Ceasarean Section with Bilateral Tubal Ligation

OBJECTIVES

General Objective:

At the end of the one hour case presentation, the presenter and the audience will establish full

comprehension about the operative procedures.

Specific Objectives:

At the end of the one and half hour case presentation, the presenter and the audience will be able to:

1. Understand the surgical procedure and the instruments being used.

2. Identify the diagnostic tests and types of surgery.

3. Discuss the preoperative, intraoperative and post-operative care of case being presented.

Definition

Bilateral Tubal Ligation is a surgical procedure that permanently prevents pregnancy. It is also casually

known as “getting your tubes tied,” and involves the cutting or blocking off of the fallopian

tubes. This stops the egg from traveling from the ovary to the uterus so fertilization and

implantation cannot occur. Tubal ligation can be done at any time, including after childbirth or in

combination with another abdominal surgery, such as a C-section. A cesarean delivery also
known as a C-section or cesarean section is the surgical delivery of a baby. It involves one

incision in the mother’s abdomen and another in the uterus.

Indication of the surgery:

The absolute indications are comparatively simple: a contracted pelvis, with a conjugate at the

brim of less than 7 cm., or with other measurements so small that delivery could be accomplished in no

other way; complete obstruction of the pelvic canal by a fibroid tumor, ovarian cyst or tumor of the

sacrum; a gigantic child, whose head will not engage in the pelvic inlet and whose anterior parietal

eminence projects well beyond the symphysis. The primary indication for tubal ligation is the desire for

permanent sterilization. Those who have completed childbearing and desire a non-reversible

contraceptive option are candidates for tubal ligation. Removal of the Fallopian tubes, or salpingectomy,

has been advocated as a method for the prevention of ovarian cancer. The surgeon can perform

salpingectomy opportunistically as a method of tubal ligation at the time of hysterectomy. Currently,

bilateral salpingectomy alone is not the recommendation for risk reduction in patients with a high risk of

ovarian cancer, such as BRCA mutation carriers.

Types of surgery:

Tubal ligations can be performed in a few different ways. In determining the right method
for you, your doctor will (in advance) consider factors such as your body weight, any previous
abdominal surgery, and whether you will be having the procedure immediately following a
vaginal birth, C-section, or other surgery.

Among the options your doctor will consider:

 Mini-laparotomy (mini-lap) tubal ligation is performed after giving birth. Within 24

hours after giving birth, you will be taken to an operating room for the procedure.
Because your uterus is still enlarged from being pregnant, your fallopian tubes are right
at the top of the uterus—which is located just under your belly button. A small incision is
made in or near the naval, the fallopian tubes are brought up through it, and a small
 section of each tube is removed. Alternately, both tubes can be removed completely,
and sometimes clips are used to close off the tubes. The laparoscope is then removed
and the incision closed with stitches or tape.

 Laparoscopic sterilization is done if you have not just given birth. For a laparoscopic
tubal ligation, the surgeon makes an incision in the lower abdomen and possibly a
second small incision in or near the naval. A laparoscope (a small, telescope-like
instrument with a light) is then inserted through the incision. The fallopian tubes are
closed up by either cutting and sealing them, clamping them, or removing them entirely.
The laparoscope is then withdrawn and the incisions are closed with stitches or special
tape

 Open tubal ligation surgery, also called a laparotomy, is typically performed

immediately following a C-section. An open laparotomy is performed immediately after
a preceding surgery is complete. The surgeon will use the incision already made to
remove or cut and seal both fallopian tubes before closing up your abdomen.

Preoperative preparation
 Guidelines recommend a minimum preoperative fasting time of at least 2 hours from
clear liquids, 6 hours from a light meal, and 8 hours from a regular meal. However,
patients are usually asked not to eat anything for 12 hours prior to the procedure.

