History FIRST PRENATAL VISIT

 General data 1. Prenatal Record

 Chief complaint 2. Routine Labs
 FMHx a. CBC, Platelet count, ABO/RH typing
 PMHx b. FBS
 PSHx c. U/A, F/A
 OBHx d. TPR, HbsAg
Menstrual Hx e. G/S of vaginal discharge
o Menarche, Menopause f. Ultrasound
o Interval i.Trans-vaginal UTZ (<12weeks AOG)
o Duration ii.Trans-abdominal UTZ (>12weeks AOG)
o Amount Indications:
o Symptoms with menses <20 weeks- fetal viability
o LMP fetal baseline biometry
Sexual Hx >32 weeks- fetal growth monitoring
o Coitarche >37 weeks- biophysical sscoring
o Frequency Final fetal presentation
o Habits (douche,masturbation) Placental localization
o Partners (number, gender preference) BPP
o Infertility (duration & mgt) iii Aging <22 weeks Early, >22 weeks Late
o STI (type, Tx) 3. Prescribe MTV
Family Planning Hx a. All trimesters- Calvit (Ca2+ Vit D)
o OCP, S/P, PAP, Intermenstrual bleeding b. <20 weeks – Carmin Forte (Vit B complex)
o Postcoital bleeding c. >20 weeks – Prenat, Hemarate, Terraferon, Sorbifer
OB Hx durule
o OB Score 4. Feminine wash BID
o Past Pregnancies 5. Prenatal milk 1 glass BID
 Number and year
 AOG, mode of delivery, birth attendant,
birth weight and status, complications PELVIC EXAM
o LMP, EDC, AOG  Inspection
o PNCU o Grossly N external genitalia, Masses, discharges, bleeding
o HBsAg/VDRL  Speculum
o TT/BT/MTV o Cervix – hyperemic/nonhyperremic; fish mouth
o UTI deformity/ping pong
 IE
o Cervical dilatation
PRENATAL CHECK-UPS o Cervical effacement
0-27 wks q4wks o Station
28 wks q 2wks o BOW (intact/leaking)
29-35 wks q2wks o Amniotic membrane PROM x days/hours
36 wksand beyond q week o Presenting part
 Clinical pelvimetry
STEROIDS o Inlet
1 dose 28-32 wks o Midplane
3 doses q 2 wks  Ischial spines
OGTT at 24-28wks  Sacrum
 Sidewalls
Fetal Movements 28-32 weeks o Outlet
Within 2 hours post-prandial  EFW
At least 10 kicks  BME
o I (introitus) - admits 2 fingers with ease/snugly
TETANUS TOXOID o C (cervix) – open/closed,; firm, doughy
0 20 wks AOG o U (uterus) – level of umbilicus
1 1 month o A (adnexae) – firm/fullness; w/ adnexal masses
2 6 months o D (discharges) – (+) (-); scanty or minimal bleeding
3 1 year o E (episiotomy) – with blood/well coaptated wound
4 1 year  RVE
o Intact rectovaginal septum, Good sphincter tone
Clearance Labs  Abdomen
ECG 12 leads o Inspection: globular/gravid; linea nigra, striae
CXR-PA o Auscultation: NABS
CBC, ABO/RH typing, CT/BT o Palpation: Leopold’s
Protime o FH, FHB R/L
U/A  Final Dx:
Crea, BUN, serum Na, serum K, SGPT, SGOT, FBS, Lipid Profile
HbsAg
 LEOPOLD’S MANEUVER INDICATIONS FOR CESAREAN SECTION
L1 (Fundal Grip)  Prior CS
 What fetal pole occupies the fundus  Labor dystocia (most frequent indication for 1’ CS)
L2 (Umbilcal grip)  Fetal distress
 Fetal back  Breech presentation
L3 (Pawlick’s grip)
 (+) engagement of head or (-) engagement CS ADMITTING NOTES
L4 (Pelvic grip)  Please admit to ROC under the service of _____
 Side of cephalic prominence  TPR q 4 hours and record
 Full diet, NPO post midnight
FUNDIC HEIGHT  Labs:
12wks-1st felt; above the symphysis pubis o CBC, APC
16wks- bet. Symphysis and umbilicus o CT, BT, PT
20wks- umbilicus o Urinalysis
36wks- below ensiform cartilage  Venoclysis
 Meds:
FHB Monitoring o Cefazolin 500mg IVTT q8H x 3 doses then shift to Co-
 Every 30mins= low risk Amox 625mg/tab, 1 tab BID
 Every 15mins= high risk o Famotidine 20mg IVTT q8H x 3 doses
o Ketomed 30mg IVTT q8H x 3 doses
AMONIOTIC FLUID INDEX o Ketomed 10mg q8H to start if px is on soft diet
 Normal: 6-24 cm o Tramadol 50mg IVTT q6H prn
 Oligohydramnios: <5 cm  Inform OR
 Low normal: 9-10  Secure signed consent
 Polyhydramnios: >24  Abdominoperineal prep please
 Request 500cc FWB of patient’s blood type as standby
 Dr. ___ for anesthesia
 Inform NROD
NSVD Admitting Notes  Refer accordingly.
