GENERAL INTRODUCTION OF THE BOOK FOR THE PART ONE FELLOWSHIP EXAMINATION OF THE FACULTY OF OBSTETRICS AND GYNAECOLOGY

OF THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA. This book which is written as a partial fulfillment of the requirement for the part ONE Fellowship examination is divided into two parts; the first part contains fifteen case reports and one long commentary in Obstetrics, while the second part contains fifteen case reports and one long commentary in Gynaecology. All the cases were seen and managed by the writer, Dr. Onwe, Abraham Bong under the supervision of the five units consultants in the Department of Obstetrics and Gynaecology, Ebonyi State University Teaching Hospital (EBSUTH), Abakaliki. The Obstetrics and Gynaecology Department of the Ebonyi State University Teaching Hospital consists of four consultant units (A to E) which are subspecialized. These are; Gynaecological Oncology(A), Urogynaecology(B), Fetomaternal(C), Infertility and Endocrinology(D), Sexual & Reproductive Health/ Family Planning(E), units respectively, each unit is managed by Consultants. REFERENCES All the references for each case reported were made to current scientific publications in journals, textbooks, and they were listed according to the Vancouver system of reference listing.
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REFERENCE RANGES FOR CHEMICAL PATHOLOGY Alkaline Phosphatase Aspartate transaminase Alanine aminotransferase Acid phosphatase Albumin Alfa-Fetoprotein Bicarbonate Bilirubin(Total) Bilirubin(Conjugated) Calcium(Total) Calcium(ionized) Chloride Cholesterol (Total) 30-150 iu/L 5-35 iu/L 5-35 iu/L 0.5-6.0mmol/L 35-50g/L <10ku/L 24-30mmol/L 3-17mmol/L < 8 mmol/ L 2.12-2.65mmol/L 1.0-1.25mmol/L 95-105mmol/L 3.9-6mmol/L

VLDL HDL LDL Cortisol (AM) Cortisol (Midnight) Creatinine Kinase (Male) Creatinine Kinase (Female) Creatinine Ferritin Folate Follicle Stimulating Hormone (Luteal) Follicle Stimulating Hormone (Menopausal) Glucose (Fasting) Glycosylated Heamoglobin Concentration(HbA1c) Glucose-6-phosphate Dehydrogenase Iron (male) Iron (female)

0.12-0.65mmol/L 0.9-1.93mmol/L 1.55-4.4mmol/L 450-700nmol/L 80-280nmol/L 25-195iu/L 25-170iu/L 70-<150mol/L 12-200mol/L 2.1mol/L 2-20u/L >25u/L 3.5-5.5mmol/L 2.3-6.5% 5.5-15.5iu/L 14-31mol/L 11-30 mol/L

Lactate Dehydrogenase Leutinizing Hormone (Luteal) Magnessium Oestrodiol (early follicular) Oestrodiol (mid cycle) Oestrodiol (luteal) Oestrodiol (postmenopausal) Oestrodiol (male) Osmolality Prolactin (female) Prolactin (Male) Protein (Total) Potassium Progesterone (follicular) Progesterone (midluteal) Progesterone (Premenopausal) Progesterone (male)

70-250mol/L 2-20 iu/L 0.75-1.05mmol/L 110-180pmol/L 550-1650pmol/L 370-770pmol/L <150pmol/L <200pmol/L 278-305mosmo/L <600u/L <450u/L 60-80g/L 3.5-5mmol/L <3.0nmol/L >15nmol/L <2.0nmol/L <2.0nmol/L

Phosphate Testosterone (female) Testosterone (male) Sodium Thyroid Binding Globulin (TBG) Triglyceride Thyroid Stimulating Hormone (TSH) Thyroxine(T4) Thyroxine(Free) Total Iron Binding Capacity(TIBC) Tri-iodothyronine(T3) Thyroxine (free) Index T3 Resin Uptake Urate (female) Urate (male) Urea Vitamine B12

