ELECTROLYTE SOLUTIONS ELECTROLYTES

IV Sol’n Glu Na Cl K Ca HCO3 a) Corrected Ca = (40-lbs) x 0.02 + serCa

D5W 5mg/L b) Corrected Na = Na + RBS mg% - 100 x 1.6 / 100
D10W 100mg/L c) Na Deficit = (140 – actual) (0.6 x BW)
0.9 NSS 154 154 d) K Deficit = (D-A) (0.4 x BW)
D5LR 130 109 4 3 28 D = 3.5 cardiac
D5NM 40 40 13 4.5 non-cardiac
D5NR 140 98 5 H20 Deficit = 0.6 x kg BW
D = 15 CKD
D5 0.9 50 mg/L
NaCl 18 NCKD
D5NMK 50 mg/L 40 40 30
Actual Na – Desired Na / Desired Na
Sol’n Na Cl K HCO3 Ca Mg
ECF 142 103 4 27 5 3
D5LR 130 109 4 28 5 CUSHING’S TRIAD
D5 0.45 77 77
3% NaCl 513 513 1) Increase systolic BP
0.9 NaCl 154 154 2) Widened pulse pressure
3) Bradycardia /AbN˚ respiratory pattern
D5W Osm = 278 a. Cheyne Stoke breathing
D5W Osm = 556
D5LR Osm = 130
NaHCO3 = 446 HEMORRHAGIC STROKE TRIAD

1) Papilledema
MECHANICAL VENTILATION 2) Headache
3) Vomiting
Indication for Intubation

1) Impending respiratory failure, apnea

2) RR >35
3) PaCO2 > 50 MEIG’S SYNDROME
4) PaO2 <60
5) TV < 3-5 ml/kg 1) Pleural Effusion
6) VC < 10-15 ml/kg 2) Polycystic Ovary / Fibromatosis
7) Inspiratory force < 25 cm H20 3) Hypoalbuminemia
8) FEV < 10 ml/kg
9) Vq / Vt > 0.6
10) To deliver high FIO2
11) Absent
12) pH <7.35

VENTILATOR SETTING GLASCOW COMA SCALE

1) TV: 6-8 ml/kg (ARDS) 8-10 ml/kg EYE RESPONSE

2) Pale: 6-20 a) Spontaneous eye opening 4
3) Mode: AC (Assist Control) b) Opens to verbal command 3
SIMV (Synchronized Intermittent 1 mV c) Responds to painful stimuli 2
4) FIO2 d) No response 1
5) PEEP 5cm H20
MOTOR
a) Obeys with command 6
INDICATIONS FOR WEANING b) Localizes pain 5
c) Flexion withdrawal 4
1) Mental status: Awake, Alery d) Decorticate / Flexion 3
2) PaCO2 > 60 mmHg w/ FIO2 < 50% e) Decerebrate / Extension 2
3) PEEP < 5 cm f) No response 1
4) PaCO2 < pH acceptable
5) Spontaneous TV < 5mL VERBAL
6) VC > 10 ml/kg a) Oriented 5
7) MIP > 25 cm H20 b) Disoriented 4
8) RR < 30/min c) Inappropriate 3
9) Rapid shallow breathing index < 100 (RBI) d) Incomprehensible 2
10) Stable vs. Ft a 1-2 hr e) No response 1

Spontaneous Trial
FIO2 room air 21%
O2 via nasal prong = # lpm x 0.4 x 20
FOUR SCALE DOPAMINE COMPUTATION
- Full outline of responsiveness
Single strength = BW x desired dose / 13.3
EYE RESPONSE Double strength = BW x desired dose / 16.6
a) Eyelids open, tracking, blinking to command 4 Single strength = BW x desired dose / 16.6
b) Eyelids open but not tracking 3 Double strength = BW x desired dose / 33.2
c) Eyelids close but open to loud voice 2
d) Eyelids close but no pain 1 Cardiac Dose = 5
e) Eyelids close with pain 0 Renal Dose = 5-10

MOTOR RESPONSE
a) Thumbs up, fist or peace sign 4
b) Localizing to pain 3
c) Flexion response to pain 2 CT SCAN BLEED VOLUME
d) Extension response to pain 1
e) No response to pain or generalized myoclonus 0 Given: 58 mm ~ 5.8
23.3 mm ~ 2.3
BRAINSTEM REFLEXES
a) Pupil and Corneal reflex 4 5.8 x 2.3 = 13.34 x 5 (constant) = 66.5 x 5.2 (constant) = 34.684 -(estimated
b) One pupil wide and fixed 3 bleeding volume)
c) Pupil or corneal reflex absent 2
d) Pupil and corneal reflex absent 1
e) Absent pupil, corneal and cough reflex 0

RESPIRATION DIAGNOSTIC THORACENTESIS DUE TO HEART FAILURE

a) Not intubated, regular breathing pattern 4
b) Not intubated, cheyne-stoke breath pattern 3 1) If the effusion are not bilateral and comparable size
c) Not intubated, irregular breathing 2 2) If the patient is febrile
d) Breath above ventilation rate 1 3) If the chest has a pleuritic chest pain
e) Breath at ventilation rate, apnea 0 4) If effusion persist despite the diuretics therapy

