OB-guide-1.doc

NSVD Admitting Notes  Side notes TPR BP Weight LMP (Last Menstrual Period) EDC (Expected Date of Confinement) AOG (Age of Gestation) FH (Fundic Height) FHB (Fetal Heart Beat) CD (Cervical Dilatation) Effacement Station BOW (Bag of Water) Leopold’s

 Please admit to ROC under the service of _____  TPR q 4 hours and record  Full diet, NPO once in active labor  Labs:  CBC  HBsAg  Urinalysis  IVF: D5LR + 10 “u” oxytocin to run at 1015 gtts/min  Meds:  Ampicillin 2g IV ANST if PROM  None if no OB complications  Special Order:  Monitor FHB and progress of labor  Puboperineal shave please  Inform NROD  Will inform service consultant on deck  Refer prn

CS ADMITTING NOTES  Please admit to ROC under the service of _____  TPR q 4 hours and record  Full diet, NPO post-midnight  Labs:  CBC, APC  CT, BT, PT  Urinalysis  Venoclysis:  Meds:  Cefazolin 500mg IVTT q8H x 3 doses then shift to      Special Order:        

Co-Amox 625mg/tab, 1 tab BID Famotidine 20mg IVTT q8H x 3 doses Ketomed 30mg IVTT q8H x 3 doses Ketomed 10mg q8H to start if px is on soft diet Inform OR Secure signed consent Abdominoperineal prep please Request 500cc FWB of patient’s blood type as standby Dr. ___ for anesthesia Inform NROD Refer accordingly Thank you

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 at 30 gtts/min  Meds:  Antibiotics  Mefenamic Acid 500 mg/cap q 8 H RTC x 24 H, then prn for pain  Methergine 1 tab TID x 3 days  Vitamins  SO:  Monitor VS q 15 min until stable  Massage uterus prn  Ice pack on hypogastrium  Perilight x 15 min OD  Routine perineal care  Watch out for profuse vaginal bleeding  Refer accordingly  Thank you

DISCHARGE ORDERS (Normal OB)  MGH  Home Meds  OPD follow-up on Saturday @ OB service clinic with photocopy of D/S  Discharge IE and summary c/o ___  TCB anytime if with profuse VB, HA, blurring of vision, any untoward s/sx

TRANS-OUT ORDERS 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

POST-OP ORDERS  To RR  Monitor VS q15 mins. until stable  NPO x 6 H, then may have sips of Clear liquids  O2 at 2-3 LPM via nasal prong  Run present IVF @ 30 gtts/min  IVF to ff:  D5LR  D5NM  D5LR x 8 H  Meds:  Antibiotics  Ranitidine (Zantac) 50mg IVTT q8H x 3 doses  SO:  Attach px to O2 at 2-3 LPM via nasal prong  Attach pc to pulse ox  MIO q H and record refer if UO is <30cc/H  Remove FC 24H post op  Standby available blood  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

NUMBER OF DAYS IN EACH MONTH SOLVING OF EXPECTED DATE OF CONFINEMENT(EDC)  By Last Menstrual Period (LMP) o Nigel’s Rule (-3,+7, +1) Example: LMP May 2,2014 or 5/2/14 5 2 14 -3 +7 +1 2 9 15 or Feb 9,2015=EDC SOLVING OF AGE OF GESTATION  By Last Menstrual Period Example: Today is April 5, 2015, LMP is Feb 10, 2014 Feb 28-10 =18 days March =31 days April = 5 days 54 days/7(7days a week)= 7 weeks and 5/7 days 

By Ultrasound Example: UTZ result AOG is 23 4/7 days(convert to days)=165 days. Today is April 16 2014. Utz is taken last March 12 2015. April 30 days-16 =14days March 31 days-12=19 days 33 days + 165 days = 198 days 198/7(convert to weeks)=28 weeks 2/7 days

Month January February

Number of days 31 28 29-Leap year 2016,2020,2024... 31 30 31 30 31 31 30 31 30 31

March April May June July August September October November December

DECIMAL POINT CONVERSION TO DAYS .1 .2 .4 .5 .7 .8 Whole number

1 days 2 days 3 days 4 days 5 days 6 days 7 days

PELVIC EXAM  Inspection  Grossly N external genitalia  Masses, discharges, bleeding  Speculum  Cervix – hyperemic/nonhyperemic;  Fish-mouth deformity/ping pong  IE  Cervical dilatation  Cervical effacement  Station  BOW (intact/leaking)  Amniotic membrane PROM x days/hours  Presenting part  Clinical pelvimetry  Inlet  Midplane Ischial spines Sacrum Sidewalls  Outlet

