 Abdominoperineal prep please

NSVD Admitting Notes  Request 500cc FWB of patient’s blood type as TRANS-OUT ORDERS
standby Side notes the ff: Orders
 Side notes  Please admit to ROC under the  Dr. ___ for anesthesia  Stable VS  May refer back to room
TPR service of _____  Inform NROD  Able to flex both legs  D/C O2 and pulse oximeter
BP  TPR q 4 hours and record  Refer accordingly  (-) vomiting  Monitor V/S q 15 min until
Weight  Full diet, NPO once in active labor  Thank you  Blurring of vision stable
LMP (Last Menstrual  Labs:  MIO q Hly (+ FC) or shift (-
Period)  CBC FC) and refer if UO <30 cc/H
EDC (Expected Date of  HBsAg POSTPARTUM ORDERS  Watch out for profuse
Confinement)  Urinalysis  Back to room/ward vaginal bleeding,
AOG (Age of Gestation)  IVF: D5LR + 10 “u” oxytocin to run  Full diet once full awake hypotension,
FH (Fundic Height) at 10-15 gtts/min  Present IVF to run at 30 gtts/min, D/C if with minimal VB tachycardia or any untoward
FHB (Fetal Heart Beat)  Meds:  IVF to ff: D5LR + 10 “u” Oxy to run at 30 gtts/min s/sx
CD (Cervical Dilatation)  Ampicillin 2g IV ANST if  Meds:  Refer accordingly
Effacement PROM  Antibiotics
Station  Mefenamic Acid 500 mg/cap q 8 H RTC x 24 H,
 None if no OB
BOW (Bag of Water) complications then prn for pain
Leopold’s  Methergine 1 tab TID x 3 days
 Special Order:
 Monitor FHB and  Vitamins
progress of labor  SO:
 Puboperineal shave  Monitor VS q 15 min until stable
please  Massage uterus prn
 Inform NROD  Ice pack on hypogastrium
 Will inform service  Perilight x 15 min OD
consultant on deck  Routine perineal care
 Refer prn  Watch out for profuse vaginal bleeding
 Refer accordingly
 Thank you
CS ADMITTING NOTES
 Please admit to ROC under the service of _____
 TPR q 4 hours and record DISCHARGE ORDERS (Normal OB)
 Full diet, NPO post-midnight  MGH
 Labs:  Home Meds
 CBC, APC  OPD follow-up on Saturday @ OB service clinic
 CT, BT, PT with photocopy of D/S
 Discharge IE and summary c/o ___
 Urinalysis
 Venoclysis:  TCB anytime if with profuse VB, HA, blurring of vision,
any untoward s/sx
 Meds:
 Cefazolin 500mg IVTT q8H x 3 doses then shift
to

 Co-Amox 625mg/tab, 1 tab BID

 Famotidine 20mg IVTT q8H x 3 doses
 Ketomed 30mg IVTT q8H x 3 doses
 Ketomed 10mg q8H to start if px is on soft diet
 Special Order:
 Inform OR
 Secure signed consent
POST-OP ORDERS NUMBER OF DAYS IN EACH MONTH
 To RR SOLVING OF EXPECTED DATE OF CONFINEMENT(EDC) 198/7(convert to weeks)=28 weeks 2/7 days
 Monitor VS q15 mins. until stable  By Last Menstrual Period (LMP)
 NPO x 6 H, then may have sips of Clear liquids o Nigel’s Rule (-3,+7, +1) Month Number of days
 O2 at 2-3 LPM via nasal prong Example: LMP May 2,2014 or 5/2/14 January 31
 Run present IVF @ 30 gtts/min 5 2 14 February 28
 IVF to ff: -3 +7 +1 29-Leap year
 D5LR 2 9 15 or Feb 9,2015=EDC 2016,2020,2024...
 D5NM March 31
 D5LR x 8 H SOLVING OF AGE OF GESTATION April 30
 Meds:  By Last Menstrual Period May 31
 Antibiotics Example: Today is April 5, 2015, LMP is Feb 10, 2014 June 30
 Ranitidine (Zantac) 50mg IVTT q8H x 3 doses Feb 28-10 =18 days July 31
 SO: March =31 days August 31
 Attach px to O2 at 2-3 LPM via nasal prong April = 5 days September 30
54 days/7(7days a week)= October 31
 Attach pc to pulse ox
7 weeks and 5/7 days
 MIO q H and record refer if UO is <30cc/H November 30
 Remove FC 24H post op December 31
 Standby available blood
 Apply abdominal binder
 Morphine precaution please DECIMAL POINT CONVERSION TO DAYS
 Specimen for histopathology  By Ultrasound
 Watch out for profuse vaginal bleeding, .1 1 days
Example: UTZ result AOG is 23 4/7 days(convert to
 hypotension, tachycardia or any untoward s/sx days)=165 days. Today is April 16 2014. Utz is taken .2 2 days
 Refer PRN last March 12 2015. .4 3 days
 Thank you April 30 days-16 =14days .5 4 days
March 31 days-12=19 days .7 5 days
33 days + 165 days = 198 days .8 6 days
Whole number 7 days

