Gynaecological Surgery Nursing Guide

Consent Considerations

• Permanent loss of fertility: No future pregnancies — patient must have been counselled by surgeon; ensure consent form documents this
• Menopause: If bilateral oophorectomy (BSO) performed — immediate surgical menopause, regardless of age; HRT usually commenced; document counselling
• Subtotal hysterectomy: Cervix remains — continued cervical screening required; no menstrual bleeding but spotting possible if residual endometrial tissue
• Radical hysterectomy: Bladder/bowel dysfunction possible post-operatively; lymph node dissection — lymphoedema risk
• Cultural considerations: In GCC context, fertility implications may carry significant emotional and social weight; ensure adequate psychosocial support and privacy for discussion

Pre-Op Checklist

• Consent signed, witnessed, and on file
• Allergies documented and allergy band applied
• Baseline observations (BP, HR, SpO2, temperature, weight)
• VTE risk score documented; stockings applied
• Pre-op bloods reviewed (FBC, U&E, G&S)
• IV access (large bore 16–18G, antecubital fossa)
• Pre-operative carbohydrate drink given (if ERAS, up to 2h pre-op)
• Fasting confirmed (6h solids / 2h clears)
• Bowel prep only if bowel involvement confirmed
• Antibiotic prophylaxis (co-amoxiclav or cefazolin) documented
• Thromboprophylaxis (LMWH) — note timing relative to spinal/epidural
• Theatre checklist completed (WHO Safe Surgery)
• Patient's valuables, jewellery, prostheses removed

Specific Risks & Monitoring

• Ureteric injury: Occurs in 1–2% — flank pain, decreased/absent urine output from affected side, urinoma; requires IVU or CT urogram
• Bladder injury: Haematuria, urine in surgical drain — methylene blue test (intravesical) to confirm vesico-vaginal fistula
• Haemorrhage: Para-vascular dissection near iliac vessels; observe drain output closely
• Bladder dysfunction: Disruption of autonomic nerve supply → voiding difficulty; prolonged catheter (often 7–14 days)

Drain Management

• Pelvic drains (x1–2 Jackson-Pratt or corrugated) typically in situ 24–48h
• Document drain colour, volume, and consistency every 4h
• Drain output >100mL/h of fresh blood → escalate immediately
• Serosanguinous output declining = expected; increasing = concern
• Milky/urine-like drain output → suspect urinary injury; send for creatinine
• Lymph drain may continue several days post-op; lymphocyst risk

Lymphoedema Prevention

• Pelvic lymph node dissection → lower limb lymphoedema risk
• Early physiotherapy and education on limb care
• Compression hosiery post-discharge

Immediate Post-Op (Recovery/PACU)

• Airway/breathing/circulation (ABCDE)
• Pain assessment (NRS 0–10); PCA or epidural management
• Hourly urine output via catheter: minimum 0.5mL/kg/h
• IV fluid management per anaesthetist prescription
• Pad count: 1 pad/h is normal; >1 pad/h of fresh blood → escalate
• Clot passage: small clots on first void normal; large clots abnormal
• Temperature monitoring: hypothermia post-GA common; warm blankets
• Nausea/vomiting: anti-emetics (ondansetron, metoclopramide) PRN

Urinary Catheter Management

• TAH: remove at 24–48h post-op (stable patient)
• LH/VH: remove at 12–24h
• Radical hysterectomy: catheter 7–14 days (bladder neuropraxia)
• After removal: voiding trial — void spontaneously within 4–6h
• If unable to void → straight catheter (PVR) or reinsert catheter

Return of Bowel Function

• Bowel sounds: auscultate 4-hourly; absent in first 24h is normal
• Flatus passage expected: day 1–2 (laparoscopic), day 2–3 (open)
• Soft diet when tolerating fluids; progress as tolerated
• Avoid constipation: lactulose or movicol prescribed preventively
• Persistent absent bowel sounds beyond 48–72h → ileus; escalate

Wound Care

• Pfannenstiel wound: dressing inspect daily; Steri-strips or subcuticular sutures common
• Signs of infection: redness, discharge, dehiscence → swab + escalate
• Laparoscopic port sites: small dressings; check for herniation, haematoma
• Abdominal binder (especially obese patients) for support and comfort

