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History CS ADMITTING NOTES

 General data  Please admit to ROC under the service of _____


 Chief complaint  TPR q 4 hours and record
 PMHx  Full diet, NPO post midnight
 PSHx  Labs:
 FMHx o CBC, APC
 OBHx o CT, BT, PT
o Menarche o Urinalysis
o Interval  Venoclysis
o Duration  Meds:
o Amount o Cefazolin 500mg IVTT q8H x 3 doses then shift to Co-Amox
o Symptoms 625mg/tab, 1 tab BID
o Coitarche o Famotidine 20mg IVTT q8H x 3 doses
o Menopause o Ketomed 30mg IVTT q8H x 3 doses
o OCP, S/P, PAP, Intermenstrual bleeding o Ketomed 10mg q8H to start if px is on soft diet
o Postcoital bleeding o Tramadol 50mg IVTT q6H prn
o OB Score  Inform OR
o LMP, EDC, AOG  Secure signed consent
o PNCU  Abdominoperineal prep please
o HBsAg/VDRL  Request 500cc FWB of patient’s blood type as standby
o TT/BT/MTV  Dr. ___ for anesthesia
o UTI  Inform NROD
 Refer accordingly
 Thank yo
NSVD Admitting Notes
 Please admit to ROC under the service of _____
 TPR q 4 hours and record
 Full diet, NPO once in active labor POST-OP ORDERS
 Labs:  To RR
o CBC  Monitor VS q15 mins until stable
o HBsAg  NPO x 6 H, then may have sips of CL
o Urinalysis
 O2 at 2-3 LPM via nasal prong
 IVF: D5LR + 10 “u” oxytocin to run at 10-15 gtts/min
 Run present IVF @ 30 gtts/min
 Meds
 IVF to ff:
o Ampicillin 2g IV ANST if PROM
o D5LR
 SO: o D5NM + 10 “u” oxytocin x 8 H
o Monitor FHB and progress of labor o D5LR x 8 H
o Puboperineal shave please
 Meds:
o Inform NROD
o Antibiotics
o Will inform service consultant on deck
o Ranitidine (Zantac) 50mg IVTT q8H x 3 doses
o Refer prn
 SO:
o Thank you
o Attach px to O2 at 2-3 LPM via nasal prong
 Side notes
o Attach pc to pulse ox
o TPR
o MIO q H and record
o BP
o Refer if UO is <30cc/H
o Wt
o Remove FC 24H post op
o LMP
o Standby available blood
o EDC
o Apply abdominal binder
o AOG
o Morphine precaution please
o FH
o Specimen for histopathology
o FHB
o Watch out for profuse vaginal bleeding, hypotension,
o CD
tachycardia or any untoward s/sx
o Effacement
o Refer PRN
o Station
o Thank you
o BOW
o Leopolds
 Final Dx: TRANS-OUT
o PU FT del via NSVD/1’LTCS/Rpt CS in cephalic presentation Side notes the ff:
to a live Bb Girl/Boy with BW: BL: AS: PAOG: OB score
 Stable VS
 Able to flex both legs
 (-) vomiting
POSTPARTUM ORDERS  Blurring of vision
 Back to room/ward Orders
 Full diet once full awake  May refer back to room
 Present IVF to run at 30 gtts/min, D/C if with minimal VB  D/C O2 and pulse oximeter
 IVF to ff: D5LR + 10 “u” Oxy to run at30 gtts/min  Monitor V/S q 15 min until stable
 Meds:  MIO q Hly (+ FC) or shift (- FC) and refer if UO <30 cc/H
o Antibiotics  Watch out for profuse vaginal bleeding, hypotension, tachycardia or any
o MA 500 mg/cap q 8 H RTC x 24 H, then prn for pain untoward s/sx
o Methergin 1 tab TID x 3 days  Refer accordingly
o Viitamins  Thank you
 SO:
o Monitor VS q 15 min until stable
o Massage uterus prn ADMITTING ORDERS (Abdomen)
o Ice pack on hypogastrium  Please admit to ROC under the service of Dr. ____
o Perilight x 15 min OD  TPR q shift and record
o Routine perineal care  NPO
o Watch out for profuse vaginal bleeding  Labs:
o Refer accordingly o CBC (save serum)
o Thank you o Serum pregnancy test
o Urinalysis
 IVF: D5LR + 10 “u” oxytocin x 30 gtts/min
 SO:
DISCHARGE ORDERS (Normal OB) o For completion curettage on call
 MGH o Secure consent
 Home Meds o Pad count at bedside
 OPD ff-up on Sat @ OB service clinic with photocopy of D/S o Save specimen passed out
 Discharge IE and summary c/o ___ o Please prescribe the ff: Nubain, Benadryl, Dormicum
 TCB anytime if with profuce VB, HA, blurring of vision, U2W ssx o Refer for profuse bleeding and other untoward ssx
o Thank you
HYPERTENSION
POST OP ORDERS (TAHBSO)  140/90MMhG
 To RR Proteinuria
 Monitor VS q 15 min, until stable  >300mg/24H urine sample
 Flat on bed x 6 H, then may turn to side  > 1000mg/random sample 6H apart
 NPO x 6 H then may have sips of CL  1+ = mild proteinuria
 Present IVF x 30 gtts/min  2+ to 4+ = heavy proteinuruia
 IVF to ff: *Edema DOES NOT validate Preeclampsia
o D5LR GESTATIONAL HPN
o D5NM + 10 “u” oxytocin x 8 H  HPN w/o Proteinuria (after 20 weeks gestation)
o D5LR x 8 H  Confirm 12 wks Postpartum