The following are also included in preoperative management:

 Placement of an intravenous (IV) line
 Infusion of IV fluids (eg, lactated Ringer solution or saline with 5% dextrose)
 Placement of a Foley catheter (to drain the bladder and to monitor urine output)
 Placement of an external fetal monitor and monitors for the patient’s blood pressure,
pulse, and oxygen saturation
 Preoperative antibiotic prophylaxis (decreases risk of endometritis after elective
cesarean delivery by 76%, regardless of the type of cesarean delivery [emergent or
elective])
 Evaluation by the surgeon and the anesthesiologist

Before anesthesia, the surgeon should evaluate the site of the intended skin incision. The
intended area need not be shaved automatically unless the hair will interfere with
reapproximation of the skin edges. If the hair is to be removed, it should be clipped immediately
before surgery. Shaving appears to be associated with a slightly increased risk for infection. The
use of chlorohexidine solution rather than a povidone iodine solution is associated with a
decrease risk of both superficial and deep wound infection.

Diagnostics
Preoperative:

The following laboratory studies may be obtained prior to cesarean delivery:

 Complete blood count
 If the decision is made to perform a cesarean delivery for an abnormal labor
course, nonreassuring fetal testing, or abnormal bleeding, then the blood work is
submitted.
 Blood type and screen, cross-match
 Screening tests for human immunodeficiency virus, hepatitis B, syphilis
 Coagulation studies (eg, prothrombin and activated partial thromboplastin times,
fibrinogen level).
 Occasionally, a coagulation profile is necessary. In patients with thrombocytopenia, a
history of a bleeding disorder, preeclampsia, or a condition with suspected disseminated
intravascular coagulation (DIC), whether consumptive or secondary to thromboplastin
release, a CBC and coagulation studies (including prothrombin time [PT], activated partial
thromboplastin time [aPTT], and fibrinogen) may be ordered to assist the attending
anesthesiologist in determining the safety of attempting regional anesthesia with an
epidural or spinal procedure.

Imaging studies.
In labor and delivery, document fetal position and estimated fetal weight. Although
ultrasonography (ultrasound) is commonly used to estimate fetal weight, a prospective study
reported the sensitivity of clinical and ultrasonographic prediction of macrosomia, respectively,
as 68% and 58%.

Intraoperative:
 Most commonly, there are no laboratory tests done intraoperatively unless much heavy
bleeding is documented. In some cases if the patient went to eclampsia.

Postoperative:
 Complete blood count if necessary or requested in cases of blood transfusion during
surgery.

Anesthesia

Postpartum tubal ligation can be accomplished under epidural, spinal or general

anesthesia. In fact, local with sedation is possible, but not desirable. Spinal anesthesia is
most commonly used. It is performed in the supine position.
Spinal Anesthesia
• Used for surgical procedures involving the lower half of the body;
• any procedure performed below the level of the diaphragm (e.g., hysterectomy,
appendectomy)
• Anesthetic technique of choice for older adults
• Benefits:
– relative safety;
– excellent lower body muscle relaxation
– absence of the effect of unconsciousness.
– does not require emptying of the stomach
.• achieved by injecting local anesthetics into the subarachnoid space.

Epidural Anesthesia
• Epidural block is achieved by introduction of an anesthetic agent into the epidural
space (entered by a needle at a thoracic, lumbar, sacral, or caudal interspace).
• Provide a blockage of the autonomic nerves and hypotension can result.
• Respiratory muscles are affected, respiratory depression or paralysis may occur if the
level of block is too high.
• Caudal Anesthesia – produced by injection of the local anesthetic into the caudal or
sacral canal. This is a variation of epidural anesthesia. This method is commonly used
with obstetric clients.

POSITION:

 During caesarean section mothers can be in different positions. Theatre tables could be
tilted laterally, upwards, downwards or flexed and wedges or cushions could be used.
There is no consensus on the best positioning at present.
 Most commonly, in this surgical procedure the position used is supine. Some tilt the
operating table 15 degrees to the left to reduce compression on the major vessels, yet
this has no conclusive evidence in this practice.