 Please admit to ROC under the service of _____  Thank you
 TPR q 4 hours and record
 Full diet, NPO once in active labor
 Labs: ADMITTING ORDERS (Abdomen)
o CBC  Please admit to ROC under the service of Dr. ____
o HBsAg  TPR q shift and record
o Urinalysis  NPO
 IVF: D5LR + 10 “u” oxytocin to run at 10-15 gtts/min  Labs:
 Meds o CBC (save serum)
o Ampicillin 2g IV ANST if PROM o Serum pregnancy test
 SO: o Urinalysis
o Monitor FHB and progress of labor  IVF: D5LR + 10 “u” oxytocin x 30 gtts/min
o Puboperineal shave please  SO:
o Inform NROD o For completion curettage on call
o Will inform service consultant on deck o Secure consent
o Refer prn o Pad count at bedside
o Thank you o Save specimen passed out
 Side notes o Please prescribe the ff: Nubain, Benadryl, Dormicum
o TPR o Refer for profuse bleeding and other untoward ssx
o BP o Thank you
o Wt
o LMP, EDC ADMITTING NOTES (Ectopic Pregnancy)
o AOG  Cc:
o FH  Imp:
o FHB  Please admit pc to ROC under the service of Dr. ___
o CD
 TPR q 4 hours and record
o Effacement
 NPO temporarily
o Station
 Labs:
o BOW
o CBC, APC
o Leopolds
o CT, BT, PT
 Final Dx:
o BT w/ Rh
o PU FT del via NSVD/1’LTCS/Rpt CS in cephalic
o U/A
presentation to a live Bb Girl/Boy with BW: BL: AS:
o S. Preg test
PAOG: OB score
 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
 POSTPARTUM ORDERS POST OP ORDERS (TAHBSO)
 Back to room/ward  To RR
 Full diet once full awake  Monitor VS q 15 min, until stable
 Present IVF to run at 30 gtts/min, D/C if with minimal VB  Flat on bed x 6 H, then may turn to side
 IVF to ff: D5LR + 10 “u” Oxy to run at30 gtts/min  NPO x 6 H then may have sips of CL
 Meds:  Present IVF x 30 gtts/min
o Antibiotics  IVF to ff:
o MA 500 mg/cap q 8 H RTC x 24 H, then prn for pain o D5LR
+ 10 “u” oxytocin x 8 H
o Methergin 1 tab TID x 3 days o D5NM
o Viitamins o D5LR x 8 H
 SO:  Meds:
o Monitor VS q 15 min until stable  SO:
o Massage uterus prn o MIO q H and record
o Ice pack on hypogastrium o Refer if UO is <30cc/H
o Perilight x 15 min OD o May return blood
o Routine perineal care o Remove FC @ ___
o Watch out for profuse vaginal bleeding o Apply abdominal binder
o Refer accordingly o Refer PRN
o Thank you o Thank you

TRANS-OUT POST OP COMPLICATIONS OF CS DELIVERY

Side notes the ff:  Hysterectomy
 Stable VS  Operative injury to pelvic structures
 Able to flex both legs  Infection
 (-) vomiting  Puerperal fever
 Blurring of vision  Transfusion
Orders
 May refer back to room DISCHARGE ORDERS (Normal OB)
 D/C O2 and pulse oximeter  MGH
 Monitor V/S q 15 min until stable  Home Meds
 MIO q Hly (+ FC) or shift (- FC)  OPD ff-up on Sat @ OB service clinic with photocopy of D/S
and refer if UO <30 cc/H  Discharge IE and summary c/o ___
 Watch out for profuse vaginal bleeding,  TCB anytime if with profuse VB, HA, blurring of vision, U2W ssx
hypotension, tachycardia or any untoward s/sx
 Refer accordingly
 Thank you BLOOD TRANSFUSION
 CP status assessed
 VS checked
POST-OP ORDERS  Please transfuse available _____ unit of patient’s blood type
 To RR after proper cross matching
 Monitor VS q15 mins until stable  Run BT @ 5-10 gtts/min for 30 mins then to titrate @ 15-20
 NPO x 6 H, then may have sips of CL gtts/min with no BT reactions
 O2 at 2-3 LPM via nasal prong  Mainline to KVO while on BT
 Run present IVF @ 30 gtts/min  Monitor VS q15 mins while on BT
