
and reliable method for finding the ureters is to expose the
common iliac artery by expanding the field of view with your
index fingers until the ureter intersects the common iliac
artery then tracing the ureter downward ( Fig. 16 ). Bleeding
and ureteral damage occur easily when trying to find the
ureters near the uterine cervix.

III. Instruments/ equipment and machines/ materials needed

 Foerster Sponge Forceps Straight-Sponge forceps are commonly utilized
in surgical procedures to firmly clasp gauze squares that will hold abundant
fluids and blood from the operatable region or surgical hemostasis. The
locking mechanism is built by a ratcheting system.

 Allis Tissue Forceps-Allis forceps have inward-curving blades and a

ratcheted handle. This design makes it ideal to grab fascia and tendons.
Forceps are used to grasp or hold objects. 

 Mixter Rt Angle Forceps-have jaws with longitudinal serrations and cross-

serrated tips that assist in a firm grip when clamping tissue or blocking
blood flow from a vessel. Due to its angle, this instrument may be used in
various scenarios, but surgeons may reach for this forceps in situations
when they need to hold or tie a suture around a structure in the body.
 Schmidt Curved Hemostat-A curved hemostat consists of two long shafts
of stainless-steel that are hinged together to work something like scissors
or pliers, but ending in a curved section. An essential difference with the
hemostat is that it has a locking mechanism between the two handle
pieces, allowing it to be locked closed. The lock consists of two metal tabs,
one on each side of the handles, that have tiny teeth on them.

 Heaney Needle Holders-is a ratcheted finger-ring instrument used to hold

the light to medium weight needles while suturing. The slightly curved
shanks and cross-serrated tips are ideal to give a secure grip on
the needles

 Heaney-Ballentine Clamps Straight & Heaney-Ballentine Clamps

Curved-  are used in hysterectomy procedures to clamp off the tough
ligament on both sides of the uterus. 

 Rochester-Ochsner Forceps Straight & Rochester-Ochsner Forceps

Curved- are hemostats that effectively clamp off blood vessels to prevent
leakage during operations such as orthopedic surgery . These forceps have
1x2 teeth on the tip of the sharpened jaws to clamp the arteries or to grip
the tissue.
 Mayo Dissecting Scissors Curved- Curved-bladed Mayo scissors allow
deeper penetration into the wound than the type with straight blades. The
curved style of Mayo scissor is used to cut thick tissues such as those
found in the uterus, muscles, breast, and foot.

 Metzenbaum Scissors Curved-  are surgical scissors designed for cutting

delicate tissue and blunt dissection. The scissors come in variable lengths
and have a relatively long shank-to-blade ratio. They are constructed of
stainless steel and may have tungsten carbide cutting surface inserts. The
blades can be curved or straight, and the tips are usually blunt. This is the
most common type of scissors used in organ-related operations.

 Russian Tissue Forceps- are used for grasping heavy or thick tissue. The

forceps are straight with a circular cup-shaped serrated tip, The forceps are
also used in wounds closure procedures. A wide range of dissecting
forceps is available in different sizes, Medical Tools dissecting forceps
feature fine serrations with precision points matching and ridges for better
grip, excellent quality used by professionals.
 DeBakey Tissue Forceps-are a type of surgical forceps used to hold
vascular vessels and tissue. They are specifically known for being
atraumatic, or non-damaging. They are capable of holding soft tissues,
blood vessels, and other delicate body parts without causing harm.

 Scalpel Handle-Holds scalpel blade 

 Deaver Retractor-is a hand-held retractor. It is named after the American

surgeon John B. Deaver. It is made up of stainless steel having a curved
retracting blade and flat handle. The width of the handle is equal to the
width of the retracting blade.