DENGUE

GRADE I INDICATION FOR CHEST TUBE THORACOSTOMY

 Fever
 Non-specific symptoms 1) Pneumothorax
o Anorexia 2) Pleural effusion
o Vomiting 3) Chylothorax
o Abdominal pain 4) Empyema
 (+) Torniquet test 5) Hemathorax
6) Hydrothorax
GRADE II
 Grade I + spontaneous bleeding

GRADE III
 Grade II + severe bleeding + circulatory failure TIMING OF TUBE REMOVAL
 The timing of tube removal depends on clinical and radiological
GRADE IV evidence of complete expulsion of all contents of pleural cavity
 Grade III + irreversible shock + massive bleeding with complete expansion of the lung
 Minimal drainage should have occurred over the previous 24
hours (<25 ml/kg)
 When the patient coughs or performs the valsalva maneuver no
ABG COMPUTATION air leak should ensue
 The chest radiograph should confirmed complete expansion of
I. 713 (decimal FIO2) – PCO2/0.8 = I the lung
II. pO2/I = II  The s____ in the fluid in the tube in the underwater seal bottle
III. (Desired FIO2/II) + pCO2/0.8 should be minimal, relating to the normal negative pressured in
________________________ x 100 the chest during the phases of respiration
713

Desired FIO2 = 104 – (0.43 x age)

A. 713 x FIO2 – PCO2/0.8 INDICATIONS FOR CTT

B. pO2 / A  Gross pus on thoracentesis
C. 02 for age / B + pC02 / 0.8  Presence of organism on gram stain of the pleural fluid
________________________________  Pleural fluid glucose < 50 mg / dL
713  Pleural fluid pH below 7.00 and 0.15 units lower than arterial pH

FIO2: 20 / 4 = L
LIGHT’S CRITERIA LOCATING MYOCARDIAL DAMAGE

1) Pleural fluid protein / serum protein > 0.5 Anterior = V2-V4 (L) coronary, LAD
2) Pleural fluid LDH / serum LDH > 0.6
3) Pleural fluid LDH > 2/3 the upper limit of normal serum LDH Anterolateral = I, qV1, V3 – V6, LAD, circumflexes

Anteroseptal = V1-V4, LAD

TRANSUDATIVE VS EXUDATIVE FLUID
Inferior = II, III, aVF, (R) coronary artery

Transudative Exudative Lateral = I, aVL, V5, V6, circumflex brance of (L) coronary artery
SG < 1.012 > 1.020
Protein < 3 g/dL >3 g / dL Posterior = V8 – V9 (R) coronary artery, circumflex artery
FP / SP < 0.5 >0.5
LDH <60% >60% (R) Ventricular = V4R, V5R, V6R, (R) coronary artery
FLDH/SLDH <0.6 >0.6
Cholesterol <45 mg / dL >45 mg / dL
JONES CRITERIA OF RF

Major:
CLASSIFICATION OF PTB
 Carditis
Class O  Polyarthritis
 NO PTB EXPOSURE  Chorea
 Not infected  Erythema marginatum
 Subcutaneous nodule
Class 1
 HISTORY OF EXPOSURE Minor:
 Neg. Skin test to tuberculin  Fever
 Polyarthralgia
Class 2  Lab: Inc. ESR / Leukocyte count
 TB INFECTION  ECG: Prolong P-R interval
 No disease  Elevated anti-streptolysin O, other strep antibody
 Positive reaction to tuberculin test  (+) throat culture
 No clinical, bacteriologic or radiographic evidence of TB  Rapid Ag test for Group A
 Strep / result: Scarlet Fever
Class 3
 TB CLINICALLY ACTIVE Criteria:
 Clinical, bacteriologic, or radiographic evidence of current  2 major/one minor and 2
disease  (+) evidence of preceding Group A strep infection

Class 4
 TB NOT CLINICALLY ACTIVE ACUTE RESPIRATORY FAILURE
 History of episode of TB
 Abnormal but stable radiographic findings TYPE I or Acute Hypoxemic Respiratory Failure
 No clinical or radiographic evidence of current disease  Occurs when alveolar flooding and subsequent intrapulmonary
shunt physiology occurs
Class 5  Alveolar flooding may be a consequence of pulmonary edema,
 TB SUSPECT pneumonia or alveolar hemorrhage
 Diagnosis pending  Low pressure pulmonary edema
 TB disease should be ruled out within 3 months  Defined by diffused bilateral airspace edema

Signs and Symptoms of TB TYPE II Respiratory Failure

 Fever  Occurs as a result of alveolar hyperventilation and results on the
 Night sweats inability to eliminate CO2 effectivity
 Weight loss  Mechanism by which this occurs are categorized by impaired CNS
 Anorexia drive to breath, impaired strength with failure of neuromuscular
function in the respiratory ____
 Weakness
 Reason for diminished CNS drive to breath including drug
 General Malaise
overdose, brainstem injury, sleep disordered breathing

Overload Respiratory System due to:

 Increase resistive loads (bronchospasms)
RECOMMENDED DOSAGE FOR INITIAL TREATMENT OF TB  Reduced lung compliance (alveolar edema)
 Reduced chest wall compliance (pneumothorax)
1) Isoniazid = 5 mg/kg, max 300 mg  Increase minute ventilation (pulmonary embolus)
2) Rifampicin = 10 mg/kg, max 600 mg
3) Pyrazinamide = 20-25 mg/kg, max 2 g
4) Ethambutol = 15-20 mg/kg
TYPE III Respiratory Failure BRONCHIECTASIS
 Occurs as a result of lung atelectasis  Is an abnormal and permanent dilatation of bronchi
 Also called perioperative respiratory failure  Associated with destruction and inflammatory changes in the wall
 After general anesthesia, decreases in functional residual capacity of the medium sized airways often at the level of segmental or
of dependent lung units subsegmental bronchi
 The dilated airways frequently contain pools of thick purulent
TYPE IV Respiratory Failure material, while more peripheral airways are often occluded by
 Due to hypoperfusion of respiratory muscles in patients in shock, secretions or obliterated and replaced by fibrous tissue
due to pulmonary edema, lactic acidosis, anemic  As the result of inflammation it produces airway damage,
impaired clearance of microorganism resulting to vascularity of
the bronchial wall increases with associated enlargement of the
DEFINITIONS USED TO DESCRIBE THE CONDITION OF SEPTIC PATIENTS bronchial arteries and anastomoses between the bronchial and
pulmonary arterial circulation
Bacteremia
 Presence of bacteria in blood as evidenced by positive blood
culture
INDICATIONS FOR INITIATING HEMODIALYSIS
Septicemia  Failure of conservative management
 Presence of microbes and their toxins in the blood  Management to relieve
a) Pulmonary congestion (unresponsive to high dose
SIRS furosemide)
 Systemic inflammatory response syndrome b) Severe metabolic acidosis
 Two or more of the following conditions: c) Severe hyperkalemia
o Fever (oral temp >38˚C) or hypothermia (<36˚C)  BUN >100 mg/dL or creatinine >10mg/dL
o Tachycardia (>90 bpm)  Note: For acute renal failure it is best to start dialysis early
o Tachypnea (>24 bpm)
o Leukocytosis (>12,000/uL) or Leukopenia (<4,000/uL)
or > 10% bands may have a non-infectious etiology
RHEUMATIC ARTHRITIS
Sepsis  Require 4 out of 2 criteria:
 SIRS that has proven or suspected microbial etiology o Morning stiffness
o Arteritis of 2 or more joints
Severe Sepsis o Arteritis of hands and joints
 Similar to sepsis “sepsis syndrome” o Systemic arthritis
 Sepsis with one or more signs of organ dysfunction o Rheumatoid nodule
o Serum Rheumatoid factor
Examples o Radiographic changes

1) Cardiovascular: Arterial systolic blood pressure <90 mmHg or

Mean Arterial Pressure ≤ 70 mmHg that responds to CHILD-PVGH CLASSIFICATION OF CIRRHOSIS
administration of IV
2) Renal: Urine output <0.5 ml/kg/hr for 1 hour despite adequate Factor Units 1 2 3
fluid resuscitation s. Bilirubin umol / L <34 34-51 >51
3) Respiratory: PaO2/FIO2 <250 or if the lung is the only mg / dL <2 2-3 >3
dysfunctional organ ≤ 200 s. Albumin g/L >35 30-35 <30
4) Hematologic: Platelet count <80,000/uL or 50% decrease in g / dL >3.5 3.0-3.5 <3
platelet from highest value recorded over the previous 3 days Protime sec 0-4 4-6 >6
5) Unexplained metabolic acidosis: a pH ≤7.30 or a base deficit ≥ 5.0 INR <1.7 1.7-2.3 >2.3
meq/L and a plasma lactate level >1.5 times upper limit of normal Ascites None Easily Poorly
for reporting controlled controlled
6) Adequate fluid resuscitation: Pulmonary artery wedge pressure ≥ Hepatic None Minimal Advanced
12 mmHg or Central Venous pressure ≥8 mmHg encephalopathy
Septic Shock
 Calculated by adding the score of the 5 factor and can range from
 Sepsis with hypotension (arterial blood pressure of ≥ 90 mmHg or
5 – 15
MAP > 70 mmHg
CHILD-PVGH Class is either:
Refractory Septic Shock
A. Score of 5 – 6
 Septic shock that last > 1 hour and does not respond to fluid or B. Score of 7 – 9
pressure administration C. Score of 10 or Above
Multi-organ Dysfunction Syndrome Decomposition
 Dysfunction of more than 1 organ requiring intervention to  indicate cirrhosis
maintain homeostasis
 N/A
 CHILD PVGH Score of 7 or more

Class 8
 Listing for liver transformation (accepted criteria)

Hepatic Fibrogenesis
 Stellate cell activation
 Collagen production
CLINICAL STAGE OF HEPATIC ENCEPHALOPATHY NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION

MS CLASS I
Stage I Euphoria, depression, mild confusion, slurred speech,  No limitation of physical activity
disturbance in sleep  No symptoms with ordinary exertion
Stage II Lethargy, moderate confusion
Stage III Marked confusion, incoherent speech, sleeping but arousable CLASS II
Stage IV Coma, initially responsive to noxious stimuli, ____ response  Slight limitation of physical activity
 Ordinary activity causes symptoms