0.8-1.4mmol/L 0.4-2.8nmol/L 10-30nmol/L 135-145mmol/L 7-17mg/L 0.55-1.90mmol/L 0.5-5.7mu/L 70-140nmol/L 9-22pmol/L 54-75mol/L 1.2-3.0nmol/L 1.8-5.5 25-37% 150-390mol/L 210-480mol/L 0.13-0.68nmol/L >150ng/L

REFERENCE RANGES FOR HEAMATOLOGY White Blood Cell Count-Total -Neutrophils -Lymphocytes -Eosinophils -Basophils -Monocytes Heamoglobin (male) (Female) Platelets Count Reticulocyte Count Packed Red Cells Volume (PCV)-male -female Mean Cell Volume (MCV) Mean Cell heamoglobin (MCH) Mean Cell Heamoglobin Concentration (MCHC) Prothrombin Time Activated Partial Thrombo-plastin Time (APTT) 5.0-10.0 X 109/L 40-75% 20-45% 1-6% 0-1% 2-10% 13.5-18g/dl 11.5-16g/dl 150-400 X 109/L 0.8-2.0% 40-54% 37-47% 76-96fL 27-32pg 30-36g/dl 10-14s 35-45

INTRODUCTION
A GENERAL GUIDE TO PATIENT CARE AND PROCEDURES All cases presented in this book were managed in the Department of Obstetrics and Gynaecology of the Ebonyi State University Teaching Hospital, Abakaliki. This hospital serves as a major referral centre for Ebonyi State and its environs. Patients are usually referred from General Hospitals, government owned health centres, private medical centres and from other departments in the hospital. OBSTETRIC CARE AND PROCEDURES The department has 50 obstetric beds and undertakes about 1,500 deliveries annually. Pregnant women are referred for antenatal care and delivery by doctors within and outside the hospital. Emergency admission of unbooked cases is made through the Accident and Emergency department. ANTENATAL BOOKING The hospital operates a free antenatal care policy supported by the State government. Patients, who had their antenatal care with our facility, are regarded as our booked patients. While patients who had their antenatal care elsewhere and were referred because of complications in pregnancy, labour or puerperium without prior booking are regarded as unbooked. A detailed history is obtained noting previous obstetric, gynaecological, menstrual, surgical, family and social features of importance. Thereafter, a complete physical examination including a pelvic

examination is conducted if indicated. In some cases pelvic examination may be deferred to the second visit. Investigations performed on all patients include: haemoglobin

concentration/haematocrit estimations, haemoglobin genotype, blood group and antibody titre, Veneral Disease Research Laboratory (V. D.R.L) test, HIV screening and mid-stream specimen of urine for urinalysis. ANTENATAL CARE Pregnant women are seen routinely at four-weekly intervals up to the 28th week of pregnancy, two weekly until the 36th week and weekly thereafter until delivery. Patients are seen more frequently if they have special problems. They are admitted into the antenatal ward if there are indications. Health talks are given to the women in the clinic on maintenance of good health, expectations during labour and delivery, the care of the infant and the puerperium. Ultrasonography and radiological examinations of the abdomen are carried out when indicated. MEDICATION Routine medication is given to all pregnant women in form of: a) Antimalarial drugs Women with clinical malaria are treated with Artemesinin based combination therapy. The intermittent prophylactic treatment with combined sulphadoxine 500mg and pyrimethamine 25mg is given to all pregnant women after quickening or 16 weeks of gestation. This is given as two doses at four weeks
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interval for non retroviral clients and three doses for retroviral women before 36 weeks of gestation. b) Haematinics Ferrous sulphate 200mg and folic acid 5mg are taken daily. These are also continued through the puerperium. c) Tetanus toxoid is administered to the unimmunized pregnant woman at first contact. This is repeated four weeks later. A third dose is given six months after the second while the fourth and fifth doses are given at yearly intervals or in the subsequent pregnancies. d) Other drugs are given when indicated, for example antibiotics for urinary tract infections. e) Booked patients are advised not to take any drugs except those prescribed by a doctor. IDENTIFICATION/ ADMISSION Each patient carries a card bearing her name, address, hospital number, blood group, haemoglobin genotype, expected date of delivery and coded risk assessment. The card also contains the name of the consultant in charge of the patients care. They are instructed to report in the labour ward when they have uterine contractions, drainage of liquor amnii or vaginal bleeding. They are admitted during the antenatal period as the indication arises. Unbooked patients who present with similar features are also admitted. MANAGEMENT IN LABOUR