 Hegar dilators-are widely used in gynecology to open up the cervix. This

may be necessary before a uterine curettage or biopsy. They are also used
to overcome stenosis in non-gynecological situations, such as in urology
and proctology. The Hegar Uterine Dilator Double End instrument and
comes in various sizes. Hegar Double-Ended Uterine Dilator is a manual,
probe-style instrument used to dilate the cervix. They are solid, nonflexible,
and available in multiple diameters. These dilators are slightly curved in
opposite directions from the center and have smooth, rounded tips.
  Auvard weighted speculum- is placed in the vagina during vaginal
surgery with the patient in the lithotomy position. The weight holds the
speculum in place and frees the surgeon's hands for other tasks.

IV. Responsibilities of the Nurse

A. Before the procedure

a) Assess and record the type, amount, and site of the bleeding;
Count and weigh perineal pads and if possible save blood clots to
be evaluated by the physician.

b) Assess the location of the uterus and degree of the contractility of

the uterus/ Massage boggy uterus using one hand and place the
second hand above the symphysis pubis.

c) Review the records and note certain conditions such as retained

placental fragments, any laceration, abruptio placenta, etc.

d) Monitor vital signs including systolic and diastolic blood pressure,

pulse and heart rate. Check for the capillary refill and observe nail
beds and mucous membranes.

e) Measure a 24-hour intake and output. Observe for signs of

voiding difficulty.

f) Maintain a nothing-by-mouth status (NPO) while assessing client

status.

g) Maintain a bed rest with an elevation of the legs by 20-30° and

trunk horizontal.

h)

i)  Prepare the patient physically and mentally for the operation.

Assess the woman's understanding of the procedure. Provide
explanation, clarification and emotional support as needed.
Reassure that the anesthesia will eleiminate any pain during the
surgery and that the medication will be administered
postoperatively to minimize discomfort.

j) Cleanse the abdominal and perineal area and if, ordered shave
the perineal area. Rationale: The woman who understands about
the procedure to be performed and what to expect after surgery
will be less anxious.
 k) If ordered administer a small cleasing enema and ask the woman
to empty her bladder. Rationale: This precaution helps prevent
contamination from the bowel or bladder during surgery.

l) Administer preoperative medications as ordered.

m) Check the chart to ensure that the consent form has been signed.

n) Document

B. After the procedure

a) Assess for signs of hemorrage. Rationale: Hemorrhage is more

common after vaginal hysterectomy than after abdominal
hysterectomy.

b) Monitor vital signs every 4 hourse, auscultate lungs every shift

and measure intake and output. Rationale: These data are
important indicators of hemodynamic status and complications.

c) Once the cathether has been removed, measure the amount of

urine voided.

d) Assess for complications, including infection, ileus, shock or

hemorrhage, thrombophlebitis and pulmonary embolus.

e) Assess vaginal discharge: instruct the woamn in perineal care.

f) Assess incision and bowel sounds every shift.

g) Encourage turning, coughing, deep breathing and early

ambulation.

h) Encourage fluid intake.

i) Teach to splint the adbomen and coigh deeply. Teach the use of
the incentive spirometer.

j) Instruct to retrict physical activity 4-6 weeks. Heavy lifting. stair

climbing, douching, tampons and sexual intercourse should be
avoided. The woman should shower, avoiding tubbaths until
bleeding has ceased. Rationale: Infection and hemorrhage are
the greatest postoperative risks; restricting activities and
preventing the introduction of any foreign material into the vagina
helps reduce risks.

k) Explain to the woman that she may fell tired for several days after
surgery and needs to rest periodically.

l) Explain that appetite may be depressed and bowel elimination

may be sluggish. Rationale: These are aftereffects of general
anesthesia, handling of the bowel during surgery and loss of
muscle tone in the bowel while empty.

m) Teach the woman to recognize signs of complications that should

be reported to the physician or nurse:
  Temperature greater than 100°F (37.7°C)

 Vaginal bleeding that is greater than a typical menstrual

period or is bright red

 Urinary incontinence, urgency, burning or frequency

 Severe pain

n) Encourage the woman to express feelings that may signal a

negative self-concept.Correct any misconceptions. Rationale:
Some women believe that hysterectomy means weight gain, the
end of sexual activity and the growth of facial hair.

o) Provide information on risk and benefits of hormone replacement

therapy.

