Concerns About Modesty During Hysterectomy

Approximately 600,000 hysterectomies performed each year in the United States. Some women have positive experiences, but sadly others are left feeling marginalized by the lack of respect given to their modesty. Many women prefer only female medical personnel for gynecological surgeries and procedures.

It is estimated that 85% to 90% of all hysterectomies are unnecessary so it is important for you to get a second opinion preferably from a naturopathic or integrative medicine physician and do some research on alternative options before you proceed with a hysterectomy to make sure that it is really necessary. Check out Why Are Hysterectomies Often Unnecessary?

Procedures for ensuring a woman’s dignity and modesty vary greatly across hospitals for hysterectomies. Some hospitals have policies that restrict male nurses from providing intimate care to women in OB/GYN wards, while other hospitals believe that the gender of the healthcare provider is irrelevant to the procedure. The other issue is that prior to surgery and then for a period of time after, some patients are heavily sedated leaving them unable to either advocate for themselves or recall what happened or who provided care. For many women, this is quite disconcerting.

Before you consent to surgery, there are two principles that should guide your discussions with your providers: 1) communicate your all your wishes and concerns to everyone involved in your surgery—even if you think they are obvious and 2) get the agreements you make with your doctor and gynecology department at the hospital in writing.

There are three domains around which you should have careful conversations and record all your agreements:

Procedures

Types of hysterectomy:

a) Vaginal Hysterectomy - A surgical procedure in which the uterus is removed through the vagina. One or both ovaries and fallopian tubes may be removed during the procedure, as well. This surgical approach avoids visible scarring and typically allows for a quicker recovery, as well as less postoperative pain and complications as compared with other types of hysterectomy. Risks associated with the vaginal approach include a slight but serious risk of shortening or damaging the vagina.

b) Laparoscopic-Assisted Vaginal Hysterectomy - This type of surgery employs video technology to provide the surgeon with greater visibility when removing the uterus through the vagina. The laparoscopic-assisted approach entails three small external incisions: one in the navel, through which the laparoscope (small video camera) is inserted, and two others in the lower abdomen for the use of surgical instruments. This procedure may be preferred because of the rapid healing time, a less noticeable scar, and less pain, although actual surgery time is longer than the abdominal approach. Because of the longer time in the operation room and the use of extra electronic equipment, this procedure is also costlier than others. Risks associated with the laparoscopic-assisted vaginal approach include a slight risk of bladder injury and urinary tract infection.

c) Abdominal Hysterectomy – This type of hysterectomy is fairly standard and remains the most common approach for removing the uterus and other reproductive organs. When performing an abdominal hysterectomy, surgeons can either use a vertical incision or a "bikini cut" incision depending on the scope of the surgery. The vertical incision cuts vertically from the navel to the pubic hair line, while the bikini cut is a horizontal incision made directly above the pubic hairline. The abdominal hysterectomy approach results in a longer recovery period and more noticeable external scarring but requires less specialty surgical skill and may be less costly and more widely available than other approaches.

d) Laparoscopic-Assisted Abdominal Hysterectomy – This type of surgery requires only one incision for both the laparoscope and the removal of the uterus. This approach is an alternative to the three-puncture laparoscopic-assisted vaginal approach; however, the laparoscopic-assisted abdominal approach is only appropriate for a supracervical hysterectomy (meaning the cervix is healthy and does not need removal). The laparoscope has the potential to be a useful tool for total and radical hysterectomies as well, however most surgeons prefer the traditional abdominal approach for these procedures.