Pregnant women are admitted into the labour ward either directly from the antenatal clinic, antenatal ward, and casualty department or from home. On admission into the labour ward, a history is taken, antenatal records are reviewed for booked patients and a full physical examination is performed by the admitting resident doctor. Intravenous infusion is given where indicated. Monitoring of labour is commenced with regular observations of the maternal pulse rate, blood pressure, uterine contractions and fetal heart rate. The progress of labour is graphically illustrated on a partograph. The partograph includes the recording of every observation made on the patient as well as such information as cervical dilatation, descent of the presenting part, the state of the membranes, the degree of caput and moulding and the fetal heart rate. The duration, frequency and strength of uterine contractions and the amount of Oxytocin, if used are also recorded. Any drug administered to the patient during labour is charted along with serial observations of the maternal pulse, blood pressure and urine analysis. In this way progress in labour for any particular parturient is easily discernible at a glance. INDUCTION AND AUGMENTATION OF LABOUR Induction of labour is carried out for specific indications such as pronged pregnancy, pre-eclampsia and diabetes mellitus. Patients for induction of labour are usually admitted in the antenatal ward for at last 12 hours during which haemoglobin concentration is estimated and blood is cross matched. A cervical assessment is done to determine the inducibility of the cervix and the need for cervical ripening.

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The induction involves artificial rupture of the fetal membranes with amniotomy or Kochers forceps and synchronous Oxytocin stimulation in escalating doses. The dose of Oxytocin used for induction of labour is 5 i.u., in a 500ml of 5% Dextrose in water solution. The infusion is started at 10 drops per minute (5m.i.u. per minute) using the British Standard Blood Giving Set. The dose is then titrated against the uterine contractions by increasing the rate by 10 drops every 30 minutes for patients who are para 0 to 4 and every 45 minutes for grandmultiparous patients. Titration is continued until uterine contractions are established at a frequency of 3 in 10 minutes each lasting 30 seconds or more, or the maximum rate of 60 drops per minute (30m.i.u. per minute) is reached. The Oxytocin dose is reduced whenever 6 or more contractions in 10 minutes or contractions lasting 60 seconds or more occur. If contractions are inadequate with 5 units of Oxytocin, the dose may be increased to 7.5 units and similarly used. A unit-modified partograph with the alert line drawn parallel from zero cervical dilatation and the action line drawn 2 hours to the right and parallel to the alert line is used to monitor the progress of induced labour. Oxytocin is used to augment labour when uterine contractions are felt to be inadequate. If at the time of decision to augment labour cervical dilatation is less than 5cm, the augmentation is begun as detailed for para 0 to 4 induction regime. When cervical dilatation is 5cm or more irrespective of the parity, augmentation is as detailed out for grandmultiparae (incremental interval of 45 minutes). In all patients receiving Oxytocin infusion in labour, the Oxytocin drip is maintained for at least one hour after delivery to prevent postpartum haemorrhage from uterine atony.