 Meds: PREECLAMPSIA
 SO:  (+) HPN, (+) Proteinuria after 20th week
o MIO q H and record ECLAMPSIA
o Refer if UO is <30cc/H  (+) convulsions, (+) Preeclampsia
o May return blood CHRONIC HPN
o Remove FC @ ___  140/90mmHg
o Apply abdominal binder SUPERIMPOSED PREECLAMPSIA
o Refer PRN  Inc diastole and systole
o Thank you  Proteinuria
 S/Sx of end organ damage
PELVIC EXAM Triad for Sever Preeclampsia
 Inspection  Hemolysis
o Grossly N external genitalia  Elevated Liver Enzyme
o Masses, discharges, bleeding  Low Platelet Count
 Speculum Hypertension etiology(Williams)
o Cervix – hyperemic/nonhyperremic; fish mouth deformity/ping  Exposed chorionic villi
pong
 Twin pregnancy (Multiple gestation)
 IE
 Vascular dses
o Cervical dilatation
 Fam hx
o Cervical effacement
o Station
THREATENED ABORTION
o BOW (intact/leaking)
 Bloody vaginal discharge or bleeding appears
o Amniotic membrane PROM x days/hours
o Presenting part  Closed vaginal os
 Clinical pelvimetry  Low abdominal pain
o Inlet  Bleeding first, cramping follows
o Midplane INEVITABLE ABORTION
 Ischial spines  Gross rupture of membrane
 Sacrum  Leaking amniotic fluid
 Sidewalls  Cervical dilatation
o Outlet COMPLETE ABORTION
 EFW  Complete detachment
 BME  Int. cervical os closes
o I (introitus) - admits 2 fingers with ease/snugly INCOMPLETE ABORTION
o C (cervix) – open/closed,; firm, doughy  Int. cervical os opens and allows passage of blood
o U (uterus) – level of umbilicus Mullerian Anomalies
o A (adnexae) – firm/fullness; w/ adnexal masses  Segmented mullerian agenensis or hyperplasia
o D (discharges) – (+) (-); scanty or minimal bleeding  Unicornuate uterus
o E (episiotomy) – with blood/well coaptated wound  Bicornuate uterus
 RVE  Septate uterus
o Intact rectovaginal septum  Uterus with internal ___? Changes
o Good sphincter tone Induction of labor
 Abdomen  Oxy drip but not in labor
o Inspection: globular/gravid; linea nigra, striae Augmentation of Labor
o Auscultation: NABS  Oxy drip however in labor
o Palpation: Leopold’s
o FH, FHB R/L PRENATAL CHECK-UPS
 Final Dx: 0-27 wks q4wks
28 wks q 2wks
NON-STRESS TEST 29-35 wks q2wks
 Test of fetal condition 36 wksand beyond q week
REACTIVE when:
 At least 2 accelerations of the FHR occurs for at least 15 bpm, lasting for TETANUS TOXOID
15 sec w/in 20 min period of observation 0 20 wks AOG
NONREACTIVE 1 1 month
 May imply that the fetus is acidotic, asleep, or drugs was administered to 2 6 months
the mother 3 1 year
A. EARLY DECELERATION 4 1 year
 Head compression
B. LATE DECELERATION STEROIDS
 Utero-placental insufficiency 1 dose 28-32 wks
C. VARIABLE DECELERATION 3 doses q 2 wks
 Cord compression ; Fetal distress OGTT at 24-28wks
 Most common ; Most ominous
MAGNESIUM SULFATE DOSES
Loading dose:
CONTRACTION STRESS TEST/OCYTOCIN CHALLENGE TEST 4gms slow IV
 A measure of utero-placental function 5gms each buttocks deep IM
 Contraction induced by using IV oxytocin Maintenance dose:5gmsIM/IV q 6hrs
 Record FHB Monitor BP, U/O, DTRs-hyporeflexia
POSITIVE Monitor RR
MgSO4 drip:
 Consistent and persistent late deceleration (50%) of the FHB in the
absence of uterine hypertonus or supine hypotension  1-2gms/hr
NEGATIVE 1L = 10gm given 100cc/hr
 @ least 3 contractions in 10 mins, each lasting 40 secs, w/o late  10meq/L(about 12mg/dL)
deceleration >respiratory depression
SUSPICIOUS  12meq/L
 Inconstant late deceleration patterns >respiratory paralysis and arrest
Antidote: Calcium gluconate 1g iV
HYPERSTIMULATION
 Uterine contractions occur more frequent than every 2 mins, or lasting
longer than 90 secs, or presence of hypertonus
UNSATISFACTORY
 Frequency of contractions is <3 per minute
FETAL DEATH DELIVERY OF PLACENTA
1. Tobacco-stained amniotic fluid
2. Spalding’ssign SHULTZE MECHANISM
o significant overlapping of fetal skull bones  Peripheral
3. Robert’s sign  Shiny portion
o Demonstration of gas bubbles in the fetus DUNCAN MECHANISM
4. Exaggeration of fetal spinal curvature  Central
 Dirty part
BIOPHYSICAL SCORING PARAMETERS DEFINE:
1. Fetal Breathing Movements  Placenta increta  invades
2. Gross Body Movement  Placenta percreta  penetrates
3. Fetal Tone  Placenta accrete  attaches
4. Reactive FHR Normal Rotation of Umbilical Cord:
5. Amniotic Fluid