 IVF to ff:  Refer for any BT reactions such as fever, chills, dyspnea,
o D5LR hypotension and pruritus
+ 10 “u” oxytocin x 8 H
o D5NM  Refer accordingly
o D5LR x 8 H
 Meds: CP STATUS
o Antibiotics  CP status assessed
o Ranitidine (Zantac) 50mg IVTT q8H x 3 doses  Pls. transfuse available ___ “u” PRBC of px blood after proper
 SO: crossmatching
o Attach px to O2 at 2-3 LPM via nasal prong  BT to run initially @ 5-10 gtts/min x 30min then ↑ to 15-20
o Attach pc to pulse ox gtts/min if with no BT rxn
o MIO q H and record  Maintain IVF x KVO while on BT
o Refer if UO is <30cc/H  BT precautions please
o Remove FC 24H post op  Watch for any untoward s/sx such as DOB, pruritus, fever
o Standby available blood  Refer prn
o Apply abdominal binder  Thank you.
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
 PLASMA GLUCOSE RESULTS: HYPERTENSION
(Blood Glucose testing performed at 24-28wks AOG)  140/90MMhG
Time NDDG Coustan & Capenter(mg/dL) Proteinuria
Fasting 105 95  >300mg/24H urine sample
1st Hr 190 180  > 1000mg/random sample 6H apart
2nd Hr 165 155  1+ = mild proteinuria
 2+ to 4+ = heavy proteinuruia
3rd Hr 145 140
*Edema DOES NOT validate Preeclampsia
GESTATIONAL HPN
BISHOP SCORE  HPN w/o Proteinuria (after 20 weeks gestation)
0 1 2 3  Confirm 12 wks Postpartum
Dilatation 0 1-2cm 3-4cm 5-6cm PREECLAMPSIA
Effacement 0-30% 31-50% 51-70% >70%  (+) HPN, (+) Proteinuria after 20th week
Station -5/-3 -2 -1 +1/+2 ECLAMPSIA
Cervical Posterior Midline Anterior -----  (+) convulsions, (+) Preeclampsia
Position CHRONIC HPN
Cervical firm medium soft -----  140/90mmHg
Consistency SUPERIMPOSED PREECLAMPSIA
*Scoring: 3-8 difficult induction  Inc diastole and systole
9-favorable induction  Proteinuria
 S/Sx of end organ damage
BIOPHYSICAL SCORING PARAMETERS Triad for Sever Preeclampsia
1. Fetal Breathing Movements  Hemolysis
2. Gross Body Movement  Elevated Liver Enzyme
3. Fetal Tone  Low Platelet Count
4. Reactive FHR Hypertension etiology(Williams)
5. Amniotic Fluid
 Exposed chorionic villi
*Perfect Score is 10/10 or 8/8
 Twin pregnancy (Multiple gestation)
CBC repeated at 28-32 AOG
 Vascular dses
HbsAg last trimester
 Fam hx
Alpha fetoprotein 16-18 wks AOG

THREATENED ABORTION
NON-STRESS TEST
 Bloody vaginal discharge or bleeding appears
 Test of fetal condition
 Closed vaginal os
REACTIVE when:
 Low abdominal pain
 At least 2 accelerations of the FHR occurs for at least 15 bpm,
lasting for 15 sec w/in 20 min period of observation  Bleeding first, cramping follows
NONREACTIVE
 May imply that the fetus is acidotic, asleep, or drugs was INEVITABLE ABORTION
administered to the mother  Gross rupture of membrane
A. EARLY DECELERATION  Leaking amniotic fluid
 Head compression  Cervical dilatation
B. LATE DECELERATION COMPLETE ABORTION
 Utero-placental insufficiency  Complete detachment
C. VARIABLE DECELERATION  Int. cervical os closes
 Cord compression ; Fetal distress INCOMPLETE ABORTION
 Most common ; Most ominous  Int. cervical os opens and allows passage of blood
Mullerian Anomalies
CONTRACTION STRESS TEST/OCYTOCIN CHALLENGE TEST  Segmented mullerian agenensis or hyperplasia
 A measure of utero-placental function  Unicornuate uterus
 Contraction induced by using IV oxytocin  Bicornuate uterus
 Record FHB  Septate uterus
POSITIVE  Uterus with internal ___? Changes
 Consistent and persistent late deceleration (50%) of the FHB in Induction of labor
