POSTPARTUM ORDERS

NSVD Admitting Notes
 Back to room/ward
 Full diet once full awake
 Side notes  Please admit to ROC under the service of  Present IVF to run at 30 gtts/min, D/C if with minimal VB
TPR _____
 IVF to ff: D5LR + 10 “u” Oxy to run at 30 gtts/min
BP  TPR q 4 hours and record
 Meds:
Weight  Full diet, NPO once in active labor
 Antibiotics
LMP (Last Menstrual Period)  Labs:  Mefenamic Acid 500 mg/cap q 8 H RTC x 24 H, then
EDC (Expected Date of  CBC prn for pain
Confinement)  HBsAg  Methergine 1 tab TID x 3 days
AOG (Age of Gestation)  Urinalysis
FH (Fundic Height)  Vitamins
 IVF: D5LR + 10 “u” oxytocin to run at 10-  SO:
FHB (Fetal Heart Beat) 15 gtts/min
CD (Cervical Dilatation)  Monitor VS q 15 min until stable
 Meds:  Massage uterus prn
Effacement  Ampicillin 2g IV ANST if
Station  Ice pack on hypogastrium
PROM  Perilight x 15 min OD
BOW (Bag of Water)
 None if no OB  Routine perineal care
Leopold’s
complications  Watch out for profuse vaginal bleeding
 Special Order:  Refer accordingly
 Monitor FHB and  Thank you
progress of labor
 Puboperineal shave
please
 Inform NROD
 Will inform service
consultant on deck
 Refer prn

DISCHARGE ORDERS (Normal OB)
CS ADMITTING NOTES  MGH
 Please admit to ROC under the service of _____  Home Meds
 TPR q 4 hours and record  OPD follow-up on Saturday @ OB service clinic
 Full diet, NPO post-midnight with photocopy of D/S
 Labs:  Discharge IE and summary c/o ___
 CBC, APC  TCB anytime if with profuse VB, HA, blurring of vision,
 CT, BT, PT any untoward s/sx
 Urinalysis
 Venoclysis:
 Meds:
 Cefazolin 500mg IVTT q8H x 3 doses then shift to TRANS-OUT ORDERS
Side notes the ff: Orders
 Co-Amox 625mg/tab, 1 tab BID  Stable VS  May refer back to room
 Famotidine 20mg IVTT q8H x 3 doses  Able to flex both legs  D/C O2 and pulse oximeter
 Ketomed 30mg IVTT q8H x 3 doses  (-) vomiting  Monitor V/S q 15 min until
 Ketomed 10mg q8H to start if px is on soft diet stable
 Blurring of vision
 Special Order:  MIO q Hly (+ FC) or shift (- FC)
 Inform OR and refer if UO <30 cc/H
 Secure signed consent  Watch out for profuse vaginal
 Abdominoperineal prep please bleeding, hypotension,
 Request 500cc FWB of patient’s blood type as tachycardia or any untoward s/sx
standby  Refer accordingly
 Dr. ___ for anesthesia
 Inform NROD
 Refer accordingly
 Thank you

Utz is taken last .2020. tachycardia or any untoward s/sx March 31 days-12=19 days .5 4 days  Refer PRN 33 days + 165 days = 198 days . then may have sips of Clear liquids  By Last Menstrual Period (LMP) January 31  O2 at 2-3 LPM via nasal prong o Nigel’s Rule (-3.  IVF to ff: 5 2 14 March 31  D5LR -3 +7 +1 April 30  D5NM 2 9 15 or Feb 9.4 3 days  hypotension.2024. LMP is Feb 10.1 1 days  Specimen for histopathology March 12 2015. 2014  Ranitidine (Zantac) 50mg IVTT q8H x 3 doses September 30 Feb 28-10 =18 days  SO: October 31 March =31 days  Attach px to O2 at 2-3 LPM via nasal prong November 30 April = 5 days  Attach pc to pulse ox December 31 54 days/7(7days a week)=  MIO q H and record refer if UO is <30cc/H 7 weeks and 5/7 days  Remove FC 24H post op  Standby available blood  By Ultrasound DECIMAL POINT CONVERSION TO DAYS  Apply abdominal binder Example: UTZ result AOG is 23 4/7 days(convert to  Morphine precaution please days)=165 days.2 2 days  Watch out for profuse vaginal bleeding. Today is April 16 2014..2014 or 5/2/14 29-Leap year 2016.+7. 2015.POST-OP ORDERS NUMBER OF DAYS IN EACH MONTH  To RR  Monitor VS q15 mins. until stable SOLVING OF EXPECTED DATE OF CONFINEMENT(EDC) Month Number of days  NPO x 6 H. April 30 days-16 =14days ..7 5 days  Thank you .2015=EDC May 31  D5LR x 8 H June 30  Meds: SOLVING OF AGE OF GESTATION July 31  Antibiotics  By Last Menstrual Period August 31 Example: Today is April 5. +1) February 28  Run present IVF @ 30 gtts/min Example: LMP May 2.8 6 days 198/7(convert to weeks)=28 weeks 2/7 days Whole number 7 days . .

