IM NOTES Editted

kaELECTROLYTE SOLUTIONS IV Sol’n D5W D10W 0.9 NSS D5LR D5NM D5NR D5 0.9 NaCl D5NMK

Glu 5mg/L 100mg/L

Sol’n ECF D5LR D5 0.45 3% NaCl 0.9 NaCl

Na 142 130 77 513 154

Na

ELECTROLYTES Cl

K

154 130 40 140

154 109 40 98

4 13 5

40

40

30

Ca

HCO3

3

28

50 mg/L 50 mg/L

Cl 103 109 77 513 154

K 4 4

HCO3 27 28

a) b) c) d)

Corrected Ca = (40-lbs) x 0.02 + serCa Corrected Na = Na + RBS mg% - 100 x 1.6 / 100 Na Deficit = (140 – (140 – actual)  actual) (0.6 x BW) K Deficit = (D-A) (0.4 x BW) D = 3.5 cardiac 4.5 non-cardiac H20 Deficit = 0.6 x kg BW D = 15 CKD 18 NCKD Actual Na – Na – Desired  Desired Na / Desired Na

Ca 5 5

D5W Osm = 278 D5W Osm = 556 D5LR Osm = 130 NaHCO3 = 446

MECHANICAL VENTILATION

Mg 3 CUSHING’S TRIAD

1) Increase systolic BP 2) Widened pulse pressure 3) Bradycardia /AbN˚ respiratory pattern a. Cheyne Stoke breathing

HEMORRHAGIC STROKE TRIAD 1) Papilledema 2) Headache 3) Vomiting

Indications for Intubation 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12)

Impending respiratory failure, apnea RR >35 PaCO2 > 50 PaO2 0.6 To deliver high FIO2 Absent pH 60 mmHg w/ FIO2 < 50% PEEP < 5 cm PaCO2 < pH acceptable Spontaneous TV < 5mL VC > 10 ml/kg MIP > 25 cm H20 RR < 30/min Rapid shallow breathing index < 100 (RBI) Stable vs. Ft a 1-2 hr

Spontaneous Trial FIO2 room air 21% O2 via nasal prong = # lpm x 0.4 x 20

MEIG’S SYNDROME

1) Pleural Effusion 2) Polycystic Ovary / Fibromatosis 3) Hypoalbuminemia

GLASCOW COMA SCALE EYE RESPONSE a) Spontaneous eye opening 4 b) Opens to verbal command 3 c) Responds to painful stimuli 2 d) No response

1

MOTOR a) Obeys with command b) Localizes pain c) Flexion withdrawal d) Decorticate / Flexion e) Decerebrate / Extension f) No response

6 5 4 3 2 1

VERBAL a) Oriented b) Disoriented c) Inappropriate d) Incomprehensible e) No response

5 4 3 2 1

FOUR SCALE Full outline of responsiveness

DOPAMINE COMPUTATION

EYE RESPONSE a) Eyelids open, tracking, blinking to command b) Eyelids open but not tracking c) Eyelids close but open to loud voice d) Eyelids close but no pain e) Eyelids close with pain

4 3 2 1 0

MOTOR RESPONSE a) Thumbs up, fist or peace sign b) Localizing to pain c) Flexion response to pain d) Extension response to pain e) No response to pain or generalized myoclonus

4 3 2 1 0

BRAINSTEM REFLEXES a) Pupil and Corneal reflex b) One pupil wide and fixed c) Pupil or corneal reflex absent d) Pupil and corneal reflex absent e) Absent pupil, corneal and cough reflex

4 3 2 1 0

RESPIRATION a) Not intubated, regular breathing pattern b) Not intubated, cheyne-stoke breath pattern c) Not intubated, irregular breathing d) Breath above ventilation rate e) Breath at ventilation rate, apnea

4 3 2 1 0

Single strength = BW x desired dose / 13.3 Double strength = BW x desired dose / 16.6 Single strength = BW x desired dose / 16.6 Double strength = BW x desired dose / 33.2 Cardiac Dose = 5 Renal Dose = 5-10

CT SCAN BLEED VOLUME Given:

58 mm ~ 23.3 mm ~

5.8 2.3

5.8 x 2.3 = 13.34 x 5 (constant) = 66.5 x 5.2 (constant) = 34.684 -(estimated bleeding volume)

DIAGNOSTIC THORACENTESIS DUE TO HEART FAILURE 1) 2) 3) 4)

If the effusion are not bilateral and comparable size If the patient is febrile If the chest has a pleuritic chest pain If effusion persist despite the diuretics therapy

DENGUE GRADE I Fever  Non-specific symptoms  o Anorexia o Vomiting o Abdominal pain (+) Torniquet test 

INDICATION FOR CHEST TUBE THORACOSTOMY 1) 2) 3) 4) 5) 6)

Pneumothorax Pleural effusion Chylothorax Empyema Hemathorax Hydrothorax

GRADE II Grade I + spontaneous bleeding  GRADE III Grade II + severe bleeding + circulatory failure  GRADE IV Grade III + irreversible shock + massive bleeding 

ABG COMPUTATION I. II. III.

