Professional Documents
Culture Documents
General data
Chief complaint
PMHx
PSHx CS ADMITTING NOTES
FMHx Please admit to ROC under the service of _____
OBHx TPR q 4 hours and record
o Menarche Full diet, NPO post midnight
o Interval Labs:
o Duration o CBC, APC
o Amount o CT, BT, PT
o Symptoms o Urinalysis
o Coitarche Venoclysis
o Menopause Meds:
o OCP, S/P, PAP, Intermenstrual bleeding o Cefazolin 500mg IVTT q8H x 3 doses then shift to Co-Amox
o Postcoital bleeding 625mg/tab, 1 tab BID
o OB Score o Famotidine 20mg IVTT q8H x 3 doses
o LMP, EDC, AOG o Ketomed 30mg IVTT q8H x 3 doses
o PNCU o Ketomed 10mg q8H to start if px is on soft diet
o HBsAg/VDRL o Tramadol 50mg IVTT q6H prn
o TT/BT/MTV Inform OR
o UTI Secure signed consent
Abdominoperineal prep please
Request 500cc FWB of patient’s blood type as standby
Dr. ___ for anesthesia
NSVD Admitting Notes Inform NROD
Please admit to ROC under the service of _____ Refer accordingly
TPR q 4 hours and record Thank yo
Full diet, NPO once in active labor
Labs:
o CBC
o HBsAg
o Urinalysis POST-OP ORDERS
To RR
IVF: D5LR + 10 “u” oxytocin to run at 10-15 gtts/min
Monitor VS q15 mins until stable
Meds
o Ampicillin 2g IV ANST if PROM NPO x 6 H, then may have sips of CL
O2 at 2-3 LPM via nasal prong
SO:
o Monitor FHB and progress of labor Run present IVF @ 30 gtts/min
o Puboperineal shave please IVF to ff:
o D5LR + 10 “u” oxytocin x 8 H
o Inform NROD
o D5NM
o Will inform service consultant on deck
o D5LR x 8 H
o Refer prn
Meds:
o Thank you
o Antibiotics
Side notes
o Ranitidine (Zantac) 50mg IVTT q8H x 3 doses
o TPR
SO:
o BP
o Attach px to O2 at 2-3 LPM via nasal prong
o Wt
o Attach pc to pulse ox
o LMP
o MIO q H and record
o EDC
o Refer if UO is <30cc/H
o AOG
o Remove FC 24H post op
o FH
o Standby available blood
o FHB
o Apply abdominal binder
o CD
o Morphine precaution please
o Effacement
o Specimen for histopathology
o Station
o Watch out for profuse vaginal bleeding, hypotension,
o BOW
tachycardia or any untoward s/sx
o Leopolds
o Refer PRN
Final Dx: o Thank you
o PU FT del via NSVD/1’LTCS/Rpt CS in cephalic presentation
to a live Bb Girl/Boy with BW: BL: AS: PAOG: OB score
TRANS-OUT
Side notes the ff:
Stable VS
POSTPARTUM ORDERS
Able to flex both legs
Back to room/ward
(-) vomiting
Full diet once full awake
Blurring of vision
Present IVF to run at 30 gtts/min, D/C if with minimal VB
Orders
IVF to ff: D5LR + 10 “u” Oxy to run at30 gtts/min
May refer back to room
Meds:
D/C O2 and pulse oximeter
o Antibiotics
Monitor V/S q 15 min until stable
o MA 500 mg/cap q 8 H RTC x 24 H, then prn for pain
MIO q Hly (+ FC) or shift (- FC) and refer if UO <30 cc/H
o Methergin 1 tab TID x 3 days
Watch out for profuse vaginal bleeding, hypotension, tachycardia or any
o Viitamins
untoward s/sx
SO: Refer accordingly
o Monitor VS q 15 min until stable Thank you
o Massage uterus prn
o Ice pack on hypogastrium
o Perilight x 15 min OD ADMITTING ORDERS (Abdomen)
o Routine perineal care Please admit to ROC under the service of Dr. ____
o Watch out for profuse vaginal bleeding TPR q shift and record
o Refer accordingly NPO
o Thank you Labs:
o CBC (save serum)
o Serum pregnancy test
o Urinalysis
DISCHARGE ORDERS (Normal OB) IVF: D5LR + 10 “u” oxytocin x 30 gtts/min
MGH SO:
Home Meds o For completion curettage on call
OPD ff-up on Sat @ OB service clinic with photocopy of D/S o Secure consent
Discharge IE and summary c/o ___ o Pad count at bedside
o Save specimen passed out NEGATIVE
o Please prescribe the ff: Nubain, Benadryl, Dormicum @ least 3 contractions in 10 mins, each lasting 40 secs, w/o late
o Refer for profuse bleeding and other untoward ssx deceleration
o Thank you 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
POST OP ORDERS (TAHBSO) UNSATISFACTORY
To RR Frequency of contractions is <3 per minute
Monitor VS q 15 min, until stable HYPERTENSION
Flat on bed x 6 H, then may turn to side 140/90MMhG
