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ELECTROLYTE SOLUTIONS

IV Soln
D5W
D10W
0.9 NSS
D5LR
D5NM
D5NR
D5 0.9
NaCl
D5NMK

Glu
5mg/L
100mg/L

Soln
ECF
D5LR
D5 0.45
3% NaCl
0.9 NaCl

ELECTROLYTES

Na

Cl

Ca

HCO3

154
130
40
140

154
109
40
98

4
13
5

28

50 mg/L

40

40

30

Na
142
130
77
513
154

Cl
103
109
77
513
154

K
4
4

HCO3
27
28

a)
b)
c)
d)

50 mg/L

Corrected Ca = (40-lbs) x 0.02 + serCa


Corrected Na = Na + RBS mg% - 100 x 1.6 / 100
Na Deficit = (140 actual) (0.6 x BW)
K Deficit = (D-A) (0.4 x BW)
D = 3.5 cardiac
4.5 non-cardiac
H20 Deficit = 0.6 x kg BW
D = 15 CKD
18 NCKD
Actual Na Desired Na / Desired Na

Ca
5
5

D5W Osm = 278


D5W Osm = 556
D5LR Osm = 130
NaHCO3 = 446

MECHANICAL VENTILATION

Mg
3
CUSHINGS TRIAD
1)
2)
3)

Increase systolic BP
Widened pulse pressure
Bradycardia /AbN respiratory pattern
a.
Cheyne Stoke breathing

HEMORRHAGIC STROKE TRIAD


1)
2)
3)

Papilledema
Headache
Vomiting

Indication for Intubation


1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)

Impending respiratory failure, apnea


RR >35
PaCO2 > 50
PaO2 <60
TV < 3-5 ml/kg
VC < 10-15 ml/kg
Inspiratory force < 25 cm H20
FEV < 10 ml/kg
Vq / Vt > 0.6
To deliver high FIO2
Absent
pH <7.35

VENTILATOR SETTING
1)
2)
3)
4)
5)

TV: 6-8 ml/kg (ARDS) 8-10 ml/kg


Pale: 6-20
Mode:
AC (Assist Control)
SIMV (Synchronized Intermittent 1 mV
FIO2
PEEP 5cm H20

INDICATIONS FOR WEANING


1)
2)
3)
4)
5)
6)
7)
8)
9)
10)

Mental status: Awake, Alery


PaCO2 > 60 mmHg w/ FIO2 < 50%
PEEP < 5 cm
PaCO2 < pH acceptable
Spontaneous TV < 5mL
VC > 10 ml/kg
MIP > 25 cm H20
RR < 30/min
Rapid shallow breathing index < 100 (RBI)
Stable vs. Ft a 1-2 hr

Spontaneous Trial
FIO2 room air 21%
O2 via nasal prong = # lpm x 0.4 x 20

MEIGS SYNDROME
1)
2)
3)

Pleural Effusion
Polycystic Ovary / Fibromatosis
Hypoalbuminemia

GLASCOW COMA SCALE


EYE RESPONSE
a) Spontaneous eye opening
b) Opens to verbal command
c)
Responds to painful stimuli
d) No response
MOTOR
a)
b)
c)
d)
e)
f)

Obeys with command


Localizes pain
Flexion withdrawal
Decorticate / Flexion
Decerebrate / Extension
No response

VERBAL
a)
b)
c)
d)
e)

Oriented
Disoriented
Inappropriate
Incomprehensible
No response

4
3
2
1

6
5
4
3
2
1

5
4
3
2
1

FOUR SCALE
Full outline of responsiveness

DOPAMINE COMPUTATION

EYE RESPONSE
a) Eyelids open, tracking, blinking to command 4
b) Eyelids open but not tracking
c)
Eyelids close but open to loud voice
d) Eyelids close but no pain
e) Eyelids close with pain

3
2
1
0

MOTOR RESPONSE
a) Thumbs up, fist or peace sign
b) Localizing to pain
c)
Flexion response to pain
d) Extension response to pain
e) No response to pain or generalized myoclonus

4
3
2
1
0

BRAINSTEM REFLEXES
a)
Pupil and Corneal reflex
b) One pupil wide and fixed
c)
Pupil or corneal reflex absent
d) Pupil and corneal reflex absent
e) Absent pupil, corneal and cough reflex

4
3
2

Single strength = BW x desired dose / 13.3


Double strength = BW x desired dose / 16.6
Single strength = BW x desired dose / 16.6
Double strength = BW x desired dose / 33.2
Cardiac Dose = 5
Renal Dose = 5-10

CT SCAN BLEED VOLUME


Given:

58 mm
~
23.3 mm ~

5.8
2.3

5.8 x 2.3 = 13.34 x 5 (constant) = 66.5 x 5.2 (constant) = 34.684 -(estimated


bleeding volume)

1
0

RESPIRATION
a) Not intubated, regular breathing pattern 4
b) Not intubated, cheyne-stoke breath pattern 3
c)
Not intubated, irregular breathing
d) Breath above ventilation rate
e) Breath at ventilation rate, apnea
0

DIAGNOSTIC THORACENTESIS DUE TO HEART FAILURE

2
1

1)
2)
3)
4)

If the effusion are not bilateral and comparable size


If the patient is febrile
If the chest has a pleuritic chest pain
If effusion persist despite the diuretics therapy

DENGUE
GRADE I

INDICATION FOR CHEST TUBE THORACOSTOMY


Fever
Non-specific symptoms
o
Anorexia
o
Vomiting
o
Abdominal pain
(+) Torniquet test

1)
2)
3)
4)
5)
6)

Pneumothorax
Pleural effusion
Chylothorax
Empyema
Hemathorax
Hydrothorax

GRADE II

Grade I + spontaneous bleeding


GRADE III

Grade II + severe bleeding + circulatory failure


GRADE IV

Grade III + irreversible shock + massive bleeding

ABG COMPUTATION
I.
II.
III.

