1. Tubal Ligation (Female Sterilization) Session IIIG: Postprocedure Tasks, Postoperative Care, and Follow-Up

2. Objectives By the end of the session, participants will be able to:
List postprocedure tasks to be performed immediately after closure of the abdominal incision
Describe the immediate postoperative care following minilaparotomy
State the signs indicating that a client is ready for discharge
Explain routine follow-up care by members of the surgical team
List the reasons why a client should return to the facility or contact the providers

3. Postprocedure Tasks
Assist the client off the operating table and escort her to the recovery area
Process all instruments
Discard syringe needles and suture needles into a puncture-resistant container.
Dispose of nonsharps infectious waste (gloves, used gauze, resected fallopian tubes, etc.)
Remove drapes and other linens for cleaning
Clean table tops
Ensure hand hygiene
Explain:
The postprocedure tasks are those tasks that are performed once the procedure has been completed and are meant to ensure that the operating area is ready for use by the next client, while at the same time ensuring that the current client is moved to a separate location for recovery.
These tasks are as follows:
Help the client to get off the operating table and escort her to the recovery area.
To process the instruments, clean all used instruments in preparation for processing and sterilization.
Discard syringe needles and suture needles into a puncture-resistant container.
Dispose of nonsharps infectious waste (gloves, used gauze, resected fallopian tubes, etc.) in accordance with standard infection prevention procedures.
Remove drapes and other linens for cleaning.
Clean all table tops.
Wash your hands thoroughly with soap and water, dry them with a clean cloth, and apply alcohol handrub.
Allow time for questions and points of clarification from participants, and respond to these accordingly.

4. Exercise: Postoperative Care
Define postoperative care.
What is included in postoperative care?
Who can provide this form of care, and where should it be provided?
Ask: “How would you define postoperative care?”
Allow some responses from the participants,and write their responses on a sheet of flipchart paper.
Conclude the discussion on the definition of postoperative care by stating: “Postoperative care includes the care of clients immediately after surgery and during recovery from surgery, before they are discharged.”
Ask: “What is included in postoperative care?” Allow a few responses, and write these on the flipchart as well. Immediately follow up responses by explaining that postoperative care entails:
Observing the client as she recovers immediately after the procedure
Providing postoperative instructions
Performing a follow-up examination
Detecting and managing any complications
Highlight that when immediate postoperative care is being provided, staff should inform the client about what the postoperative care activities will entail and the reasons for them.
Advance the slide and ask the participants the following questions:
“Who can or should provide immediate postoperative care?
“Where should postoperative care be provided?”
“"Who is ultimately responsible for client care?”
Allow a few responses from the participants, then explain the following:
Any trained, qualified health care professional can provide immediate postoperative care, including the surgeon.
Nevertheless, the surgeon is ultimately responsible for client care. Nurses or assistant nurses traditionally provide immediate postoperative care and discharge; however, it is essential for the surgeon to assess the client and supervise her management during this period, as the surgeon retains ultimate responsibility for quality of care.
Immediate postoperative care should be provided at the health facility where the client had the procedure, preferably in the recovery area or recovery room.
The personnel who are responsible for immediate postoperative care and discharge of the client perform a vital function, because it is during this period that the effects of surgical trauma and other postoperative complications may first be noticed.

5. Immediate Postoperative Care
Which tasks should be performed in the immediate postpartum period?
Monitoring vital signs
Observing for vaginal bleeding (in suprapubic minilaparotomy)
Checking dressing for bleeding
Giving client a warm sweetened drink
Completing client records
Show this slide
Ask: “What tasks should be performed in the immediate postoperative period?” After a few responses, click to reveal correct answers to the question.
Explain
Immediate postoperative client monitoring includes the following:
Checking vital signs as soon as the client arrives at the recovery area. If her heart and respiratory rates and blood pressure are within the normal range, continue to monitor the vital signs every 30 minutes until the client has fully recovered from the effects of moderate sedation or anesthesia.
Documenting your findings in the clinical record.
Continuously observing the client’s general condition (including changes in skin/mucus membrane color, levels of postoperative pain, level of consciousness, and orientation to time and space).
Following a suprapubic procedure, observing the client for vaginal bleeding other than menstruation. If there is continuous bleeding through the vagina, the surgeon should be called to determine if the uterine elevator or tenaculum caused an injury to the cervix.
Examining the surgical dressing for evidence of bleeding. If the surgical dressing is heavily soaked with blood and there is evidence of continued bleeding from the wound, the surgeon should be called to examine the wound, confirm where the blood is oozing from, and arrange to ligate any bleeder(s), if needed.
Providing the client with warm/hot liquids containing sugar, to raise blood glucose levels. (Care should be exercised when the client is a known diabetic.)
Handling the client gently when helping her move.
Keeping the client comfortable at room temperature.
Completing the required client record forms.
Circulate to the participants samples of client records and inform them that they should be familiar with the contents of such forms and what needs to be captured in the notes.
Add that during the immediate postoperative period (within the first hour after the procedure), the following symptoms and signs are within the range of normal:
Mild pain
Vaginal spotting
Drowsiness, despite being responsive
Nausea and vomiting (associated with certain drugs)
Initial faintness and dizziness
Initial inability to stand, walk, or urinate
Initial inability to take fluids