713 (decimal FIO2) – PCO2/0.8 = I pO2/I = II (Desired FIO2/II) + pCO2/0.8  ________________________ 713

x 100

TIMING OF TUBE REMOVAL The timing of tube removal depends on clinical and radiological  evidence of complete expulsion of all contents of pleural cavity with complete expansion of the lung Minimal drainage should have occurred over the previous 24 hours  ( 0.5 2) Pleural fluid LDH / serum LDH > 0.6 3) Pleural fluid LDH > 2/3 the upper limit of normal serum LDH

 Anterior =

V2-V4 (L) coronary, LAD

 Anterolateral =

I, qV1, V3 – V6, LAD, circumflexes

 Anteroseptal =

V1-V4, LAD

Inferior =

II, III, aVF, (R) coronary artery

Lateral =

I, aVL, V5, V6, circumflex brance of (L) coronary artery

Posterior =

V8 – V9 (R) coronary artery, circumflex artery

(R) Ventricular =

V4R, V5R, V6R, (R) coronary artery

TRANSUDATIVE VS EXUDATIVE FLUID

SG Protein FP / SP LDH FLDH/SLDH Cholesterol

Transudative < 1.012 < 3 g/dL < 0.5 0.5 >60% >0.6 >45 mg / dL

JONES CRITERIA OF RF CLASSIFICATIONS OF PTB Class O NO PTB EXPOSURE  Not infected  Class 1 HISTORY OF EXPOSURE  Neg. Skin test to tuberculin  Class 2 TB INFECTION  No disease  Positive reaction to tuberculin test  No clinical, bacteriologic or radiographic evidence of TB  Class 3 TB CLINICALLY ACTIVE  Clinical, bacteriologic, or radiographic evidence of current disease  Class 4 TB NOT CLINICALLY ACTIVE  History of episode of TB  Abnormal but stable radiographic findings  No clinical or radiographic evidence of current disease  Class 5 TB SUSPECT  Diagnosis pending  TB disease should be ruled out within 3 months  Signs and Symptoms of TB Fever  Night sweats  Weight loss  Anorexia  Weakness  General Malaise 

RECOMMENDED DOSAGE FOR INITIAL TREATMENT OF TB 1) 2) 3) 4)

Isoniazid = 5 mg/kg, max 300 mg Rifampicin = 10 mg/kg, max 600 mg Pyrazinamide = 20-25 mg/kg, max 2 g Ethambutol = 15-20 mg/kg

Major: Carditis  Polyarthritis  Chorea  Erythema marginatum  Subcutaneous nodule  Minor: Fever  Polyarthralgia  Lab: Inc. ESR / Leukocyte count  ECG: Prolong P-R interval  Elevated anti-streptolysin O, other strep antibody  (+) throat culture  Rapid Ag test for Group A  Strep / result: Scarlet Fever  Criteria: 2 major/one minor and 2  (+) evidence of preceding Group A strep infection 

ACUTE RESPIRATORY FAILURE TYPE I or Acute Hypoxemic Respiratory Failure Occurs when alveolar flooding and subsequent intrapulmonary  shunt physiology occurs Alveolar flooding may be a consequence of pulmonary edema,  pneumonia or alveolar hemorrhage Low pressure pulmonary edema  Defined by diffused bilateral airspace edema  TYPE II Respiratory Failure Occurs as a result of alveolar hyperventilation and results on the  inability to eliminate CO2 effectivity Mechanism by which this occurs are categorized by impaired CNS  drive to breath, impaired strength with failure of neuromuscular function in the respiratory ____ Reason for diminished CNS drive to breath including drug  overdose, brainstem injury, sleep disordered breathing Overload Respiratory System due to: Increase resistive loads (bronchospasms)  Reduced lung compliance (alveolar edema)  Reduced chest wall compliance (pneumothorax)  Increase minute ventilation (pulmonary embolus) 