713 (decimal FIO2) PCO2/0.8 = I


pO2/I = II
(Desired FIO2/II) + pCO2/0.8
________________________
713

x 100

TIMING OF TUBE REMOVAL

The timing of tube removal depends on clinical and radiological


evidence of complete expulsion of all contents of pleural cavity
with complete expansion of the lung

Minimal drainage should have occurred over the previous 24


hours (<25 ml/kg)

When the patient coughs or performs the valsalva maneuver no


air leak should ensue

The chest radiograph should confirmed complete expansion of


the lung

The s____ in the fluid in the tube in the underwater seal bottle
should be minimal, relating to the normal negative pressured in
the chest during the phases of respiration

Desired FIO2 = 104 (0.43 x age)


A.
B.
C.

713 x FIO2 PCO2/0.8


pO2 / A
02 for age / B
+
pC02 / 0.8
________________________________
713

FIO2: 20 / 4 = L

INDICATIONS FOR CTT

Gross pus on thoracentesis

Presence of organism on gram stain of the pleural fluid

Pleural fluid glucose < 50 mg / dL

Pleural fluid pH below 7.00 and 0.15 units lower than arterial pH

LIGHTS CRITERIA
1)
2)
3)

LOCATING MYOCARDIAL DAMAGE

Pleural fluid protein / serum protein > 0.5


Pleural fluid LDH / serum LDH > 0.6
Pleural fluid LDH > 2/3 the upper limit of normal serum LDH

Anterior = V2-V4 (L) coronary, LAD


Anterolateral = I, qV1, V3 V6, LAD, circumflexes
Anteroseptal = V1-V4, LAD

TRANSUDATIVE VS EXUDATIVE FLUID


Inferior = II, III, aVF, (R) coronary artery

SG
Protein
FP / SP
LDH
FLDH/SLDH
Cholesterol

Transudative
< 1.012
< 3 g/dL
< 0.5
<60%
<0.6
<45 mg / dL

Exudative
> 1.020
>3 g / dL
>0.5
>60%
>0.6
>45 mg / dL

Lateral = I, aVL, V5, V6, circumflex brance of (L) coronary artery


Posterior = V8 V9 (R) coronary artery, circumflex artery
(R) Ventricular = V4R, V5R, V6R, (R) coronary artery

JONES CRITERIA OF RF
Major:

Carditis
Polyarthritis
Chorea
Erythema marginatum
Subcutaneous nodule

Minor:

Fever
Polyarthralgia
Lab: Inc. ESR / Leukocyte count
ECG: Prolong P-R interval
Elevated anti-streptolysin O, other strep antibody
(+) throat culture
Rapid Ag test for Group A
Strep / result: Scarlet Fever

TB CLINICALLY ACTIVE
Clinical, bacteriologic, or radiographic evidence of current
disease

Criteria:

2 major/one minor and 2


(+) evidence of preceding Group A strep infection

Class 4

TB NOT CLINICALLY ACTIVE


History of episode of TB
Abnormal but stable radiographic findings
No clinical or radiographic evidence of current disease

ACUTE RESPIRATORY FAILURE

Class 5

TB SUSPECT
Diagnosis pending
TB disease should be ruled out within 3 months

CLASSIFICATION OF PTB
Class O

NO PTB EXPOSURE
Not infected

Class 1

HISTORY OF EXPOSURE
Neg. Skin test to tuberculin

Class 2

TB INFECTION
No disease
Positive reaction to tuberculin test
No clinical, bacteriologic or radiographic evidence of TB

Class 3

TYPE I or Acute Hypoxemic Respiratory Failure

Occurs when alveolar flooding and subsequent intrapulmonary


shunt physiology occurs

Alveolar flooding may be a consequence of pulmonary edema,


pneumonia or alveolar hemorrhage

Low pressure pulmonary edema

Defined by diffused bilateral airspace edema

Signs and Symptoms of TB

Fever

Night sweats

Weight loss

Anorexia

Weakness

General Malaise

TYPE II Respiratory Failure

Occurs as a result of alveolar hyperventilation and results on the


inability to eliminate CO2 effectivity

Mechanism by which this occurs are categorized by impaired CNS


drive to breath, impaired strength with failure of neuromuscular
function in the respiratory ____

Reason for diminished CNS drive to breath including drug


overdose, brainstem injury, sleep disordered breathing

RECOMMENDED DOSAGE FOR INITIAL TREATMENT OF TB

Overload Respiratory System due to:

Increase resistive loads (bronchospasms)

Reduced lung compliance (alveolar edema)

Reduced chest wall compliance (pneumothorax)

Increase minute ventilation (pulmonary embolus)

1)
2)
3)
4)

Isoniazid = 5 mg/kg, max 300 mg


Rifampicin = 10 mg/kg, max 600 mg
Pyrazinamide = 20-25 mg/kg, max 2 g
Ethambutol = 15-20 mg/kg

TYPE III Respiratory Failure

Occurs as a result of lung atelectasis

Also called perioperative respiratory failure

After general anesthesia, decreases in functional residual capacity


of dependent lung units
TYPE IV Respiratory Failure

Due to hypoperfusion of respiratory muscles in patients in shock,


due to pulmonary edema, lactic acidosis, anemic

DEFINITIONS USED TO DESCRIBE THE CONDITION OF SEPTIC PATIENTS

BRONCHIECTASIS

Is an abnormal and permanent dilatation of bronchi

Associated with destruction and inflammatory changes in the wall


of the medium sized airways often at the level of segmental or
subsegmental bronchi

