You are on page 1of 7

History  TCB anytime if with profuce VB, HA, blurring of vision, U2W ssx

 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

FETAL DEATH DELIVERY OF PLACENTA


1. Tobacco-stained amniotic fluid
2. Spalding’ssign SHULTZE MECHANISM
o significant overlapping of fetal skull bones  Peripheral
3. Robert’s sign  Shiny portion
o Demonstration of gas bubbles in the fetus DUNCAN MECHANISM
4. Exaggeration of fetal spinal curvature  Central
 Dirty part
BIOPHYSICAL SCORING PARAMETERS DEFINE:
1. Fetal Breathing Movements  Placenta increta  invades
2. Gross Body Movement  Placenta percreta  penetrates
3. Fetal Tone  Placenta accrete  attaches
4. Reactive FHR Normal Rotation of Umbilical Cord:
5. Amniotic Fluid  Counter clockwise or Left-handed maneuver
*Perfect Score is 10/10 or 8/8
CBC repeated at 28-32 AOG PLACENTA PREVIA
HbsAg last trimester  Types:
Alpha fetoprotein 16-18 wks AOG o Totalis  placenta covers cervical os completely
o Partialis  internal os partially covered by placenta
PLASMA GLUCOSE RESULTS:
o Marginal  edge of the placenta is at margin of internal os
(Blood Glucose testing performed at 24-28wks AOG)
 Etiology: (P2ALM2)
Time NDDG Coustan & Capenter(mg/dL)
o Previous CS
Fasting 105 95
o Puerperal Endometritis
1st Hr 190 180 o Advancing age
2nd Hr 165 155 o Multiparity
o Multiple induced abortions
3rd Hr 145 140
 Diagnosis:
o Painless third trimester bleeding
o UTZ for placental localization
o Placental Migration (placenta close to the internal os during
LEOPOLD’S MANEUVER 2nd trimester migrate to fundus as pregnancy advances
L1 (Fundal Grip)
 What fetal pole occupies the fundus
L2 (Umbilcal grip) PLACENTA ABRUPTION
 Fetal back  premature separation of the normally implanted placenta after the 20th
L3 (Pawlick’s grip) week of pregnancy and before birth of fetus
 (+) engagement of head or (-) engagement  Etiology: (PECSS)
L4 (Pelvic grip) o Pre-eclampsia
 Side of cephalic prominence o External trauma
o Chronic hypertension
FUNDIC HEIGHT o Short umbilical cord
12wks-1st felt; above the symphysis pubis o Sudden uterine decompression
16wks- bet. Symphysis and umbilicus
20wks- umbilicus LACERATIONS
36wks- below ensiform cartilage  1st Degree
o Fourchette, perineal skin, vaginal mucosa but not the
FHB Monitoring
underlying fascia and muscle
 Every 30mins= low risk
 nd
2 Degree
 Every 15mins= high risk
o Fascia and muscles of the perineal body but not the anal
sphincter
BISHOP SCORE
 3rd Degree
0 1 2 3
o Extend from vaginal mucosa, perineal skin and fascia up to
Dilatation 0 1-2cm 3-4cm 5-6cm
anal sphincter but not the rectal mucosa
Effacement 0-30% 31-50% 51-70% >70%
 4th Degree
Station -5/-3 -2 -1 +1/+2
o Encompasses extension up to rectal mucosa
Cervical Posterior Midline Anterior -----
Position
BRAXTON HICKS CONTRACTION
Cervical Firm medium soft -----
 The uterus undergoes palpable but originally painless contractions at
Consistency
irregular intervals from the early stages of gestation
*Scoring: 3-8 difficult induction
9-favorable induction SIGNS OF PLACENTAL SEPARATION
 Calkin’s Sign (uterus becomes globular and firmer from discoid)
MYOMA
 Sudden gush of blood
 causes soft tissue dystocia
 Uterus rises in the abdomen as the detached placenta drops to the lower
 etiology: unopposed estrogen stimulation
segment and vagina
 types: Subserous, Intramural, Submucous
 Lengthening of the cord
ROT-right occiput transverse
Montevideo Units- 200 units or pressure of > 60
AMONIOTIC FLUID INDEX
Depoprovera- injectable CP is G1 to HPN patients
 Normal: 6-24 cm
EXCISION OF BARTHOLIN’S CYST  Oligohydramnios: <5 cm
 Hyperplasia (uterus) – provera  Low normal: 9-10
 Endocervical  Polyhydramnios: >24
For Functional Curettage
 Endometrial
 Endometrial  for D & C
INDICATIONS FOR CESAREAN SECTION
AUGMENTATION OF LABOR
 Prior CS
 ↓ amniotic fluid
 Labor dystocia (most frequent indication for 1’ CS)
 Oligohydramnios (causes)
 Fetal distress
o Cord compression
 Breech presentation
o Macrosomia
o Deformations
POST OP COMPLICATIONS OF CS DELIVERY
o Fetal distress
 Hysterectomy 8. Kelly plication sutures with vicryl 2-0 through the margins of levator ani
 Operative injury to pelvic structures muscles from apex down to posterior fourchette is done and progressively
 Infection tied.
 Puerperal fever 9. The excess posterior vaginal mucosa trimmed.
 Transfusion 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
STAGES OF LABOR interlocking stitches to posterior fourchette.
 I: Active labor to full cervical dilatation (4-10 cm) 12. Vaginal packing done with 1 os.
13. Perineal wash done.
 II: Full cervical dilatation to delivery of baby
14. End of procedure.
 II: Delivery of baby to expulsion of placenta
 IV: Delivery of placenta to 1 hour after

1’ LOW TRANSVERSE CESAREAN SECTION


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

SIGNS OF MALIGNANCY UTZ:


COMPLETION CURETTAGE  Septations
 Internal echoes
1. Induction of anesthesia.  Ascites
2. Patient in dorsal lithotomy position  Multiple daughter cysts
3. Asepsis/Antisepsis <5 cm cyst  in postmenopausal women expectant management
4. Drapings done leaving operative site exposed
5. Insertion of straight catheter.
6. Speculum applied at posterior vaginal wall
7. Application of tenaculum forceps at 12 o’clock position of cervical lip.
8. Sharp/blunt curette done. Evacuated 1 tablespoon cup of products of
conception.
9. Betadine wash done.
10. End of procedure.
11. Specimen sent for histopathology.

VAGINAL BIRTH AFTER A CESAREAN SECTION (VBAC)


 Allow a trial of labor under double set-up for all previous cesarean of one
low segment incision after excluding an inadequate pelvis and unless a
new indication arises
 Selection Criteria:
o 1 or 2 prior low-transverse cesarean section delivery
PIPERACILLIN TAZOBACTAM
Mode of Action:
 Highly active against piperacillin-sensitive microorganisms as wells as B-
lactamase-producing piperacillin-resistant microorganisms
Indication:
 For UTI, lower resp tract, intraabdominal & skin infections & septicemia
Side effects:
 Upset stomach, vomiting, unpleasant or abnormal taste, diarrhea, gas,
headache, constipation, insomnia, rash, itching skin, swelling, shortness of
breath, unusual bruising or bleeding

CgMg (CALMAG)
Mode of action:

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

ISOXUPRINE HCl (Duvadilan)


Mode of Action:

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

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

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

Percentage risk of becoming malignant

Simple hyperplasia without atypia- 1%


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