the absence of uterine hypertonus or supine hypotension  Oxy drip but not in labor
NEGATIVE Augmentation of Labor
 @ least 3 contractions in 10 mins, each lasting 40 secs, w/o late  Oxy drip however in labor
deceleration
SUSPICIOUS FETAL DEATH
 Inconstant late deceleration patterns 1. Tobacco-stained amniotic fluid
HYPERSTIMULATION 2. Spalding’ssign
 Uterine contractions occur more frequent than every 2 mins, or o significant overlapping of fetal skull bones
lasting longer than 90 secs, or presence of hypertonus 3. Robert’s sign
UNSATISFACTORY o Demonstration of gas bubbles in the fetus
 Frequency of contractions is <3 per minute 4. Exaggeration of fetal spinal curvature
 LACERATIONS
MYOMA  1st Degree
 causes soft tissue dystocia o Fourchette, perineal skin, vaginal mucosa but not the
 etiology: unopposed estrogen stimulation underlying fascia and muscle
 types: Subserous, Intramural, Submucous  2nd Degree
ROT-right occiput transverse o Fascia and muscles of the perineal body but not the
Montevideo Units- 200 units or pressure of > 60 anal sphincter
Depoprovera- injectable CP is G1 to HPN patients  3rd Degree
o Extend from vaginal mucosa, perineal skin and fascia
EXCISION OF BARTHOLIN’S CYST up to anal sphincter but not the rectal mucosa
 Hyperplasia (uterus) – provera  4th Degree
 Endocervical o Encompasses extension up to rectal mucosa
For Functional Curettage
 Endometrial
 Endometrial  for D & C BRAXTON HICKS CONTRACTION
 The uterus undergoes palpable but originally painless contractions
AUGMENTATION OF LABOR at irregular intervals from the early stages of gestation
 ↓ amniotic fluid
 Oligohydramnios (causes) SIGNS OF PLACENTAL SEPARATION
o Cord compression  Calkin’s Sign (uterus becomes globular and firmer from discoid)
o Macrosomia  Sudden gush of blood
o Deformations  Uterus rises in the abdomen as the detached placenta drops to
o Fetal distress the lower segment and vagina
 Lengthening of the cord
HYOSCINE N-BUTYL BROMIDE (Buscopan)  for softening of the cervix
STAGES OF LABOR
NST: Fetal condition “7 days”  I: Active labor to full cervical dilatation (4-10 cm)
 II: Full cervical dilatation to delivery of baby
CST: Uteroplacental contraction  II: Delivery of baby to expulsion of placenta
 IV: Delivery of placenta to 1 hour after

DELIVERY OF PLACENTA CARDINAL MOVEMENTS

SHULTZE MECHANISM  Engagement
 Peripheral  Descent
 Shiny portion  Flexion
DUNCAN MECHANISM  Internal rotation
 Central  Extension
 Dirty part  External rotation
DEFINE:  Expulsion
 Placenta increta  invades ASYNCLITISM  such lateral deflection of the head to a more anterior or
 Placenta percreta  penetrates posterior position of the pelvis
 Placenta accrete  attaches
Normal Rotation of Umbilical Cord: ANTERIOR COLPORRHAPY
 Counter clockwise or Left-handed maneuver 1. Induction of anesthesia.
2. Patient is placed in dorsal lithotomy position.
PLACENTA PREVIA 3. Asepsis/Antisepsis
 Types: 4. Drapings done leaving the operative site exposed
o Totalis  placenta covers cervical os completely 5. Evacuation of urine using straight catheter.
o Partialis  internal os partially covered by placenta 6. The lateral edges of the vaginal cuff are held with Allis. Several
o Marginal  edge of the placenta is at margin of Allis clamps are placed 3-4 cm apart up the midline of anterior
internal os vaginal wall.