COMPLICATIONS OF ERCP CLASS III

 Marked limitation of physical activity
1) Infection  Less than ordinary activity causes symptoms
2) Perforation  Asymptomatic at rest
3) Pneumothorax
4) Bleeding CLASS IV
 Inability to carry out any physical activity without discomfort
 Symptomatic at rest
MUSCLE STRENGTH

O – No muscular contraction
1 – Trace contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity FRAMINGHAM CIRTERIA FOR DIAGNOSIS OF CHF
4 – Active movement against gravity & slight resistance
5 – Against full resistance MAJOR CRITERIA
 Paroxysmal Nocturnal Dyspnea
 Neck vein distention
 Rales
 Cardiomegaly
IDEAL PEAK FLOW  Acute pulmonary edema
 S3 gallop
Ideal peak flow: Hg (m) – 100 x 5 (+) 175 (M) (+) 170 (F)  Increased venous pressure (>16 cmH20)
 Positive hepatojugular reflux
N ≥ 80%
PEFR = Peak flow reading / Ideal peak flow x 100 = _____ %
MINOR CRITERIA
 Extremity edema
N ≤ 20%
 Night cough
PEFR variability: Highest reading – Lower x 100 = ______ %
 Dyspnea on exertion
Highest Reading
 Hepatomegaly
 Pleural effusion
 Vital capacity reduced by one-third from normal
 Tachycardia (>120 bpm)
GRADING OF MURMURS
MAJOR OR MINOR
1 – Faint  Weight loss of >4.5 kg over 5 days treatment
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  SO:
 General data o Monitor VS q 15 min until stable
 Chief complaint o Massage uterus prn
 PMHx o Ice pack on hypogastrium
 PSHx o Perilight x 15 min OD
 FMHx o Routine perineal care
 OBHx o Watch out for profuse vaginal bleeding
o Menarche o Refer accordingly
o Interval o Thank you
o Duration
o Amount DISCHARGE ORDERS (Normal OB)
o Symptoms  MGH
o Coitarche  Home Meds
o Menopause  OPD ff-up on Sat @ OB service clinic with photocopy of D/S
o OCP, S/P, PAP, Intermenstrual bleeding  Discharge IE and summary c/o ___
o Postcoital bleeding  TCB anytime if with profuse VB, HA, blurring of vision, U2W ssx
o OB Score
o LMP, EDC, AOG CS ADMITTING NOTES
o PNCU  Please admit to ROC under the service of _____
o HBsAg/VDRL  TPR q 4 hours and record
o TT/BT/MTV  Full diet, NPO post midnight
o UTI  Labs:
o CBC, APC
NSVD Admitting Notes o CT, BT, PT
 Please admit to ROC under the service of _____ o Urinalysis
 TPR q 4 hours and record  Venoclysis
 Full diet, NPO once in active labor  Meds:
 Labs: o Cefazolin 500mg IVTT q8H x 3 doses then shift to Co-
o CBC Amox 625mg/tab, 1 tab BID
o HBsAg o Famotidine 20mg IVTT q8H x 3 doses
o Urinalysis o Ketomed 30mg IVTT q8H x 3 doses
 IVF: D5LR + 10 “u” oxytocin to run at 10-15 gtts/min o Ketomed 10mg q8H to start if px is on soft diet
 Meds o Tramadol 50mg IVTT q6H prn
o Ampicillin 2g IV ANST if PROM  Inform OR
 SO:  Secure signed consent
o Monitor FHB and progress of labor  Abdominoperineal prep please
o Puboperineal shave please  Request 500cc FWB of patient’s blood type as standby
o Inform NROD  Dr. ___ for anesthesia
o Will inform service consultant on deck  Inform NROD
o Refer prn  Refer accordingly
o Thank you  Thank you
 Side notes
o TPR
o BP
o Wt POST-OP ORDERS
o LMP  To RR
o EDC  Monitor VS q15 mins until stable
o AOG  NPO x 6 H, then may have sips of CL
o FH
 O2 at 2-3 LPM via nasal prong
o FHB
 Run present IVF @ 30 gtts/min
o CD
 IVF to ff:
o Effacement
o D5LR
o Station + 10 “u” oxytocin x 8 H
o D5NM
o BOW
o D5LR x 8 H
o Leopolds
 Meds:
 Final Dx:
o Antibiotics
o PU FT del via NSVD/1’LTCS/Rpt CS in cephalic
o Ranitidine (Zantac) 50mg IVTT q8H x 3 doses
presentation to a live Bb Girl/Boy with BW: BL: AS:
 SO:
PAOG: OB score
o Attach px to O2 at 2-3 LPM via nasal prong
o Attach pc to pulse ox
o MIO q H and record
o Refer if UO is <30cc/H
POSTPARTUM ORDERS
o Remove FC 24H post op
 Back to room/ward
o Standby available blood
 Full diet once full awake
o Apply abdominal binder
 Present IVF to run at 30 gtts/min, D/C if with minimal VB
o Morphine precaution please
 IVF to ff: D5LR + 10 “u” Oxy to run at30 gtts/min o Specimen for histopathology
 Meds: o Watch out for profuse vaginal bleeding, hypotension,
o Antibiotics tachycardia or any untoward s/sx
o MA 500 mg/cap q 8 H RTC x 24 H, then prn for pain o Refer PRN
o Methergin 1 tab TID x 3 days o Thank you
o Viitamins
  Clinical pelvimetry
o Inlet
TRANS-OUT o Midplane
Side notes the ff:  Ischial spines
 Stable VS  Sacrum
 Able to flex both legs  Sidewalls
 (-) vomiting o Outlet
 Blurring of vision  EFW
Orders  BME
 May refer back to room o I (introitus) - admits 2 fingers with ease/snugly
 D/C O2 and pulse oximeter o C (cervix) – open/closed,; firm, doughy
 Monitor V/S q 15 min until stable o U (uterus) – level of umbilicus
 MIO q Hly (+ FC) or shift (- FC) and refer if UO <30 cc/H o A (adnexae) – firm/fullness; w/ adnexal masses
 Watch out for profuse vaginal bleeding, hypotension, tachycardia o D (discharges) – (+) (-); scanty or minimal bleeding
or any untoward s/sx o E (episiotomy) – with blood/well coaptated wound
 Refer accordingly  RVE
 Thank you o Intact rectovaginal septum