6. Warning Signs The surgeon should be alerted immediately if:
Systolic pressure falls below 90 mmHg
Diastolic pressure changes by 10mmHg
Perioral cyanosis
Respiratory rate is 10 breaths/min
Rapid pulse
Other additional reasons
Explain:
The surgeon should be alerted immediately under the following circumstances:
The client’s systolic blood pressure is less than 90 mm Hg or her systolic blood pressure changes by 20 or more mm Hg from baseline or preprocedure levels.
The client’s diastolic blood pressure changes by 10 or more mm Hg from baseline or preprocedure levels.
The client’s respiratory rate is less than 10 breaths per minute or has changed by five or more respirations per minute from baseline or preprocedure rates.
The client’s pulse is rapid (more than 90 beats per minute), has changed by 20 beats or more per minute from baseline, or is weak.
The client is pallid.
The client shows signs of perioral cyanosis.
The client is sleeping excessively and is only purposefully responding to painful stimulus.
The client is hyperventilating.
If the following findings persist 1–2 hours after the procedure:
Feeling of faintness when the client rises
Inability to urinate
Inability to take fluids (vomiting)
Inability to walk (unsteady when standing)
When notified, the surgeon should evaluate the client and manage the situation at the facility or make arrangements for a transfer to another facility, as appropriate.

7. Assessing Readiness for Discharge
Discharge the client if:
She does not have excessive pain.
She is able to dress herself.
She is able to walk upright with minimal support.
She is able to converse coherently.
There are no signs of pallor or cyanosis.
Her vital signs are stable or have returned to preoperative rates.
Ask: “What clinical indicators would you use to determine if a client who has had minilaparotomy is ready for discharge?” Allow a few responses from the participants, and write these on a sheet of flipchart paper.
Click to reveal the correct answers, and spend some time comparing the list of signs and symptoms mentioned by participants and what is on the slide, to confirm that the participants have mentioned all points and emphasize why these clinical indicators need to be assessed.
Remind the participants that they may also use the Romberg test to assess the client’s recovery:
The client is asked to stand with her feet close together and eyes closed. The normal response would be that the client does not sway or fall
Clients should not be discharged if they have the following:
Inability to take fluids and/or vomiting
Inability to walk without assistance
Incomplete recovery from sedation
Lack of a responsible adult available to accompany or transport the client home
Signs of hypovolemia, such as inability to urinate; dizziness; or increased pulse rate when going from lying to sitting or standing

8. Postoperative Client Instructions
How can you be sure that the client has understood the instructions that you have given her?
For the client who does not read, what can you do to help her remember the discharge instructions?
Ask:
How can you be sure that the client has understood the instructions that you have given her?
After a few responses, tell participants they are going to perform role plays of client-provider interactions when giving postoperative instructions.
Divide the group into three groups, each group consisting of three participants each. In each group there should be a provider, client, and observer. Give participants playing the role of the client and observer subgroups a copy of the client’s notes at discharge. The observer should then look for correct handling of the problem by the provider, using the postoperative discharge instruction checklist as a guide.
Display the role-play scenarios on a prepared flipchart:
A client who does not understand why she will need to return for a follow-up visit, since she feels fine and cannot see the stitches
A client who after an interval procedure notices light spotting on her vaginal pad
A client who laughs when you tell her that she must return to the facility or her nearest health center if she ever experiences symptoms of pregnancy
Assign each triad one of the role-play scenarios and give them five minutes to practice.
Call each group with a different role-play scenario to play their role in plenary. Allow five minutes for the role play.
At the end of each role play allow for feedback from the participants who played the roles of client and the provider, then from the observer. Finally from any other participant.
Conclude this session by summarizing the importance of giving postoperative instructions and ensuring that the client understands and follows them

9. Discharge Instruction Guidelines
The client should:
Know the warning symptoms and signs of complications to watch for
Understand that she should return to the facility immediately or seek emergency care if a problem develops
Know how to contact the clinic if she has any questions or concerns
Be aware of where to go for routine and emergency follow-up
In preparation for discharge, the provider must ensure that the client understands each instruction before discharge
The instructions include the following;
Know the warning symptoms and signs of complications to watch for
Understand that she should return to the facility immediately or seek emergency care if a problem develops
Know how to contact the clinic if she has any questions or concerns (including having telephone numbers)
Be aware of where to go for routine and emergency follow-up
As you explain each instruction point, allow time for questions and comments and clarify as needed.
Continue with the list on the next slide.