 Bimanual Examination(BME)  I (introitus) – admits 2 fingers with ease/snugly  C (cervix) – open/closed,; firm, doughy  U (uterus) – level of umbilicus  A (adnexae) – firm/fullness; w/ adnexal masses  D (discharges) – (+) (-); scanty or minimal bleeding  E (episiotomy) – with blood/well coaptated wound  Rectal Vault Exam(RVE)  Intact rectovaginal septum  Good sphincter tone  Abdomen  Inspection: globular/gravid; linea nigra, striae  Auscultation: NABS  Palpation: Leopold’s  FH, FHB R/L

BIOPHYSICAL SCORING PARAMETERS

1. Fetal Breathing Movements 2. Gross Body Movement 3. Fetal Tone 4. Reactive FHR(not included in Modified BPS) 5. Amniotic Fluid *Perfect Score is 10/10 or 8/8 NON-STRESS TEST  Test of fetal condition REACTIVE  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 B. EARLY DECELERATION  Head compression C. LATE DECELERATION  Utero-placental insufficiency  Most common ; Most ominous

CONTRACTION STRESS TEST/OXYTOCIN 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  atleast 3 contractions in 10 mins, each lasting 40 secs, w/o late deceleration SUSPICIOUS  Inconstant late deceleration patterns HYPERSTIMULATION  Uterine contractions occur more frequent than every 2 mins, or lasting longer than 90 secs, or presence of hypertonus UNSATISFACTORY  Frequency of contractions is <3 per minute

HYPERTENSION  140/90mmHg Etiology (Williams)  Exposed chorionic villi  Twin pregnancy (Multiple gestation)  Vascular dses  Family hx 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 before 20 weeks AOG SUPERIMPOSED PREECLAMPSIA  Inc diastole and systole  Proteinuria  S/Sx of end organ damage

THREATENED ABORTION

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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

L4 (Pelvic grip)  Side of cephalic prominence

INCOMPLETE ABORTION  Int. cervical os opens and allows passage of blood FETAL DEATH  Tobacco-stained amniotic fluid  Spalding’s sign – significant overlapping of fetal skull bones  Robert’s sign – Demonstration of gas bubbles in the fetus  Exaggeration of fetal spinal curvature

AMONIOTIC FLUID INDEX  Normal: 6-24 cm  Oligohydramnios: <5 cm  Low normal: 9-10  Polyhydramnios: >24 PRENATAL CHECK-UPS  0-27 wks q4wks  28 wks q 2wks  29-35 wks q2wks 36 wks and beyond q week OGTT (Oral Glucose Tolerance Test)  24-28wks Complete Blood COunt  repeated at 28-32 AOG HbsAg  last trimester Alpha fetoprotein  16-18 wks AOG

LEOPOLD’S MANEUVER

NDDG 105 190 165 145

L2 (Umbilical grip)  Fetal back L3 (Pawlick’s grip)  (+) engagement of head or (-) engagement

COMPLETE ABORTION  Complete detachment  Int. cervical os closes

PLASMA GLUCOSE RESULTS: Time Fasting 1st Hr 2nd Hr 3rd Hr

L1 (Fundal Grip)  What fetal pole occupies the fundus

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’S Scoring BISHOP 0 1 SCORE Dilatatio 0 1-2cm n Effaceme 0-30% 31-50% nt Station -5/-3 -2 Cervical Posteri Midline Position or Cervical firm medium Consiste ncy Favorable induction: ? 6(recheck!) Unfavorable induction: ?