ERAS Pathway Milestones

• Oral fluids: 2–4h post-op
• Mobilise: 4–6h post-op (with support)
• Regular oral analgesia: paracetamol ± NSAID ± opioid step-down
• Remove catheter early per approach
• Encourage independent activity within 24h

Vaginal Vault Haemorrhage

Assessment

• Vaginal pad count: >1 soaked pad/hour is excessive
• Vital signs: tachycardia/hypotension = haemodynamic compromise
• Speculum examination if concerned (medical staff)
• FBC and clotting: urgent if suspected significant haemorrhage
• Haematoma: vault haematoma may present as pelvic pain, urinary retention, or sepsis days later

Management

• IV access × 2 large bore; IV fluids resuscitation
• Call for senior; group and cross-match
• Vaginal packing: may be applied as temporising measure
• Return to theatre for examination under anaesthesia (EUA) and haemostasis
• Interventional radiology: uterine/pelvic artery embolisation (UAU) if appropriate

Intra-Abdominal Haematoma

• Subfascial haematoma: common in Pfannenstiel wounds — can present as mass, pain, anaemia
• Pelvic haematoma: fever, pelvic pain, urinary symptoms
• Management: conservative if small/stable; drainage if infected or expanding

Signs & Early Escalation

Bladder Injury

Recognition

• Haematuria (blood in catheter bag) — persistent pink/red urine post-op
• Urine-like drainage from pelvic drain (clear/pale yellow)
• High drain/wound output creatinine compared to serum = urinary fistula
• Vesico-vaginal fistula (VVF): painless constant watery vaginal discharge post-operatively

Methylene Blue Test

• Instil 200–300mL methylene blue (diluted) into bladder via catheter
• Blue staining in drain or vaginal vault confirms bladder injury/fistula
• Positive test → senior/surgical review for repair

Management

• Intra-operative recognition: immediate primary repair by surgeon
• Post-op: catheter drainage × 10–14 days; cystogram before removal
• VVF: conservative (catheter) if small; surgical repair usually after 3 months

Ureteric Injury

Signs

• Unilateral loin/flank pain (ipsilateral to injury)
• Decreased urine output (bilateral injury → anuria)
• Fever and flank tenderness (urinoma → sepsis)
• Raised serum creatinine

Investigations

• CT urogram or IVU (intravenous urogram): identifies obstruction/leak
• Ultrasound: hydronephrosis
• Ureteric reimplantation or stenting by urology

Management

• Ureteric stent (JJ stent): percutaneous nephrostomy if severe obstruction
• Surgical repair (ureteroureterostomy, reimplantation) depending on injury level
• Monitor renal function closely

Ileus vs Mechanical Obstruction

Bowel Injury

• Rare but serious — higher risk with severe adhesions, endometriosis, repeat surgery
• Signs: peritonism, fever, rising CRP/WCC post-op day 3–5
• Faeculent drain output or wound discharge = emergency
• Bowel prep more important when bowel injury risk identified pre-op

Conservative Management of Ileus

• Nil by mouth; nasogastric tube (free drainage)
• IV fluid and electrolyte replacement (correct K+)
• Regular mouth care; IV anti-emetics
• Ambulation encouraged (promotes peristalsis)
• Avoid opiates where possible (reduce motility); NSAIDs preferred
• Escalate if no resolution within 48–72h or signs of perforation

DVT Recognition

• Calf pain, tenderness, swelling, warmth
• Homan's sign (unreliable — not recommended for diagnosis)
• Duplex USS: investigation of choice
• D-dimer: useful if low pre-test probability only

PE Recognition

• Sudden dyspnoea, pleuritic chest pain, haemoptysis
• Tachycardia, tachypnoea, hypoxia
• CTPA: gold standard; V/Q scan if contrast contraindicated
• Massive PE: cardiovascular collapse, cyanosis — call cardiac arrest team

Prophylaxis Protocol

All Gynaecological Surgery

• IPC stockings: applied in anaesthetic room, worn until mobile
• Anti-embolism stockings: worn until discharge or fully mobile
• LMWH: enoxaparin 40mg SC daily (standard dose)
• Start: 12h pre-op or 6–12h post-op (after haemostasis confirmed)

Cancer Surgery — Extended Prophylaxis

• LMWH self-injection training: abdominal technique, disposal of sharps
• Provide 28-day supply and written instructions
• Dose adjustment for renal impairment and extremes of weight