o Good sphincter tone
 Abdomen
ADMITTING ORDERS (Abdomen) o Inspection: globular/gravid; linea nigra, striae
 Please admit to ROC under the service of Dr. ____ o Auscultation: NABS
 TPR q shift and record o Palpation: Leopold’s
 NPO o FH, FHB R/L
 Labs:  Final Dx:
o CBC (save serum)
o Serum pregnancy test
o Urinalysis NON-STRESS TEST
 IVF: D5LR + 10 “u” oxytocin x 30 gtts/min  Test of fetal condition
REACTIVE when:
 SO:
o For completion curettage on call  At least 2 accelerations of the FHR occurs for at least 15 bpm,
o Secure consent lasting for 15 sec w/in 20 min period of observation
o Pad count at bedside NONREACTIVE
o Save specimen passed out  May imply that the fetus is acidotic, asleep, or drugs was
o Please prescribe the ff: Nubain, Benadryl, Dormicum administered to the mother
o Refer for profuse bleeding and other untoward ssx A. EARLY DECELERATION
o Thank you  Head compression
B. LATE DECELERATION
 Utero-placental insufficiency
POST OP ORDERS (TAHBSO) C. VARIABLE DECELERATION
 To RR  Cord compression ; Fetal distress
 Monitor VS q 15 min, until stable  Most common ; Most ominous
 Flat on bed x 6 H, then may turn to side
 NPO x 6 H then may have sips of CL
 Present IVF x 30 gtts/min CONTRACTION STRESS TEST/OCYTOCIN CHALLENGE TEST
 IVF to ff:  A measure of utero-placental function
o D5LR  Contraction induced by using IV oxytocin
+ 10 “u” oxytocin x 8 H  Record FHB
o D5NM
o D5LR x 8 H POSITIVE
 Meds:  Consistent and persistent late deceleration (50%) of the FHB in
 SO: the absence of uterine hypertonus or supine hypotension
o MIO q H and record NEGATIVE
o Refer if UO is <30cc/H  @ least 3 contractions in 10 mins, each lasting 40 secs, w/o late
o May return blood deceleration
o Remove FC @ ___ SUSPICIOUS
o Apply abdominal binder  Inconstant late deceleration patterns
o Refer PRN HYPERSTIMULATION
o Thank you  Uterine contractions occur more frequent than every 2 mins, or
lasting longer than 90 secs, or presence of hypertonus
PELVIC EXAM UNSATISFACTORY
 Inspection  Frequency of contractions is <3 per minute
o Grossly N external genitalia
o Masses, discharges, bleeding
 Speculum
o Cervix – hyperemic/nonhyperremic; fish mouth
deformity/ping pong
 IE
o Cervical dilatation
o Cervical effacement
o Station
o BOW (intact/leaking)
o Amniotic membrane PROM x days/hours
o Presenting part
HYPERTENSION STEROIDS
 140/90MMhG 1 dose 28-32 wks
Proteinuria 3 doses q 2 wks
 >300mg/24H urine sample OGTT at 24-28wks
 > 1000mg/random sample 6H apart
 1+ = mild proteinuria MAGNESIUM SULFATE DOSES
 2+ to 4+ = heavy proteinuruia Loading dose:
*Edema DOES NOT validate Preeclampsia 4gms slow IV
GESTATIONAL HPN 5gms each buttocks deep IM
 HPN w/o Proteinuria (after 20 weeks gestation) Maintenance dose:5gmsIM/IV q 6hrs
 Confirm 12 wks Postpartum Monitor BP, U/O, DTRs-hyporeflexia
PREECLAMPSIA Monitor RR
 (+) HPN, (+) Proteinuria after 20th week MgSO4 drip:
ECLAMPSIA  1-2gms/hr
 (+) convulsions, (+) Preeclampsia 1L = 10gm given 100cc/hr
CHRONIC HPN  10meq/L(about 12mg/dL)
 140/90mmHg >respiratory depression
SUPERIMPOSED PREECLAMPSIA  12meq/L
 Inc diastole and systole >respiratory paralysis and arrest
 Proteinuria Antidote: Calcium gluconate 1g iV
 S/Sx of end organ damage
Triad for Sever Preeclampsia
FETAL DEATH
 Hemolysis
1. Tobacco-stained amniotic fluid
 Elevated Liver Enzyme
2. Spalding’ssign
 Low Platelet Count
o significant overlapping of fetal skull bones
Hypertension etiology(Williams)
3. Robert’s sign
 Exposed chorionic villi o Demonstration of gas bubbles in the fetus
 Twin pregnancy (Multiple gestation) 4. Exaggeration of fetal spinal curvature
 Vascular dses
 Fam hx BIOPHYSICAL SCORING PARAMETERS
1. Fetal Breathing Movements
THREATENED ABORTION 2. Gross Body Movement
 Bloody vaginal discharge or bleeding appears 3. Fetal Tone
 Closed vaginal os 4. Reactive FHR
 Low abdominal pain 5. Amniotic Fluid
 Bleeding first, cramping follows *Perfect Score is 10/10 or 8/8
INEVITABLE ABORTION CBC repeated at 28-32 AOG
 Gross rupture of membrane HbsAg last trimester
 Leaking amniotic fluid Alpha fetoprotein 16-18 wks AOG
 Cervical dilatation
COMPLETE ABORTION PLASMA GLUCOSE RESULTS:
 Complete detachment (Blood Glucose testing performed at 24-28wks AOG)
 Int. cervical os closes Time NDDG Coustan & Capenter(mg/dL)
INCOMPLETE ABORTION Fasting 105 95
 Int. cervical os opens and allows passage of blood 1st Hr 190 180
Mullerian Anomalies 2nd Hr 165 155
 Segmented mullerian agenensis or hyperplasia
3rd Hr 145 140
 Unicornuate uterus
 Bicornuate uterus
 Septate uterus LEOPOLD’S MANEUVER
L1 (Fundal Grip)
 Uterus with internal ___? Changes
Induction of labor  What fetal pole occupies the fundus
L2 (Umbilcal grip)
 Oxy drip but not in labor
Augmentation of Labor  Fetal back
L3 (Pawlick’s grip)
 Oxy drip however in labor
 (+) engagement of head or (-) engagement
L4 (Pelvic grip)
 Side of cephalic prominence