 Etiology: (P2ALM2) 7. The vaginal mucosa is undermined for approximately 3-4 cm up
o Previous CS to first Allis clamps placed in midline.
o Puerperal Endometritis 8. The vaginal mucosa is dissected off the pubovesical cervical fascia
o Advancing age and opened with scissors in the midline. The vaginal mucosa is
o Multiparity opened in midline up to next Allis clamp. This is continued until
o Multiple induced abortions the vagina is opened to within 1 cm of urethral meatus.
 Diagnosis: 9. The PVC fascia is separated from the vaginal mucosa. The
o Painless third trimester bleeding dissection is continued until bladder and urethra are separated
o UTZ for placental localization from the vaginal mucosa and clearly identified and urethral vesical
o Placental Migration (placenta close to the internal os angle has been ascertained.
during 2nd trimester migrate to fundus as pregnancy 10. Kelly plication done with chromic 2-0. The anterior repair is
advances started by placing suture in PVC fascia, starting at the level of first
PLACENTA ABRUPTION Kelly placation suture
 premature separation of the normally implanted placenta after 11. The edges of vaginal mucosa retracted laterally with Allis clamps
the 20th week of pregnancy and before birth of fetus and remaining PVC fascia is plicated in midline with multiple
 Etiology: (PECSS) interrupted mattress sutures. The edge of vaginal mucosa are
o Pre-eclampsia held in tension and excessive mucosa trimmed.
o External trauma 12. The vaginal mucosa is sutured in midline down to previously
o Chronic hypertension incised site by continuous interlocking suture.
o Short umbilical cord 13. Perineal wash done
o Sudden uterine decompression 14. End of procedure.
POSTERIOR COLPORRHAPY 16. Closure of incision site done layer by layer
1. Induction of spinal anesthesia. a. First (endometrial) layer closed by continuous interlocking
2. Patient is placed in dorsal lithotomy position. stitches using Chromic 1.
3. Asepsis/Antisepsis b. Second (myometrial) layer closed by continuous interlocking
4. Drapings done leaving the operative site exposed stitches using Chromic 1.
5. Allis clamps are applied at the posterior vaginal mucosa, elevated creating a c. Third (Vesico-uterine folds) closed by simple continuous
triangle. stitches using chromic 2-0.
6. A transverse incision made at the posterior fourchette. A portion of the 17. Suction of blood and amniotic fluid and sponge done.
posterior vaginal mucosa is elevated using an Allis clamp and an index 18. Inspection of the ovaries, fallopian tubes and ligaments
finger covered with gauze is inserted upward and laterally, dissecting the 19. Parietal peritoneum closed with continuous suture using chromic 2-0
posterior vaginal mucosa of the perirecteal fascia. 20. Transversalis fascia sutured with continuous interlocking stitches using
7. Vertical incision in posterior vaginal mucosa made. Perirectal fascia Vicryl 1-0
dissected off the posterior vaginal mucosa. The apex of triangle held with 21. Subcutaneous tissue sutured simple interrupted stitches using Plain 2-0
Allis clamp. The dissection of perirectal fascia off the vaginal mucosa is 22. Skin closed by subcuticular stitches using Monocryl 4-0.
started with scalpel but is completed with blunt dissection. 23. Incision site painted with betadine
8. Kelly plication sutures with vicryl 2-0 through the margins of levator ani 24. Top dressing applied.
muscles from apex down to posterior fourchette is done and progressively 25. End of procedure.
tied.
9. The excess posterior vaginal mucosa trimmed. ENDOCERVICAL POLYPECTOMY
10. The perineal fascia closed with interrupted vicryl 2-0 1. Induction of labor.
11. Vicryl 2-0 suture is placed at the apex of vaginal mucosa using continuous 2. Sepsis/Antisepsis/drapings done leaving operative site exposed.
interlocking stitches to posterior fourchette. 3. Insertion of straight catheter to empty the urinary bladder.
12. Vaginal packing done with 1 os. 4. Posterior vaginal retractor positioned, endocervix identified.
13. Perineal wash done. 5. Anterior lip of the cervix grasped with tenaculum forceps.
14. End of procedure. 6. Endocervical polyp found.
7. Polyp grasped, twisted, and removed using an ovum forcep.
1’ LOW TRANSVERSE CESAREAN SECTION 8. Vaginal packing inserted.