p) Reinforce the needs to obtain gynecologic examinations regularly

even after hysterectomy.

q) Document

I. Definition of the operation

Internal Iliac Artery Ligation -Ligation of the internal iliac

arteries may be indicated as a life-saving procedure in the control of
severe pelvic hemorrhage occurring spontaneously or operatively (when
noninvasive methods are not indicated or feasible). Indications are as
follows:

 Spontaneous hemorrhage due to advanced pelvic cancer,  control of

postoperative pelvic hemorrhage, intraoperative control of hemorrhage,
and prophylactic ligation prior to extensive pelvic surgery  (though some
studies have found that prophylactic ligation does not reduce
intraoperative blood loss

 Postprostatectomy bleeding

 Damage control in a select group of patients with massive retroperitoneal

hemorrhage after pelvic fracture

II. Procedure (preoperative, intraoperative and postoperative period)

A. Preoperative

i. Blood and urine tests are taken.

ii. Hair in the abdominal and pelvic areas may be clipped.

iii. An intravenous (IV) line is placed in a vein in your arm to

deliver medications and fluids.

B. Intraoperative
i. Anatomy of the internal iliac artery. Basic anatomic structures and
branches of the internal
iliac artery; Right pelvic
side wall, superior view

1. Common iliac artery,

2. External iliac artery,

3. Internal iliac artery

(IIA),

4. Superior gluteal
artery,

5. Iliolumbar artery,

6. Lateral sacral artery,

7. Uterine artery (red

line),

8. Ureter (white line),

9. Umbilical artery (obliterated),

10. Inferior gluteal artery,

11. Internal pudendal artery,

12. Obturator artery,

13. Obturator nerve (yellow line),

14. Lumbosacral trunk (yellow line),

15. S1 Nerve (yellow line),

16. Middle rectal artery, X. Ligation point of IIA)

ii. Entering the retroperitoneum.

a. The lateral parietal peritoneum over the pelvic side wall (over
the psoas major muscle and external iliac artery) between the round
ligament (ligamentum teres uteri) (blue line) and infundibulopelvic
ligament (ligamentum suspensorium ovarii) (red line) is cut (X). During
this step the uterus is pulled towards the counter side (caudally) of the
 pelvic wall where we plan to enter the retroperitoneum. (A: Uterus, B:
Right fallopian tube, C: Right ovary, D: Rectum, E: Bladder),

b. The incision is extended cranially to the level of pelvic brim

(green line) parallel to the infundibulopelvic ligament,

c. superior view, d. lateral view: Posterior leaf of the broad

ligament (ligamentum latum uteri), (the peritoneum with the ovarian
vessels), is retracted medially so the retroperitoneal area (red circle)
is visualized

iii. Identification of the ureter and internal iliac artery .

a. The ureter runs on the posterior leaf of the broad

ligament under the ovarian vessels, medial to the anterior branch of internal iliac
artery; therefore, holding the posterior leaf and making a blunt dissection towards
sacrum (white arrow) targeting the deeper part of posterior leaf will guide to identify
the ureter; b, c. The ureter (F, white line) is identified on the base of the broad
ligament, medial to the internal iliac artery (G, red line); d, e. The adipose and
lymphatic tissue over the internal iliac artery is dissected with a caudal movement
(white arrow) (3d). The ureter (F, white line), internal iliac artery (G, red line),
external iliac artery (H), and the common iliac artery (I) will be noticed just over the
pelvic brim at the upper part of pararectal space (3e) [borders of pararectal space:
posteriorly sacrum, medially ureter and rectum, laterally internal iliac artery and
anteriorly uterine artery and cardinal ligament (ligamentum transversum cervicis)

iv. Ligation of internal iliac artery.