The dilated airways frequently contain pools of thick purulent


material, while more peripheral airways are often occluded by
secretions or obliterated and replaced by fibrous tissue

As the result of inflammation it produces airway damage,


impaired clearance of microorganism resulting to vascularity of
the bronchial wall increases with associated enlargement of the
bronchial arteries and anastomoses between the bronchial and
pulmonary arterial circulation

Bacteremia

Presence of bacteria in blood as evidenced by positive blood


culture
Septicemia

Presence of microbes and their toxins in the blood


SIRS

Sepsis

Systemic inflammatory response syndrome


Two or more of the following conditions:
o
Fever (oral temp >38C) or hypothermia (<36C)
o
Tachycardia (>90 bpm)
o
Tachypnea (>24 bpm)
o
Leukocytosis (>12,000/uL) or Leukopenia (<4,000/uL)
or > 10% bands may have a non-infectious etiology

SIRS that has proven or suspected microbial etiology

Severe Sepsis

Similar to sepsis sepsis syndrome

Sepsis with one or more signs of organ dysfunction


Examples
1)

2)
3)
4)
5)

6)

Cardiovascular: Arterial systolic blood pressure <90 mmHg or


Mean Arterial Pressure 70 mmHg that responds to
administration of IV
Renal: Urine output <0.5 ml/kg/hr for 1 hour despite adequate
fluid resuscitation
Respiratory: PaO2/FIO2 <250 or if the lung is the only
dysfunctional organ 200
Hematologic: Platelet count <80,000/uL or 50% decrease in
platelet from highest value recorded over the previous 3 days
Unexplained metabolic acidosis: a pH 7.30 or a base deficit 5.0
meq/L and a plasma lactate level >1.5 times upper limit of normal
for reporting
Adequate fluid resuscitation: Pulmonary artery wedge pressure
12 mmHg or Central Venous pressure 8 mmHg

Septic Shock

Sepsis with hypotension (arterial blood pressure of 90 mmHg or


MAP > 70 mmHg
Refractory Septic Shock

Septic shock that last > 1 hour and does not respond to fluid or
pressure administration
Multi-organ Dysfunction Syndrome

Dysfunction of more than 1 organ requiring intervention to


maintain homeostasis

INDICATIONS FOR INITIATING HEMODIALYSIS

Failure of conservative management

Management to relieve
a) Pulmonary congestion (unresponsive to high dose
furosemide)
b) Severe metabolic acidosis
c)
Severe hyperkalemia

BUN >100 mg/dL or creatinine >10mg/dL

Note: For acute renal failure it is best to start dialysis early

RHEUMATIC ARTHRITIS

Require 4 out of 2 criteria:


o
Morning stiffness
o
Arteritis of 2 or more joints
o
Arteritis of hands and joints
o
Systemic arthritis
o
Rheumatoid nodule
o
Serum Rheumatoid factor
o
Radiographic changes

CHILD-PVGH CLASSIFICATION OF CIRRHOSIS


Factor
s. Bilirubin

Units
umol / L
mg / dL
g/L
g / dL
sec
INR

s. Albumin
Protime
Ascites
Hepatic
encephalopathy

1
<34
<2
>35
>3.5
0-4
<1.7
None
None

2
34-51
2-3
30-35
3.0-3.5
4-6
1.7-2.3
Easily
controlled
Minimal

Calculated by adding the score of the 5 factor and can range from
5 15

CHILD-PVGH Class is either:


A. Score of 5 6
B. Score of 7 9
C. Score of 10 or Above
Decomposition

indicate cirrhosis

N/A

CHILD PVGH Score of 7 or more


Class 8

3
>51
>3
<30
<3
>6
>2.3
Poorly
controlled
Advanced

Listing for liver transformation (accepted criteria)

Hepatic Fibrogenesis

Stellate cell activation

Collagen production

CLINICAL STAGE OF HEPATIC ENCEPHALOPATHY

Stage I
Stage II
Stage III
Stage IV

MS
Euphoria, depression, mild confusion, slurred speech,
disturbance in sleep
Lethargy, moderate confusion
Marked confusion, incoherent speech, sleeping but arousable
Coma, initially responsive to noxious stimuli, ____ response

COMPLICATIONS OF ERCP
1)
2)
3)
4)

Infection
Perforation
Pneumothorax
Bleeding

NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION


CLASS I

No limitation of physical activity


No symptoms with ordinary exertion

CLASS II

Slight limitation of physical activity


Ordinary activity causes symptoms

CLASS III

Marked limitation of physical activity

Less than ordinary activity causes symptoms

Asymptomatic at rest
CLASS IV

Inability to carry out any physical activity without discomfort

Symptomatic at rest

MUSCLE STRENGTH
O No muscular contraction
1 Trace contraction
2 Active movement with gravity eliminated
3 Active movement against gravity
4 Active movement against gravity & slight resistance
5 Against full resistance

IDEAL PEAK FLOW


Ideal peak flow: Hg (m) 100 x 5 (+) 175 (M) (+) 170 (F)
N 80%
PEFR = Peak flow reading / Ideal peak flow x 100 = _____ %
N 20%
PEFR variability: Highest reading Lower x 100 = ______ %
Highest Reading

GRADING OF MURMURS
1 Faint
2 Audible
3 Moderately Loud
4 Loud with palpable thrill
5 Loud with thrill, stet partially off
6 Loud with thrill, w/o stet

BLOOD TRANSFUSION

CP status assessed
VS checked
Please transfuse available _____ unit of patients blood type after
proper cross matching
Run BT @ 5-10 gtts/min for 30 mins then to titrate @ 15-20
gtts/min with no BT reactions
Mainline to KVO while on BT
Monitor VS q15 mins while on BT
Refer for any BT reactions such as fever, chills, dyspnea,
hypotension and pruritus
Refer accordingly