PRENATAL CHECK-UPS FUNDIC HEIGHT

0-27 wks q4wks 12wks-1st felt; above the symphysis pubis
28 wks q 2wks 16wks- bet. Symphysis and umbilicus
29-35 wks q2wks 20wks- umbilicus
36 wksand beyond q week 36wks- below ensiform cartilage

TETANUS TOXOID FHB Monitoring

0 20 wks AOG  Every 30mins= low risk
1 1 month  Every 15mins= high risk
2 6 months
3 1 year
4 1 year
BISHOP SCORE o Placental Migration (placenta close to the internal os
0 1 2 3 during 2nd trimester migrate to fundus as pregnancy
Dilatation 0 1-2cm 3-4cm 5-6cm advances
Effacement 0-30% 31-50% 51-70% >70%
Station -5/-3 -2 -1 +1/+2 PLACENTA ABRUPTION
Cervical Posterior Midline Anterior -----  premature separation of the normally implanted placenta after
Position the 20th week of pregnancy and before birth of fetus
Cervical firm medium soft -----  Etiology: (PECSS)
Consistency o Pre-eclampsia
*Scoring: 3-8 difficult induction o External trauma
9-favorable induction o Chronic hypertension
o Short umbilical cord
MYOMA o Sudden uterine decompression
 causes soft tissue dystocia
 etiology: unopposed estrogen stimulation LACERATIONS
 types: Subserous, Intramural, Submucous  1st Degree
ROT-right occiput transverse o Fourchette, perineal skin, vaginal mucosa but not the
Montevideo Units- 200 units or pressure of > 60 underlying fascia and muscle
Depoprovera- injectable CP is G1 to HPN patients  2nd Degree
o Fascia and muscles of the perineal body but not the
EXCISION OF BARTHOLIN’S CYST anal sphincter
 Hyperplasia (uterus) – provera  3rd Degree
 Endocervical o Extend from vaginal mucosa, perineal skin and fascia
For Functional Curettage up to anal sphincter but not the rectal mucosa
 Endometrial
 Endometrial  for D & C  4th Degree
o Encompasses extension up to rectal mucosa
AUGMENTATION OF LABOR
BRAXTON HICKS CONTRACTION
 ↓ amniotic fluid
 The uterus undergoes palpable but originally painless contractions
 Oligohydramnios (causes)
at irregular intervals from the early stages of gestation
o Cord compression
o Macrosomia
SIGNS OF PLACENTAL SEPARATION
o Deformations
o Fetal distress  Calkin’s Sign (uterus becomes globular and firmer from discoid)
 Sudden gush of blood
HYOSCINE N-BUTYL BROMIDE (Buscopan)  for softening of the cervix  Uterus rises in the abdomen as the detached placenta drops to
the lower segment and vagina
NST: Fetal condition “7 days”  Lengthening of the cord