NPO x 6 H then may have sips of CL Proteinuria
Present IVF x 30 gtts/min >300mg/24H urine sample
IVF to ff: > 1000mg/random sample 6H apart
o D5LR 1+ = mild proteinuria
+ 10 “u” oxytocin x 8 H
o D5NM 2+ to 4+ = heavy proteinuruia
o D5LR x 8 H *Edema DOES NOT validate Preeclampsia
Meds: GESTATIONAL HPN
SO: HPN w/o Proteinuria (after 20 weeks gestation)
o MIO q H and record Confirm 12 wks Postpartum
PREECLAMPSIA
o Refer if UO is <30cc/H
(+) HPN, (+) Proteinuria after 20th week
o May return blood
ECLAMPSIA
o Remove FC @ ___
(+) convulsions, (+) Preeclampsia
o Apply abdominal binder
CHRONIC HPN
o Refer PRN 140/90mmHg
o Thank you SUPERIMPOSED PREECLAMPSIA
Inc diastole and systole
PELVIC EXAM Proteinuria
Inspection S/Sx of end organ damage
o Grossly N external genitalia Triad for Sever Preeclampsia
o Masses, discharges, bleeding Hemolysis
Speculum Elevated Liver Enzyme
o Cervix – hyperemic/nonhyperremic; fish mouth deformity/ping Low Platelet Count
pong Hypertension etiology(Williams)
IE Exposed chorionic villi
o Cervical dilatation Twin pregnancy (Multiple gestation)
o Cervical effacement Vascular dses
o Station Fam hx
o BOW (intact/leaking)
o Amniotic membrane PROM x days/hours THREATENED ABORTION
o Presenting part Bloody vaginal discharge or bleeding appears
Clinical pelvimetry Closed vaginal os
o Inlet Low abdominal pain
o Midplane Bleeding first, cramping follows
Ischial spines INEVITABLE ABORTION
Sacrum Gross rupture of membrane
Sidewalls Leaking amniotic fluid
o Outlet Cervical dilatation
EFW COMPLETE ABORTION
BME Complete detachment
o I (introitus) - admits 2 fingers with ease/snugly Int. cervical os closes
o C (cervix) – open/closed,; firm, doughy INCOMPLETE ABORTION
o U (uterus) – level of umbilicus Int. cervical os opens and allows passage of blood
o A (adnexae) – firm/fullness; w/ adnexal masses Mullerian Anomalies
o D (discharges) – (+) (-); scanty or minimal bleeding Segmented mullerian agenensis or hyperplasia
o E (episiotomy) – with blood/well coaptated wound Unicornuate uterus
RVE Bicornuate uterus
o Intact rectovaginal septum Septate uterus
o Good sphincter tone Uterus with internal ___? Changes
Abdomen Induction of labor
o Inspection: globular/gravid; linea nigra, striae Oxy drip but not in labor
o Auscultation: NABS Augmentation of Labor
o Palpation: Leopold’s Oxy drip however in labor
o FH, FHB R/L
PRENATAL CHECK-UPS
Final Dx:
0-27 wks q4wks
28 wks q 2wks
NON-STRESS TEST
29-35 wks q2wks
Test of fetal condition
36 wksand beyond q week
REACTIVE when:
At least 2 accelerations of the FHR occurs for at least 15 bpm, lasting for TETANUS TOXOID
15 sec w/in 20 min period of observation 1 20 wks AOG
NONREACTIVE 2 1 month
May imply that the fetus is acidotic, asleep, or drugs was administered to 3 6 months
the mother 4 1 year
A. EARLY DECELERATION 5 1 year
Head compression
B. LATE DECELERATION STEROIDS
Utero-placental insufficiency 1 dose 28-32 wks
C. VARIABLE DECELERATION 3 doses q 2 wks
Cord compression ; Fetal distress OGTT at 24-28wks
Most common ; Most ominous
MAGNESIUM SULFATE DOSES
Loading dose:
CONTRACTION STRESS TEST/OCYTOCIN CHALLENGE TEST 4gms slow IV
A measure of utero-placental function 5gms each buttocks deep IM
Contraction induced by using IV oxytocin Maintenance dose:5gmsIM/IV q 6hrs
Record FHB Monitor BP, U/O, DTRs-hyporeflexia
POSITIVE Monitor RR
Consistent and persistent late deceleration (50%) of the FHB in the MgSO4 drip:
absence of uterine hypertonus or supine hypotension 1-2gms/hr
1L = 10gm given 100cc/hr
10meq/L(about 12mg/dL) HYOSCINE N-BUTYL BROMIDE (Buscopan) for softening of the cervix
>respiratory depression
12meq/L NST: Fetal condition “7 days”
>respiratory paralysis and arrest
Antidote: Calcium gluconate 1g iV CST: Uteroplacental contraction
CgMg (CALMAG)
Mode of action:
Indication:
Calcium deficiency, nutritional supplement to prevent osteoporosis
Side effects:
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