 Counter clockwise or Left-handed maneuver
*Perfect Score is 10/10 or 8/8
CBC repeated at 28-32 AOG
PLACENTA PREVIA
HbsAg last trimester
 Types:
Alpha fetoprotein 16-18 wks AOG
o Totalis  placenta covers cervical os completely
o Partialis  internal os partially covered by placenta
PLASMA GLUCOSE RESULTS:
o Marginal  edge of the placenta is at margin of internal os
(Blood Glucose testing performed at 24-28wks AOG)
 Etiology: (P2ALM2)
Time NDDG Coustan & Capenter(mg/dL)
o Previous CS
Fasting 105 95
o Puerperal Endometritis
1st Hr 190 180 o Advancing age
o Multiparity
2nd Hr 165 155 o Multiple induced abortions
3rd Hr 145 140  Diagnosis:
o Painless third trimester bleeding
o UTZ for placental localization
o Placental Migration (placenta close to the internal os during
2nd trimester migrate to fundus as pregnancy advances
LEOPOLD’S MANEUVER
L1 (Fundal Grip)
 What fetal pole occupies the fundus PLACENTA ABRUPTION
L2 (Umbilcal grip)  premature separation of the normally implanted placenta after the 20th
 Fetal back week of pregnancy and before birth of fetus
L3 (Pawlick’s grip)  Etiology: (PECSS)
 (+) engagement of head or (-) engagement o Pre-eclampsia
L4 (Pelvic grip) o External trauma
 Side of cephalic prominence o Chronic hypertension
o Short umbilical cord
FUNDIC HEIGHT o Sudden uterine decompression
12wks-1st felt; above the symphysis pubis
16wks- bet. Symphysis and umbilicus LACERATIONS
20wks- umbilicus  1st Degree
36wks- below ensiform cartilage o Fourchette, perineal skin, vaginal mucosa but not the
underlying fascia and muscle
FHB Monitoring  2nd Degree
 Every 30mins= low risk o Fascia and muscles of the perineal body but not the anal
 Every 15mins= high risk sphincter
 3rd Degree
BISHOP SCORE o Extend from vaginal mucosa, perineal skin and fascia up to
0 1 2 3 anal sphincter but not the rectal mucosa
Dilatation 0 1-2cm 3-4cm 5-6cm  th
4 Degree
Effacement 0-30% 31-50% 51-70% >70% o Encompasses extension up to rectal mucosa
Station -5/-3 -2 -1 +1/+2
Cervical Posterior Midline Anterior ----- BRAXTON HICKS CONTRACTION
Position  The uterus undergoes palpable but originally painless contractions at
Cervical Firm medium soft ----- irregular intervals from the early stages of gestation
Consistency
*Scoring: 3-8 difficult induction SIGNS OF PLACENTAL SEPARATION
9-favorable induction  Calkin’s Sign (uterus becomes globular and firmer from discoid)
 Sudden gush of blood
MYOMA  Uterus rises in the abdomen as the detached placenta drops to the lower
 causes soft tissue dystocia segment and vagina
 etiology: unopposed estrogen stimulation  Lengthening of the cord
 types: Subserous, Intramural, Submucous
ROT-right occiput transverse AMONIOTIC FLUID INDEX
Montevideo Units- 200 units or pressure of > 60  Normal: 6-24 cm
Depoprovera- injectable CP is G1 to HPN patients  Oligohydramnios: <5 cm
 Low normal: 9-10
EXCISION OF BARTHOLIN’S CYST  Polyhydramnios: >24
 Hyperplasia (uterus) – provera
 Endocervical
 Endometrial For Functional Curettage
 Endometrial  for D & C INDICATIONS FOR CESAREAN SECTION
 Prior CS
AUGMENTATION OF LABOR  Labor dystocia (most frequent indication for 1’ CS)
 ↓ amniotic fluid  Fetal distress
 Oligohydramnios (causes)  Breech presentation
o Cord compression
o Macrosomia POST OP COMPLICATIONS OF CS DELIVERY
o Deformations  Hysterectomy
o Fetal distress  Operative injury to pelvic structures
 Infection
HYOSCINE N-BUTYL BROMIDE (Buscopan)  for softening of the cervix  Puerperal fever
 Transfusion
NST: Fetal condition “7 days”
STAGES OF LABOR
CST: Uteroplacental contraction  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
1’ LOW TRANSVERSE CESAREAN SECTION
1. Induction of spinal anesthesia.
CARDINAL MOVEMENTS 2. Patient in supine position.
 Engagement 3. Insertion of foley catheter.
 Descent 4. Asepsis/Antisepsis
 Flexion 5. Drapings done, exposing operative site.
 Internal rotation 6. Vertical incision done from 2 FB above the symphysis pubis up to 3 FB below
 Extension the umbilicus. Incision deepened to subcutaneous tissues and transversalis
 External rotation fascia, rectus muscle split, peritoneum cut longitudinally.
 Expulsion 7. Bleeders clamped and ligated as encountered
8. Retractors applied exposing pelvic structures.