Wound Infection

• Risk factors: obesity, diabetes, immunosuppression, repeat surgery, prolonged operative time
• Signs: erythema, warmth, purulent discharge, wound dehiscence, fever
• Swab and send for C&S
• Antibiotics: co-amoxiclav (first line); MRSA cover if high risk
• Dehiscence: secondary intention healing with wound dressings
• VAC therapy if large wound breakdown

Vault Granulation

• Occurs weeks–months post-hysterectomy
• Presents: post-coital or spontaneous vaginal bleeding/discharge
• Speculum reveals: friable, irregular tissue at vault
• Treatment: silver nitrate application (outpatient) by gynaecology team
• Nurse role: explain procedure to patient; apply topical anaesthetic gel PRN; post-procedure: mild discharge/spotting expected for 1–2 days
• Recurrent granulation → surgical excision

Lymphocyst

• After radical hysterectomy with pelvic node dissection
• Collection of lymph fluid in pelvic retroperitoneum
• Usually asymptomatic; may cause pelvic pressure, DVT, ureteric obstruction
• Diagnosis: pelvic USS or CT
• Small: conservative management, observation
• Symptomatic: percutaneous drainage (interventional radiology)
• Infected lymphocyst: fever, leucocytosis → urgent drainage + antibiotics

Trendelenburg Position

• Facilitates bowel shift out of pelvis for surgical access
• Risks: raised ICP, airway oedema, shoulder brace pressure injuries, brachial plexus injury (if sliding prevented with shoulder supports incorrectly placed)
• Return to flat position periodically if operation prolonged
• Eyes protected with tape/pads (corneal abrasion risk)

CO2 Pneumoperitoneum

• Carbon dioxide insufflated to create working space: pressure 12–15mmHg
• Physiological effects: increased PaCO2, raised peak airway pressures, vagal stimulation (bradycardia), decreased venous return
• Shoulder tip pain: Referred diaphragmatic irritation from residual CO2; normal after laparoscopy; resolves 24–48h post-op; reassure patient; mild analgesia, positioning (semi-recumbent), gentle mobilisation helps dispersion
• Gas embolism (rare): sudden cardiovascular collapse; left lateral decubitus position + aspiration

Port Site Care

• Typical ports: umbilical (camera, 10–12mm) + 2–3 lateral (5mm)
• Umbilical port: deeper, higher risk of haematoma or hernia
• Port site hernia: uncommon; presents as bulge ± bowel sounds at port site
• Dressings: small adhesive dressings; keep dry 24–48h
• Sutures: absorbable (no removal needed) or Steri-strips
• Pain at port sites: sharp, localised; differentiate from shoulder tip pain

Conversion to Open Procedure

• Rate: 1–3% conversion to laparotomy
• Reasons: haemorrhage, dense adhesions, organ injury, poor visualisation, equipment failure
• Ensure consent documents possibility of laparotomy
• Family counselling: ensure family aware pre-operatively; nurse communicates update when conversion occurs
• Patient counselling: longer incision, longer recovery, longer hospital stay — explain rationale (safety)

Outpatient vs Inpatient Hysteroscopy

Vasovagal Reaction (Outpatient)

• Common: bradycardia, dizziness, pallor during cervical instrumentation
• Lay flat, raise legs, oxygen, IV access if unwell
• Atropine 0.5–1mg IV if bradycardia persists
• Usually self-limiting; pre-warn patient

Distension Media — Fluid Deficit Monitoring

• Deficit = fluid in − fluid out; monitor continuously during procedure
• Deficit thresholds: glycine — stop at 1000–1500mL deficit; saline (bipolar) — stop at 2500–3000mL
• Signs of absorption: nausea, confusion, bradycardia, hypertension
• Management: stop procedure, furosemide, correct sodium, ITU if severe
• Document fluid balance meticulously; communicate deficit to surgeon in real-time

Post-Hysteroscopy Instructions

• Light bleeding and cramping 24–48h normal
• Avoid tampons, intercourse, swimming for 1 week
• Return if: heavy bleeding, offensive discharge, fever, severe pain

Procedure Types

• NovaSure: Bipolar radiofrequency energy — 90 seconds
• Thermachoice: Balloon thermal ablation
• Microwave endometrial ablation (MEA)
• First generation: TCRE (transcervical resection of endometrium) under hysteroscopic vision