TYPE III Respiratory Failure Occurs as a result of lung atelectasis  Also called perioperative respiratory failure  After general anesthesia, decreases in functional residual capacity  of dependent lung units TYPE IV Respiratory Failure Due to hypoperfusion of respiratory muscles in patients in shock,  due to pulmonary edema, lactic acidosis, anemic

DEFINITIONS USED TO DESCRIBE THE CONDITION OF SEPTIC PATIENTS Bacteremia Presence of bacteria in blood as evidenced by positive blood  culture Septicemia Presence of microbes and their toxins in the blood  SIRS  

Systemic inflammatory response syndrome Two or more of the following conditions: o Fever (oral temp >38˚C) or hypothermia (90 bpm) o Tachypnea (>24 bpm) o Leukocytosis (>12,000/uL) or Leukopenia (10% bands may have a non-infectious etiology

Sepsis SIRS that has proven or suspected microbial etiology  Severe Sepsis Similar to sepsis “sepsis syndrome”  Sepsis with one or more signs of organ dysfunction  Examples: 1) Cardiovascular: Arterial systolic blood pressure 10mg/dL  Note: For acute renal failure it is best to start dialysis early 

RHEUMATIC ARTHRITIS Require 4 out of 2 criteria:  o Morning stiffness o Arteritis of 2 or more joints o Arteritis of hands and joints o Systemic arthritis o Rheumatoid nodule o Serum Rheumatoid factor o Radiographic changes

CHILD-PVGH CLASSIFICATION OF CIRRHOSIS Factor Units 1 2 3 s. Bilirubin umol / L 51 mg / dL 3 g/L >35 30-35 3.5 3.0-3.5 6 Protime INR 2.3 Ascites None Easily Poorly controlled controlled None Minimal Advanced Hepatic encephalopathy 

≥ 90

mmHg or

Refractory Septic Shock Septic shock that last > 1 hour and does not respond to fluid or  pressure administration Multi-organ Dysfunction Syndrome Dysfunction of more than 1 organ requiring intervention to  maintain homeostasis

Calculated by adding the score of the 5 factor and can range from 5 – 15

CHILD-PVGH Class is either: A. Score of 5 – 6 B. Score of 7 – 9 C. Score of 10 or Above

Decomposition indicate cirrhosis  N/A  CHILD PVGH Score of 7 or more  Class 8 Listing for liver transformation (accepted criteria) 

Hepatic Fibrogenesis Stellate cell activation  Collagen production 

Stage I Stage II Stage III Stage IV

CLINICAL STAGE OF HEPATIC ENCEPHALOPATHY MS Euphoria, depression, mild confusion, slurred speech, disturbance in sleep Lethargy, moderate confusion Marked confusion, incoherent speech, sleeping but arousable Coma, initially responsive to noxious stimuli, ____ response

COMPLICATIONS OF ERCP 1) Infection 2) Perforation 3) Pneumothorax 4) Bleeding

MUSCLE STRENGTH O – No muscular contraction 1 – Trace contraction 2 – Active movement with gravity eliminated 3 – Active movement against gravity 4 – Active movement against gravity & slight resistance 5 – Against full resistance

IDEAL PEAK FLOW Ideal peak flow: Hg (m)  – 100 x 5 (+) 175 (M) (+) 170 (F) N ≥ 80% PEFR = Peak flow reading / Ideal peak flow x 100 = _____ % N ≤ 20% PEFR variability: Highest reading – Lower x 100 = ______ % Highest Reading

NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION CLASS I No limitation of physical activity  No symptoms with ordinary exertion  CLASS II Slight limitation of physical activity  Ordinary activity causes symptoms  CLASS III Marked limitation of physical activity  Less than ordinary activity causes symptoms  Asymptomatic at rest  CLASS IV Inability to carry out any physical activity without discomfort  Symptomatic at rest 

FRAMINGHAM CIRTERIA FOR DIAGNOSIS OF CHF MAJOR CRITERIA Paroxysmal Nocturnal Dyspnea  Neck vein distention  Rales  Cardiomegaly  Acute pulmonary edema  S3 gallop  Increased venous pressure (>16 cmH20)  Positive hepatojugular reflux  MINOR CRITERIA Extremity edema  Night cough  Dyspnea on exertion  Hepatomegaly  Pleural effusion  Vital capacity reduced by one-third from normal  Tachycardia (>120 bpm)  MAJOR OR MINOR Weight loss of >4.5 kg over 5 days treatment 

GRADING OF MURMURS 1 – Faint 2 – Audible 3 – Moderately Loud 4 – Loud with palpable thrill 5 – Loud with thrill, stet partially off 6 – Loud with thrill, w/o stet