PROCEDURE:
Informed Consent

• A legal document that signifies that the client has been told about and understands all aspects
of as specific invasive procedure.
• Guards the client against unwanted invasive procedures
• Protects the health care facility and health care professionals when the client denies
understanding about the procedure
• Physician’s responsibility to provide appropriate information,
• Nurse’s duty to ask the client to sign the consent form, and may be a witness to the client’s
signature

Preoperative Nursing Care

1. Preparation of the skin

a. shower/bathing the night before a scheduled surgery as per institutional policy.
b. Clean the site with soap and water or antimicrobial solution to diminish the # of
microbes on the skin
2. Clean the area before the surgery
3. Padding on bony prominences to prevent trauma in the skin during transfer
4. The gastrointestinal tract is prepared the night before the surgery.

Preoperative Nursing Care

• Preparations for the gastrointestinal tract include the following:
a. Restricting food and fluid 8-10 hrs before the operations
1. Explain the reason for restriction
2. Remove food and water from bedside at midnight
3. Place “NPO” signs on the door and bed
4. Mark the care plan or the Kardex with “NPO”
5. Inform the diet and nutrition dept and family about the status
6. If the client has been instructed to take impt meds orally:
1. Allow only small sips of water
2. Explain why this permission is permissible
3. Document the med and amount of fluid taken in the chart

Preoperative Preparation Immediately Before Surgery

1. All known allergies are recorded and an allergy wristband is present.

2. Vitals signs are checked and recorded.
3. The identification band is present and correct.
4. The consent formed is signed and the surgical procedure is listed correctly.
5. Skin preparation is completed if ordered preoperatively.
6. Any special orders are completed (enema, IV line)
7. The client has not eaten or had fluids by mouth for the last eight hours.
8. The client has just voided.
9. Oral hygiene or other physical/hygiene care is completed.
10. The presence of dentures, bridgework, or other prostheses is noted.
11. Storage is arranged and documented for valuables according to health care facility policy.
12. The client has removed jewelry.
13. The perioperative nurse is notified about the presence of a hearing aid.
14. The client is wearing a hospital gown and protective cap.
15. Make-up is removed.
16. Preoperative medications are given.
17. Transfer the client from bed to a stretcher

POSTOPERATIVE PHASE

GOAL:
To assist an uncomplicated return to safe physiologic function after an anesthetic procedure
by providing safe, knowledgeable, individualized nursing care for clients and their family
members in the immediate post-anesthesia phase.

Post-Anesthesia Care Unit (PACU)

Immediate Assessment
– Supporting vital physiologic functions until the effect of anesthetic agents abate.
– Proper positioning of a sedated, unconscious or semiconscious client ensuring airway patency.

Review client’s record noting the following:

1. Anesthesia record for IV medications and blood received during surgery
2. Any unanticipated complications
3. Significant preoperative findings
4. Presence of tubes, drains, and types of wound closure
5. Length of time the client was in surgery

IMMEDIATE: Perform an assessment which includes the following:

1. Airway
a. Patency
b. Presence of tubes and respiratory assistance device
2. Breathing
a. Respiration rate and depth
b. Presence of bilateral breath sounds, stridor, wheezes, hoarseness , or decreased
breath sounds
c. Return of gag reflex
3. Level of consciousness
4. Circulation
a. Pulse, BP, skin color, pulse oximeter
b. Muscle strength
b. ECG tracing if attached
c. Ability to follow commands
 c. Wound status and dressings
d. IV infusions, dressings, drains, and
d. Slight increase in the heart rate – special may be normal due to stress response
equipments; tubes and drains that must be after surgery attached to containers or
suction
e. Reddened or bruised areas on the skin unrelated to surgery
f. Temperature.

Incision Types

 Vertical. Also known as a “classical” C-section, this cut is down the middle of the
abdomen, usually from below the navel to the pubic hair line.
 Horizontal. A low-transverse incision (or a “bikini cut”) is used in 95 percent of C-
sections today. That’s because it’s done across the lowest part of the uterus, which is
thinner ,meaning less bleeding .The doctor makes an incision from one side of the
abdomen to the other, just above the pubic hair line.

Methods For skin closure

 Non-absorbable staples
 Absorbable subticular

Contraindication:

 Ambivalent patients,
 Lack of finances,
 Very young age,
 Incapable of making a medical decision,
 Presence of gynecological malignancy,
 Morbidly obese patients.