There is no getting around the fact that you will be exposed to many people for the procedure. It is the job of doctors and their assistants to make you feel as comfortable as possible. In that effort, they are likely to either skip over details of what they will be doing, or they will try to make it sound as clinical as possible. The basic truth is that once you are in the operating room your legs will be placed into stirrups and your doctor will perform a pelvic exam on you. Your gown will then be removed (yes that means you will be naked) or pulled up to allow access to your abdomen and genitals.. Your vagina and rectum will be prepped (cleaned) inside and out, and if you are having either an abdominal or laparoscopic hysterectomy your abdomen will also be cleaned. You will then lie there for at least another 3-5 minutes until you are dry. At that point, you will be draped. There will be openings in the drape for your vagina and abdomen. A urinary catheter will be inserted and depending on the procedure, other objects like a speculum or uterine manipulator will be inserted through your vagina. Once the surgery is finished, the incisions are closed, the draping will be removed from your body, at about the same time if you were anesthetized you will be “awakened” and likely given more sedation, then you will be taken to the PACU where they will care for you for about 1-2 hours. You will then be taken to a regular room.

The description above is very general and may be different for your doctor or hospital, but the purpose is to give you a frame for asking questions. For example, you might ask if you will be covered while your doctor examines you in the Operating Room or you might ask to be awake for the exam. You can also ask who will insert the catheter or if the catheter can be inserted while you’re awake. Lastly, you may be more comfortable if your doctor or her assistant perform the vaginal prep rather than the hospital scrub nurse/circulating nurse. Also, be sure to ask about the windows in the Operating Room. In some hospitals, there are windows everywhere so that people can watch procedures. Some hospitals screen windows for gynecological procedures and others do not.

Be aware that accidentally cutting a hole in your bladder is a potential complication of hysterectomy. Patients are often not informed that their bladder could be perforated during hysterectomy. The standard of care calls for bladder perforations to be identified in surgery and repaired while the patient is still under anesthesia. The repair of bladder perforation can either be done vaginally or through an open abdominal surgery. Whichever technique is used, an urologist or urogynecologist should be called into the operating room to perform the repair. This means that your gynecologist could call in an urologist while you are under anesthesia without your consent. Most urologists are male. Check out experiences of some hysterectomy patients who had bladder perforations.

People Who Will Be Involved in Your Medical Care

Patients rarely consider the fact that there are a number of people in and out of an Operating Room before and during a surgery. Your doctor will have an assistant to help with the procedure. Generally the doctor selects his/her assistant. The hospital will assign several medical personnel for the operation including nurses, anesthesiologist or nurse anesthetist, surgical scrub technicians, and a scrub/circulating nurse. The job of a scrub / circulating nurse is to make sure all the tools are ready for the doctor, bring you into the Operating Room, prep your body for surgery, and record information about your preparation. Generally, you only meet anesthesiologist or nurse anesthetist just before the surgery. There will also likely be 2 other surgical scrub technicians involved. Their job is to bring things to the scrub nurse, doctors or assistants, clean up discarded items and assist in any other way they are asked. You should be aware that nurses can take breaks in the middle of surgeries. When this happens, a team comes in to relieve them. This means that they could bring in male nurses to replace the female nurses during their breaks.

Some hospitals allow medical students to participate in hysterectomies. Some hospitals especially teaching hospitals still allow medical students to practice pelvic exams on gynecological surgery patients without their consent. See more information on non-consensual pelvic exams.

Questions you might consider are:

1) Who is going to assist the surgeon? Do not assume you know this. A doctor will often have someone in her office that does most of the surgeries with her. If that person is unavailable, the doctor will call someone else and usually not bother to tell you unless you ask. If you want to have an all-female team, you must tell her that you only accept a female assistant.

2) Who will the scrub/ circulating nurse going be?

3) Who will be the anesthesiologist?

4) Who will be the surgical scrub technicians?

5) Who will be the PACU nurse?

6) Who will be performing which procedures on you? For example, ask who will be suturing you, placing your legs in the stirrups, undressing and dressing you, etc.

7) Is there any chance that medical students will be present? If so, what role will they play?

8) Can someone such as my husband, friend, or family member be present with me for the surgery?

9) Ask who would be your urologist or urogynecologist if you had a bladder perforation. Repair of bladder perforation is often done while you are still under anesthesia.