FRAMINGHAM CIRTERIA FOR DIAGNOSIS OF CHF


MAJOR CRITERIA

Paroxysmal Nocturnal Dyspnea

Neck vein distention

Rales

Cardiomegaly

Acute pulmonary edema

S3 gallop

Increased venous pressure (>16 cmH20)

Positive hepatojugular reflux


MINOR CRITERIA

Extremity edema

Night cough

Dyspnea on exertion

Hepatomegaly

Pleural effusion

Vital capacity reduced by one-third from normal

Tachycardia (>120 bpm)


MAJOR OR MINOR

Weight loss of >4.5 kg over 5 days treatment

History

General data
Chief complaint
PMHx
PSHx
FMHx
OBHx
o
Menarche
o
Interval
o
Duration
o
Amount
o
Symptoms
o
Coitarche
o
Menopause
o
OCP, S/P, PAP, Intermenstrual bleeding
o
Postcoital bleeding
o
OB Score
o
LMP, EDC, AOG
o
PNCU
o
HBsAg/VDRL
o
TT/BT/MTV
o
UTI

NSVD Admitting Notes

Please admit to ROC under the service of _____

TPR q 4 hours and record

Full diet, NPO once in active labor

Labs:
o
CBC
o
HBsAg
o
Urinalysis

IVF: D5LR + 10 u oxytocin to run at 10-15 gtts/min

Meds
o
Ampicillin 2g IV ANST if PROM

SO:
o
Monitor FHB and progress of labor
o
Puboperineal shave please
o
Inform NROD
o
Will inform service consultant on deck
o
Refer prn
o
Thank you

Side notes
o
TPR
o
BP
o
Wt
o
LMP
o
EDC
o
AOG
o
FH
o
FHB
o
CD
o
Effacement
o
Station
o
BOW
o
Leopolds

Final Dx:
o
PU FT del via NSVD/1LTCS/Rpt CS in cephalic
presentation to a live Bb Girl/Boy with BW: BL: AS:
PAOG: OB score

POSTPARTUM ORDERS

Back to room/ward

Full diet once full awake

Present IVF to run at 30 gtts/min, D/C if with minimal VB

IVF to ff: D5LR + 10 u Oxy to run at30 gtts/min

Meds:
o
Antibiotics
o
MA 500 mg/cap q 8 H RTC x 24 H, then prn for pain
o
Methergin 1 tab TID x 3 days
o
Viitamins

SO:
o
o
o
o
o
o
o
o

Monitor VS q 15 min until stable


Massage uterus prn
Ice pack on hypogastrium
Perilight x 15 min OD
Routine perineal care
Watch out for profuse vaginal bleeding
Refer accordingly
Thank you

DISCHARGE ORDERS (Normal OB)

MGH

Home Meds

OPD ff-up on Sat @ OB service clinic with photocopy of D/S

Discharge IE and summary c/o ___

TCB anytime if with profuse VB, HA, blurring of vision, U2W ssx
CS ADMITTING NOTES

Please admit to ROC under the service of _____

TPR q 4 hours and record

Full diet, NPO post midnight

Labs:
o
CBC, APC
o
CT, BT, PT
o
Urinalysis

Venoclysis

Meds:
o
Cefazolin 500mg IVTT q8H x 3 doses then shift to CoAmox 625mg/tab, 1 tab BID
o
Famotidine 20mg IVTT q8H x 3 doses
o
Ketomed 30mg IVTT q8H x 3 doses
o
Ketomed 10mg q8H to start if px is on soft diet
o
Tramadol 50mg IVTT q6H prn

Inform OR

Secure signed consent

Abdominoperineal prep please

Request 500cc FWB of patients blood type as standby

Dr. ___ for anesthesia

Inform NROD

Refer accordingly

Thank you

POST-OP ORDERS

To RR

Monitor VS q15 mins until stable

NPO x 6 H, then may have sips of CL

O2 at 2-3 LPM via nasal prong

Run present IVF @ 30 gtts/min

IVF to ff:
o
D5LR
+ 10 u oxytocin x 8 H
o
D5NM
o
D5LR x 8 H

Meds:
o
Antibiotics
o
Ranitidine (Zantac) 50mg IVTT q8H x 3 doses

SO:
o
Attach px to O2 at 2-3 LPM via nasal prong
o
Attach pc to pulse ox
o
MIO q H and record
o
Refer if UO is <30cc/H
o
Remove FC 24H post op
o
Standby available blood
o
Apply abdominal binder
o
Morphine precaution please
o
Specimen for histopathology
o
Watch out for profuse vaginal bleeding, hypotension,
tachycardia or any untoward s/sx
o
Refer PRN
o
Thank you


TRANS-OUT
Side notes the ff:

Stable VS

Able to flex both legs

(-) vomiting

Blurring of vision
Orders

May refer back to room

D/C O2 and pulse oximeter

Monitor V/S q 15 min until stable

MIO q Hly (+ FC) or shift (- FC) and refer if UO <30 cc/H

Watch out for profuse vaginal bleeding, hypotension, tachycardia


or any untoward s/sx

Refer accordingly

Thank you

ADMITTING ORDERS (Abdomen)

Please admit to ROC under the service of Dr. ____

TPR q shift and record

NPO

Labs:
o
CBC (save serum)
o
Serum pregnancy test
o
Urinalysis

IVF: D5LR + 10 u oxytocin x 30 gtts/min

SO:
o
For completion curettage on call
o
Secure consent
o
Pad count at bedside
o
Save specimen passed out
o
Please prescribe the ff: Nubain, Benadryl, Dormicum
o
Refer for profuse bleeding and other untoward ssx
o
Thank you