9. Vesico-uterine folds identified, lifted out and cut 1 cm above the bladder.
10. Bladder pushed downward and a curvilinear incision is done on the lower
ASYNCLITISM  such lateral deflection of the head to a more anterior or posterior
uterine segment using bandage scissors, bag of water ruptured.
position of the pelvis
11. Rupture of membranes.
12. Amniotic fluid suctioned and fetal head exposed.
13. Delivery of baby boy in left occiput transverse position.
14. Umbilical cord doubly clamped and cut.
15. Manual extraction of placenta.
16. Closure of incision site done layer by layer
a. First (endometrial) layer closed by continuous interlocking
stitches using Chromic 1.
b. Second (myometrial) layer closed by continuous interlocking
stitches using Chromic 1.
c. Third (Vesico-uterine folds) closed by simple continuous
ANTERIOR COLPORRHAPY
stitches using chromic 2-0.
1. Induction of anesthesia.
17. Suction of blood and amniotic fluid and sponge done.
2. Patient is placed in dorsal lithotomy position.
18. Inspection of the ovaries, fallopian tubes and ligaments
3. Asepsis/Antisepsis
19. Parietal peritoneum closed with continuous suture using chromic 2-0
4. Drapings done leaving the operative site exposed
20. Transversalis fascia sutured with continuous interlocking stitches using
5. Evacuation of urine using straight catheter.
Vicryl 1-0
6. The lateral edges of the vaginal cuff are held with Allis. Several Allis
21. Subcutaneous tissue sutured simple interrupted stitches using Plain 2-0
clamps are placed 3-4 cm apart up the midline of anterior vaginal wall.
22. Skin closed by subcuticular stitches using Vicryl 4-0.
7. The vaginal mucosa is undermined for approximately 3-4 cm up to first
23. Incision site painted with betadine
Allis clamps placed in midline.
24. Top dressing applied.
8. The vaginal mucosa is dissected off the pubovesical cervical fascia and
25. End of procedure.
opened with scissors in the midline. The vaginal mucosa is opened in
midline up to next Allis clamp. This is continued until the vagina is opened
to within 1 cm of urethral meatus.
9. The PVC fascia is separated from the vaginal mucosa. The dissection is
continued until bladder and urethra are separated from the vaginal
REPEAT LOW TRANSVERSE CESAREAN SECTION
mucosa and clearly identified and urethral vesical angle has been
1. Induction of spinal anesthesia.
ascertained.
2. Patient in supine position.
10. Kelly plication done with chromic 2-0. The anterior repair is started by
3. Insertion of foley catheter.
placing suture in PVC fascia, starting at the level of first Kelly placation
4. Asepsis/Antisepsis
suture
5. Drapings done, exposing operative site.
11. The edges of vaginal mucosa retracted laterally with Allis clamps and
6. Old scar removed. Vertical incision done from 2 FB above the symphysis
remaining PVC fascia is plicated in midline with multiple interrupted
pubis up to 3 FB below the umbilicus. Incision deepened to subcutaneous
mattress sutures. The edge of vaginal mucosa are held in tension and
tissues and transversalis fascia, rectus muscle split, peritoneum cut
excessive mucosa trimmed.
longitudinally.
12. The vaginal mucosa is sutured in midline down to previously incised site by
7. Bleeders clamped and ligated as encountered
continuous interlocking suture.
8. Retractors applied exposing pelvic structures.
13. Perineal wash done
9. Vesico-uterine folds identified, lifted out and cut 1 cm above the bladder.
14. End of procedure.
10. Bladder pushed downward and a curvilinear incision is done on the lower
uterine segment using bandage scissors.
11. Rupture of membranes.
12. Amniotic fluid suctioned and fetal head exposed.
13. Delivery of baby boy in left occiput transverse position.
14. Umbilical cord doubly clamped and cut.
15. Manual extraction of placenta.
16. Closure of incision site done layer by layer
a. First (endometrial) layer closed by continuous interlocking
stitches using Chromic 1.
b. Second (myometrial) layer closed by continuous interlocking
stitches using Chromic 1.
c. Third (Vesico-uterine folds) closed by simple continuous
POSTERIOR COLPORRHAPY
stitches using chromic 2-0.
1. Induction of spinal anesthesia.
17. Suction of blood and amniotic fluid and sponge done.
2. Patient is placed in dorsal lithotomy position.
18. Inspection of the ovaries, fallopian tubes and ligaments
3. Asepsis/Antisepsis
19. Parietal peritoneum closed with continuous suture using chromic 2-0
