Fetal nonstress test is a procedure whereby two monitors are applied to a pregnant woman’s abdomen. This is typically performed at about 22 weeks and beyond if pregnancy complications (such as preterm contractions, vaginal bleeding, abdomen pain, decreased fetal movement) occur. One monitor records the speed of the baby’s heart rate and the other monitor picks up contractions if they are present. This test is typically performed once or twice weekly in high risk pregnancies in the third trimester. Certain high risk pregnancies include those affected by diabetes, high blood pressure, poor fetal growth, and maternal age more than 35 years. A normal result indicates that the baby is healthy at that time. Abnormal results may require additional monitoring of the baby or an ultrasound test such as a Biophysical Profile.

Today, ultrasound technology is better than ever. The providers at Health Care for Women use state-of-the-art ultrasound technology to provide optimal care for our patients. Obstetrical ultrasound is performed early in pregnancy to determine if the pregnancy is progressing normally, the number of fetuses present (one or more, such as in the case of twins), as well as the anticipated due date for delivery. Second trimester obstetrical ultrasound can determine the gender of the fetus as well as evaluate for any potential birth problems. Third trimester ultrasound is often used to assess fetal well-being in high risk pregnancies or in low risk pregnancies complicated by decreased fetal movement or when the maternal abdomen measures smaller or larger than expected.

The fetal biophysical profile is an ultrasound test that assesses the health of the baby. It examines the amount of fluid around the baby (known as amniotic fluid) and whether the baby demonstrates breathing activity, body movements (such as upper body twisting), and bodily tone (such as a hand opening and closing or an arm or leg being extended then returned to its starting position). If the amniotic fluid level is normal and the baby displays breathing movements, body movements, and tone, it indicates a healthy baby. Abnormality of one or more of these items may indicate the baby’s health is at risk and additional monitoring as with a nonstress test may be needed. In some cases, if the tests are concerning then delivery of the baby may be needed.

LEEP (Loop Electrosurgical Excision Procedure) is a technique used to treat precancerous abnormalities of the cervix, known as cervical dysplasia, as well as some benign conditions such as vaginal or cervical polyps. Local anesthesia is injected into the area to be treated and a wire “Loop” device is employed to excise the abnormal tissue. The device excises and heats/cauterizes at the same time to control bleeding.

Cryosurgery involves applying extreme cold to treat precancerous cervical conditions of the cervix as well as benign ones such as genital warts. The cold temperature essentially creates frostbite to the affected tissue and the abnormal tissue sloughs.

Endometrial biopsy is a procedure where a thin plastic tube is inserted through the opening of the cervix into the uterus. The tube is rotated and moved in and out to remove a sample of the tissue lining the inside of the uterus. This is performed as one step in evaluating abnormal uterine bleeding, generally in women 40 years of age or older but in some cases, it is performed in women younger than this. Cramping during the procedure is expected and may linger for 1-3 days after the procedure. Light bleeding is common for a few days after the procedure. If uterine cancer is present, an office endometrial biopsy will detect it in about 80-90% of cases.

Colposcopy is a procedure that is typically performed to evaluate abnormal PAP smears. It can also be employed to evaluate vaginal or vulvar abnormalities. The colposcope acts as a telescope magnifying the tissue being examined to see if appears normal or abnormal. A weak acidic solution is applied to the area that is to be evaluated. This may cause a mild tingling sensation. This solution causes abnormal tissues to appear white in appearance. Abnormal tissues are usually biopsied. Local anesthetic may or may not be needed depending on the location of the biopsy. The procedure commonly takes less than 10 minutes and may cause mild discomfort. Results return in about 7 days and additional management is based on these results.

Cystometrics is a procedure performed in women with urinary incontinence. It determines how well the bladder empties, bladder capacity, and it gives information on why urine loss is present. In order to complete this procedure, a thin catheter (tube) is inserted into the bladder through the urethra and a second catheter is placed into the vagina. Sterile water is instilled into the bladder and the patient is asked to cough or tighten their abdominal muscles at certain times to assess for urine loss. Cystometrics can help determine whether urine loss is due to conditions such as bladder spasms or pelvic muscle weakness (often referred to as stress urinary incontinence). Test results aid in determining treatment options.

