General Care PrinciplesChapter 1

Collect and arrange all supplies needed.

Ensure availability of instruments and their functionality.

Take informed consent.

Explain procedures/surgeries and need for it.

Give required pain medications.

Position patient as per requirement, place in lithotomy position for all obstetrical procedures.

Maintain privacy of patient by covering all exposed areas.

Always have a female attendant even if you are a female Obstetricians/Gynecologist.

Wash hands thoroughly with soap/mild detergents and water.

Put on gloves as per requirement or procedures.

Prepare part with antiseptic solution.

Drape surgical area with clean and sterile towels (usage of skin drape is optional and costly).

Reassess instruments trolley and apprise ORA's.

Inform anesthetist or attendant caring for women before beginning any procedure/operative approach.

Fix light with back up batteries at operative/procedure area.

Music in operation theater is conducive.

Dip hands in antiseptic solution.

Use plain or antimicrobial soaps, solutions non-allergic to skin types.

Vigorously rub together all surface of hands up to elbow to raise large amount of lather at least for 30 sec each time before rinsing with running (preferred) or poured water.

Wash hand for 1 minute for minor procedure and at least for 3 minutes before operative work.

Wash hands for 30 sec/60 sec after exposure to blood or body fluids (secretion /excretions), even if gloves are worn.

Wash hands after removing gloves for 15–30 sec (rubber gloves may have minor holes in them).

Remove all jewellary.

Hold hands above level of elbow, wet under running water thoroughly.

Apply soap-iodophore antimicrobial (betadine/ chlorohexidine) soap.

Begin at fingertip, lather using a circular motion of both hands.

Soap between all fingers.

Move from finger tips to above elbow (at least 3–5 cm) of one hand and there after repeat for second hand.

Soap and wash at least for 3 to 5 minutes.

Rinse each arm separately; finger tips first, holding hands above the elbow. Allow water to run down as drip in sink itself only.7

Dry hands with a clean or disposal towel use each surface for each hand.

Air drying is preferred method, if available.

Do not touch scrubbed hands with object/surface which are not sterile.

It the hands touch a contaminated surface repeat the surgical hands scrub as given above.

Prepare with antiseptic solution (e.g. betadine, etc.)

Antiseptic solution application at least for three times.

Begin at operation site and move out and away from incision area.

Discard swab at edge/corner of sterile area.

Never go back to sterile area with same swab.

Keep hands, gloves. Gowns away and above from operation site.

Place drape with window, directly over and above incision site first.

Unfold drape away from site to avoid contamination.

Essential for avoiding self inflicted injury.

Patients less likely to move.

Give emotional support and encouragement.

Music, light and quiet atmosphare appropriate to region is soothing for patients.8

Usage of liberal and appropriate anesthesia is conducive for correct and rapid procedures.

A must, regularly at short intervals (5 mts/15 mts) throughout the procedure.

Monitor vitals, level of consciousness, blood loss.

Record all findings on a chart.

Maintain adequate hydration to have adequate urine output.9

Flowing urine output is adequate indication of hemodynamic stability.

Hook up the multiparameter patient monitor.

Prophylactic antibiotics—injection cifran 200 mg IV stat or injection cefatoxime 1 g IV stat, before starting procedure at OT.

Give prophylactic antibiotics for women undergoing CS, immediately after baby is delivered.

Given incision appropriate for procedure:

Make incision only as large as necessary for required procedure.

Make incision layer-by-layer, avoid injuries to abdominal organs.

Use of cautry reduces blood loss.

Use of retractors, appropriately placed, give good exposure to operative field.

Freshen up edges before resuturing.

Gentle handing of tissue gives good healing.

Use clamp with closure of one ratchet (Click) only, whenever possible.

Use clamps to catch small tissue (fat, vessels) so as to avoid trauma, thus preventing risk of infection.

Cleaning area with betadine before resuturing removes debris and as well small clots (Good practice).

Ensure hemostasis throughout the procedure.

Keep blood loss to minimum (women in India with obstetrical complications generally have anemia).

Always count instrument, sharps and sponges before and after the procedure.

Document count at closure of body cavity.

Use “safe zones” when handling and passing instruments and sharps.

Use a pan, kidney basin to carry and pass sharp item, e.g. knives.

Use a needle holder to pass suture needles.

Alternatively, pass the instruments with the handle, rather than sharp end, pointing towards the receiver.12

Leave abdominal drain if:

Closed abdominal drainage is preferred today against corrugated three channel rubber drain.

Drain removal is guided by, if no pus, blood stained fluid has drained for 48 hours or the amount is less than 30 ml in 24 hours.