Complication:
  Mortality is low and about 0.01% to 0.02% and mostly related to general anesthesia.
 Conversion to open laparotomy
 Bowel injury from trocar, electrocautery
 Vascular injury from trocar

 Ectopic pregnancy
 Vascular injury
 Failure to sterile because of lack of anatomical knowledge, failure to identify oviduct, poor
technique
 Pain
 Infection
 Patient regret

Postoperative Mangement

 Transfer to postpartum ward when stable

 Vital Signs q15 minutes for 1 hour, then q4 hours

 Monitor intakes and outputs every 4 hours for 24 hours

 Activity:

1. Bed rest
2. Supine for 8 hours after spinal anesthetic
3. Incentive Spirometry every 1 hour while awake

 Standard Diet

4. Nothing by mouth for 8 hours after cesarean section

5. Sips of water after 8 hour window
6. Advance to clear liquids as tolerated
7. Advance to Regular diet when flatus or Bowel Movement

 Early Solid Diet Protocol

8. Solid food within 8 hours of C-Section

9. Well tolerated
10. Resulted in faster bowel function return
 11. Shortened hospital stay by 24 hours
12. Patolia (2001) Obstet Gynecol 98:113-6 [PubMed] (or open in [QxMD Read])

 Intravenous fluids

13. D5LR OR D51/2NS at 125 cc/hour

14. Foley to gravity

 Contact physician for

15. Temperature > 100.4

16. Systolic Blood Pressure <90 mmHg or >140 mmHg
17. Diastolic Blood Pressure >90 mmHg or <50 mmHg
18. Heart Rate >130 or <60
19. Respiratory Rate >32 or <8
20. Urine output
a. Foley Catheter in place: <60 cc in 2 hours
b. Intermittent Urine collection: <300 cc per shift

 Medications

Antibiotics if patient labored before cesarean section

21. Cefoxitin 2 grams IV every 4 hours for 3 doses or

22. Ancef 1 gram IVPB every 8 hours for 3 doses

Nausea

23. Inapsine 1.25 mg IM/IV every 4-6 hours prn Nausea

Initial Analgesia

24. Demerol 50-75 mg IM every 3-4 hours prn

25. Morphine 10 mg IM every 3-4 hours prn
26. Vistaril 25-50 mg IM every 3-4 hours prn

Later analgesia

27. Ibuprofen 800 mg PO tid prn

28. Tylenol #3 1-2 mg PO every 4-6 hours prn

Other Medications

29. Iron Sulfate dosing based on Postpartum Anemia

 30. Prenatal Vitamin po qd
31. Colace 100 mg PO bid OR 200 mg PO at bedtime
32. Mylicon 80 mg PO qid prn bloating
33. Milk of Magnesia

Surgery Instrument Set

4 Foerster Sponge Serrated Str 91/2"

1 Allis Tissue Forceps 5x6 7 1/2"

1 Roch-pean Forceps Cvd 6 1/4"

1 Delee Univ Bld Retr 2 3/4x2"

1 Heaney Nh Cvd Serr 8 1/4" Tc

1 Jackson Med Bld 3 1/2x1 1/2"se

1 Instrument Tray 10 3/8x6 3/8x2 1/2"

1 Tray Cover For 10-1742

Crile Hemostatic Forceps 5-1/2″ (13.8cm), curved

Crile Hemostatic Forceps 5-1/2″ (13.8cm), straight

Babcock Forceps 8-1/4″ (20.6cm), 10mm wide jaws

Metzenbaum Scissors 7″ (17.5cm), tungsten carbide, curved

Mayo Scissors 6-3/4″ (1j6.9cm), tungsten carbide, straight, beveled blades

Tissue Forceps 6″ (15cm), 1×2 teeth

Dressing Forceps 6″ (15cm), serrated tips

DeBakey Crile-Wood Needle Holder 7″ (17.5cm), serrated jaws, tungsten carbide

Mayo-Hegar Needle Holder 7″ (17.5cm), serrated, tungsten carbide

Richardson Retractor w/ Loop Handle, small 1

Richardson Retractor w/ Loop Handle, medium 1-1/4″ (3.2cm) x 1″ (2.5cm), 9-1/2″ (23.8cm)
Scalpel Handle #3 Graduated CM’s – for blade sizes #10-15