a. A right-angle clamp is placed under the anterior division

of internal iliac artery (white arrow), after the main trunk
gives the branches of the posterior division (3.5 cm after the
origin of internal iliac artery);

b. Care should be taken not to harm the underlying external

iliac vein, located on the infero-lateral part of the internal iliac
artery. Accordingly, the right-angle clamp should be moved
from lateral to medial under the internal iliac artery (white
arrow) while holding the end point of clamp upperly;

c. After getting on the other side beneath the internal iliac

artery, the suture material is grasped (red circle) and pulled
backwards in the same direction;

d. The ureter, external iliac artery, and other important

anatomic landmarks are re-checked and finally the suture is
tied carefully (red rectangle);
e. Superior view of right pelvic side wall, how to ligate the
internal iliac artery, with close anatomic structures
III. Instruments/ equipment and machines/ materials needed

IV. Responsibilities of the Nurse

Before the procedure

 You may be asked to stop taking aspirin, ibuprofen (Advil, Motrin),

naproxen (Aleve, Naprosyn), Clopidogrel (Plavix), warfarin (Coumadin), and
other blood thinners.
 Ask your doctor which drugs you should still take on the day of the surgery.
 Discuss any possible bleeding disorders or other medical conditions that
you may have.
 You will have blood samples taken in case you need a blood transfusion.
 Do not smoke. This will help you to recover quicker.

During the procedure

 If you are to have general anesthesia, you will usually be asked not to drink
or eat anything after midnight the night before the surgery.
 Take the drugs your doctor told you to take with a small sip of water.
 Your doctor or nurse will tell you when to arrive at the hospital.

After the procedure

 Most patients can go home the same day.

 You may have increased cramping and vaginal bleeding for a day or two
after the procedure.
 You may experience gas pains for about a day or so due to gas
administered during the procedure. This may extend into your upper
abdomen and shoulder. Walking will help relieve this pressure.
 This surgery has a quick recovery with most patients feeling much better
within the first few days.

Recovery: what to expect in the next few weeks

 Most women feel better within the first week following surgery; however, do
not lift, push or pull any heavy objects for a few weeks.
 Do not resume sexual intercourse or douche until your doctor says it is OK.
 Full recovery takes about four weeks to allow for internal healing.

I. Dilation and curettage (D&C) - s a procedure to remove tissue from

inside your uterus. Doctors perform dilation and curettage to diagnose and
treat certain uterine conditions — such as heavy bleeding — or to clear
the uterine lining after a miscarriage or abortion.

II. Procedure (preoperative, intraoperative and postoperative period)

A. Preoperative
 i. Blood and urine tests are taken.

ii. Hair in the abdominal and pelvic areas may be clipped.

iii. An intravenous (IV) line is placed in a vein in your arm to

deliver medications and fluids.

B. Intraoperative

a)  The patient is positioned

on an operating or
examination table, with
her feet and legs
supported as for a pelvic
examination.

b) An intravenous (IV) line

may be started in her arm
or hand.

c) A urinary catheter may be

inserted.

d) The doctor will insert an

instrument called a
speculum into your vagina to spread the walls of the vagina
apart to expose the cervix.

e) The cervix may be cleansed with an antiseptic solution.

f) For local anesthesia, the doctor may numb the area using a
small needle to inject medication.

g) If general or regional anesthesia is used, the anesthesiologist

will continuously monitor your heart rate, blood pressure,
breathing, and blood oxygen level during surgery.

h) A type of forceps, called a tenaculum, may be used to hold

the cervix steady for the procedure.

i) The inside of the cervical canal may be scraped with a small

curette if the cervical tissue needs to be examined.

j) A thin, rod-like instrument, called a uterine sound, may be

inserted through the cervical opening to determine the length
of the uterus. If you have local anesthesia, this may cause
some cramping. The sound will then be removed.

k) The cervix will be dilated by inserting a series of thin rods.

Each rod will be larger in diameter than the previous one.
This process will gradually enlarge the opening of the cervix
so that the curette (spoon-shaped instrument) can be
inserted.

l) The curette will be inserted through the cervical opening into

the uterus and the sharp spoon-shaped edges will be passed
across the lining of the uterus to scrape away the tissues. In
 some cases, suction may be used to remove tissues. If you
have local anesthesia, this may cause cramping.

m) The instruments will be removed.

n) Any tissues collected with the procedure will be sent to the

lab for examination. Pregnancy tissues (called products of
conception) may be sent to the lab for culture or testing for
genetic or chromosomal abnormalities.

