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
o

Methergin 1 tab TID x 3 days

Viitamins

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

SO:

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 profuce 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 Co-Amox 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
o
D5NM
x8H
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
o
o
o
o
o

Apply abdominal binder

Morphine precaution please
Specimen for histopathology
Watch out for profuse vaginal bleeding,
hypotension, tachycardia or any untoward
s/sx
Refer PRN
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
o
D5NM
x8H
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


Oxy drip but not in labor
Augmentation of Labor

Oxy drip however in labor

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

PRENATAL CHECK-UPS
0-27 wks
28 wks
29-35 wks
36 wksand beyond
TETANUS TOXOID
1
2
3
4
5
STEROIDS
1 dose
3 doses
OGTT at 24-28wks

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

q 2wks

q4wks
q2wks
q week

20 wks AOG
1 month
6 months
1 year
1 year
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. Tobacco-stained amniotic fluid
2. Spaldingssign
o
significant overlapping of fetal skull bones
3. Roberts sign
o
Demonstration of gas bubbles in the fetus
4. 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)

Normal

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
Dilatatio
0
1-2cm
n
Effaceme 0-30%
31-50%
nt
Station
-5/-3
-2
Cervical
Posterio
Midline
Position
r
Cervical
firm
mediu
Consiste
m
ncy
*Scoring: 3-8 difficult induction
9-favorable induction

2
3-4cm

3
5-6cm

51-70%

>70%

-1
Anterior

+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
Endometrial
Curettage
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
Rotation of Umbilical Cord:
Counter clockwise or Left-handed maneuver

PLACENTA PREVIA

Types:
o
Totalis placenta covers cervical os
completely
o
Partialis internal os partially covered by
placenta
o
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
o
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
1
2
3
4
5
6

7
8
9
10
11
12
13
14
15
16

17
18
19
20
21
22
23

TRANSVERSE CESAREAN SECTION

Induction of spinal anesthesia.
Patient in supine position.
Insertion of foley catheter.
Asepsis/Antisepsis
Drapings done, exposing operative site.
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.
Bleeders clamped and ligated as encountered
Retractors applied exposing pelvic structures.
Vesico-uterine folds identified, lifted out and cut 1 cm
above the bladder.
Bladder pushed downward and a curvilinear incision
is done on the lower uterine segment using bandage
scissors, bag of water ruptured.
Rupture of membranes.
Amniotic fluid suctioned and fetal head exposed.
Delivery of baby boy in left occiput transverse
position.
Umbilical cord doubly clamped and cut.
Manual extraction of placenta.
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.
Suction of blood and amniotic fluid and sponge done.
Inspection of the ovaries, fallopian tubes and
ligaments
Parietal peritoneum closed with continuous suture
using chromic 2-0
Transversalis
fascia
sutured
with
continuous
interlocking stitches using Vicryl 1-0
Subcutaneous tissue sutured simple interrupted
stitches using Plain 2-0
Skin closed by subcuticular stitches using Vicryl 4-0.
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.

7.
8.
9.
10.
11.
12.
13.
14.
15.
16.

17.
18.
19.
20.
21.
22.
23.
24.
25.

Incision deepened to subcutaneous tissues and

transversalis fascia, rectus muscle split, peritoneum
cut longitudinally.
Bleeders clamped and ligated as encountered
Retractors applied exposing pelvic structures.
Vesico-uterine folds identified, lifted out and cut 1 cm
above the bladder.
Bladder pushed downward and a curvilinear incision
is done on the lower uterine segment using bandage
scissors
Rupture of membranes.
Amniotic fluid suctioned and fetal head exposed.
Delivery of live full term baby boy in left occiput
transverse position.
Umbilical cord doubly clamped and cut.
Manual extraction of placenta.
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.
Suction of blood and amniotic fluid and sponge done.
Inspection of the ovaries, fallopian tubes and
ligaments
Parietal peritoneum closed with continuous suture
using chromic 2-0
Transversalis
fascia
sutured
with
continuous
interlocking stitches using Vicryl 1-0
Subcutaneous tissue sutured simple interrupted
stitches using Plain 2-0
Skin closed by subcuticular stitches using Vicryl 4-0.
Incision site painted with betadine
Top dressing applied.
End of procedure.

TAHBSO
1. Induction of spinal/epidural anesthesia
2. Patient in supine position.
3. Insertion of foley catheter done.
4. Asepsis/Antisepsis
5. Drapings done leaving operative site exposed.
6. 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.
7. Bleeders clamped and ligated as encountered.
8. Self retaining and bladder retractors were applied to
expose pelvic structures.
9. Moist pack applied.
10. Inspection of the pelvic structures done.
11. 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.
12. Right round ligament is doubly clamped, then cut and
ligated with Chromic 1. The same procedure is done
on the opposite side.
13. Anterior and posterior leaves of the broad ligament
opened. Anterior leaf of the broad ligament incised to
the point of bladder reflection.
14. Infundibulopelvic ligament triply clamped, cut and
doubly ligated using Chromic 1-0.
15. Vesicouterine folds cut transversely
16. Bladder dissected by blunt and sharp dissection.
17. Uterine arteries triply clamped, cut and doubly
ligated with Chromic 1-0 on both sides.
18. Pubovesical fascia incised and pushed down with use
of sponge

19. Cardinal ligaments clamped, cut and suture ligated

with Chromic 1-0.
20. Amputation of cervix at level of cervical os.
21. Betadinized OS inserted to the vaginal stump.
22. 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.
23. Bleeders clamped and ligated as encountered.
24. Parietal peritoneum closed with continuous stitches
using chromic 2-0.
25. Transversalis fascia sutured with continuous stitches
using vicryl 1-0.
26. Subcutaneous tissue closed with simple interrupted
stitches with Plain 2-0.
27. Skin closed by subcuticular stitches using Monocryl 30.
28. Operative site painted with betadine
29. Top dressing done.
30. Specimen sent for Histopath.
31. 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 10 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 nonelectronic 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
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