Standardized Obstetric Procedure: Endometriosis
- The objective of this standardized procedure is to provide a systematic approach to managing endometriosis among obstetrics patients. It is to be used when obstetric nurses take care of patient needs even in the absence of a physician.
II Development and Review
- The department’s interdisciplinary committee (IDC) collaborated in the development of this standardized procedure to ensure it touches on aspects of endometriosis diagnosis and management across all the interlinked disciplines.
- The procedure will be approved, signed and stamped following its acceptance by the IDC, and then it will be made available for reference within the obstetrics department at the target facility.
- The statement of approval, once signed, indicates that all the procedures in the document are approved and accepted for application in the department, and that there is an intention to support collaboration among all the department’s members, promoting adherence to standard procedures. The signed statement of approval will be provided as a reference material for the future, particularly for obstetrics nurses and obstetric physicians who are in a position that requires them to handle patients with endometriosis.
III Scope and Setting
A The functions outlined in the standardized procedure will be the responsibility of the obstetric nurses who will also support functions that go beyond the scope of their mandate. Coordination will be promoted at all times through the communication tools that form part of the general organizational procedures.
B The obstetric nurses have the mandate to follow the standardized procedures in their practice both within the organization’s in-patient pediatric department and to cater for patients presenting at the department’s outpatient section where necessary.
IV Education and Training/Qualifications
A The qualifications required of obstetric nurses for both the outpatient and inpatient sections are as follows:
1 At least a diploma in nursing
2 A registered nurse practicing certificate.
3 An associate degree and certification in obstetrics – the National Certification Corporation (NCC) offers courses on inpatient nursing certification for obstetrics nurses.
4 Should have a combined nursing experience of at least 2,000 hrs and obstetrics experience of at least 24 months.
5 Should work closely with physicians at the facility to help in the delivery of pregnant women.
B There will be a general requirement for obstetric nurses to prove their competency outside the described academic qualifications and the general registration requirements. To achieve this, all obstetric nurses at the institution will be expected to prove their capability through consistent delivery of effectiveness during actual service. Additionally, the physicians with whom the nurses work will be required to provide periodic performance reviews to foster performance monitoring at all times. All the performance appraisals will be conducted in a particular format.
V Supervision and Evaluation
An obstetric nurse works in collaboration with physicians in the obstetrics department and is responsible for ensuring patient safety and effective treatment outcomes. The nurse is expected to be individually driven towards adhering to these procedures both in the presence of and in the absence of a supervising physician.
It is expected that obstetric patients, nurses and physicians will adhere to the standard consultation procedures for the department.
VII Patient Records
The institutions keeps electronic patient records that are updated periodically based on patient progress and treatment outcomes. The obstetric nurses are expected to document patient reports during daily follow-ups, and will also be considered responsible for maintaining the electronic medical reports of the patients.
Endometriosis Presentation at the Obstetrics Department
The objective of this protocol is to enable nurses to identify the signs and symptoms of endometriosis in patients presenting at the obstetrics department, and to be able to use the right diagnostic processes (both symptomatic and scientific), to come up with the best diagnosis that can enable initiation of treatment.
Endometriosis is a condition in which the endometrial tissue, which is similar to the tissue that lines the uterus, is formed outside the uterus. The tissue may form along the uterus, the ovaries, e.t.c. The tissue exhibits behavior similar to that of conventional endometrial tissue in that it thickens, breaks down and bleeds. Since there is no exit from the body as a result of its positioning, the tissue can result in the formation of scar tissue and can cause extreme pain during menstrual periods and sexual activity.
A Endometriosis is often associated with a wide range of reproductive factors, the most prevalent of which is hormonal variation.
B Reproductive factors such as low age, short menstrual cycle period, parity, and on-going use of oral contraceptives are associated with lower risk of endometriosis.
C There is an inverse relationship between the body mass index (BMI) and endometriosis.