CST: Uteroplacental contraction AMONIOTIC FLUID INDEX

 Normal: 6-24 cm
 Oligohydramnios: <5 cm
DELIVERY OF PLACENTA  Low normal: 9-10
SHULTZE MECHANISM  Polyhydramnios: >24
 Peripheral
 Shiny portion
DUNCAN MECHANISM
 Central
 Dirty part INDICATIONS FOR CESAREAN SECTION
DEFINE:  Prior CS
 Placenta increta  invades  Labor dystocia (most frequent indication for 1’ CS)
 Placenta percreta  penetrates  Fetal distress
 Placenta accrete  attaches  Breech presentation
Normal Rotation of Umbilical Cord:
 Counter clockwise or Left-handed maneuver POST OP COMPLICATIONS OF CS DELIVERY
 Hysterectomy
PLACENTA PREVIA  Operative injury to pelvic structures
 Types:  Infection
o Totalis  placenta covers cervical os completely  Puerperal fever
o Partialis  internal os partially covered by placenta  Transfusion
o Marginal  edge of the placenta is at margin of
internal os
 Etiology: (P2ALM2)
o Previous CS
o Puerperal Endometritis STAGES OF LABOR
o Advancing age  I: Active labor to full cervical dilatation (4-10 cm)
o Multiparity  II: Full cervical dilatation to delivery of baby
o Multiple induced abortions  II: Delivery of baby to expulsion of placenta
 Diagnosis:  IV: Delivery of placenta to 1 hour after
o Painless third trimester bleeding
o UTZ for placental localization
CARDINAL MOVEMENTS 1’ LOW TRANSVERSE CESAREAN SECTION
 Engagement 1. Induction of spinal anesthesia.
 Descent 2. Patient in supine position.
 Flexion 3. Insertion of foley catheter.
 Internal rotation 4. Asepsis/Antisepsis
 Extension 5. Drapings done, exposing operative site.
 External rotation 6. Vertical incision done from 2 FB above the symphysis pubis up to
 Expulsion 3 FB below the umbilicus. Incision deepened to subcutaneous
ASYNCLITISM  such lateral deflection of the head to a more anterior or tissues and transversalis fascia, rectus muscle split, peritoneum
posterior position of the pelvis cut longitudinally.
7. Bleeders clamped and ligated as encountered
8. Retractors applied exposing pelvic structures.
ANTERIOR COLPORRHAPY 9. Vesico-uterine folds identified, lifted out and cut 1 cm above the
1. Induction of anesthesia. bladder.
2. Patient is placed in dorsal lithotomy position. 10. Bladder pushed downward and a curvilinear incision is done on
3. Asepsis/Antisepsis the lower uterine segment using bandage scissors, bag of water
4. Drapings done leaving the operative site exposed ruptured.
5. Evacuation of urine using straight catheter. 11. Rupture of membranes.
6. The lateral edges of the vaginal cuff are held with Allis. Several 12. Amniotic fluid suctioned and fetal head exposed.
Allis clamps are placed 3-4 cm apart up the midline of anterior 13. Delivery of baby boy in left occiput transverse position.
vaginal wall. 14. Umbilical cord doubly clamped and cut.
7. The vaginal mucosa is undermined for approximately 3-4 cm up 15. Manual extraction of placenta.
to first Allis clamps placed in midline. 16. Closure of incision site done layer by layer
8. The vaginal mucosa is dissected off the pubovesical cervical fascia a. First (endometrial) layer closed by continuous
and opened with scissors in the midline. The vaginal mucosa is interlocking stitches using Chromic 1.
opened in midline up to next Allis clamp. This is continued until b. Second (myometrial) layer closed by continuous
the vagina is opened to within 1 cm of urethral meatus. interlocking stitches using Chromic 1.
9. The PVC fascia is separated from the vaginal mucosa. The c. Third (Vesico-uterine folds) closed by simple
dissection is continued until bladder and urethra are separated continuous stitches using chromic 2-0.
from the vaginal mucosa and clearly identified and urethral vesical 17. Suction of blood and amniotic fluid and sponge done.
angle has been ascertained. 18. Inspection of the ovaries, fallopian tubes and ligaments
10. Kelly plication done with chromic 2-0. The anterior repair is 19. Parietal peritoneum closed with continuous suture using chromic
started by placing suture in PVC fascia, starting at the level of first 2-0
Kelly placation suture 20. Transversalis fascia sutured with continuous interlocking stitches
11. The edges of vaginal mucosa retracted laterally with Allis clamps using Vicryl 1-0
and remaining PVC fascia is plicated in midline with multiple 21. Subcutaneous tissue sutured simple interrupted stitches using
interrupted mattress sutures. The edge of vaginal mucosa are Plain 2-0
held in tension and excessive mucosa trimmed. 22. Skin closed by subcuticular stitches using Vicryl 4-0.
12. The vaginal mucosa is sutured in midline down to previously 23. Incision site painted with betadine
incised site by continuous interlocking suture. 24. Top dressing applied.
13. Perineal wash done 25. End of procedure.
14. End of procedure.
REPEAT LOW TRANSVERSE CESAREAN SECTION
1. Induction of spinal anesthesia.
POSTERIOR COLPORRHAPY 2. Patient in supine position.
1. Induction of spinal anesthesia. 3. Insertion of foley catheter.
2. Patient is placed in dorsal lithotomy position. 4. Asepsis/Antisepsis
3. Asepsis/Antisepsis 5. Drapings done, exposing operative site.
4. Drapings done leaving the operative site exposed 6. Old scar removed. Vertical incision done from 2 FB above the