III. Instruments/ equipment and machines/ materials needed

 Suction Cannula- Dilation and Curettage (D & C) Suction Set is single-

use, cost-effective intra-uterine aspiration used after a spontaneous
abortion or early miscarriage to ensure that no fetal tissue remains inside
the uterus. Semi-rigid plastic curette is commonly used and is less likely
to damage the uterus than metal one. It features flexible and allow some
scraping as well as sucking, and they are supplied in diameters from 4 to
12 mm so that less dilatation of the cervix is required.

 D&C Machine- it is a suction device used to remove tissue from inside

the uterus. It has a collection container and a filter used to collect tissue
specimen.
  Curette is a surgical instrument designed for scraping or debriding
biological tissue or debris in a biopsy, excision, or cleaning procedure. In
form, the curette is a small hand tool, often similar in shape to a stylus; at
the tip of the curette is a small scoop, hook, or gouge.

IV. Responsibilities of the Nurse

A. Before the procedure

a. Assess and record the type, amount, and site of the bleeding;
Count and weigh perineal pads and if possible save blood
clots to be evaluated by the physician.

b. Assess the location of the uterus and degree of the

contractility of the uterus/ Massage boggy uterus using one
hand and place the second hand above the symphysis pubis.

c. Ensure that the patient remains NPO after midnight on the

day of surgery

d. Asked the patient to remove clothing and be given a gown to

wear.

e. Instructed the patient to empty your bladder

f. Positioned the patient on an operating or examination table,

with her feet and legs supported as for a pelvic examination.

g. Administer an intravenous (IV) line may be started in her arm

or hand and preoperative medicine.

h. A urinary catheter may be inserted

i. Administer preoperative medications as ordered.

j. Check the chart to ensure that the consent form has been
signed.

k. Document

B. After the procedure

a) Monitor vital signs

b) Monitor circulation and sensation in the legs and avoid

compression of the popliteal area.

c) Instruct the woman to use perinealpads and avoid tampons

for 2 weeks. Rationale: This reduces the risk of infection and
allows tissues to heal.

d) Explain that the onset ofthe next menstrual period may be

delayed.

e) Explain that intercourse should be avoided until after the

postoperative check up and after vaginal discharge has
ceased. Rationale: This precaution reduces risk of infection.
 f) Instruct the patient to rest for several days after surgery,
avoid heavy lifting and report any bleeding that is bright red
or exceeds that of normal menstruation period. Rationale:
Vigorous activity, lifting or straining interferes with healing
and may cause hemorrhage.

g) Inform the patient that she may feel groggy for a while and
have some brief nausea and vomiting