An intrauterine device (also known as an IUD) is a “T” shaped device that fits inside the uterus. It is inserted by your healthcare provider through the opening of the cervix. Ibuprofen or Tylenol is taken about 1 hour before insertion to minimize cramping during insertion. All IUDs can be used as forms of contraception. Progestin (hormonal) releasing IUDs may also be used to decrease menstrual flow. Progestin releasing IUDs followed by the number of years they are effective are as follows: Mirena (6 years), Liletta (6 years), Kyleena (5 years), and Skyla (3 years). These devices prevent pregnancy through a series of actions which include thickening the cervical mucus, thinning the lining of the uterus, and making it harder for sperm to reach the egg. The only nonhormonal IUD is the Paragard. It contains copper that acts to interfere sperm transport and egg fertilization. Paragard is effective for 10 years. The chances of becoming pregnant are less than 1% per year when an IUD is used for contraception. Because the IUD is a foreign object, it may cause pain and is associated with a small risk of uterine infection. IUDs have a less than 5% chance of falling out in the first year. Women are instructed to feel for the IUD strings monthly to ensure the device has not fallen out. If pregnancy occurs while the IUD is in place, the risk of ectopic (tubal) pregnancy is increased and immediate evaluation is needed.

Nexplanon is a long-acting, flexible reversible contraceptive implant that contains progestin only. It is 4 cm long and 2 mm in diameter. It is inserted in the office underneath the skin of the upper, inner arm using local anesthesia. Nexplanon works by preventing ovulation (the release of an egg from the ovary). It also acts to thicken the mucus in the cervix, thin the lining of the uterus, and may prevent sperm from reaching the egg (if it is released). It is effective for 3 years and the chances of becoming pregnant are less than 1% per year when it is used for contraception. Side effects may include menstrual irregularity, no menses, weight gain, moodiness, and arm soreness.

Cervical cerclage placement is a procedure carried out in an operating room setting. It is performed in select pregnant women who are at risk for preterm delivery, and it is usually performed in the early 2nd trimester. It involves placing a permanent suture into the cervix in a purse string fashion to keep the cervix from dilating early, thereby decreasing the risk of preterm birth. The suture is removed within 3-4 weeks of a woman’s due date in most cases to allow for vaginal delivery. In women who have a cerclage who are scheduled for a Cesarean section, it may be removed at the time of the Cesarean delivery. In certain cases, cerclage may be placed laparoscopically or through a low abdominal incision. In these cases, Cesarean section is needed to deliver the baby.

Cesarean section is needed to safely deliver a baby in about 20% of pregnant women. This is performed in an operating room. Anesthesia is necessary and usually is either via regional (epidural or spinal) techniques. In emergencies, general anesthesia (being put asleep) may be required.  With regional anesthetics, the pregnant mother is made numb from the upper abdomen to her toes. Before making the abdominal incision to deliver her baby, the skin is tested to make sure pain is not present. Typically a low abdominal (bikini) incision is made and the baby is delivered followed by the placenta. The incised tissues and lastly the skin are closed with absorbable sutures to complete the surgery. A bandage is placed on the incision when surgery is over. The typical hospital stay is 1-2 days.

Hysteroscopy is a surgical procedure performed in the operating room, in most cases, to visually inspect the inside of the uterus and cervix. It is recommended in cases of abnormal uterine bleeding where a mass is identified within the uterus or if bleeding continues despite medical treatment. It may be recommended if office endometrial biopsy cannot be completed. A slender telescope is inserted through the opening of the cervix and sterile fluid is instilled into the uterus, distending it, so complete visualization of the inside of the uterus and cervix can be completed. If an abnormality such as a polyp or fibroid is present, it can be removed. A dilatation and curettage (D&C) is often performed at the same time to remove additional intrauterine tissue. Patients are sent home within a few hours after surgery. Mild cramping and light bleeding for a few days are commonly experienced after the procedure.

Dilatation and curettage, more commonly known as a “D&C”, is a surgical procedure performed in an operating room. It is completed by passing small metal “dilators” of gradually increasing size through the opening of the cervix to enlarge it enough to then pass a metal “curette” which is a device used to gently scrape the inside of the uterus to obtain a tissue sample. This procedure is performed in some cases of miscarriage but also in cases of abnormal uterine bleeding. A D&C is often carried out at the same time as a hysteroscopy. Patients are sent home within a few hours after surgery. Mild cramping and light bleeding for a few days are commonly experienced after the procedure.

Laparoscopic surgeries are completed in the operating room and are one of the most common of all surgical procedures. A general anesthetic, one where the patient is put to sleep with a breathing tube, is required. Two or more small abdominal incisions are made in the abdomen and a telescope is inserted through one of the incision sites to view abdominal organs such as the uterus, fallopian tubes, and ovaries. A gas known as carbon dioxide is instilled into the abdomen to elevate the inner abdominal wall away from internal organs to allow for adequate viewing of these structures. The image from the telescope is projected onto a monitor that the surgeon uses to guide surgery. Grasping devices and other surgical instruments can be inserted through incision sites to allow for safe completion of surgery.