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VAGINAL EXAMINATION IN LABOUR After the admitting vaginal examination, another is performed 4 hours later and thereafter 2 hourly in the first stage and more frequently in the second stage or when indicated. For this examination, the patient assumes the dorsal position with the legs drawn up. The lithotomy position is sometimes employed especially when other manipulations are anticipated. The vulva and vagina are cleaned with Cetrimide or Chlorhexidine in aqueous solution before the procedure. ANALGESIA AND ANAESTHESIA Analgesia during the first stage of labour is achieved with intramuscular Pentazocine hydrochloride (Sesogon) 30mg and Promethazine hydrochloride (Phenergan) injections. Intramuscular Tramadol hydrochloride (100mg) is used towards the end of first stage to minimize neonatal respiratory depression. Occasionally, inhalational Entonox (Nitrous oxide: Oxygen, 50:50) is used during the first and second stages of labour and for short obstetric procedures. Other forms of analgesia used in labour are: LUMBAR EPIDURAL: This is especially useful as operative procedures (vaginal and abdominal) and can be done without any further anaesthesia. When used, it is usually applied and maintained by the anaesthetist. PUDENDAL NERVE BLOCK: This is used for some operative vaginal deliveries such as forceps deliveries and vacuum extractions. The patient is placed in the lithotomy position and the vulva and vagina are cleaned and draped. The

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transvaginal approach involves using a specially guided needle, advanced through the vaginal wall until it lies just below and beyond the sacrospinous ligament. 8 20ml of 1% Xylocaine is then injected into each side after ensuring that the needle is not in a blood vessel. The transperineal approach may be necessary if the fetal head is well advanced and a vaginal approach considered dangerous. The needle is inserted half way between the fourchette and the ischial tuberosity and advanced to the sacrospinous ligament, which is palpated intravaginally with the other hand. PERINEAL INFILTRATION: This is done with 1% Xylocaine and is used for the repair of episiotomies. It may occasionally be adequate for easy lift-out forceps or vacuum delivery at the outlet. GENERAL ANAESTHESIA General anaesthesia is employed for abdominal delivery when epidural catheter is not in place and for more difficult vaginal manipulations like internal podalic version, breech extraction and manual removal of retained placenta. A premedication is usually given in the form of intramuscular Atropine sulphate 0.4 0.6mg. Induction is performed with a sleeping dose of 200-300mg intravenous Pentothal (Sodium thiopentone) and muscle paralysis is achieved with

Suxamethonium. Endotracheal intubation is then performed and anaesthesia is maintained with Nitrous oxide and Oxygen. D-tubocurarine is given as a long acting skeletal muscle relaxant. At the end of the procedure Neostigmine is given to reverse the action of the muscle relaxant. Extubation is carried out only when the

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patients reflexes are active and after careful aspiration of any secretions in the naso- and oropharynx. VAGINAL DELIVERY This is usually conducted with the patient in supine position and the knees drawn up. She is not encouraged to push until the onset of the second stage is confirmed by the finding of a full cervical dilatation on vaginal examination. Inhalational analgesia is sometimes provided with an Entonox mixture. A careful vaginal examination is done to assess the presenting part and position of the fetus. The delivery of the head and body is controlled by the accoucheur. OPERATIVE VAGINAL DELIVERIES The lithotomy position is used. The accoucheur is scrubbed, gowned and gloved. The vulva and vagina are cleaned and draped as described earlier. Anaesthesia is usually provided in the form of bilateral pudendal nerve block or epidural block. Local perineal infiltration with 1% Xylocaine may also be used. EPISIOTOMY This is applied for specific indications such as in the primigravida with rigid perineum, during operative vaginal deliveries and when the perineum threatens to tear. A right medio-lateral episiotomy is usually favoured. The repair is usually carried out in three layers: Interrupted or continuous suture of No 0 chromic catgut for the vaginal mucosa.

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 One or two layers of interrupted or continuous sutures of No 1 chromic catgut for the perineal muscles, and Subcuticular sutures of No 0 chromic catgut for the perinial skin. THIRD STAGE This is actively managed. Intravenous Ergometrine 0.5mg is given with the delivery of the anterior shoulder, the placenta is then delivered by controlled cord traction without awaiting the signs of placental separation. A retained placenta which cannot be removed in this manner is removed manually under general anaesthesia in the theatre. Patients with elevated blood pressure or cardiac conditions are given intravenous Oxytocin 10 i.u. bolus in place of the Ergometrine. Patients with high risk of primary postpartum haemorrhage receive critical care. This entails commencement of Oxytocin infusion with 20 40 units in 500ml of 5% dextrose in water, synchronously with the intravenous Oxytocin injection. The infusion is maintained for at least one hour at a minimum dose of 8 to 16 drops per minute (16 to 64 miu.). CAESAREAN SECTION The patient is transferred to the labour ward operating theatre. Thirty (30) ml of Magnesium Trisilicate is given orally and a nasogastric tube is passed if she had eaten within the previous six hours of the operation. Alternatively, intravenous Cimetidine 200mg or Ranitidine 150mg is given when available. The bladder is emptied by catheterization in the theatre and this is usually left in-situ during the operation.