POST OP ORDERS (TAHBSO)

To RR

Monitor VS q 15 min, until stable

Flat on bed x 6 H, then may turn to side

NPO x 6 H then may have sips of CL

Present IVF x 30 gtts/min

IVF to ff:
o
D5LR
+ 10 u oxytocin x 8 H
o
D5NM
o
D5LR x 8 H

Meds:

SO:
o
MIO q H and record
o
Refer if UO is <30cc/H
o
May return blood
o
Remove FC @ ___
o
Apply abdominal binder
o
Refer PRN
o
Thank you
PELVIC EXAM

Inspection
o
Grossly N external genitalia
o
Masses, discharges, bleeding

Speculum
o
Cervix hyperemic/nonhyperremic; fish mouth
deformity/ping pong

IE
o
Cervical dilatation
o
Cervical effacement
o
Station
o
BOW (intact/leaking)
o
Amniotic membrane PROM x days/hours
o
Presenting part

Clinical pelvimetry
o
Inlet
o
Midplane

Ischial spines

Sacrum

Sidewalls
o
Outlet
EFW
BME
o
I (introitus) - admits 2 fingers with ease/snugly
o
C (cervix) open/closed,; firm, doughy
o
U (uterus) level of umbilicus
o
A (adnexae) firm/fullness; w/ adnexal masses
o
D (discharges) (+) (-); scanty or minimal bleeding
o
E (episiotomy) with blood/well coaptated wound
RVE
o
Intact rectovaginal septum
o
Good sphincter tone
Abdomen
o
Inspection: globular/gravid; linea nigra, striae
o
Auscultation: NABS
o
Palpation: Leopolds
o
FH, FHB R/L
Final Dx:

NON-STRESS TEST

Test of fetal condition


REACTIVE when:

At least 2 accelerations of the FHR occurs for at least 15 bpm,


lasting for 15 sec w/in 20 min period of observation
NONREACTIVE

May imply that the fetus is acidotic, asleep, or drugs was


administered to the mother
A. EARLY DECELERATION

Head compression
B. LATE DECELERATION

Utero-placental insufficiency
C. VARIABLE DECELERATION

Cord compression ; Fetal distress

Most common ; Most ominous

CONTRACTION STRESS TEST/OCYTOCIN CHALLENGE TEST

A measure of utero-placental function

Contraction induced by using IV oxytocin

Record FHB
POSITIVE

Consistent and persistent late deceleration (50%) of the FHB in


the absence of uterine hypertonus or supine hypotension
NEGATIVE

@ least 3 contractions in 10 mins, each lasting 40 secs, w/o late


deceleration
SUSPICIOUS

Inconstant late deceleration patterns


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

HYPERTENSION

140/90MMhG
Proteinuria

>300mg/24H urine sample

> 1000mg/random sample 6H apart

1+ = mild proteinuria

2+ to 4+ = heavy proteinuruia
*Edema DOES NOT validate Preeclampsia
GESTATIONAL HPN

HPN w/o Proteinuria (after 20 weeks gestation)

Confirm 12 wks Postpartum


PREECLAMPSIA

(+) HPN, (+) Proteinuria after 20th week


ECLAMPSIA

(+) convulsions, (+) Preeclampsia


CHRONIC HPN

140/90mmHg
SUPERIMPOSED PREECLAMPSIA

Inc diastole and systole

Proteinuria

S/Sx of end organ damage


Triad for Sever Preeclampsia

Hemolysis

Elevated Liver Enzyme

Low Platelet Count


Hypertension etiology(Williams)

Exposed chorionic villi

Twin pregnancy (Multiple gestation)

Vascular dses

Fam hx
THREATENED ABORTION

Bloody vaginal discharge or bleeding appears

Closed vaginal os

Low abdominal pain

Bleeding first, cramping follows


INEVITABLE ABORTION

Gross rupture of membrane

Leaking amniotic fluid

Cervical dilatation
COMPLETE ABORTION

Complete detachment

Int. cervical os closes


INCOMPLETE ABORTION

Int. cervical os opens and allows passage of blood


Mullerian Anomalies

Segmented mullerian agenensis or hyperplasia

Unicornuate uterus

Bicornuate uterus

Septate uterus

Uterus with internal ___? Changes


Induction of labor

Oxy drip but not in labor


Augmentation of Labor

Oxy drip however in labor

PRENATAL CHECK-UPS
0-27 wks
28 wks
29-35 wks
36 wksand beyond
TETANUS TOXOID
0
1
2
3
4

q4wks
q 2wks
q2wks
q week

20 wks AOG
1 month
6 months
1 year
1 year

STEROIDS
1 dose
3 doses
OGTT at 24-28wks

28-32 wks
q 2 wks

MAGNESIUM SULFATE DOSES


Loading dose:
4gms slow IV
5gms each buttocks deep IM
Maintenance dose:5gmsIM/IV q 6hrs
Monitor BP, U/O, DTRs-hyporeflexia
Monitor RR
MgSO4 drip:

1-2gms/hr
1L = 10gm
given 100cc/hr

10meq/L(about 12mg/dL)
>respiratory depression

12meq/L
>respiratory paralysis and arrest
Antidote: Calcium gluconate 1g iV

FETAL DEATH
1.
2.
3.
4.