Sterilization Container – Small w/ Perforated Lid

Wire Basket for Sterilization Container – Small

Nursing Diagnosis
Preoperative
 Deficit knowledge related to unfamiliar surgical experience.
 Anxiety/fear related to pain, death, disfigurement, or the unknown

Post operative
Initial Nursing Diagnoses
 Impaired skin integrity related to invasive procedure, immobilization, and altered
metabolic and circulatory state.
 Risk for fluid volume deficit related to blood loss, food and fluid deprivation, vomiting,
and indwelling tubes.
 Pain related to surgical incision and tissue trauma.

DISCHARGE PLAN

1. Exercise/Activity and Home Environment

Types of activity that should not be allowed

 Do not take long baths, soak in a hot tub, or go swimming until your skin has
healed.
 Avoid heavy exercise for several days after the procedure. Try not to lift
anything heavier than 10 pounds (about a gallon, 5 kg, jug of milk).
 Prolonged sitting and standing.
 Don’t have sexual intercourse until after you’ve had a checkup with
your healthcare provider.

Type of Activity Allowed/to be continued:

 Easy and non-strenuous household chores are allowed.
 Taking a bath or shower with proper precaution to the post-operative site.
 Basic stretches that aids in faster recovery with proper consultation with OBGYN
  Ambulation and
Home Environmental Hazards:
 Avoid highly stressful environment.
 Avoid tight fitting clothes on a hot weather. It may affect post-operative site.

2. Treatments/Therapies
a. Yoga
b. Meditation
c. Breathing exercises

3. Health Teaching/Education
Health Prevention/Promotion

 Get lots of rest. Take naps in the afternoon.

 Increase your activities bit by bit.
 Plan your activities so that you don’t have to go up or down stairs more than needed.
 If you feel sick to your stomach, try dry toast or crackers with tea.
 Keep your incision areas clean, dry, and covered. Change your dressings (bandages) as
your health care provider told you to.
 Some discharge or bleeding from your vagina is expected, however bleeding that
requires a new sanitary pad every hour is not normal.
 Hold a pillow against the incision when you laugh or cough and when you get up from a
lying or sitting position.
 Contact doctor if any of these are present; severe pain in the abdomen, pain or urgency
with urination, foul odor from vaginal discharge, trouble urinating or emptying your
bladder, no bowel movement within 1 week after the birth of your baby.

4. Diet
a. Prescribed Diet: High protein, minerals and calcium rich food
Diet Restrictions:
 Avoid food items that cause gas and constipation. Avoid consumption of junk
food and carbonated drinks and consume food items such as soup, cottage
cheese, broth, yoghurt and other items which are easily digested by the body.

5. Spiritual Care and Psychological or Sexual Needs (Give special consideration to

religious and cultural practices)
 Spiritual and Psychological Needs
Spiritual Counseling
Family Therapy
Prayer
Meditation, Reflection, and Spiritual Devotion
Sexual Needs
Marriage Counseling
Sex Therapy

Prognosis

The risk of professional liability for operative complications is increased with this

procedure. This risk is low, but real. Furthermore, sterilization failure occurs in about 1 in 100

cases even though the operation was performed properly.

REFERENCES

https://www.statpearls.com/ArticleLibrary/viewarticle/30649

https://www.germedusa.com/p-3196-vaginal-tubal-ligation-instrument-set.aspx

https://www.ncbi.nlm.nih.gov/books/NBK549873/

https://www.clinicalpainadvisor.com/home/decision-support-in-
medicine/anesthesiology/postpartum-tubal-ligation/

https://emedicine.medscape.com/article/263424-overview#a1

https://www.medscape.com/answers/263424-184943/how-is-the-site-of-the-incision-prepared-
prior-to-cesarean-delivery-c-section

https://medlineplus.gov/ency/patientinstructions/000620.htm

https://www.lybrate.com/topic/diet-after-c-section
https://www.fairview.org/patient-education/86307
https://reference.medscape.com/drug/ceftin-zinacef-cefuroxime-342500