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The patient is positioned on the operating table in the supine position with a 15 degree left lateral tilt to prevent supine aorto-caval occlusion. The abdominal skin is prepared with a solution of Centrimide (Savlon) or Chlorhexidine (Hibitane) in 75% alcohol. The operation area is isolated with sterile towel secured with clips. A midline incision of about 12.5cm between the umbilicus and pubic symphysis is sometimes employed. The incision is deepened through the skin and subcutaneous fat to incise the linea alba. The cut edges of this fascia are then separated from the underlying rectus muscle. The rectus muscle is separated with forceps to expose the peritoneum which is picked up with two artery forceps on both sides of the midline and incised to open into the peritoneal cavity. THE PFANNENSTIEL INCISION This is usually used for cosmetic purposes and also because it affords direct access to the pelvis and causes minimal disturbance to the bowel. The incidence of postoperative incisional hernia is less with this incision compared to the vertical incision. The incision is made transversely on the skin crease above symphysis pubis and deepened until the rectus sheath is encountered. This too, is cut transversely and lifted off the underlying muscles, which are then separated vertically. The peritoneum is also incised vertically. OPENING THE UTERUS A 10 x 22cm gauze is used to pack either sides of the uterus to displace the

intestines. Inspection of the round ligaments help to identify any rotation of the uterus and the need for appropriate correction. A Doyens retractor is used to gently retract the bladder downwards. The loose uterovesical peritoneum covering the
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lower uterine segment is then lifted up with dissecting forceps and divided with scissors well out to both sides. The lower flap of peritoneum is then lifted up with forceps and stripped off and downwards with the bladder and kept in place with a Doyens retractor. Stay sutures are sometimes used as in cases of prolonged obstructed labour. A small transverse incision is made in the uterine muscle of the lower segment and deepened until the fetal membranes are reached. The incision is then widened laterally on each side with curved scissors or using both index fingers. DELIVERY OF THE BABY A hand is introduced into the uterus, below the level of the presenting part and used to extract the head after removing Doyens retractor (to prevent trauma). Occasionally, the obstetric forceps (Wrigleys) is used to extract the head. The head is dislodged from the pelvis and delivered with the assistant giving fundal pressure. The face is cleaned and the mouth and airways are sucked. By hooking the right index finger under the right axilla, the right shoulder and arm are delivered. The same procedure is repeated on the left side. Ergometrine 0.5mg is given intravenously by the anaesthetist and the rest of the baby is delivered. The umbilical cord is clamped in two places and divided in between the clamps. The baby is handed over to the paediatrician. The placenta and membranes are delivered by controlled cord traction or by manual removal and the uterine cavity is cleaned with sterile gauze. Green-Armytage spring clamps are used to control bleeding points on the uterine incision. Starting at the

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angles, the incision is repaired in two layers using No 1 chromic catgut mounted on a half circle round bodied needle (for example Mayos needle No 85 mm). The first layer is haemostatic while the second layer is to cover the first. Continuous sutures are used for both layers. In addition, haemostasis is maintained by ligating bleeding points with figure of eight stitches of No 0 chromic catgut. The two edges of the visceral peritoneum are then approximated using No 0 chromic catgut continuous stitches. CLOSING THE ABDOMEN A final inspection is made to ensure adequate haemostasis. The gauze packs are removed and free blood and blood clots are evacuated. The uterus, the tubes and the ovaries are inspected. The edges of the parietal peritoneum are drawn up with several pairs of artery forceps and brought together with a continuous suture of No 0 chromic catgut mounted on a round-bodied needle. The anterior rectus sheath is sutured with continuous No 1 chromic catgut on a half-circle trocar point needle. The superficial fat and fascia are then approximated with a continuous suture No 2-0 plain catgut. The skin edges are usually approximated with continuous subcuticular suture of nylon or dexon (polyglycolic acid) or sometimes with interrupted mattress silk or nylon sutures or with clips. A dry dressing is placed on the wound and blood clots are expelled from the vagina.