In gynecologic surgeries, laparoscopy is used for tubal sterilization, treatment of ectopic pregnancies, ovarian cyst removal, evaluating and treating pelvic pain caused by endometriosis, and to assist in performing hysterectomies in select cases. Laparoscopy is also commonly used for removal of the gallbladder and appendix by general surgeons. Once the surgery is completed, the carbon dioxide gas is drained from the abdomen and the incisions are closed with absorbable sutures. Postoperative pain is mostly for a few days to a week but soreness at incision sites can last up to a few weeks.

Tubal sterilization is performed in women who have completed their families and desire a permanent method of contraception and should be considered irreversible. This surgery is completed in an operating room on an outpatient basis. In most cases, it is completed laparoscopically through several small abdominal incisions. Typical methods to complete this surgery include heating and sealing shut the middle of the fallopian tubes, placing a surgical clip in the middle of the fallopian tubes, or removing the fallopian tubes. It is true that clip and heating procedures may be reversible, but undoing the surgery does not guarantee that the tube will function normally to transport the egg. Fallopian tube removal is absolutely irreversible. If pregnancy occurs after sterilization, there is an increased risk of ectopic pregnancy (pregnancy not located within the uterus and usually within the fallopian tube) and immediate medical evaluation is recommended.

Removal of ovarian cysts or ovary(ies) is conducted in an operating room. These procedures are performed in situations where the cyst causes acute or chronic pain or if the cyst has suspicious features such as those that might be present in cancer. Ovarian cysts are common and most often occur in premenopausal women and are caused by ovulation. They usually resolve without causing symptoms. Problematic cysts, those that cause pain or are are detected as a mass on pelvic examination, are usually further evaluated by pelvic ultrasound and in some cases CAT scans or MRI studies. Treatment depends on the radiologic features of the cyst and if it is causing symptoms. Cysts are classified as simple or complex. Simple cysts are uniform in appearance and contain clear fluid. The fluid appears black on ultrasound. Complex cysts or ovarian masses may have an irregular internal appearance, have solid components, or may be fully solid.

If a cyst or ovary needs to be removed, it is generally performed laparoscopically through several small abdominal incisions.

Urinary incontinence is a common condition experienced by women. There are a number of causes for this and evaluation is needed before surgery is considered. In women who experience stress urinary incontinence, the loss of urine with activities such as coughing, laughing, or running, surgery may be recommended to improve symptoms. Surgery is carried out in an operating room. Usually a surgical product known as a sling is placed underneath the mid aspect of the urethra to support it and prevent urine loss. The sling is a permanent, flexible material. Placing the sling requires that an incision be made in the portion of the vagina under the urethra. In addition, small incisions are placed just above the pubic bone or just outside the vulvar tissues to allow for sling placement. Once the sling is in place, all incisions are closed thereby covering the sling so none of it is visible. Over time, the sling grows into the tissues that surround it.

Cervical cone biopsy is a procedure undertaken in an operating room. It is performed to treat precancerous and possible early cancerous cervical conditions. After adequate anesthesia is administered, the cervix is visualized. Typically a scalpel is used to make a 360 degree incision into the cervix and a “cone” shaped cervical specimen is removed. The cervix is sutured or sewn with absorbable sutures to control bleeding. Cramping is common as the cervix heals. the cervical specimen is examined by a pathologist to determine if additional treatment is needed after surgery.

Rectocele refers to a medical condition when the tissue between the vagina and rectum is lax. It may result in a protrusion of vaginal tissue to the vaginal opening or beyond it. Some women experience incomplete emptying of the bowels or pelvic pressure. They may need to place their fingers into the vagina to compress the vaginal tissue to aid with bowel movements. Discomfort with sexual intercourse may occur. Cystocele is a condition where the vaginal laxity is between the bladder and vagina. As with a rectocele, the vaginal tissue may descend to the vaginal opening or past it. Incomplete bladder emptying and pelvic pressure are commonly experienced. Surgeries used to treat rectocele and/or cystocele are performed in the operating room. Vaginal incisions are made over the lax tissues from the vaginal opening to the upper vagina. The incised tissues are dissected to the sides and the lax tissues overlying the rectum or bladder are sutured in a way to strengthen them thereby reducing the bulge previously present. The vaginal incisions are then closed with absorbable sutures. A gauze packing may be placed in the vagina for a few hours to 24 hours after surgery to minimize postoperative bleeding. While the packing is in place, it may be difficult to urinate requiring a bladder catheter to temporarily remain in place until the packing is removed.