Coustan & Capenter(mg/dL) 95 180 155 140

AUGMENTATION OF LABOR

2

3

3-4cm

5-6cm

51-70%

>70%

-1 Anterior

+1/+2 -----

soft

-----

 ↓ amniotic fluid  Oligohydramnios (causes)  Cord compression  Macrosomia  Deformations  Fetal distress

1st Degree

Induction of labor  Oxy drip but not in labor

4th Degree

Augmentation of Labor  Oxy drip however in labor

BRAXTON HICKS CONTRACTION  The uterus undergoes palpable but originally painless contractions at irregular intervals from the early stages of gestation  20 weeks-primigravida  18 weeks-multipara 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

MYOMA  causes soft tissue dystocia  etiology: unopposed estrogen stimulation  types: Subserous, Intramural, Submucous EXCISION OF BARTHOLIN’S CYST  Hyperplasia (uterus) – provera  Endocervical  Endometrial  Endometrial for D & C PLACENTA PREVIA Placenta increta invades Placenta percreta penetrates Placenta accrete attaches PLACENTA PREVIA Types:  Totalis placenta covers cervical os completely  Partialis internal os partially covered by placenta  Marginal edge of the placenta is at margin of internal os Etiology: (P2ALM2)  Previous CS  Puerperal Endometritis  Advancing age  Multiparity  Multiple induced abortions Diagnosis:  Painless third trimester bleeding  UTZ for placental localization  Placental Migration (placenta close to the internal os during 2nd trimester migrate to fundus as pregnancy advances PLACENTA ABRUPTION  premature separation of the normally implanted placenta after the 20th week of pregnancy and before birth of fetus  Etiology: (PECSS)  Pre-eclampsia  External trauma  Chronic hypertension  Short umbilical cord  Sudden uterine decompression LACERATIONS

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2nd Degree



Fourchette, perineal skin, vaginal mucosa but not the underlying fascia and muscle Fascia and muscles of the perineal body but not the anal sphincter

3rd Degree

 

Extend from vaginal mucosa, perineal skin and fascia up to anal sphincter but not the rectal mucosa Encompasses extension up to rectal mucosa

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-Pelvic Inlet  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

DELIVERY OF PLACENTA SHULTZE MECHANISM  Peripheral  Shiny portion DUNCAN MECHANISM  Central  Dirty part Normal Rotation of Umbilical Cord:  Counter clockwise or Left-handed maneuver SIGNS OF PLACENTAL SEPARATION  Calkin’s 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 SIGNS OF MALIGNANCY UTZ:  Septations  Internal echoes  Ascites  Multiple daughter cysts  <5 cm cyst postmenopausal women expectant management

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:  1 or 2 prior low-transverse cesarean section delivery  Clinically adequate pelvic  No other uterine scars or previous rupture  Physicians immediately available throughout active labor capable of monitoring labor and performing an emergency cesarean section delivery  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

ADMITTING NOTES (Ectopic Pregnancy)  Please admit pc to ROC under the service of Dr. ___  TPR q 4 hours and record  IVF: D5LR 1L X 8 Hrs  NPO temporarily  Labs:  CBC, APC  CT, BT, PT  BT w/ Rh  U/A  S. Preg test  Meds: None temporarily  SO:  Monitor VS, abdominal status hourly  Refer once lab result is in  Dr. ___ seen px at ER  Watch out for any untoward s/sx  Refer prn

 *CaMg (CALMAG) Calcium:  Regulates heartbeat and prevents heart disease  Aids the growth and contraction of muscles  Combats cholesterol by increasing HDL  Reduces the occurrence of kidney stones  Reduces high blood pressure  Prevents muscle cramping  Transmits nerve impulses Magnesium:  Assists calcium metabolism  Helps maintain arterial health, normal blood pressure  and normal heart rhythm  Works with calcium to form the structure of the bone Indication:  Calcium deficiency, nutritional supplement to prevent osteoporosis Side effects:  Diarrhea

*ISOXUPRINE HCl (Duvadilan) Mode of Action:  beta-adrenergic agonist that causes direct relaxation of uterine and vascular smooth muscle via beta-2 receptors Indication:  Treatment of circulatory disorders and uterine hypermotility Side effects:  Transient palpitations, fall in BP, dizziness *DYDROGESTERONE (Duphaston)  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

MEDICATIONS

*METOCLOPRAMIDE (Plasil)



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 *PIPERACILLIN TAZOBACTAM  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 TETANUS TOXOID 1st- 20 wks AOG 2nd- 1 month after birth 3rd- 6 months 4th- 1 year 5th- 1 year *STEROIDS (Prematurity)  1 dose 28-32 wks  3 doses q 2 wks *MAGNESIUM SULFATE DOSES (Eclampsia) Loading dose:  4gms slow IV  5gms each buttocks deep IM Maintenance dose:  5gms IM/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 *HYOSCINE N-BUTYL BROMIDE (Buscopan) for softening of the cervix