Reactive FHR(not included in Modified BPS)  Speculum 5. LATE DECELERATION Sacrum  Utero-placental insufficiency Sidewalls  Most common . EARLY DECELERATION  Midplane  Head compression Ischial spines C. Fetal Tone  Masses. w/ adnexal masses  D (discharges) – (+) (-). Amniotic Fluid  Cervix – hyperemic/nonhyperemic. *Perfect Score is 10/10 or 8/8  Fish-mouth deformity/ping pong  IE NON-STRESS TEST  Cervical dilatation  Test of fetal condition  Cervical effacement REACTIVE  Station  At least 2 accelerations of the FHR occurs for at least 15  BOW (intact/leaking) bpm. Fetal Breathing Movements  Inspection 2. linea nigra. FHB R/L BIOPHYSICAL SCORING PARAMETERS .. asleep. bleeding 4. lasting for 15 sec w/in 20 min period of observation  Amniotic membrane PROM x days/hours NONREACTIVE  Presenting part  May imply that the fetus is acidotic. striae  Auscultation: NABS  Palpation: Leopold’s  FH. doughy  U (uterus) – level of umbilicus  A (adnexae) – firm/fullness. firm.PELVIC EXAM 1. Most ominous  Outlet  Bimanual Examination(BME)  I (introitus) – admits 2 fingers with ease/snugly  C (cervix) – open/closed. 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. discharges. or drugs was  Clinical pelvimetry administered to the mother  Inlet B. Gross Body Movement  Grossly N external genitalia 3.

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

perineal skin and fascia up to anal sphincter but not the rectal mucosa Induction of labor 4th Degree  Oxy drip but not in labor  Encompasses extension up to rectal mucosa Augmentation of Labor BRAXTON HICKS CONTRACTION  Oxy drip however in labor  The uterus undergoes palpable but originally painless contractions at irregular intervals from the early stages of MYOMA gestation  causes soft tissue dystocia  20 weeks-primigravida  etiology: unopposed estrogen stimulation  18 weeks-multipara  types: Subserous. Submucous INDICATIONS FOR CESAREAN SECTION  Prior CS EXCISION OF BARTHOLIN’S CYST  Labor dystocia (most frequent indication for 1’ CS)  Hyperplasia (uterus) – provera  Fetal distress  Endocervical  Breech presentation  Endometrial POST OP COMPLICATIONS OF CS DELIVERY  Endometrial for D & C  Hysterectomy  Operative injury to pelvic structures  Infection PLACENTA PREVIA  Puerperal fever Placenta increta invades  Transfusion Placenta percreta penetrates Placenta accrete attaches PLACENTA PREVIA Types:  Totalis placenta covers cervical os completely  Partialis internal os partially covered by placenta  Marginal edge of the placenta is at margin of internal os Etiology: (P2ALM2)  Previous CS  Puerperal Endometritis  Advancing age  Multiparity  Multiple induced abortions Diagnosis:  Painless third trimester bleeding  UTZ for placental localization  Placental Migration (placenta close to the internal os during 2nd trimester migrate to fundus as pregnancy advances PLACENTA ABRUPTION  premature separation of the normally implanted placenta after the 20th week of pregnancy and before birth of fetus  Etiology: (PECSS)  Pre-eclampsia  External trauma  Chronic hypertension  Short umbilical cord  Sudden uterine decompression LACERATIONS . perineal skin. Intramural. vaginal mucosa but not the underlying  Cord compression fascia and muscle 2nd Degree  Macrosomia  Fascia and muscles of the perineal body but not the anal sphincter  Deformations 3rd Degree  Fetal distress  Extend from vaginal mucosa. ↓ amniotic fluid 1st Degree  Oligohydramnios (causes)  Fourchette.

STAGES OF LABOR  I: Active labor to full cervical dilatation (4-10 cm)  II: Full cervical dilatation to delivery of baby  II: Delivery of baby to expulsion of placenta  IV: Delivery of placenta to 1 hour after CARDINAL MOVEMENTS  Engagement-Pelvic Inlet  Descent  Flexion  Internal rotation  Extension  External rotation  Expulsion ASYNCLITISM such lateral deflection of the head to a more anterior or posterior position of the pelvis DELIVERY OF PLACENTA SHULTZE MECHANISM  Peripheral  Shiny portion DUNCAN MECHANISM  Central  Dirty part Normal Rotation of Umbilical Cord:  Counter clockwise or Left-handed maneuver SIGNS OF PLACENTAL SEPARATION  Calkin’s Sign (uterus becomes globular and firmer from discoid)  Sudden gush of blood  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 .

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