4. Drapings done leaving the operative site exposed
20. Transversalis fascia sutured with continuous interlocking stitches using
5. Allis clamps are applied at the posterior vaginal mucosa, elevated creating
Vicryl 1-0
a triangle.
21. Subcutaneous tissue sutured simple interrupted stitches using Plain 2-0
6. A transverse incision made at the posterior fourchette. A portion of the
22. Skin closed by subcuticular stitches using Monocryl 4-0.
posterior vaginal mucosa is elevated using an Allis clamp and an index
23. Incision site painted with betadine
finger covered with gauze is inserted upward and laterally, dissecting the
24. Top dressing applied.
posterior vaginal mucosa of the perirecteal fascia.
25. End of procedure.
7. Vertical incision in posterior vaginal mucosa made. Perirectal fascia
dissected off the posterior vaginal mucosa. The apex of triangle held with
Allis clamp. The dissection of perirectal fascia off the vaginal mucosa is
started with scalpel but is completed with blunt dissection.
8. Kelly plication sutures with vicryl 2-0 through the margins of levator ani
muscles from apex down to posterior fourchette is done and progressively
tied.
ENDOCERVICAL POLYPECTOMY
9. The excess posterior vaginal mucosa trimmed.
1. Induction of labor.
10. The perineal fascia closed with interrupted vicryl 2-0
2. Sepsis/Antisepsis/drapings done leaving operative site exposed.
11. Vicryl 2-0 suture is placed at the apex of vaginal mucosa using continuous
3. Insertion of straight catheter to empty the urinary bladder.
interlocking stitches to posterior fourchette.
4. Posterior vaginal retractor positioned, endocervix identified.
12. Vaginal packing done with 1 os.
5. Anterior lip of the cervix grasped with tenaculum forceps.
13. Perineal wash done.
6. Endocervical polyp found.
14. End of procedure.
7. Polyp grasped, twisted, and removed using an ovum forcep.
8. Vaginal packing inserted.
9. End of procedure.
1’ LOW TRANSVERSE CESAREAN SECTION (PFANNENSTIEL)
1. Induction of spinal anesthesia.
2. Patient in supine position.
3. Insertion of foley catheter.
4. Asepsis/Antisepsis
5. Drapings done, exposing operative site.
6. Curvilinear incision done from 2 FB above the symphysis pubis up to 3 FB
below the umbilicus. Incision deepened to subcutaneous tissues and
transversalis fascia, rectus muscle split, peritoneum cut longitudinally.
7. Bleeders clamped and ligated as encountered
8. Retractors applied exposing pelvic structures.
9. Vesico-uterine folds identified, lifted out and cut 1 cm above the bladder.
10. Bladder pushed downward and a curvilinear incision is done on the lower
uterine segment using bandage scissors
11. Rupture of membranes.
12. Amniotic fluid suctioned and fetal head exposed.
13. Delivery of live full term baby boy in left occiput transverse position.
14. Umbilical cord doubly clamped and cut.
15. Manual extraction of placenta.
16. Closure of incision site done layer by layer
a. First (endometrial) layer closed by continuous interlocking
stitches using Chromic 1.
b. Second (myometrial) layer closed by continuous interlocking
stitches using Chromic 1.
c. Third (Vesico-uterine folds) closed by simple continuous
stitches using chromic 2-0.
17. Suction of blood and amniotic fluid and sponge done.
18. Inspection of the ovaries, fallopian tubes and ligaments
19. Parietal peritoneum closed with continuous suture using chromic 2-0
20. Transversalis fascia sutured with continuous interlocking stitches using
Vicryl 1-0
21. Subcutaneous tissue sutured simple interrupted stitches using Plain 2-0
22. Skin closed by subcuticular stitches using Vicryl 4-0.
23. Incision site painted with betadine VAGINAL HYSTERECTOMY
24. Top dressing applied. 1. Induction of anesthesia.
25. End of procedure. 2. Patient is placed in dorsal lithotomy position.
3. Asepsis/Antisepsis
4. Drapings done leaving the operative site exposed
TAHBSO 5. Evacuation of urine using straight catheter
1. Induction of spinal/epidural anesthesia 6. Vaginal mucosa is incised with a scalpel around the entire cervix.
2. Patient in supine position. 7. Downward traction is applied using tenacula, Metzenbaum used to dissect
3. Insertion of foley catheter done. the bladder off the anterior lower uterine segment.
4. Asepsis/Antisepsis 8. A sponge covered finger dissects the bladder all the way up to the
5. Drapings done leaving operative site exposed. vesicouterine fold, facilitates entry to anterior cul de sac.