Use appropriate sizes and types of sutures for the tissue.

Sutures are identified and recalled by a number of “0”s (zeros).

Smaller sutures have greater number of “0” such as 000 (3-0).

000 (3-0) is a smaller suture than 00 (2-0).14

Suture labeled as “1” is larger in diameter than “0” suture.

A suture which is small in diameter breaks easily as it is weak and larger diameter suture cuts through soft tissue (pregnant uterus, intestines).

Use only recommended size and type of suture for a procedure.

Generally three knots are used for commonly used sutured of catgut, silk, as more knots abrade sutures and weaken them.

Nylon, proline and other polyglycolic sutures are used with 4 or 6 knots to avoid their loosing or slippage.

After surgery, surgical wound are covered with sterile dressing.

Use breathing dressing materials.

“Tagaderm” a self applicable medicated dressing though costly is useful for covering surgical operative sites.

Dressing are kept for 1–3 days for facilitation of “re-epithelialization” and to protect from infection.

If bleeding or leakage of fluids occur:

If loosens do not remove but reapply with more adhesive tape rather replacement.

Change any dressing using sterile technique only.

Also known as standard precautions.

Designed to block the spread of infection and disease.

Apply to bodily fluid, non-intact skin and mucous membranes of all persons.

They should be followed by all heath workers with all patients all the times regardless of patient's diagnosis and/or presumed infective status.

Standard precautions include:

Place patient in appropriate recovery position.

Constant supervision for next 4–5 hours or until fully conscious.

Check vitals every 15 minutes for first hour and then every 30 minutes for next 2–3 hours and the 1–2 hourly for next 24 hours.

Level of consciousness to be checked every 30 minutes /60 minutes till patient fully alert.

Ensure a clear airway and adequate ventilation.

No fluids per oral till all gag reflexes are recovered.

Transfuse blood, if surgery or situation warrants.

If vitals become unstable or hematocrit falls despite transfusion, return to OT as patient may be bleeding.

Usage for 48 hours after procedures in a non-infective patient is sufficient to cover perioperative infections.

Antibiotics once started should be continued at least until the women is fever free for 48 hours.

Prophylactic antibiotics for minor procedures are sufficient.

Therapeutic antibiotics are needed in a seriously infected patients of septic abortions, prolonged labor with multiple P/V examinations or prolonged rupture of membranes, prolonged surgical procedures lasting more than 2–3 hours or if blood loss more then one liter.19

Two doses of prophylactic antibiotics for cases of LSCS, manual removal of placenta, uterine inversion, are sufficient etc.

Usage of combination of antibiotics form gold standard in obstetrics and gynecology practice (gram +ve, gram -ve and for anaerobes).

If clinical response is poor after 48 hours—reassess, drainage of pus, look for deep vein thrombosis. Consider resistant organism to above group of antibiotics.

Culture and sensitivity of body fluids, pus, urine, and blood should be used in patients with poor responders.

Stop antibiotics, if patient is fever free for 48 hours.20

No requirement of oral antibiotics as has no additional benefits.

Women with bloodstream infections, antibiotics are required for seven to ten days, at least.

If infection is not severe, amoxicillin 500 mg by mouth can be given instead of Ampicillin. In addition, Metronidazole also can be given orally instead of IV infusion.

Catheter used perioperatively.

Generally not required after first 24 hours.

Early catheter removal decreases infection risk and encourages early ambulation.

If urine output is adequate and urine is clear, remove after first postoperative night.

If urine is not clear, keep in place until urine is clear (but not more than 7 days).

Keep catheter in situ in following conditions:

If bladder injury occurs, per se or due to operative injury:

Skin sutures removed after 5–7 days after surgery.

Early suture removal in cases, where drainage of collected fluid or pus is required.

Subcuticular proline can be removed after 72 hours.

Newer sutures such as absorable polyglycan (PDS or Monocryl) need not be removed, if edges buried within the wound.

Early.

Enhances circulation.

Stimulates early return of gastrointestinal function.

Encourage deep breathing exercises—at least 10 deep breathing exercises every hour.

Encourage foot, limb, exercises as soon as possible; definitely within 24 hours.

Returns soon for obstetrical patients.

12 hours after major abdominal surgeries.

Start with liquids after 12–24 hours.

For infective cases, complicated prolonged surgeries wait till bowel sounds have returned.

When patient passes gas, begin semi soft, solid diet.

Continue IV fluids till patients accepting oral liquid fluids well.

Ensure patient eating regular normal diet prior to discharge from hospital.

Avoid sugary liquids, fruit juices or aerated drinks.