BLOOD TRANSFUSION  CP status assessed  VS checked  Please transfuse available _____ unit of patient’s blood type after proper cross matching  Run BT @ 5-10 gtts/min for 30 mins then to titrate @ 15-20 gtts/min with no BT reactions  Mainline to KVO while on BT  Monitor VS q15 mins while on BT  Refer for any BT reactions such as fever, chills, dyspnea, hypotension and pruritus  Refer accordingly

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:  CBC  HBsAg  Urinalysis  IVF: D5LR + 10 “u” oxytocin to run at 10 -15 gtts/min  Meds  Ampicillin 2g IV ANST if PROM SO:   Monitor FHB and progress of labor  Puboperineal shave please  Inform NROD  Will inform service consultant on deck  Refer prn  Thank you Side notes   TPR  BP  Wt  LMP  EDC  AOG  FH  FHB  CD  Effacement  Station  BOW  Leopolds Final Dx:   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

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:   Antibiotics  MA 500 mg/cap q 8 H RTC x 24 H, then prn for pain  Methergin 1 tab TID x 3 days  Viitamins 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 ff-up on Sat @ OB service clinic with photocopy of D/S  Discharge IE and summary c/o ___  TCB anytime if with profuse 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:   CBC, APC  CT, BT, PT  Urinalysis Venoclysis  Meds:   Cefazolin 500mg IVTT q8H x 3 doses then shift to 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  Tramadol 50mg IVTT q6H prn  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

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 x 8 H o D5NM o 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 respiratory paralysis and arrest Antidote: Calcium gluconate 1g iV

BISHOP SCORE 1 0 1-2cm 0-30% 31-50% -5/-3 -2 Posterior Midline 0

Dilatation Effacement Station Cervical Position Cervical firm medium Consistency *Scoring: 3-8 difficult induction 9-favorable induction

*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 1stHr

190

180

nd

2 Hr

165

155

3rdHr

145

140

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

FHB Monitoring Every 30mins= low risk  Every 15mins= high risk 

-----

EXCISION OF BARTHOLIN’S CYST Hyperplasia (uterus) – Provera  Endocervical  For Functional Curettage Endometrial  Endometrial  for D & C 

BIOPHYSICAL SCORING PARAMETERS 1. Fetal Breathing Movements 2. Gross Body Movement 3. Fetal Tone 4. Reactive FHR 5. Amniotic Fluid

FUNDIC HEIGHT 1st felt; above the symphysis pubis 12wksbet. Symphysis and umbilicus 16wks20wks-  umbilicus below ensiform cartilage 36wks-

soft

3 5-6cm >70% +1/+2 -----

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

FETAL DEATH 1. Tobacco-stained amniotic fluid 2. Spalding’ssign o significant overlapping of fetal skull bones 3. Robert’s sign o Demonstration of gas bubbles in the fetus 4. Exaggeration of fetal spinal curvature

LEOPOLD’S MANEUVER L1 (Fundal Grip) What fetal pole occupies the fundus  L2 (Umbilcal grip) Fetal back  L3 (Pawlick’s grip) (+) engagement of head or (-) engagement  L4 (Pelvic grip) Side of cephalic prominence 

2 3-4cm 51-70% -1 Anterior

SHULTZE MECHANISM Peripheral  Shiny portion  DUNCAN MECHANISM Central  Dirty part  DEFINE: Placenta increta invades  Placenta percreta penetrates  Placenta accrete  attaches  Normal 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

PLACENTAL ABRUPTION th  premature separation of the normally implanted placenta after the 20 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 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  AMONIOTIC FLUID INDEX Normal: 6-24 cm  Oligohydramnios: 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 levatorani 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 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. 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, 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 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 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. 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 24. Top dressing applied. 25. 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 3-0. 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-desac 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 uterosacralligament, 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 1-0 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 0’clock position. 8. Hysterometer inserted. 9. Pre-curettage uterine depth measured 9 cms. 10. Sharp and dull curettage done in a clockwise manner, evacuated ½ 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 Goodell’s dilator 7. Retractor applied at posterior & anterior vaginal wall 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 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 o’clock 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 ½ 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 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 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 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

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:   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

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  55 y.o Glucose > 200mg/dl WBC > 16,000/cumm LDH > 350 IU/L AST > 250 U/L

After Initial 48 hrs Serum Ca++ < 8mg/dl Arterial PO2 < 60mmHg Base Deficit > 4meq/L BUN Increase > 5mg/dl Hematocrit fall > 10% Fluid Sequestration > 6,000ml