Tobacco-stained amniotic fluid


Spaldingssign
o
significant overlapping of fetal skull bones
Roberts sign
o
Demonstration of gas bubbles in the fetus
Exaggeration of fetal spinal curvature

BIOPHYSICAL SCORING PARAMETERS


1. Fetal Breathing Movements
2. Gross Body Movement
3. Fetal Tone
4. Reactive FHR
5. Amniotic Fluid
*Perfect Score is 10/10 or 8/8
CBC repeated at 28-32 AOG
HbsAg
last trimester
Alpha fetoprotein
16-18 wks AOG
PLASMA GLUCOSE RESULTS:
(Blood Glucose testing performed at 24-28wks AOG)
Time
NDDG
Coustan & Capenter(mg/dL)
Fasting
105
95
1st Hr
190
180
2nd Hr
165
155
3rd Hr
145
140
LEOPOLDS MANEUVER
L1 (Fundal Grip)
What fetal pole occupies the fundus
L2 (Umbilcal grip)
Fetal back
L3 (Pawlicks grip)
(+) engagement of head or (-) engagement
L4 (Pelvic grip)
Side of cephalic prominence
FUNDIC HEIGHT
12wks-1st felt; above the symphysis pubis
16wks- bet. Symphysis and umbilicus
20wks- umbilicus
36wks- below ensiform cartilage
FHB Monitoring
Every 30mins= low risk
Every 15mins= high risk

BISHOP SCORE
0

1
1-2cm
31-50%
-2
Midline

Dilatation
0
Effacement
0-30%
Station
-5/-3
Cervical
Posterior
Position
Cervical
firm
medium
Consistency
*Scoring: 3-8 difficult induction
9-favorable induction

2
3-4cm
51-70%
-1
Anterior

3
5-6cm
>70%
+1/+2
-----

soft

-----

MYOMA
causes soft tissue dystocia
etiology: unopposed estrogen stimulation
types: Subserous, Intramural, Submucous
ROT-right occiput transverse
Montevideo Units- 200 units or pressure of > 60
Depoprovera- injectable CP is G1 to HPN patients
EXCISION OF BARTHOLINS CYST
Hyperplasia (uterus) provera
Endocervical
For Functional Curettage
Endometrial
Endometrial for D & C
AUGMENTATION OF LABOR
amniotic fluid
Oligohydramnios (causes)
o
Cord compression
o
Macrosomia
o
Deformations
o
Fetal distress
HYOSCINE N-BUTYL BROMIDE (Buscopan) for softening of the cervix
NST: Fetal condition 7 days
CST: Uteroplacental contraction

DELIVERY OF PLACENTA
SHULTZE MECHANISM

Peripheral

Shiny portion
DUNCAN MECHANISM

Central

Dirty part
DEFINE:

Placenta increta invades

Placenta percreta penetrates

Placenta accrete attaches


Normal Rotation of Umbilical Cord:

Counter clockwise or Left-handed maneuver


PLACENTA PREVIA

Types:
o
o
o

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)
o
Previous CS
o
Puerperal Endometritis
o
Advancing age
o
Multiparity
o
Multiple induced abortions
Diagnosis:
o
Painless third trimester bleeding
o
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)
o
Pre-eclampsia
o
External trauma
o
Chronic hypertension
o
Short umbilical cord
o
Sudden uterine decompression
LACERATIONS

1st Degree
o
Fourchette, perineal skin, vaginal mucosa but not the
underlying fascia and muscle

2nd Degree
o
Fascia and muscles of the perineal body but not the
anal sphincter

3rd Degree
o
Extend from vaginal mucosa, perineal skin and fascia
up to anal sphincter but not the rectal mucosa

4th Degree
o
Encompasses extension up to rectal mucosa
BRAXTON HICKS CONTRACTION

The uterus undergoes palpable but originally painless contractions


at irregular intervals from the early stages of gestation
SIGNS OF PLACENTAL SEPARATION

Calkins 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


AMONIOTIC FLUID INDEX

Normal: 6-24 cm

Oligohydramnios: <5 cm

Low normal: 9-10

Polyhydramnios: >24

INDICATIONS FOR CESAREAN SECTION

Prior CS

Labor dystocia (most frequent indication for 1 CS)

Fetal distress

Breech presentation
POST OP COMPLICATIONS OF CS DELIVERY

Hysterectomy

Operative injury to pelvic structures

Infection

Puerperal fever

Transfusion

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

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

ANTERIOR COLPORRHAPY
1. Induction of anesthesia.
2. Patient is placed in dorsal lithotomy position.
3. Asepsis/Antisepsis
4. Drapings done leaving the operative site exposed
5. Evacuation of urine using straight catheter.
6. The lateral edges of the vaginal cuff are held with Allis. Several
Allis clamps are placed 3-4 cm apart up the midline of anterior
vaginal wall.
7. The vaginal mucosa is undermined for approximately 3-4 cm up
to first Allis clamps placed in midline.
8. The vaginal mucosa is dissected off the pubovesical cervical fascia
and 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 mucosa and clearly identified and urethral vesical
angle has been ascertained.
10. Kelly plication done with chromic 2-0. The anterior repair is
started by placing suture in PVC fascia, starting at the level of first
Kelly placation suture
11. The edges of vaginal mucosa retracted laterally with Allis clamps
and remaining PVC fascia is plicated in midline with multiple
interrupted mattress sutures. The edge of vaginal mucosa are
held in tension and excessive mucosa trimmed.
12. The vaginal mucosa is sutured in midline down to previously
incised site by continuous interlocking suture.
13. Perineal wash done
14. End of procedure.