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CARE OF THE INFANT At delivery of the head, the mouth and nostrils are cleaned and sucked. The eyes are swabbed with sterile cotton wool. Further resuscitative measures like intubation and intermittent positive pressure ventilation are carried out when necessary. The Apgar scores at 1 and 5 minutes after delivery are noted and recorded. These give a prognostic index and influence further management. SPECIAL CARE BABY UNIT The Special Care Baby Unit is managed by experienced neonatologists and caters for newborn babies with special problems and also for those babies who need urgent care and resuscitation. Each baby is thoroughly examined to exclude any congenital defect or birth injury and the appropriate management instituted. Bacille Calmette Guerrin (B.C.G) vaccination is given. THE PUERPERIUM Babies are put to breast immediately after delivery and exclusive breast-feeding is encouraged. Delivered mothers are allowed out of bed as soon as possible after delivery. Those who have undergone abdominal delivery become ambulant usually on the second post-operative day. Resumption of oral intake usually commences after 24 36 hours when peristalsis is well established. Perineal wounds are kept clean by twice daily sitz baths and non-absorbable perineal sutures are removed on the fifth day. Care of the breasts, infant feeding and routine health care of the mother and child are supervised in the lying-in ward by trained midwives. Puerperal pyrexia is vigorously investigated and treated. Where non absorbable sutures are used on the abdomen, they are removed on the seventh
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post-operative day for vertical skin incisions and on the fifth day for Pfannenstiel incisions closed with subcuticular stitches. Before discharge, the haematocrit is estimated and a full physical examination conducted with particular emphasis on the breasts, abdomen, vagina and the perineum. Most patients are fit to go home on the second or third day except after caesarean section when they spend between five to eight days on the ward. POSTNATAL CLINIC All delivered mothers are seen with their babies at this clinic approximately six weeks after delivery. The baby is weighed and examined. The mother is examined; a vaginal speculum examination is done to inspect the cervix. Cervical smears are taken when indicated. The events of pregnancy and labour are reviewed and outstanding problems are attended to. Prospects for future pregnancy are discussed and advice about contraception and infant care are given. GYNAECOLOGICAL CARE AND PROCEDURES The Gynaecological unit has 24 beds. Admissions are made through the Gynaecological Clinic or the Accident and Emergency department. GYNAECOLOGICAL CLINIC Patients seen are referred by doctors in and outside the hospital, mainly from Abakaliki and its environs. After a detailed gynaecological history and a full physical examination, a clinical impression of the patients illness is made. Relevant investigations are requested for, to further elucidate the diagnosis. The nature of the
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illness and plan of management are discussed with the patient, occasionally with the consort or parents where necessary. An admission register is kept. Emergency gynaecological patients are admitted directly from the Accident and Emergency department. Post-operative patients are also reviewed in the gynaecological clinic FAMILY PLANNING CLINIC This clinic is supervised by doctors in the department and specially trained nursing staff who offer family planning advice to women in and outside the hospital at minimal cost. The different methods of contraception are discussed with the client and the patient allowed to make an informed choice. THE ADOLESCENT AND ADVISORY CENTRE The centre is involved in providing the unmet family planning needs of adolescents and young adults. Family Life Education (F. L. E.) and counseling on sexually transmitted diseases are done at the centre. Contraceptive services in form of condoms, vaginal foaming tablets and oral contraceptives pills are provided when necessary. Career counseling and recreational facilities are also provided. The centre is located outside the department to ensure that the target population has free access without fear of molestation or embarrassment. All adolescents and young adult patients managed for problems preventable by contraception such as unwanted pregnancy and illegal abortion are referred to the centre for counseling and follow-up.