h) Inform patient that mild cramping and light spotting may

experience for a few days

i) Document

IV. NURSING MANAGEMENT

a. Nursing Care Plan

NURSIN
SCIENTIFIC NURSING
G OBJECTI RATIONAL EVALUATI
CUES EXPLANATIO INTERVENTI
DIAGNO VE ES ON
N ONS
SIS

Subjecti Risk for Risk for After 4  Determin  To be The patient

ve infection infection is the hours of e able to shows
cues: related to condition NPI and patient’s know understand
presence wherein the interventi level of where ing and
(-) of person looses ons, understa the appreciatio
incisional his body patient nding of nurse n to the
wound defenses that will be the will start health
Objectiv secondar makes him aware of problem his teachings
e cues: y to susceptible/ the and health given.
limited making him at possible establish teachin
Weakn knowledg risk for different interventi rapport. gs.
ess e infections and ons that
noted regarding diseases. In the could  Assess  To have
proper case of a one minimize the a
Limited patient baseline
wound day post-op her risk of
range and get data
care. patient, the having
of initial vital and
primary infection
motion signs. know
defense of the brought
body which is by her  the
Irritable Provide
the skin was condition. manifes
and health
broken allowing tations
restless teachings
microorganisms of the
regarding problem
Pallor to enter in the aseptic .
body and cause
With technique
infections and
intact s  Aseptic
diseases.
dressin applicabl techniq
Manifestations
g. e to ues
of impending wound help
infection care. minimiz
include e the
elevation of  Demonstr contami
WBC primarily ate
the proper nation
lymphocytes way of of the
and fever. cleaning wound
surgical by
wound. microor
Use of ganisms
betadine .
is
advised.  Betadin
e is a
 Encourag known
e the use antisepti
of clean c that
and helps
sterile reduce
dressing microor
and ganisms
changing .
it
regularly  The
or as dressin
prescribe g is a
d. good
place
 Encourag for
e proper microor
way of ganisms
hand to live.
washing. Changin
g it
 regularl
y
 Encourag
prevent
e patient
s it from
to
contami
maintain
nation.
good
personal  Hand
hygiene washing
like doing is the
bed bath best
regularly way to
and oral prevent
care. the
spread
 Encourag
of
e client to
infection
wear
.
clean and
loose  Good
clothes. persona
l
 Promote
hygiene
comfort
remove
measure
s
s such as
 changing microor
of linens. ganisms
in the
 Encourag body.
e to have
fewer  Clean
visitors/ and
minimize loose
interactio clothes
n with facilitate
other aeration
people. of the
wound
 Monitor thus
vital promoti
signs ng
frequentl faster
y healing.
 Encourag  Clean
e client to linens
eat and reduce
drink the
prescribe microor
d diet ganisms
that is in the
nutritious environ
and ment.
balance.
These  This
include reduces
CHON- the
rich, microor
CHO-rich ganism
and Vit.- that the
rich foods patient
like could
chicken/fi get from
sh and others
fruits & and
vegetable promote
s good
rest.
 Advise
client to  To
drink know if
medicatio there
ns and are
suppleme deviatio
nts ns from
prescribe the
d by the normal
physician range.
religiousl
y.  Nutritiou
s and
 balance
meals
provide
sufficien
t energy
to client
and
good
resistan
ce to
the
body.

 Medicati
ons and
supple
ment
help
prevent
complic
ations
of the
disease
and
promote
cure
and
recover
y to
patient.

NURSIN
NURSING
G SCIENTIFIC OBJECTI RATIONAL EVALUATI
CUES INTERVENTI
DIAGNO EXPLANATION VE ES ON
ONS
SIS

Subjecti Acute Pain is an After 3  Perform  Pain is The patient

ve Pain unpleasant hours of compreh a verbalizes
cues: related sensory and nursing ensive subjecti a decrease
to tissue emotional interventio assessm ve in pain
“Masaki injury experience that n, the ent of experie scale of
t ya ing secondar is normally patient pain to nce and below 5/10,
meoper y to associated with will include must be grimaces
a ku.” surgical injury to body verbalize location, describ are
interventi tissues. The decrease character ed by diminished
on. basic elements level of istic, the and
Objecti of pain are the pain. onset, client in achieved
ve sensory duration, order to tolerance
cues: impulses quality, plan to activity.
generated by intensity, effectiv
With injury-sensitive and its e
limited receptors in the precipitati treatme
mobility nervous system. ng factor. nt.
These sense
 Encourag  Relaxati
 organs, called e use of ons
nociceptors, relaxation techniq
Facial convert technique ues
grimace mechanical, such as help
noted thermal, or focused reduce
chemical breathing skeletal
stimulations that . muscle
With injure or tension,
threaten tissues  Monitor which
guardin
into impulses vital will
g
that are signs. reduce
behavio
transmitted assess the
r
along peripheral intensit
 Create a
nerves to the y of
quiet,
spinal cord, and pain.
Irritable nondisru
from there to
and ptive  Person
higher brain
restless environm al
centers. ent. factors
can
 Administ
Weakn influenc
er
ess e pain
analgesic
noted and
as
pain
ordered.
toleranc
 Provide e.
Pain
socializati
scale Comfort
on as 
above able
diversion
8/10 and
al
activity. quiet
atmosp
 Administ here
er pain promot
medicatio e a
n as relax
order. feeling
and
permit
the
client to
focus
on the
relaxati
on
techniq
ue
rather
than
external
distracti
on.