POSTERIOR COLPORRHAPY
1. Induction of spinal anesthesia.
2. Patient is placed in dorsal lithotomy position.
3. Asepsis/Antisepsis
4. Drapings done leaving the operative site exposed
5. Allis clamps are applied at the posterior vaginal mucosa, elevated
creating a triangle.
6. A transverse incision made at the posterior fourchette. A portion
of the posterior vaginal mucosa is elevated using an Allis clamp
and an index finger covered with gauze is inserted upward and
laterally, dissecting the posterior vaginal mucosa of the
perirecteal fascia.
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.
9. The excess posterior vaginal mucosa trimmed.
10. The perineal fascia closed with interrupted vicryl 2-0
11. Vicryl 2-0 suture is placed at the apex of vaginal mucosa using
continuous interlocking stitches to posterior fourchette.
12. Vaginal packing done with 1 os.
13. Perineal wash done.
14. End of procedure.

1 LOW TRANSVERSE CESAREAN SECTION


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. Vertical 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, bag of water
ruptured.
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 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
24. Top dressing applied.
25. End of procedure.
REPEAT LOW TRANSVERSE CESAREAN SECTION
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. Old scar removed. Vertical 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 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 Monocryl 4-0.
23. Incision site painted with betadine
24. Top dressing applied.
25. End of procedure.

ENDOCERVICAL POLYPECTOMY
1. Induction of labor.
2. Sepsis/Antisepsis/drapings done leaving operative site exposed.
3. Insertion of straight catheter to empty the urinary bladder.
4. Posterior vaginal retractor positioned, endocervix identified.
5. Anterior lip of the cervix grasped with tenaculum forceps.
6. Endocervical polyp found.
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
24. Top dressing applied.
25. End of procedure.

TAHBSO
1.
2.
3.
4.
5.

Induction of spinal/epidural anesthesia


Patient in supine position.
Insertion of foley catheter done.
Asepsis/Antisepsis
Drapings done leaving operative site exposed.

6.

7.
8.
9.
10.
11.

12.
13.

14.
15.
16.
17.
18.
19.
20.
21.
22.

23.
24.
25.
26.
27.
28.
29.
30.
31.

Midline incision done from symphysis pubis up to 2 FB below the


umbilicus cutting through skin, subcutaneous tissue and fascia,
rectus muscle split and peritoneum incised.
Bleeders clamped and ligated as encountered.
Self retaining and bladder retractors were applied to expose
pelvic structures.
Moist pack applied.
Inspection of the pelvic structures done.
Abdominopelvic structures examined revealed that the uterus
measures 8x7cms with smooth serosa. Both ovaries grossly
normal .Both measures 3x2 cm. Left fallopian tube dilated to 7x3
cm and its ampullary area containing serous fluid. Right fallopian
tube with small cystic paratubal masses ~1x1cm.
Right round ligament is doubly clamped, then cut and ligated with
Chromic 1. The same procedure is done on the opposite side.
Anterior and posterior leaves of the broad ligament opened.
Anterior leaf of the broad ligament incised to the point of bladder
reflection.
Infundibulopelvic ligament triply clamped, cut and doubly ligated
using Chromic 1-0.
Vesicouterine folds cut transversely
Bladder dissected by blunt and sharp dissection.
Uterine arteries triply clamped, cut and doubly ligated with
Chromic 1-0 on both sides.
Pubovesical fascia incised and pushed down with use of sponge
Cardinal ligaments clamped, cut and suture ligated with Chromic
1-0.
Amputation of cervix at level of cervical os.
Betadinized OS inserted to the vaginal stump.
Closure of vaginal stump with continuous interlocking suture using
Vicryl 1-0. Stump angles are anchored to the cardinal ligaments on
both sides with figure of eight stitches using Vicryl 1-0.
Bleeders clamped and ligated as encountered.
Parietal peritoneum closed with continuous stitches using chromic
2-0.
Transversalis fascia sutured with continuous stitches using vicryl 10.
Subcutaneous tissue closed with simple interrupted stitches with
Plain 2-0.
Skin closed by subcuticular stitches using Monocryl 3-0.
Operative site painted with betadine
Top dressing done.
Specimen sent for Histopath.
End of procedure.

VAGINAL HYSTERECTOMY
1. Induction of anesthesia.
2. Patient is placed in dorsal lithotomy position.
3. Asepsis/Antisepsis
4. Drapings done leaving the operative site exposed
5. Evacuation of urine using straight catheter
6. Vaginal mucosa is incised with a scalpel around the entire cervix.
7. Downward traction is applied using tenacula, Metzenbaum used
to dissect the bladder off the anterior lower uterine segment.
8. A sponge covered finger dissects the bladder all the way up to the
vesicouterine fold, facilitates entry to anterior cul de sac.
9. Right angle retractor is placed under the vaginal mucosa and
bladder, elevating the bladder. Strong downward traction is
applied to the tenacula on the cervix, and the peritoneal
vesicouterine fold is grasped with Allis clamps and incised with
sharp curved mayo scissors.
10. Elevating the peritoneal vesicouterine fold with Allis clamps,
definite hole can be seen. Finger is inserted in the hole.
11. Tenacula are brought acutely up toward the pubic symphysis,
exposing the cul- de-sac, second right angle at posterior cul-de-sac
12. The posterior vaginal retractor is removed. The broad ligament is
exposed from the uterosacral ligaments to the tuboovarian
ligament. A finger is placed in the posterior cul-de-sac and moved
laterally revealing the uterosacral ligament as it attaches to the
lower uterine cervix.