6. Midline incision done from symphysis pubis up to 2 FB below the umbilicus 9. Right angle retractor is placed under the vaginal mucosa and bladder,
cutting through skin, subcutaneous tissue and fascia, rectus muscle split elevating the bladder. Strong downward traction is applied to the tenacula
and peritoneum incised. on the cervix, and the peritoneal vesicouterine fold is grasped with Allis
7. Bleeders clamped and ligated as encountered. clamps and incised with sharp curved mayo scissors.
8. Self retaining and bladder retractors were applied to expose pelvic 10. Elevating the peritoneal vesicouterine fold with Allis clamps, definite hole
structures. can be seen. Finger is inserted in the hole.
9. Moist pack applied. 11. Tenacula are brought acutely up toward the pubic symphysis, exposing the
10. Inspection of the pelvic structures done. cul- de-sac, second right angle at posterior cul-de-sac
11. Abdominopelvic structures examined revealed that the uterus measures 12. The posterior vaginal retractor is removed. The broad ligament is exposed
8x7cms with smooth serosa. Both ovaries grossly normal .Both measures from the uterosacral ligaments to the tuboovarian ligament. A finger is
3x2 cm. Left fallopian tube dilated to 7x3 cm and its ampullary area placed in the posterior cul-de-sac and moved laterally revealing the
containing serous fluid. Right fallopian tube with small cystic paratubal uterosacral ligament as it attaches to the lower uterine cervix.
masses ~1x1cm. 13. With the cervix on upward and lateral retraction using the tenacula, a clamp
12. Right round ligament is doubly clamped, then cut and ligated with Chromic is placed in the posterior cul-de-sac with one blade underneath the
1. The same procedure is done on the opposite side. uterosacral ligament, and the opposite blade over the uterosacral ligament.
13. Anterior and posterior leaves of the broad ligament opened. Anterior leaf of This is done to prevent possible ureteral damage from clamping the
the broad ligament incised to the point of bladder reflection. ligaments in lateral position.
14. Infundibulopelvic ligament triply clamped, cut and doubly ligated using 14. Uterosacral ligament is cut using the mayo scissors.
Chromic 1-0. 15. Chromic 1-0 suture is used to suture ligate the uterosacral ligament.
15. Vesicouterine folds cut transversely 16. When tied, the suture is held with a Kelly clamp for traction.
16. Bladder dissected by blunt and sharp dissection. 17. With uterus on upward and lateral retraction using the tenacula on the cervix,
17. Uterine arteries triply clamped, cut and doubly ligated with Chromic 1-0 on cardinal ligaments is clamped adjacent to the lower uterine segment and
both sides. incised.
18. Pubovesical fascia incised and pushed down with use of sponge 18. Cardinal ligaments is sutured ligated with Chromic 1-0 suture. Suture is held
19. Cardinal ligaments clamped, cut and suture ligated with Chromic 1-0. with a Kelly clamp for traction
20. Amputation of cervix at level of cervical os. 19. The remaining portion of the broad ligament attached to lower uterine cervix
21. Betadinized OS inserted to the vaginal stump. segment containing the uterine artery is clamped and ligated.
22. Closure of vaginal stump with continuous interlocking suture using Vicryl 1- 20. With all the ligaments on both sides, clamped and ligated, cervix is retracted
0. Stump angles are anchored to the cardinal ligaments on both sides with upward in midline with the tenacula. Posterior uterine wall is grasped, the
figure of eight stitches using Vicryl 1-0. fundus is delivered posteriorly.
23. Bleeders clamped and ligated as encountered. 21. Two cochers clamps are applied to the tubo ovarian round ligaments, incised
24. Parietal peritoneum closed with continuous stitches using chromic 2-0. close to the fundus.
25. Transversalis fascia sutured with continuous stitches using vicryl 1-0. 22. Infundibulo-pelvic ligament is tied twice using Vicryl 1.0. Second suture
26. Subcutaneous tissue closed with simple interrupted stitches with Plain 2-0. ligation is tied in a fixation stitch, placing the suture in the mid portion of its
27. Skin closed by subcuticular stitches using Monocryl 3-0. pedicle.
28. Operative site painted with betadine 23. The anterior and posterior clamps right angle retractors are removed, and
29. Top dressing done. the weighted posterior retractor is placed in the vagina. Any bleeding from
30. Specimen sent for Histopath. any pedicle is clamped.