PELVIC EXAM
 Inspection
 Grossly N external genitalia
  Masses, discharges, bleeding 3. Fetal Tone
4. Reactive FHR(not included in Modified BPS)
 Speculum 5. Amniotic Fluid
 Cervix – hyperemic/nonhyperemic; *Perfect Score is 10/10 or 8/8
 Fish-mouth deformity/ping pong
NON-STRESS TEST
 IE  Test of fetal condition
 Cervical dilatation REACTIVE
 Cervical effacement  At least 2 accelerations of the FHR occurs for at
 Station least 15 bpm, lasting for 15 sec w/in 20 min period
 BOW (intact/leaking) of observation
 Amniotic membrane PROM x days/hours NONREACTIVE
 Presenting part  May imply that the fetus is acidotic, asleep, or
drugs was administered to the mother
 Clinical pelvimetry B. EARLY DECELERATION
 Inlet  Head compression
 Midplane C. LATE DECELERATION
Ischial spines  Utero-placental insufficiency
Sacrum  Most common ; Most ominous
Sidewalls
 Outlet

 Bimanual Examination(BME)
 I (introitus) – admits 2 fingers with ease/snugly
 C (cervix) – open/closed,; firm, doughy
 U (uterus) – level of umbilicus
 A (adnexae) – firm/fullness; w/ adnexal masses
 D (discharges) – (+) (-); scanty or minimal bleeding
 E (episiotomy) – with blood/well coaptated wound

 Rectal Vault Exam(RVE)

 Intact rectovaginal septum
 Good sphincter tone
 Abdomen
 Inspection: globular/gravid; linea nigra, striae
 Auscultation: NABS
 Palpation: Leopold’s
 FH, FHB R/L

BIOPHYSICAL SCORING PARAMETERS

1. Fetal Breathing Movements
2. Gross Body Movement
CONTRACTION STRESS TEST/OXYTOCIN CHALLENGE TEST SUPERIMPOSED PREECLAMPSIA Alpha fetoprotein
 A measure of utero-placental function  Inc diastole and systole  16-18 wks AOG
 Contraction induced by using IV oxytocin  Proteinuria
 Record FHB  S/Sx of end organ damage PLASMA GLUCOSE NDDG Coustan &
RESULTS: Time Capenter(mg/dL)
POSITIVE Fasting 105 95
 Consistent and persistent late deceleration (50%) of 1st Hr 190 180
the FHB in the absence of uterine hypertonus or THREATENED ABORTION 2nd Hr 165 155
supine hypotension  Bloody vaginal discharge or bleeding appears 3rd Hr 145 140
 Closed vaginal os
NEGATIVE  Low abdominal pain
 atleast 3 contractions in 10 mins, each lasting 40  Bleeding first, cramping follows LEOPOLD’S MANEUVER
secs, w/o late deceleration L1 (Fundal Grip)
INEVITABLE ABORTION  What fetal pole occupies the fundus
SUSPICIOUS  Gross rupture of membrane
 Inconstant late deceleration patterns  Leaking amniotic fluid L2 (Umbilical grip)
 Cervical dilatation  Fetal back
HYPERSTIMULATION
 Uterine contractions occur more frequent than COMPLETE ABORTION L3 (Pawlick’s grip)
every 2 mins, or lasting longer than 90 secs, or  Complete detachment  (+) engagement of head or (-) engagement
presence of hypertonus  Int. cervical os closes
UNSATISFACTORY L4 (Pelvic grip)
 Frequency of contractions is <3 per minute INCOMPLETE ABORTION  Side of cephalic prominence
 Int. cervical os opens and allows passage of blood
FUNDIC HEIGHT
FETAL DEATH  12wks-1st felt; above the symphysis pubis
 Tobacco-stained amniotic fluid  16wks- bet. Symphysis and umbilicus
HYPERTENSION  20wks- umbilicus
 Spalding’s sign – significant overlapping of fetal
 140/90mmHg  36wks- below ensiform cartilage
skull bones
Etiology (Williams)
 Robert’s sign – Demonstration of gas bubbles in the
 Exposed chorionic villi FHB Monitoring
fetus
 Twin pregnancy (Multiple gestation)  Exaggeration of fetal spinal curvature  Every 30mins= low risk
 Vascular dses  Every 15mins= high risk
 Family hx
Proteinuria BISHOP’S Scoring
 >300mg/24H urine sample AMONIOTIC FLUID INDEX
 > 1000mg/random sample 6H apart BISHOP 0 1 2 3
 Normal: 6-24 cm
SCORE
 1+ = mild proteinuria  Oligohydramnios: <5 cm Dilatatio 0 1-2cm 3-4cm 5-6cm
 2+ to 4+ = heavy proteinuruia  Low normal: 9-10 n
*Edema DOES NOT validate Preeclampsia  Polyhydramnios: >24 Effaceme 0-30% 31-50% 51-70% >70%
PRENATAL CHECK-UPS nt
GESTATIONAL HPN  0-27 wks q4wks Station -5/-3 -2 -1 +1/+2
 HPN w/o Proteinuria (after 20 weeks gestation)  28 wks q 2wks Cervical Posteri Midline Anterior -----
 Confirm 12 wks Postpartum Position or
 29-35 wks q2wks 36 wks and beyond q week
PREECLAMPSIA Cervical firm medium soft -----
OGTT (Oral Glucose Tolerance Test) Consiste
 (+) HPN, (+) Proteinuria after 20th week  24-28wks ncy
ECLAMPSIA Complete Blood COunt Favorable induction: ? 6(recheck!)
 (+) convulsions, (+) Preeclampsia  repeated at 28-32 AOG Unfavorable induction: ?
CHRONIC HPN HbsAg
 140/90mmHg before 20 weeks AOG  last trimester AUGMENTATION OF LABOR
 ↓ amniotic fluid  premature separation of the normally implanted placenta
 Oligohydramnios (causes) after the 20th week of pregnancy and before birth of fetus
 Cord compression  Etiology: (PECSS)
 Macrosomia  Pre-eclampsia
 Deformations  External trauma
 Fetal distress  Chronic hypertension
 Short umbilical cord
Induction of labor  Sudden uterine decompression
 Oxy drip but not in labor