10. Discharge Instructions Guidelines (cont.)
Understand the postoperative instructions and be able to repeat them, including the date of the scheduled follow-up visit
Know how to care for the wound
Know how to take the prescribed medication
Be aware of how to obtain any medications that have been ordered
Understand when she can resume normal activities, including sexual activity
Know contraceptive effects of female sterilization
Understands there is a small risks of failure
Take a printed copy of instructions home
Explain
Understand the postoperative instructions and be able to repeat them, including the date of the scheduled follow-up visit
Know how to care for the wound
Know how to take the prescribed medication
Be aware of how to obtain any medications that have been ordered
Understand when she can resume normal activities, including sexual activity
Know that the contraceptive effects of this method begins from the time the operation is completed and that her monthly periods will continue until menopause
Understand that the procedure, although highly effective, is not a 100% certainty, and that if she ever misses a menstrual period, shows any other signs suggestive of pregnancy, or has abdominal or pelvic pain, she should contact the facility
Take printed or illustrated postoperative instructions with her.
Distribute Handout #15, which is a sample of the postoperative instructions, and review the content, highlighting what has just been discussed.

11. Postoperative Follow-Up Care
Routine Follow-Up
Scheduled
Should take place within 7 days
Purpose is to assess client’s well-being, remove stitches, and identify any complications
Emergency Follow-Up
Unscheduled
Requires immediate attention
Explain
There are two situation of follow up care, routine or scheduled visits, and emergency or unscheduled visits.
Ask for a volunteer to explain the differences between the two types of follow up care.
Possible responses include the following:
The routine follow-up visit is a scheduled visit and should take place within seven days of surgery. The purpose of the visit is to assess the client’s wellbeing, removal of stitches and identify any postoperative complications. A trained, qualified health professional (a nurse, midwife, clinical or surgical assistant, clinical officer, or community health worker) who is not a surgeon can conduct the routine follow-up examination and manage minor complications.
An emergency follow-up visit is unscheduled. It may take place any time after the operation and the client’s discharge. Clients coming for emergency follow-up require immediate attention. The staff interviewing clients who return to the facility 1–3 days after surgery with a complaint must be alert to the possibility of internal bleeding, bowel injury, bladder laceration, or infection.
Inform participants that they will now work in groups to review case studies.
Divide the large group into four subgroups, and explain that they will be presented with a case study to learn about the different follow-up situations.
Assign one case study to each subgroup in the Handout: Postoperative Care Case Studies.
Have each subgroup choose a writer and presenter.
Allow 10 minutes for the group discussion and reporting in plenary.
At plenary, allow each subgroup five minutes to present their results and for questions and discussion
Wrap up the session by moving to the next slide (slide 15) on routine follow up tasks

12. Routine Follow Up Tasks
Check medical records
Ask if client has experienced any problem (bleeding, fever, discharge)
Determine her level of satisfaction
Examine surgical site
Clean operative site, remove stitches
Treat identified complications
Remind client to return if she experiences signs of pregnancy
Update client’s medical records
Explain
Remind the participants about the tasks providers have to perform during aroutine follow-up visit:
Check the medical records or referral form to determine background information on the client and on the surgical procedure.
Determine if the client has experienced any problems or has had any complaints since the surgery. Ask specifically if she has experienced vaginal discharge or bleeding, wound discharge or bleeding, urinary difficulties, fever, pain, or other distress.
Assess the level of client satisfaction.
Examine the operation site to assess healing and absence of infection.
Clean the operation site and removing stitches, if necessary.
Treat any complications and make appropriate referrals and follow-up appointments, as needed.
Remind the client to return to the facility if she misses a period or has other signs of pregnancy.
Document the history, examination findings, treatment, and subsequent follow-up in the client’s medical records.
Note: A pelvic examination is not necessary at the follow-up assessment for minilaparotomy, unless it is indicated by the client’s medical history.