 Keepin
g the
 client
busy
will
reduce
the pain
sensati
on.
Socializ
ation is
a
means
to divert
the
attentio
n of the
client.

 To
alleviat
e or if
not,
reduce
the pain
experie
nce.

NURSIN
NURSING
G SCIENTIFIC OBJECTI RATIONAL EVALUATI
CUES INTERVENTI
DIAGNO EXPLANATION VE ES ON
ONS
SIS

Subjecti Risk for Postpartum After 8 Independent:  To After 8

ve: ineffectiv hemorrhage is hours of measur hoursof
e tissue defined as a nursing  Monitor e the nursing
“Halos perfusion loss of blood in interventio amounto amount interventio
ilang related to the postpartum ns, the f of blood ns, the
linggo hemorrh period of more patient bleeding loss. patient was
na ako age than 500 mL. will by able to
nakapa demonstr weighing demonstrat
nganak The average, ate all pads. e adequate
pero spontaneous adequate  Early perfusion
malaka vaginal birth will perfusion  Frequent recognit and stable
s pa rin typically have a and stable ly ion of vital signs.
ang 500 mL blood vital signs. monitor possible
pagdur loss. In vital adverse
ugo ko cesarean births signs. effectsa
” (I’m the average llows for
still blood loss rises  Massage prompti
bleedin to 800-1000 mL. the ntervent
g There is a uterus. ion.
heavily greater risk of  Place
after hemorrhage in  To help
the expel
weeks the first 24 mother
of hours after the clots of
in blood
giving birth, called Trendele
birth) primary and
nberg
as postpartum position.  it is also
hemorrhage. A
verbaliz secondary  Provide used to
ed by hemorrhage comfort check
patient. occurs after the measure the tone
first 24 hours of like back of the
Objecti birth. In the rubs, uterus
ve: majority of deep and
cases the cause breathin ensure
Restles of hemorrhage g. that it is
snes is uterine atony, clampin
meaning that  Instruct g down
Confusi in
on. the uterus is not to
contracting relaxatio prevent
Irritabilit enough to n or excessi
y. control the visualizat ve
bleeding at the ion bleedin
placental site. exercise g.
Other reasons s.
for a  Encour
hemorrhage  Provided ages
would include iversiona venous
retained l return
placental activities. to
fragments facilitate
Collaborative circulati
(possibly :
including a on, and
placenta  Administ prevent
accreta), trauma er further
of some form, oxygen bleedin
like a cervical as g.
laceration, indicated
uterine inversion  Promot
. es
or even uterine
rupture, and  Administ relaxati
clotting er on and
disorders medicati may
on as enhanc
indicated e
(e.g patient’
Pitocin, s
Methergi coping
ne) abilities
by
refocusi
ng
attentio
n.

 To
supplya
dequate
oxygent
o the
fetus
and
mother
and
prevent
s further
complic
ation.

 To
promote
 contract
ion and
prevent
s
furtherbl
eeding.

b. Actual FDAR

DATE/TIME FOCUS DATA, ACTION, and

RESPONSE
2/26/21 Abdominal pain with heavy D: Patient is pale with cool
bleeding and clammy extremities. She
is also drowsy. Her BP show
105/50mmHg and HR is
112/min. Upon palpation there
is minimal tenderness but the
uterus is palpable
approximately 6cm above the
symphysis pubis.

A: Speculum examination
reveals large clots of blood in
the vagina. When these are
removed, the cervix is seen to
be open.

R: The nurse notes secondary

postpartum hemorrhage upon
doing the examination.