A Causes: The actual causes of endometriosis have not been determined. However, it is speculated that some of the possible causes may include retrograde menstruation (a situation in which menstrual blood flows back through the fallopian tube instead of outside the body); embryonic cell transformation; surgical scar implantation; immune system disorder; peritoneal cell transformation; and endometrial cell transport among others.
B Symptoms: Symptoms of endometriosis include pelvic pain, premenstrual bleeding and bleeding between periods. Other symptoms include back pain, pain associated with micturition, and dyspareunia. Infertility and pain during sexual intercourse may also appear as symptoms of endometriosis.
V Physical Exam
A Physical examination of patients for endometriosis involves symptomatic confirmation. Additionally, laparoscopy may be used for the physical examination of patients although it is an invasive procedure. It is one of the more accurate methods to diagnosing endometriosis since non-invasive procedures such as symptomatic perceptions are non-specific.
VI Diagnostic tests
A The most common diagnostic procedure, which also involves physical examination is laparoscopy and subsequent histologic confirmation of the existence of features such as hemosiderin-laden macrophages and stroma. Differential diagnosis may alos be conducted to confirm symptoms such as pelvic pain, diminished lubrication or vaginal expansion due to insufficient arousal, and benign or malignant neoplasms.
VII Management – Based on presentation and suspicion, it is clinically reasonable to conduct empiric diagnosis and treatment of endometriosis. Patients with symptoms persisting after empiric treatment are often referred for laparoscopy as the most definite confirmation of endometriosis. During on-going treatment, the measurement of CA 125 levels is effective towards indicating the progress of treatment. The medical treatment of endometriosis begins with the administration of analgesics or acetaminophen; followed by oral contraceptive pills. Other medications include progesterone and androgenic agents.
The management of endometriosis can take place in stages. The first stage is the observatory suspicion based on symptoms and patient history. Patients from families in which there is a history of endometriosis are considered possibly affected. The next step involves confirmation of whether the patient is also interested in maintaining their fertility or not. In case the patient is interested in maintaining their fertility, they are subjected to laparoscopy and subsequently surgical excision of the problematic tissues. On the other hand, patients with no interest in fertility are subjected to progestogens or oral contraceptive pills with or without analgesics.
The patient is monitored via CA 125 level measurement. If improved, the patient is advised to progress with medication until completely healed.
If no improvement
- If there is no indication of improvement, the patient is first subjected to gonadotropin-releasing hormone analogues either with or without add-back therapy.
- If there is still no improvement, the patient is advised to go for laparoscopy.
- Surgical treatment follows laparoscopy.
- Lack of improvement following surgical treatment is addressed by hysterectomy and oophorectomy.
Endometriosis and Observed Escalation
- Ensure the patient is presented at an obstetrics department for observation prior to any medication.
- The primary physician at the department collects information about the patient history and the symptoms, and confirms whether the patient is concerned with retaining their fertility.
- If the patient is interested in maintaining their fertility, they are subjected to laparoscopy and subsequently surgical excision of the problematic tissues.
- Patients who are not interested in retaining their fertility are subjected to oral contraceptive pills and/or progestogens with or without analgesics.
- If there is no improvement after the first treatment, the patient is subjected to gonadotropin-releasing hormone analogues with or without add-back therapy.
- Further lack of improvement is addressed through laparoscopy followed by surgical treatment.
- Failure of the surgical treatment is handled by referring hysterectory or oophorectomy.
- The practitioners then follow up on the ongoing recovery to ensure effectiveness.
IX Creation and Approval of the Developed Standardized Procedure
The interdisciplinary team collaborated to develop this standardized procedure for use in handling endometriosis patients. This standardized procedure will be reviewed and updated biennially due to the probability of technological and pharmacological changes.
Revision Date_____________ Review Date______________
X The interdisciplinary committee members named below has approved this standardized procedure for use:
Obstetrics Department Chair
Director of Nursing Practice
XI All practitioners in the obstetrics department are authorized to follow this standardized procedure when working with patients with endometriosis. This may include practitioners such as obstetrics nurses, physicians and any other healthcare practitioners in the department.
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