1. Induction of spinal anesthesia. 9. End of procedure.
2. Patient in supine position.
3. Insertion of foley catheter. 1’ LOW TRANSVERSE CESAREAN SECTION (PFANNENSTIEL)
4. Asepsis/Antisepsis 1. Induction of spinal anesthesia.
5. Drapings done, exposing operative site. 2. Patient in supine position.
6. Vertical incision done from 2 FB above the symphysis pubis up to 3 FB 3. Insertion of foley catheter.
below the umbilicus. Incision deepened to subcutaneous tissues and 4. Asepsis/Antisepsis
transversalis fascia, rectus muscle split, peritoneum cut longitudinally. 5. Drapings done, exposing operative site.
7. Bleeders clamped and ligated as encountered 6. Curvilinear incision done from 2 FB above the symphysis pubis up to 3 FB
8. Retractors applied exposing pelvic structures. below the umbilicus. Incision deepened to subcutaneous tissues and
9. Vesico-uterine folds identified, lifted out and cut 1 cm above the bladder. transversalis fascia, rectus muscle split, peritoneum cut longitudinally.
10. Bladder pushed downward and a curvilinear incision is done on the lower 7. Bleeders clamped and ligated as encountered
uterine segment using bandage scissors, bag of water ruptured. 8. Retractors applied exposing pelvic structures.
11. Rupture of membranes. 9. Vesico-uterine folds identified, lifted out and cut 1 cm above the bladder.
12. Amniotic fluid suctioned and fetal head exposed. 10. Bladder pushed downward and a curvilinear incision is done on the lower
13. Delivery of baby boy in left occiput transverse position. uterine segment using bandage scissors
14. Umbilical cord doubly clamped and cut. 11. Rupture of membranes.
15. Manual extraction of placenta. 12. Amniotic fluid suctioned and fetal head exposed.
16. Closure of incision site done layer by layer 13. Delivery of live full term baby boy in left occiput transverse position.
a. First (endometrial) layer closed by continuous interlocking 14. Umbilical cord doubly clamped and cut.
stitches using Chromic 1. 15. Manual extraction of placenta.
b. Second (myometrial) layer closed by continuous interlocking 16. Closure of incision site done layer by layer
stitches using Chromic 1. a. First (endometrial) layer closed by continuous interlocking
c. Third (Vesico-uterine folds) closed by simple continuous stitches using Chromic 1.
stitches using chromic 2-0. b. Second (myometrial) layer closed by continuous interlocking
17. Suction of blood and amniotic fluid and sponge done. stitches using Chromic 1.
18. Inspection of the ovaries, fallopian tubes and ligaments c. Third (Vesico-uterine folds) closed by simple continuous
19. Parietal peritoneum closed with continuous suture using chromic 2-0 stitches using chromic 2-0.
20. Transversalis fascia sutured with continuous interlocking stitches using 17. Suction of blood and amniotic fluid and sponge done.
Vicryl 1-0 18. Inspection of the ovaries, fallopian tubes and ligaments
21. Subcutaneous tissue sutured simple interrupted stitches using Plain 2-0 19. Parietal peritoneum closed with continuous suture using chromic 2-0
22. Skin closed by subcuticular stitches using Vicryl 4-0. 20. Transversalis fascia sutured with continuous interlocking stitches using
23. Incision site painted with betadine Vicryl 1-0
24. Top dressing applied. 21. Subcutaneous tissue sutured simple interrupted stitches using Plain 2-0
25. End of procedure. 22. Skin closed by subcuticular stitches using Vicryl 4-0.
23. Incision site painted with betadine
REPEAT LOW TRANSVERSE CESAREAN SECTION 24. Top dressing applied.
1. Induction of spinal anesthesia. 25. End of procedure.
2. Patient in supine position.
3. Insertion of foley catheter. TAHBSO
4. Asepsis/Antisepsis 1. Induction of spinal/epidural anesthesia
5. Drapings done, exposing operative site. 2. Patient in supine position.
6. Old scar removed. Vertical incision done from 2 FB above the symphysis 3. Insertion of foley catheter done.
pubis up to 3 FB below the umbilicus. Incision deepened to subcutaneous 4. Asepsis/Antisepsis
tissues and transversalis fascia, rectus muscle split, peritoneum cut 5. Drapings done leaving operative site exposed.
longitudinally. 6. Midline incision done from symphysis pubis up to 2 FB below the umbilicus
7. Bleeders clamped and ligated as encountered cutting through skin, subcutaneous tissue and fascia, rectus muscle split
8. Retractors applied exposing pelvic structures. and peritoneum incised.
9. Vesico-uterine folds identified, lifted out and cut 1 cm above the bladder. 7. Bleeders clamped and ligated as encountered.