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GENERAL PRE-OPERATIVE CARE The minimum haematocrit accepted for most operations is 30%. Anaemic patients are investigated and occasionally blood may be transfused pre-operatively. Crossmatching of compatible blood is done before major procedures, elective or emergency. The haemoglobin genotype is determined before major operations requiring general anaesthesia. The urine is tested routinely and special investigations are done where indicated. Infections, hypertension, diabetes mellitus and other disorders are treated or controlled before the operation. The proposed operation is discussed with the patient or/and relative and a written consent is obtained. Adequate rest is ensured, sometimes by overnight sedation before the morning of the operation. VAGINAL OPERATIONS The patient is prepared in the ward. She is given a bath after the vulva and montes veneris have been shaved. The vaginal douches are given when necessary. In the theatre, the patient is placed in the lithotomy position and adjustable leg rests are attachd to the operating table being used. The vagina and surrounding skin of the vulva, mons veneris and inner thighs are cleansed with Savlon (Centrimide) solution or Hibitane (chlorhexidine) solution. Sterile drapes secured with clips are then applied exposing only the field of operation. The light source is correctly focused on the operation field. The bladder is emptied by urethral catheterization. When packs are inserted after the operation and indwelling foley catheter is usually left in-situ.

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ABDOMINAL OPERATION Pre-operative preparation for abdominal operations involve shaving the hair on the anterior abdominal wall and perineum after the patient has had a bath. In the operating theatre, the patient is placed in the supine position. The bladder is emptied by urethral catheterization. The skin of the anterior abdominal wall is cleansed with an aqueous solution of Savlon (Centrimide) 1:2000 or Hibitane (Chlorhexidine) 1:2000 solution and then Hibitane in 70% alcohol solution or iodine solution. Sterile drapes are then applied and secured with clips, exposing only the field of operation, OPENING AND CLOSING THE ABDOMEN This is essentially the same procedure previously described for caesarean section. The vertical midline incision is occasionally extended upwards around the umbilicus if the nature of the operation demands it, for example, a big pelvic tumour. ANAESTHESIA PARACERVICAL BLOCK This is used for procedures such as dilatation and curettage. Infiltration of the paracervical tissues on both sides is carried out with a 5-10ml, 1% Xylocaine (Lignocaine) solution at 5 and 7 Oclock positions. Premedication is sometimes given with intravenous Pentazocine hydrochloride 30mg and Promethazine hydrochloride 25mg. EPIDURAL BLOCK This is used occasionally for major pelvic operations. Hypotension is closely anticipated and prevented in the patient.

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GENERAL ANAESTHESIA This is usually used for major procedures. The choice of drug depends on the Anaesthetist. The technique is essentially as stated for obstetric anaesthesia, except that Halothane is used in addition to Nitrous oxide and Oxygen. POST-OPERATIVE CARE The immediate post-operative observation and management of the patient is carried out in the recovery room, attached to the operating theatre before the patient is transferred back to the ward. Analgesia after major procedures is provided by intramuscular injection of Pentazocine hydrochloride 30mg in 4 to 6 hourly doses, for the first 24 48 hours. Intravenous fluids are given until the bowel sounds are adjudged adequate to commence graded oral fluids. Prophylactic antibiotics and post-operative blood transfusions are instituted when required. Vaginal packs are usually removed after 12 24 hours. Early ambulation is encouraged and chest and leg exercise commenced to discourage respiratory complications and deep vein thromboses. The post-operative packed cell volume is usually checked on the third day. All nonabsorbable skin sutures are removed either on the fifth or seventh post-operative day as described for caesarean section. The suture lines are inspected before the patient is discharged. Follow-up of post-operative patients is carried out at the gynaecological clinic for as long as it is necessary for the individual cases.

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