31. End of procedure. 24. Cardinal ligaments, uterosacral ligaments and utero ovarian ligaments
anchored at the posterior vaginal mucosa.
25. Reperitonealization of the pelvis, carried out with purse string sutures.
26. Perineal wash done.
27. End of procedure.
CRITERIA FOR TIMING OF ELECTIVE REPEAT CS DELIVERY (At least 1):
 Fetal heart sounds documented for 20 weeks by non-electronic fetoscope
or for 30 weeks by Doppler
EVACUATION CURETTAGE  It has been 36 weeks since a (+) serum/urine hCG pregnancy test was
performed by a reliable laboratory
1. Induction of spinal anesthesia.  An UTZ measurement of the CRL obtained at 6-11 weeks supports a
2. Patient in dorsal lithotomy position. gestational age at least 39 weeks
3. Asepsis/Antisepsis.  UTZ obtained at 12-20 weeks confirms the gestational age of at least 39
4. Drapings done leaving the operative site exposed. weeks determined by clinical history and PE
5. Straight Catheterization done.
6. Right angle retractor applied to expose cervix. CP STATUS
7. Anterior cervical lip grasped with tenaculum forceps at 12 0’clock position.  CP status assessed
8. Hysterometer inserted.  Pls. transfuse available ___ “u” PRBC of px blood after proper
9. Pre-curettage uterine depth measured 9 cms. crossmatching
10. Sharp and dull curettage done in a clockwise manner, evacuated ½ cup of  BT to run initially @ 5-10 gtts/min x 30min then ↑ to 15-20 gtts/min if with
products of conception and placental tissues. no BT rxn
11. Post curettage uterine depth was not measured.
 Maintain IVF x KVO while on BT
12. Perineal washing done.
 BT precautions please
13. Specimen for histopathology.
 Watch for any untoward s/sx such as DOB, pruritus, fever
 Refer prn
 Thank you.
DIAGNOSTIC CURETTAGE
ADMITTING NOTES (Ectopic Pregnancy)
1. Induction of anesthesia.  Cc:
2. Patient in dorsal lithotomy position  Imp:
3. Asepsis/Antisepsis  Please admit pc to ROC under the service of Dr. ___
4. Drapings done leaving operative site exposed  TPR q 4 hours and record
5. Straight catheter was inserted.  NPO temporarily
6. Cervix dilated with Goodell’s dilator  Labs:
7. Retractor applied at posterior & anterior vaginal wall o CBC, APC
8. Application of tenaculum forceps at 12 o’clock position of cervical lip. o CT, BT, PT
9. Insertion of hysterometer to measure pre-curettage uterine depth of 3 o BT w/ Rh
inches. o U/A
10. Blunt curette done in a clockwise manner. Evacuated scanty endometrial o S. Preg test
scrapings.  IVF: D5LR 1L X 8 Hrs
11. Perineal wash done  Meds: None temporarily
12. Specimen sent for histopath  SO:
o Monitor VS, abdominal status hourly
o Refer once lab result is in
FRACTIONAL CURETTAGE o Dr. ___ seen px at ER
o Watch out for any untoward s/sx
1. Induction of anesthesia. o Refer prn
2. Patient in dorsal lithotomy position.
3. Asepsis/Antisepsis.
4. Drapings done leaving operative site exposed. ANESTHESIA
5. Straight catheterization done. Pre-meds:
6. Weight-bearing retractor applied at posterior vaginal wall. Cervix smooth  Cefuroxime (Zegen) 1.5 gms IV
with no erosions.  Omeprazole 20mg IV
7. Application of tenaculum forceps at 12 o’clock position of cervical lip.  Metoclopramide (Plasil) 10mg IV
8. Endocervical curettage done, evacuated minimal endocervical scrapings. Anesthetic Agent: Bupivacaine 15mg + MgSO4 16mg
9. Hysterometer inserted. Pre-curettage uterine depth measured 9cm. Detailed Technique: RA-SAB
10. Endometrial curettage done. Evacuated ½ teaspoon of endometrial
 X-LLDP, SAS
scrapings/tissues and placental tissues.
 LA w/ 2% Lidocain
11. Post curettage uterine depth measured, approximately 8 cm.
 LP at L3 L4
12. Tenaculum and retractors removed.
13. Perineal wash done  CSF clear and free flowing
14. Specimen sent for histopath.  Intrathecal administration of anesthetic
15. End of procedure.
SIGNS OF MALIGNANCY UTZ:
 Septations
COMPLETION CURETTAGE  Internal echoes
 Ascites
1. Induction of anesthesia.  Multiple daughter cysts
2. Patient in dorsal lithotomy position <5 cm cyst  in postmenopausal women expectant management
3. Asepsis/Antisepsis
4. Drapings done leaving operative site exposed
5. Insertion of straight catheter.
6. Speculum applied at posterior vaginal wall
7. Application of tenaculum forceps at 12 o’clock position of cervical lip.
8. Sharp/blunt curette done. Evacuated 1 tablespoon cup of products of
conception.
9. Betadine wash done.
10. End of procedure.
11. Specimen sent for histopathology.