10. Bladder pushed downward and a curvilinear incision is done on the lower 8. Self retaining and bladder retractors were applied to expose pelvic
uterine segment using bandage scissors. structures.
11. Rupture of membranes. 9. Moist pack applied.
12. Amniotic fluid suctioned and fetal head exposed. 10. Inspection of the pelvic structures done.
13. Delivery of baby boy in left occiput transverse position. 11. Abdominopelvic structures examined revealed that the uterus measures
14. Umbilical cord doubly clamped and cut. 8x7cms with smooth serosa. Both ovaries grossly normal .Both measures
15. Manual extraction of placenta. 3x2 cm. Left fallopian tube dilated to 7x3 cm and its ampullary area
 containing serous fluid. Right fallopian tube with small cystic paratubal EVACUATION CURETTAGE
masses ~1x1cm. 1. Induction of spinal anesthesia.
12. Right round ligament is doubly clamped, then cut and ligated with Chromic 2. Patient in dorsal lithotomy position.
1. The same procedure is done on the opposite side. 3. Asepsis/Antisepsis.
13. Anterior and posterior leaves of the broad ligament opened. Anterior leaf of 4. Drapings done leaving the operative site exposed.
the broad ligament incised to the point of bladder reflection. 5. Straight Catheterization done.
14. Infundibulopelvic ligament triply clamped, cut and doubly ligated using 6. Right angle retractor applied to expose cervix.
Chromic 1-0. 7. Anterior cervical lip grasped with tenaculum forceps at 12 0’clock position.
15. Vesicouterine folds cut transversely 8. Hysterometer inserted.
16. Bladder dissected by blunt and sharp dissection. 9. Pre-curettage uterine depth measured 9 cms.
17. Uterine arteries triply clamped, cut and doubly ligated with Chromic 1-0 on 10. Sharp and dull curettage done in a clockwise manner, evacuated ½ cup of
both sides. products of conception and placental tissues.
18. Pubovesical fascia incised and pushed down with use of sponge 11. Post curettage uterine depth was not measured.
19. Cardinal ligaments clamped, cut and suture ligated with Chromic 1-0. 12. Perineal washing done.
20. Amputation of cervix at level of cervical os. 13. Specimen for histopathology.
21. Betadinized OS inserted to the vaginal stump.
22. Closure of vaginal stump with continuous interlocking suture using Vicryl 1- DIAGNOSTIC CURETTAGE
0. Stump angles are anchored to the cardinal ligaments on both sides with 1. Induction of anesthesia.
figure of eight stitches using Vicryl 1-0. 2. Patient in dorsal lithotomy position
23. Bleeders clamped and ligated as encountered. 3. Asepsis/Antisepsis
24. Parietal peritoneum closed with continuous stitches using chromic 2-0. 4. Drapings done leaving operative site exposed
25. Transversalis fascia sutured with continuous stitches using vicryl 1-0. 5. Straight catheter was inserted.
26. Subcutaneous tissue closed with simple interrupted stitches with Plain 2-0. 6. Cervix dilated with Goodell’s dilator
27. Skin closed by subcuticular stitches using Monocryl 3-0. 7. Retractor applied at posterior & anterior vaginal wall
28. Operative site painted with betadine 8. Application of tenaculum forceps at 12 o’clock position of cervical lip.
29. Top dressing done. 9. Insertion of hysterometer to measure pre-curettage uterine depth of 3
30. Specimen sent for Histopath. inches.
31. End of procedure. 10. Blunt curette done in a clockwise manner. Evacuated scanty endometrial
scrapings.
VAGINAL HYSTERECTOMY 11. Perineal wash done
1. Induction of anesthesia. 12. Specimen sent for histopath
2. Patient is placed in dorsal lithotomy position.
3. Asepsis/Antisepsis FRACTIONAL CURETTAGE
4. Drapings done leaving the operative site exposed 1. Induction of anesthesia.
5. Evacuation of urine using straight catheter 2. Patient in dorsal lithotomy position.
6. Vaginal mucosa is incised with a scalpel around the entire cervix. 3. Asepsis/Antisepsis.
7. Downward traction is applied using tenacula, Metzenbaum used to dissect 4. Drapings done leaving operative site exposed.
the bladder off the anterior lower uterine segment. 5. Straight catheterization done.