13. With the cervix on upward and lateral retraction using the
tenacula, a clamp is placed in the posterior cul-de-sac with one
blade underneath the uterosacral ligament, and the opposite
blade over the uterosacral ligament. This is done to prevent
possible ureteral damage from clamping the ligaments in lateral
position.
14. Uterosacral ligament is cut using the mayo scissors.
15. Chromic 1-0 suture is used to suture ligate the uterosacral
ligament.
16. When tied, the suture is held with a Kelly clamp for traction.
17. With uterus on upward and lateral retraction using the tenacula
on the cervix, cardinal ligaments is clamped adjacent to the lower
uterine segment and incised.
18. Cardinal ligaments is sutured ligated with Chromic 1-0 suture.
Suture is held with a Kelly clamp for traction
19. The remaining portion of the broad ligament attached to lower
uterine cervix segment containing the uterine artery is clamped
and ligated.
20. With all the ligaments on both sides, clamped and ligated, cervix is
retracted upward in midline with the tenacula. Posterior uterine
wall is grasped, the fundus is delivered posteriorly.
21. Two cochers clamps are applied to the tubo ovarian round
ligaments, incised close to the fundus.
22. Infundibulo-pelvic ligament is tied twice using Vicryl 1.0. Second
suture ligation is tied in a fixation stitch, placing the suture in the
mid portion of its pedicle.
23. The anterior and posterior clamps right angle retractors are
removed, and the weighted posterior retractor is placed in the
vagina. Any bleeding from any pedicle is clamped.
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.
EVACUATION CURETTAGE
1. Induction of spinal anesthesia.
2. Patient in dorsal lithotomy position.
3. Asepsis/Antisepsis.
4. Drapings done leaving the operative site exposed.
5. Straight Catheterization done.
6. Right angle retractor applied to expose cervix.
7. Anterior cervical lip grasped with tenaculum forceps at 12 0clock
position.
8. Hysterometer inserted.
9. Pre-curettage uterine depth measured 9 cms.
10. Sharp and dull curettage done in a clockwise manner, evacuated
cup of products of conception and placental tissues.
11. Post curettage uterine depth was not measured.
12. Perineal washing done.
13. Specimen for histopathology.

DIAGNOSTIC CURETTAGE
1. Induction of anesthesia.
2. Patient in dorsal lithotomy position
3. Asepsis/Antisepsis
4. Drapings done leaving operative site exposed
5. Straight catheter was inserted.
6. Cervix dilated with Goodells dilator
7. Retractor applied at posterior & anterior vaginal wall
8. Application of tenaculum forceps at 12 oclock position of cervical
lip.
9. Insertion of hysterometer to measure pre-curettage uterine depth
of 3 inches.
10. Blunt curette done in a clockwise manner. Evacuated scanty
endometrial scrapings.
11. Perineal wash done
12. Specimen sent for histopath

FRACTIONAL CURETTAGE
1. Induction of anesthesia.
2. Patient in dorsal lithotomy position.
3. Asepsis/Antisepsis.
4. Drapings done leaving operative site exposed.
5. Straight catheterization done.
6. Weight-bearing retractor applied at posterior vaginal wall. Cervix
smooth with no erosions.
7. Application of tenaculum forceps at 12 oclock position of cervical
lip.
8. Endocervical curettage done, evacuated minimal endocervical
scrapings.
9. Hysterometer inserted. Pre-curettage uterine depth measured
9cm.
10. Endometrial curettage done. Evacuated teaspoon of
endometrial scrapings/tissues and placental tissues.
11. Post curettage uterine depth measured, approximately 8 cm.
12. Tenaculum and retractors removed.
13. Perineal wash done
14. Specimen sent for histopath.
15. End of procedure.
COMPLETION CURETTAGE
1. Induction of anesthesia.
2. Patient in dorsal lithotomy position
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 oclock 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
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

It has been 36 weeks since a (+) serum/urine hCG pregnancy test


was performed by a reliable laboratory

An UTZ measurement of the CRL obtained at 6-11 weeks supports


a gestational age at least 39 weeks

UTZ obtained at 12-20 weeks confirms the gestational age of at


least 39 weeks determined by clinical history and PE
CP STATUS

CP status assessed

Pls. transfuse available ___ u PRBC of px blood after proper


crossmatching

BT to run initially @ 5-10 gtts/min x 30min then to 15-20


gtts/min if with no BT rxn

Maintain IVF x KVO while on BT

BT precautions please

Watch for any untoward s/sx such as DOB, pruritus, fever

Refer prn

Thank you.

ADMITTING NOTES (Ectopic Pregnancy)

Cc:

Imp:

Please admit pc to ROC under the service of Dr. ___

TPR q 4 hours and record

NPO temporarily

Labs:
o
CBC, APC
o
CT, BT, PT
o
BT w/ Rh
o
U/A
o
S. Preg test

IVF: D5LR 1L X 8 Hrs

Meds: None temporarily

SO:
o
Monitor VS, abdominal status hourly
o
Refer once lab result is in
o
Dr. ___ seen px at ER
o
Watch out for any untoward s/sx
o
Refer prn
ANESTHESIA
Pre-meds:

Cefuroxime (Zegen) 1.5 gms IV

Omeprazole 20mg IV

Metoclopramide (Plasil) 10mg IV


Anesthetic Agent: Bupivacaine 15mg + MgSO4 16mg
Detailed Technique: RA-SAB

X-LLDP, SAS

LA w/ 2% Lidocain

LP at L3 L4

CSF clear and free flowing

Intrathecal administration of anesthetic


SIGNS OF MALIGNANCY UTZ:

Septations

Internal echoes

Ascites

Multiple daughter cysts


<5 cm cyst in postmenopausal women expectant management

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
CaMg (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

Ransons Criteria ( objective signs of severity of acute pancreatitis)


On Admission:
Age > 55 y.o
Glucose > 200mg/dl
WBC > 16,000/cumm
LDH > 350 IU/L
AST > 250 U/L
After Initial 48 hrs
Serum Ca++ < 8mg/dl
Arterial PO2 < 60mmHg
Base Deficit > 4meq/L
BUN Increase > 5mg/dl
Hematocrit fall > 10%
Fluid Sequestration > 6,000ml