Expected Post-Procedure Effects

• Watery/bloody vaginal discharge: up to 3–4 weeks
• Cramping: first 24–48h; NSAIDs effective
• Spotting at next expected period then reduced/absent menses
• Up to 30–40% achieve amenorrhoea

Discharge Instructions

• No tampons for 4 weeks (risk of infection)
• No intercourse for 2 weeks
• No swimming for 2 weeks
• Light activities resume 24–48h; return to work 2–7 days
• Avoid heavy lifting for 1 week
• Continue effective contraception: ablation is NOT sterilisation; pregnancy after ablation is high risk (abnormal implantation, ectopic risk)

Red Flags Post-Ablation

• Fever >38°C → endometritis; antibiotics
• Heavy fresh bleeding → haemorrhage
• Severe abdominal pain → uterine perforation (rare)
• Haematometra: cyclical pelvic pain, no menstruation — blood trapped behind scarred cervix

POP-Q Staging System

Types of Prolapse

• Cystocele: Anterior vaginal wall — bladder herniation; urinary symptoms (frequency, urgency, incomplete emptying)
• Rectocele: Posterior wall — rectum herniation; difficulty defaecating, need to digitate
• Uterine prolapse: Uterus descends; feeling of bearing down, lump
• Vault prolapse: After hysterectomy — vaginal vault descends
• Enterocele: Peritoneal sac + small bowel; posterior upper vaginal wall

Non-Surgical Management

Pelvic Floor Physiotherapy

• Kegel exercises: Contract pelvic floor muscles for 5–10 seconds × 10 repetitions × 3 sets daily; minimum 12 weeks for measurable benefit
• Biofeedback-assisted physiotherapy if exercises are difficult to perform correctly
• Weight loss, constipation management, cough treatment (COPD)

Vaginal Pessaries

Pessary Teaching for Patients

• Insertion and removal technique (if self-managing)
• Cleaning: warm water + mild soap, rinse, dry before reinsertion
• Local oestrogen cream: reduces atrophy, improves mucosa tolerance
• Signs to report: vaginal bleeding, offensive discharge, inability to remove, pain, pressure ulcer symptoms

TVT / TOT — Stress Incontinence

Procedure Overview

• TVT (Tension-free Vaginal Tape): Retropubic route; tape at mid-urethra; risk bladder perforation (cystoscopy performed intra-op to confirm)
• TOT (Transobturator Tape): Through obturator foramen; lower bladder injury risk; may cause more groin pain
• Day case or overnight; local/spinal/GA

Post-Op Voiding Trial

• Catheter removed in recovery (or ward 4–6h post-op)
• Patient encouraged to void; measure voided volume
• Bladder scan for PVR immediately after voiding
• PVR >100mL or unable to void → reinsert catheter (2–3 day TWOC)
• PVR >300mL persistently → de Gramont catheter or intermittent self-catheterisation (ISC) teaching

Sacral Colpopexy — Vault Prolapse

• Mesh attached from vaginal vault to sacral promontory (laparoscopic or open)
• Mesh awareness: Patient must be counselled that mesh is permanent; mesh erosion possible (vaginal discharge, pain, partner discomfort)
• Post-op care: as per laparoscopic surgery + urinary catheter 24h

Activity Restrictions Post-Pelvic Floor Repair

• 6 weeks restriction:
  • No sexual intercourse for 6 weeks
  • No heavy lifting (>5kg) for 6 weeks
  • No strenuous exercise (running, aerobics, HIIT) for 6 weeks
• Ongoing:
  • Continue pelvic floor exercises permanently
  • Avoid constipation (high fibre, fluids, laxatives PRN)
  • Weight management
  • Avoid high-impact activities long-term (running, trampolining)
• Light walking: from day 1 post-discharge
• Driving: when able to do emergency stop — usually 2–4 weeks
• Return to work: sedentary 2–3 weeks; manual 6–8 weeks

Female Surgical Team Preference

• Female surgical and nursing teams are strongly preferred by many GCC patients — this is both a cultural and religious norm
• Document patient preference at pre-assessment; flag for theatre allocation
• Where female surgeon unavailable: explain necessity; obtain verbal consent; minimise exposure; maintain draping
• Male nurses should not perform intimate examinations/catheterisation of female patients unless absolutely no female staff available — document all instances
• Islamic principle of darurah (necessity) permits cross-gender care when no alternative exists