Uterine prolapse occurs when the uterus descends close to the vaginal opening or beyond it. Common symptoms include pelvic pressure, low back pain, and discomfort with sexual intercourse. Rectocele and cystocele are often present at the same time. In women who have not completed childbearing, a vaginal support device known as a pessary may be used to support the uterus. In women who have completed childbearing, typically a hysterectomy is performed. In addition to removing the uterus, procedures are needed to elevate and support the vaginal tissues or else these tissues may prolapse after surgery. Surgery may be performed vaginally in some cases; however, women with recurrent vaginal prolapse or with complete uterine prolapse (when the entire uterus descends past the vaginal opening) may benefit from a surgery known as a sacral colpopexy. In this surgery, after the uterus is removed the upper inside (intraabdominal) aspect of the vagina is attached via a mesh to intraabdominal sacral tissues to support the vagina. The mesh is placed laparoscopically or via an abdominal incision.

Cysts occurring on the vulva are common. Small ones that are incidentally noticed usually can be followed without any treatment. For those that are growing or become painful, the cyst can be drained or excised. In some cases, this can be carried out in the office. To complete this, the skin overlying the cyst is cleansed, a local anesthetic is administered where the incision into the cyst is planned, and an incision is made in the skin over the cyst and then into it. Fluid is drained. In some cases, this is all that is needed. In other situations, attempts to remove the cyst or place a temporary tube into the cyst to prevent recurrence may be recommended. Larger cysts that are located deep in the vulva usually require treatment in an operating room.

Endometriosis is a condition that may cause painful menses, painful sexual intercourse, chronic abdominal pain, and infertility. When conservative medical therapies fail to resolve symptoms, surgery is often needed. Laparoscopy is the most common surgical technique employed for this. Attempts are made to remove or destroy areas of endometriosis. Care is taken to do nothing surgically that might affect fertility in women who desire childbearing. In women who have completed childbearing, hysterectomy with removal of the fallopian tubes and sometimes the ovaries may be needed if more conservative surgery is not effective in resolving symptoms.

Hysterectomy is carried out in an operating room. It refers to removal of the uterus. A “total” hysterectomy means removal of the uterus and cervix. A “subtotal” or “supracervical” hysterectomy is when the uterus is removed but the cervix is left in place. Removing the cervix prevents the development of cervical cancer in the future. In women who do not have a history of precancerous cervical conditions who undergo a “total” hysterectomy, PAP smears may not be needed after hysterectomy. When the cervix is left in place, routine PAP smears are collected after surgery. The cervix may be left in place if removing it would be difficult such as in women who have had Cesarean sections (as the bladder may be scarred to the cervix) or if the cervix is scarred to the rectum (as may occur in severe endometriosis). Fallopian tubes are commonly removed during hysterectomy as they are not needed after hysterectomy. Also, up to two-thirds of ovarian cancers begin in the fallopian tubes so removing them decreases the risk of ovarian cancer in the future. Ovaries are typically removed in women over the age of 65. Younger women may or may not have an ovary or ovaries removed based on the reasons for hysterectomy. Removal of both ovaries in premenopausal women results menopause, therefore, they are usually left in place.

Hysterectomies can be performed vaginally, abdominally, or laparoscopically (with or without robotic assistance), or a combination of these techniques may be used. The exact method will be reviewed with the woman before surgery and the rationale for this method will be discussed. Cystoscopy, a procedure where a telescope is inserted into the bladder via the urethra, may be performed at the time of hysterectomy to assess for potential urinary tract injuries that have a small risk of occurring during surgery.

Some women are discharged the day of surgery or the next day. It may take a few weeks to 1-2 months to feel physically back to “normal” after hysterectomy.

Robotic surgery refers to a laparoscopic technique that employs a surgical “robot”. The robot does not think or act on its own. It is a device that holds instruments during the surgery but it is fully controlled by the surgeon. Typically four small abdominal incisions are needed for this surgery. Benefits of robotic surgery may include greater magnification through the robotic telescope so visualization of structures is optimized. Also, laparoscopic suturing of tissues using the robot is often easier than suturing without it. The surgical robot may be used in treating endometriosis, removing uterine fibroids, and hysterectomies.