V. LEARNING DERIVE

Understanding one’s disease is the best way for us to have the best knowledge
and health teachings that we could give to our patient. It is through this case study that
we realized that presence of an infirmity affects the totality of one person. One might
face/accept it very well but others might not. It is our duty as health care providers to
take the initiative to find and provide for possible explanations/ support that our clients
need.

As for this case- Postpartum hemorrhage, the pathophysiology of the disease is

the main key to have better understanding of the disease process itself. With this, risk
factors are modified; possible prevention are given and proper treatments and cure are
provided.

VI. REFERENCES

Books
  Silbert-Flagg, Pillitteri(2017) Maternal & Child Health Nursing, Care of the
Childbearing & Childbearing Family. 8th Edition. 839 EDSA South Triangle,
Quezon City, Manila: C&E Publishing, Inc.

 Vanputte, Regan, Russo (2019) Seeley’s Essentials of Anatomy and

Physiology. 10th Edition. 839 EDSA South Triangle, Quezon City, Manila: C&E
Publishing, Inc.

 Spratto, Woods (2008) Nurse’s Drug Handbook. 8th Edition.

 Wolters Kluwer (2021) Nursing Drug Handbook. Aptara, Inc.

Internet / Website

 Traci C. Johnson, MD on February 04, 2021, What Is a Hysterectomy and

Why Is It Performed?. Available from:
https://www.webmd.com/women/guide/hysterectomy#:~:text=A
%20hysterectomy%20is%20an%20operation,the%20uterus%2C%20cervix
%2C%20or%20ovaries Accessed: February 22, 2021

 Hiramatsu Y. (2019). Basic Standard Procedure of Abdominal Hysterectomy:

Part 1. Surgery journal (New York, N.Y.), 5(Suppl 1), S2–S10. Available from:
https://doi.org/10.1055/s-0039-1678575 Accessed: February 23, 2021

 Selçuk, İ., Uzuner, B., Boduç, E., Baykuş, Y., Akar, B., & Güngör, T. (2019).
Step-by-step ligation of the internal iliac artery. Journal of the Turkish German
Gynecological Association, 20(2), 123–128. Available from:
https://doi.org/10.4274/jtgga.galenos.2018.2018.0124 Accessed: February 23,
2021

 Singh, A., Kishore, R., & Saxena, S. S. (2016). Ligating Internal Iliac Artery:
Success beyond Hesitation. Journal of obstetrics and gynaecology of
India, 66(Suppl 1), 235–241. Available from: https://doi.org/10.1007/s13224-
016-0859-1 Accessed: February 23, 2021

 (TAHBSO) Nursing Care Plan & Management. RnPedia. Available from:

https://www.rnpedia.com/nursing-notes/maternal-and-child-nursing-notes/8-
tahbso-hysterectomy-nursing-care-plans/ Accessed: February 24, 2021
 Available from: https://www.mayoclinic.org/tests-procedures/dilation-and-
curettage/about/pac-20384910#:~:text=Dilation%20and%20curettage%20(D
%26C)%20is,after%20a%20miscarriage%20or
%20abortion.https://www.webmd.com/women/guide/d-and-c-dilation-and-
curettage Accessed: February 24, 2021

 Available from:
https://wps.prenhall.com/wps/media/objects/737/755395/dilation_curettage.pdf
Accessed: February 24, 2021

 Dilation and curettage (D and C). John Hopkins Medicine. Available from:
https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/dilation-
and-curettage-d-and-c Accessed: February 25, 2021

 (2019) Dilation and curettage (D&C). Mayo Clinic. Available from:

https://www.mayoclinic.org/tests-procedures/dilation-and-curettage/about/pac-
20384910 Accessed: February 25, 2021
  University of Birmingham. (2018, April 26). Effective drugs to stop bleeding
after childbirth. ScienceDaily. Available from:
www.sciencedaily.com/releases/2018/04/180426102842.htm Accessed: March
1, 2021

 (2019). Data on Selected Pregnancy Complications in the United States.

Centers for Disease Control and Prevention. Available from:
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-
complications-data.htm Accessed: March 1, 2021

VII. APPENDICES