Privacy Measures in Theatre

• Maintain draping at all times; expose only operative field
• Minimise staff in theatre; exclude unnecessary observers
• Patient remains covered during patient transfer and positioning
• Discuss findings and examination with patient in private (not corridors)

Communication & Consent

• Interpreter service: use professional medical interpreter, not family member, for consent and sensitive discussions
• Written materials in Arabic available where possible
• Mahram (male guardian): some patients will want husband/guardian present for consent discussions; balance with patient autonomy — patient's consent is legally primary
• Psychosocial impact of hysterectomy/infertility: may be profound in cultures where fertility is central to identity; involve social work, chaplaincy as needed

Consanguinity & Gynaecological Conditions

• High rates of consanguineous marriage (first-cousin) in GCC countries
• Higher prevalence of rare autosomal recessive conditions: congenital adrenal hyperplasia, androgen insensitivity, Müllerian anomalies
• Increased rates of congenital genitourinary abnormalities requiring surgical intervention
• Genetic counselling should be offered pre-operatively for complex congenital cases

Fibroids — African Migrant Population

• Uterine fibroids (leiomyomata) are 3× more prevalent in women of African descent compared to White/Asian populations
• Large migrant African worker populations in GCC (particularly UAE, Qatar, Saudi Arabia) mean fibroid disease is a significant gynaecological workload
• Earlier onset, multiple fibroids, larger size, higher recurrence post-myomectomy in African women
• Cultural: heavy menstrual bleeding (HMB) may be normalised; encourage early presentation
• Screen for iron deficiency anaemia (very common in this group); transfuse if required before elective surgery

Endometriosis — Diagnosis Delay

• Average diagnostic delay worldwide is 7–10 years; likely longer in GCC
• Dysmenorrhoea (painful periods) is widely normalised in GCC culture; "it is normal for women to suffer"
• Healthcare-seeking behaviour around menstrual issues is lower; social shame around gynaecological complaints
• Nurse's role: normalise help-seeking; educate that severe dysmenorrhoea is not normal; facilitate early referral
• Screen patients presenting for other gynaecological surgery for endometriosis symptoms

Cervical Screening — Coverage Gaps

• Cervical cancer screening uptake is low in GCC — cultural barriers (embarrassment, fear, husband's permission perceived as needed)
• Opportunistic screening during any gynaecological visit should be offered
• HPV vaccination programmes: expanding in GCC but coverage variable
• Nurse education: explain purpose of smear test in culturally sensitive manner; same-gender provider preferred
• Link with community health outreach programmes

Hymenoplasty Requests

• Requests driven by cultural/social pressure related to pre-marital virginity expectations
• Legal status varies by GCC country: some countries have specific prohibitions; others have no explicit law
• Nurse's role: non-judgmental care; do not perform or facilitate outside scope of practice; escalate to senior medical staff or ethics committee as required
• Support patient autonomy; address psychological safety
• Document all interactions carefully

FGM in Gynaecological Care

• WHO Types I–IV: Clitoridectomy, excision, infibulation (Type III — most severe), other procedures
• Complications: dysmenorrhoea, dyspareunia, recurrent UTIs, obstructed labour, psychological trauma
• Defibulation: Surgical opening of infibulation scar — performed by specialist gynaecologist; nurse supports with emotional care and post-operative pain management
• Referral pathways: Specialist FGM clinics (available in major GCC hospitals); social work referral for women at risk/with daughters at risk
• Non-judgemental approach; approach with sensitivity and cultural humility
• Mandatory reporting requirements vary by GCC country — know your local policy

Ramadan & Elective Gynaecological Surgery

• Scheduling: Patients may prefer to defer elective surgery outside Ramadan; respect this preference where clinically safe
• Urgent/cancer surgery proceeds regardless — Islamic scholars confirm necessity overrides fasting obligation
• Pre-operative fasting: Ramadan fasting already satisfies NBM requirements for morning operations; coordinate surgery timing accordingly
• Post-operative analgesia:
  • IV analgesia does not break fast (Hanafi/majority scholarly opinion — medicine for treatment)
  • Oral medications break the fast — IV or suppository routes preferred during daylight post-op hours where possible
  • Discuss with patient regarding their personal religious practice
• IV fluids: Do not break fast — administer freely as clinically required
• Post-operative discharge: consider evening discharge so patient can break fast (iftar) at home
• Spiritual care: ensure prayer facilities accessible during recovery; allow prayer times as patient condition permits; Quran/prayer items available