8. A sponge covered finger dissects the bladder all the way up to the 6. Weight-bearing retractor applied at posterior vaginal wall. Cervix smooth
vesicouterine fold, facilitates entry to anterior cul de sac. with no erosions.
9. Right angle retractor is placed under the vaginal mucosa and bladder, 7. Application of tenaculum forceps at 12 o’clock position of cervical lip.
elevating the bladder. Strong downward traction is applied to the tenacula 8. Endocervical curettage done, evacuated minimal endocervical scrapings.
on the cervix, and the peritoneal vesicouterine fold is grasped with Allis 9. Hysterometer inserted. Pre-curettage uterine depth measured 9cm.
clamps and incised with sharp curved mayo scissors. 10. Endometrial curettage done. Evacuated ½ teaspoon of endometrial
10. Elevating the peritoneal vesicouterine fold with Allis clamps, definite hole scrapings/tissues and placental tissues.
can be seen. Finger is inserted in the hole. 11. Post curettage uterine depth measured, approximately 8 cm.
11. Tenacula are brought acutely up toward the pubic symphysis, exposing the 12. Tenaculum and retractors removed.
cul- de-sac, second right angle at posterior cul-de-sac 13. Perineal wash done
12. The posterior vaginal retractor is removed. The broad ligament is exposed 14. Specimen sent for histopath.
from the uterosacral ligaments to the tuboovarian ligament. A finger is 15. End of procedure.
placed in the posterior cul-de-sac and moved laterally revealing the COMPLETION CURETTAGE
uterosacral ligament as it attaches to the lower uterine cervix. 1. Induction of anesthesia.
13. With the cervix on upward and lateral retraction using the tenacula, a 2. Patient in dorsal lithotomy position
clamp is placed in the posterior cul-de-sac with one blade underneath the 3. Asepsis/Antisepsis
uterosacral ligament, and the opposite blade over the uterosacral ligament. 4. Drapings done leaving operative site exposed
This is done to prevent possible ureteral damage from clamping the 5. Insertion of straight catheter.
ligaments in lateral position. 6. Speculum applied at posterior vaginal wall
14. Uterosacral ligament is cut using the mayo scissors. 7. Application of tenaculum forceps at 12 o’clock position of cervical lip.
15. Chromic 1-0 suture is used to suture ligate the uterosacral ligament. 8. Sharp/blunt curette done. Evacuated 1 tablespoon cup of products of
16. When tied, the suture is held with a Kelly clamp for traction. conception.
17. With uterus on upward and lateral retraction using the tenacula on the 9. Betadine wash done.
cervix, cardinal ligaments is clamped adjacent to the lower uterine segment 10. End of procedure.
and incised. 11. Specimen sent for histopathology.
18. Cardinal ligaments is sutured ligated with Chromic 1-0 suture. Suture is held
with a Kelly clamp for traction VAGINAL BIRTH AFTER A CESAREAN SECTION (VBAC)
19. The remaining portion of the broad ligament attached to lower uterine  Allow a trial of labor under double set-up for all previous cesarean of one
cervix segment containing the uterine artery is clamped and ligated. low segment incision after excluding an inadequate pelvis and unless a new
20. With all the ligaments on both sides, clamped and ligated, cervix is indication arises
retracted upward in midline with the tenacula. Posterior uterine wall is  Selection Criteria:
grasped, the fundus is delivered posteriorly. o 1 or 2 prior low-transverse cesarean section delivery
21. Two cochers clamps are applied to the tubo ovarian round ligaments, o Clinically adequate pelvic
incised close to the fundus. o No other uterine scars or previous rupture
22. Infundibulo-pelvic ligament is tied twice using Vicryl 1.0. Second suture o Physicians immediately available throughout active labor
ligation is tied in a fixation stitch, placing the suture in the mid portion of its capable of monitoring labor and performing an emergency
pedicle. cesarean section delivery
23. The anterior and posterior clamps right angle retractors are removed, and o Availability of anesthesiologist and personnel for emergency
the weighted posterior retractor is placed in the vagina. Any bleeding from cesarean section delivery
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.
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

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