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Department of Reproductive Health and Research (RHR), World Health Organization

Managing Complications in Pregnancy and Childbirth

A guide for midwives and doctors 

 


Section 3 - Procedures


Salpingectomy for ectopic pregnancy

- ampicillin 2 g IV;

- OR cefazolin 1 g IV.

  • Open the abdomen:

- Make a midline vertical incision below the umbilicus to the pubic hair, through the skin and to the level of the fascia;

- Make a 2–3 cm vertical incision in the fascia;

- Hold the fascial edge with forceps and lengthen the incision up and down using scissors;

- Use fingers or scissors to separate the rectus muscles (abdominal wall muscles);

- Use fingers to make an opening in the peritoneum near the umbilicus. Use scissors to lengthen the incision up and down in order to see the entire uterus. Carefully, to prevent bladder injury, use scissors to separate layers and open the lower part of the peritoneum;

- Place a bladder retractor over the pubic bone and place self-retaining abdominal retractors.

  • Identify and bring to view the fallopian tube with the ectopic gestation and its ovary.

  • Apply traction forceps (e.g. Babcock) to increase exposure and clamp the mesosalpinx to stop haemorrhage.

  • Aspirate blood from the lower abdomen and remove blood clots.

  • Apply gauze moistened with warm saline to pack off the bowel and omentum from the operative field.

  • Divide the mesosalpinx using a series of clamps (Fig P-58 A–C). Apply each clamp close to the tubes to preserve ovarian vasculature.

  • Transfix and tie the divided mesosalpinx with 2-0 chromic catgut (or polyglycolic) suture before releasing the clamps.

  • Place a proximal suture around the tube at its isthmic end and excise the tube.

Figure P-58

 Clamping, dividing and cutting the mesosalpinx 

 

      

  • Close the abdomen:

- Ensure that there is no bleeding. Remove clots using a sponge;

- In all cases, check for injury to the bladder. If a bladder injury is identified, repair the injury;

- Close the fascia with continuous 0 chromic catgut (or polyglycolic) suture;

Note: There is no need to close the bladder peritoneum or the abdominal peritoneum.

- If there are signs of infection, pack the subcutaneous tissue with gauze and place loose 0 catgut (or polyglycolic) sutures. Close the skin with a delayed closure after the infection has cleared;

- If there are no signs of infection, close the skin with vertical mattress sutures of 3-0 nylon (or silk) and apply a sterile dressing.

SALPINGOSTOMY

Rarely, when there is little damage to the tube, the gestational sac can be removed and the tube conserved. This should be done only in cases where the conservation of fertility is very important to the woman since she is at risk for another ectopic pregnancy.

  • Open the abdomen and expose the appropriate ovary and fallopian tube.

  • Apply traction forceps (e.g. Babcock) on either side of the unruptured tubal pregnancy and lift to view.

  • Use a scalpel to make a linear incision through the serosa on the side opposite to the mesentery and along the axis of the tube, but do not cut the gestational sac. 

  • Use the scalpel handle to slide the gestational sac out of the tube.

  • Ligate bleeding points.

  • Return the ovary and fallopian tube to the pelvic cavity.

  • Close the abdomen.

POST-PROCEDURE CARE

- ampicillin 2 g IV every 6 hours; 

- PLUS gentamicin 5 mg/kg body weight IV every 24 hours; 

- PLUS metronidazole 500 mg IV every 8 hours.

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Clinical principles

Rapid initial assessment

Talking with women and their families

Emotional and psychological support

Emergencies

General care principles

Clinical use of blood, blood products and replacement fluids

Antibiotic therapy

Anaesthesia and analgesia

Operative care principles

Normal Labour and childbirth

Newborn care principles

Provider and community linkages

Symptoms

Shock

Vaginal bleeding in early pregnancy

Vaginal bleeding in later pregnancy and labour

Vaginal bleeding after childbirth

Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Unsatisfactory progress of Labour

Malpositions and malpresentations

Shoulder dystocia

Labour with an overdistended uterus

Labour with a scarred uterus

Fetal distress in Labour

Prolapsed cord

Fever during pregnancy and labour

Fever after childbirth

Abdominal pain in early pregnancy

Abdominal pain in later pregnancy and after childbirth

Difficulty in breathing

Loss of fetal movements

Prelabour rupture of membranes

Immediate newborn conditions or problems

Procedures

Paracervical block

Pudendal block

Local anaesthesia for caesaran section

Spinal (subarachnoid) anaesthesia

Ketamine

External version

Induction and augmentation of labour

Vacuum extraction

Forceps delivery

Caesarean section

Symphysontomy

Craniotomy and craniocentesis

Dilatation and curettage

Manual vacuum aspiration

Culdocentesis and colpotomy

Episiotomy

Manual removal of placenta

Repair of cervical tears

Repair of vaginal and perinetal tears

Correcting uterine inversion

Repair of ruptured uterus

Uterine and utero-ovarian artery ligation

Postpartum hysterectomy

Salpingectomy for ectopic pregnancuy

Appendix

 

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