Drugs

This is the area that perhaps is the most ignored by patients. Many patients genuinely do not want to know what is happening and want to be sedated for as long as possible—that is absolutely their right. However, if you wish to be aware of what is happening, you need to make your wishes clear to your doctor and thoroughly ask your anesthesiologist or nurse anesthetist about his/her plan.

First of all, be aware that “awake” to a doctor is different than “awake” to a layperson. Patients are often given Versed or other sedatives prior to entering the Operating Room to alleviate stress and help you to relax. While Versed is an anti-anxiety medication, it also has a powerful amnesia effect. Versed is also known as a date-rape drug. It is used to make a person compliant and induces conscious sedation. It causes a person to not remember. It's a dangerous drug which is not in the best interest of patients. Many patients will not be able to remember anything while under its influence. If you’re given Versed prior to being brought into the Operating Room, you will likely not remember who is in the room, being placed on the OR table or being prepared for anesthesia. So while the doctor may say you will be “awake,” be sure to clarify what that means. Further, once surgery is over, you will likely be give few more doses of Versed, again that means you will likely not remember being in the PACU.

One hysterectomy patient who spoke up that she did not want any male medical personnel present was given Versed so she could not advocate for herself. She ended up with a male anesthesiologist, a male assistant, and a male circulating nurse against her wishes. You are no longer able to advocate for yourself once you are given Versed because it causes you to have a powerful amnesia effect. Versed gives medical personnel the opportunities to do many things without your consent. Versed also legally invalidates any patient testimony regarding their treatment.

There is no reason for you to be given Versed. You should write on your consent form that you do not give consent for Versed to be administered at all.

All three of these areas are vital to your care and your concerns about modesty. Remember that a conversation is not enough. Once you have come to an agreement with your doctor about the issues above, you need to be sure that you write those directives on your consent form.

Important Tips For Women Concerned About Modesty During Hysterectomy:

1) You should write a list of expectations that you and your doctor sign. Make several copies of the list. Then when you sign your hospital consent forms and any other form you are asked to sign, note by your signature that you have a list of expectations that are attached and have the person witnessing your signature initial that note.

Your list of expectations should be clear and direct. For example:

• I withhold consent for any sedation until after I have been brought to the OR and have been placed into stirrups.
  
  
• I withhold consent for Versed.
  
  
• I withhold consent for any male medical personnel or medical students being present during my surgery or observing my surgery. If my wishes cannot be accommodated for an all-female team, the surgery must be cancelled or postponed.
  
  
• The only person I allow to insert the urinary catheter is my doctor.
  
  
• I only give consent to Mary Smith to assist Dr. Jones in my hysterectomy.
  
  

2) Try to get all consent forms prior to the day of surgery and read them carefully. Write in any changes or requests.

3) Visit the hospital you will be having the surgery at and ask to speak to the nursing supervisor and/or manager of the gynecology dept. Discuss your wishes about who you want to be present. Make sure you indicate if you don't wish for even female medical students to be there. Some women who want an all-female team are open to female medical students observing their gynecological surgery.

4) Insist that they do not give you an IV until you have been prepped for surgery. Check out how female urinary catheterization is done.

5) It is prudent to have an advocate not employed by the hospital such as your husband present the whole time for pre-op, surgery, and post-op to make sure that your wishes are honored. This is the only way you can have a guarantee that your wishes will be honored. Remember that someone else could come in middle of your surgery including a sales representative, a janitor, or other nurses. Check out Why You Should Have a Personal Advocate For Surgery?

6) Walk out and cancel the surgery if you see that your wishes will not be honored for an all-female medical team. Patients need to stand up to show medical professionals that they are not willing to compromise.

7) Find another doctor if she is not willing to work to accommodate your wishes.

Other Related Articles:

How is Female Urinary Catheterizations Done?

Why Are Hysterectomies Often Unnecessary?

Tips For OB/Gyn Patients

Female Patient Modesty

What You Should Know About Sedation and Versed?

Sources:

National Women's Health Network - Hysterectomy

Is Bladder Perforation During Hysterectomy Medical Negligence?