Augmentation of Labor LACERATIONS

 Oxy drip however in labor 1st Degree
 Fourchette, perineal skin, vaginal mucosa but not
MYOMA the underlying fascia and muscle
 causes soft tissue dystocia 2nd Degree
 etiology: unopposed estrogen stimulation  Fascia and muscles of the perineal body but not the
 types: Subserous, Intramural, Submucous anal sphincter
3rd Degree
EXCISION OF BARTHOLIN’S CYST  Extend from vaginal mucosa, perineal skin and
 Hyperplasia (uterus) – provera fascia up to anal sphincter but not the rectal
 Endocervical mucosa
 Endometrial 4th Degree
 Endometrial for D & C  Encompasses extension up to rectal mucosa

BRAXTON HICKS CONTRACTION

PLACENTA PREVIA  The uterus undergoes palpable but originally
Placenta increta invades painless contractions at irregular intervals from the
Placenta percreta penetrates early stages of gestation
Placenta accrete attaches  20 weeks-primigravida
PLACENTA PREVIA Types:  18 weeks-multipara
 Totalis placenta covers cervical os completely INDICATIONS FOR CESAREAN SECTION
 Partialis internal os partially covered by placenta  Prior CS
 Marginal edge of the placenta is at margin of internal os  Labor dystocia (most frequent indication for 1’ CS)
Etiology: (P2ALM2)  Fetal distress
 Previous CS  Breech presentation
 Puerperal Endometritis POST OP COMPLICATIONS OF CS DELIVERY
 Advancing age  Hysterectomy
 Multiparity  Operative injury to pelvic structures
 Multiple induced abortions  Infection
Diagnosis:  Puerperal fever
 Painless third trimester bleeding  Transfusion
 UTZ for placental localization
 Placental Migration (placenta close to the internal
os during 2nd trimester migrate to fundus as
pregnancy advances

PLACENTA ABRUPTION
DELIVERY OF PLACENTA STAGES OF LABOR
 I: Active labor to full cervical dilatation (4-10 cm)
SHULTZE MECHANISM  II: Full cervical dilatation to delivery of baby
 Peripheral  II: Delivery of baby to expulsion of placenta
 Shiny portion  IV: Delivery of placenta to 1 hour after

DUNCAN MECHANISM CARDINAL MOVEMENTS

 Central  Engagement-Pelvic Inlet
 Dirty part  Descent
 Flexion
Normal Rotation of Umbilical Cord:  Internal rotation
 Counter clockwise or Left-handed maneuver  Extension
 External rotation
SIGNS OF PLACENTAL SEPARATION  Expulsion
 Calkin’s Sign (uterus becomes globular and firmer
from discoid) ASYNCLITISM such lateral deflection of the head to a more
 Sudden gush of blood anterior or posterior position of the pelvis
 Uterus rises in the abdomen as the detached
placenta drops to the lower segment and vagina
 Lengthening of the cord

SIGNS OF MALIGNANCY UTZ:

 Septations
 Internal echoes
 Ascites
 Multiple daughter cysts
 <5 cm cyst postmenopausal women expectant
management
VAGINAL BIRTH AFTER A CESAREAN SECTION (VBAC)  Combats cholesterol by increasing HDL Indications:
 Allow a trial of labor under double set-up for all previous  Reduces the occurrence of kidney stones  For disturbances of GIT motility, GERD, diabetic
cesarean of one low segment incision after excluding an  Reduces high blood pressure gastroporesis, nausea, vomiting, migraine HA
inadequate pelvis and unless a new indication arises
 Prevents muscle cramping
 Selection Criteria: Side effects:
 Transmits nerve impulses
 1 or 2 prior low-transverse cesarean section delivery  Restlessness, drowsiness, fatigue, lassitude
 Clinically adequate pelvic Magnesium:
 No other uterine scars or previous rupture *PIPERACILLIN TAZOBACTAM
 Assists calcium metabolism  Highly active against piperacillin-sensitive
 Physicians immediately available throughout active
 Helps maintain arterial health, normal blood pressure microorganisms as wells as B-lactamase-producing
labor capable of monitoring labor and performing an
 and normal heart rhythm piperacillin-resistant microorganisms
emergency cesarean section delivery
 Works with calcium to form the structure of the bone
 Availability of anesthesiologist and personnel for Indication:
emergency cesarean section delivery Indication:
 Calcium deficiency, nutritional supplement to prevent  For UTI, lower resp tract, intraabdominal & skin
osteoporosis infections & septicemia
CRITERIA FOR TIMING OF ELECTIVE REPEAT CS DELIVERY
(At least 1): Side effects:
 Fetal heart sounds documented for 20 weeks by non- Side effects:
 Diarrhea  Upset stomach, vomiting, unpleasant or abnormal
electronic fetoscope or for 30 weeks by Doppler
taste, diarrhea, gas, headache, constipation, insomnia,
 It has been 36 weeks since a (+) serum/urine hCG *ISOXUPRINE HCl (Duvadilan) rash, itching skin, swelling, shortness of breath,
pregnancy test was performed by a reliable laboratory Mode of Action: unusual bruising or bleeding
 An UTZ measurement of the CRL obtained at 6-11  beta-adrenergic agonist that causes direct relaxation
weeks supports a gestational age at least 39 weeks of uterine and vascular smooth muscle via beta-2 TETANUS TOXOID
 UTZ obtained at 12-20 weeks confirms the gestational receptors 1st- 20 wks AOG
age of at least 39 weeks determined by clinical history
2nd- 1 month after birth
and PE Indication: 3rd- 6 months
 Treatment of circulatory disorders and uterine 4th- 1 year
ADMITTING NOTES (Ectopic Pregnancy) hypermotility
 Please admit pc to ROC under the service of Dr. ___ 5th- 1 year
 TPR q 4 hours and record Side effects:
 IVF: D5LR 1L X 8 Hrs  Transient palpitations, fall in BP, dizziness *STEROIDS (Prematurity)
 NPO temporarily
 1 dose 28-32 wks
 Labs: *DYDROGESTERONE (Duphaston)  3 doses q 2 wks
 CBC, APC  Orally active progesterone *MAGNESIUM SULFATE DOSES (Eclampsia)
 CT, BT, PT  Promotes pregnancy in case of luteal insufficiency for Loading dose:
 BT w/ Rh maintaining pregnancy in threatened and habitual  4gms slow IV
 U/A abortions  5gms each buttocks deep IM
 S. Preg test Maintenance dose:
 Meds: None temporarily Indications:  5gms IM/IV q 6hrs
 SO:  Dysfunctional uterine bleeding, irregular cycles, Monitor BP, U/O, DTRs – hyporeflexia
 Monitor VS, abdominal status hourly threatened and habitual abortion, infertility, Monitor RR
 Refer once lab result is in premenstrual syndrome, endometriosis, MgSO4 drip:
 Dr. ___ seen px at ER dysmenorrheal  1-2gms/hr
 Watch out for any untoward s/sx Side effects: 1L = 10gm given 100cc/hr
 Refer prn  Breakthrough bleedings, hemolytic anemia, edema,  10meq/L(about 12mg/dL) respiratory depression
asthenia or malaise, jaundice and abdominal pain  12meq/L respiratory paralysis and arrest
Antidote: Calcium gluconate 1g IV

MEDICATIONS *METOCLOPRAMIDE (Plasil) *HYOSCINE N-BUTYL BROMIDE (Buscopan) for softening of

 Stimulates motility of the upper GIT w/o stimulating the cervix
*CaMg (CALMAG) gastric, biliary or pancreatic secretions
Calcium:  Sensitization of tissues to action of acetylcholine
 Regulates heartbeat and prevents heart disease
 Aids the growth and contraction of muscles