VAGINAL BIRTH AFTER A CESAREAN SECTION (VBAC)


 Allow a trial of labor under double set-up for all previous cesarean of one
low segment incision after excluding an inadequate pelvis and unless a
new indication arises
 Selection Criteria:
o 1 or 2 prior low-transverse cesarean section delivery
o Clinically adequate pelvic
o No other uterine scars or previous rupture
o Physicians immediately available throughout active labor
capable of monitoring labor and performing an emergency
cesarean section delivery
o Availability of anesthesiologist and personnel for emergency
cesarean section delivery
PIPERACILLIN TAZOBACTAM
Mode of Action:
 Highly active against piperacillin-sensitive microorganisms as wells as B-
lactamase-producing piperacillin-resistant microorganisms
Indication:
 For UTI, lower resp tract, intraabdominal & skin infections & septicemia
Side effects:
 Upset stomach, vomiting, unpleasant or abnormal taste, diarrhea, gas,
headache, constipation, insomnia, rash, itching skin, swelling, shortness of
breath, unusual bruising or bleeding

CgMg (CALMAG)
Mode of action:

Indication:
 Calcium deficiency, nutritional supplement to prevent osteoporosis
Side effects:

ISOXUPRINE HCl (Duvadilan)


Mode of Action:

Indication:
 Treatment of circulatory disorders and uterine hypermotility
Side effects:
 Transient palpitations, fall in BP, dizziness

DYDROGESTERONE (Duphaston)
Mode of Action:
 Orally active progesterone
 Promotes pregnancy in case of luteal insufficiency for maintaining
pregnancy in threatened and habitual abortions
Indications:
 Dysfunctional uterine bleeding, irregular cycles, threatened and habitual
abortion, infertility, premenstrual syndrome, endometriosis, dysmenorrheal
Side effects:
 Breakthrough bleedings, hemolytic anemia, edema, asthenia or malaise,
jaundice and abdominal pain

METOCLOPRAMIDE (Plasil)
Mode of Action:
 Stimulates motility of the upper GIT w/o stimulating gastric, biliary or
pancreatic secretions
 Sensitization of tissues to action of acetylcholine
Indications:
 For disturbances of GIT motility, GERD, diabetic gastroporesis, nausea,
vomiting, migraine HA
Side effects:
 Restlessness, drowsiness, fatigue, lassitude

Percentage risk of becoming malignant

Simple hyperplasia without atypia- 1%


Complex hyperplasia without atypia- 3%
Simple hyperplasia with atypia- 8%
Complex hyperplasia with atypia- 29%