5. Allis clamps are applied at the posterior vaginal mucosa, elevated symphysis pubis up to 3 FB below the umbilicus. Incision
creating a triangle. deepened to subcutaneous tissues and transversalis fascia, rectus
6. A transverse incision made at the posterior fourchette. A portion muscle split, peritoneum cut longitudinally.
of the posterior vaginal mucosa is elevated using an Allis clamp 7. Bleeders clamped and ligated as encountered
and an index finger covered with gauze is inserted upward and 8. Retractors applied exposing pelvic structures.
laterally, dissecting the posterior vaginal mucosa of the 9. Vesico-uterine folds identified, lifted out and cut 1 cm above the
perirecteal fascia. bladder.
7. Vertical incision in posterior vaginal mucosa made. Perirectal 10. Bladder pushed downward and a curvilinear incision is done on
fascia dissected off the posterior vaginal mucosa. The apex of the lower uterine segment using bandage scissors.
triangle held with Allis clamp. The dissection of perirectal fascia 11. Rupture of membranes.
off the vaginal mucosa is started with scalpel but is completed 12. Amniotic fluid suctioned and fetal head exposed.
with blunt dissection. 13. Delivery of baby boy in left occiput transverse position.
8. Kelly plication sutures with vicryl 2-0 through the margins of 14. Umbilical cord doubly clamped and cut.
levator ani muscles from apex down to posterior fourchette is 15. Manual extraction of placenta.
done and progressively tied. 16. Closure of incision site done layer by layer
9. The excess posterior vaginal mucosa trimmed. a. First (endometrial) layer closed by continuous
10. The perineal fascia closed with interrupted vicryl 2-0 interlocking stitches using Chromic 1.
11. Vicryl 2-0 suture is placed at the apex of vaginal mucosa using b. Second (myometrial) layer closed by continuous
continuous interlocking stitches to posterior fourchette. interlocking stitches using Chromic 1.
12. Vaginal packing done with 1 os. c. Third (Vesico-uterine folds) closed by simple
13. Perineal wash done. continuous stitches using chromic 2-0.
14. End of procedure. 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 6. Midline incision done from symphysis pubis up to 2 FB below the
2-0 umbilicus cutting through skin, subcutaneous tissue and fascia,
20. Transversalis fascia sutured with continuous interlocking stitches rectus muscle split and peritoneum incised.
using Vicryl 1-0 7. Bleeders clamped and ligated as encountered.
21. Subcutaneous tissue sutured simple interrupted stitches using 8. Self retaining and bladder retractors were applied to expose
Plain 2-0 pelvic structures.
22. Skin closed by subcuticular stitches using Monocryl 4-0. 9. Moist pack applied.
23. Incision site painted with betadine 10. Inspection of the pelvic structures done.
24. Top dressing applied. 11. Abdominopelvic structures examined revealed that the uterus
25. End of procedure. 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
ENDOCERVICAL POLYPECTOMY tube with small cystic paratubal masses ~1x1cm.
1. Induction of labor. 12. Right round ligament is doubly clamped, then cut and ligated with
2. Sepsis/Antisepsis/drapings done leaving operative site exposed. Chromic 1. The same procedure is done on the opposite side.
3. Insertion of straight catheter to empty the urinary bladder. 13. Anterior and posterior leaves of the broad ligament opened.
4. Posterior vaginal retractor positioned, endocervix identified. Anterior leaf of the broad ligament incised to the point of bladder
5. Anterior lip of the cervix grasped with tenaculum forceps. reflection.
6. Endocervical polyp found. 14. Infundibulopelvic ligament triply clamped, cut and doubly ligated
7. Polyp grasped, twisted, and removed using an ovum forcep. using Chromic 1-0.
8. Vaginal packing inserted. 15. Vesicouterine folds cut transversely
9. End of procedure. 16. Bladder dissected by blunt and sharp dissection.
17. Uterine arteries triply clamped, cut and doubly ligated with
1’ LOW TRANSVERSE CESAREAN SECTION (PFANNENSTIEL) Chromic 1-0 on both sides.
1. Induction of spinal anesthesia. 18. Pubovesical fascia incised and pushed down with use of sponge
2. Patient in supine position. 19. Cardinal ligaments clamped, cut and suture ligated with Chromic
3. Insertion of foley catheter. 1-0.
4. Asepsis/Antisepsis 20. Amputation of cervix at level of cervical os.
5. Drapings done, exposing operative site. 21. Betadinized OS inserted to the vaginal stump.
6. Curvilinear incision done from 2 FB above the symphysis pubis up 22. Closure of vaginal stump with continuous interlocking suture using
to 3 FB below the umbilicus. Incision deepened to subcutaneous Vicryl 1-0. Stump angles are anchored to the cardinal ligaments on
tissues and transversalis fascia, rectus muscle split, peritoneum both sides with figure of eight stitches using Vicryl 1-0.
cut longitudinally. 23. Bleeders clamped and ligated as encountered.
7. Bleeders clamped and ligated as encountered 24. Parietal peritoneum closed with continuous stitches using chromic
8. Retractors applied exposing pelvic structures. 2-0.
9. Vesico-uterine folds identified, lifted out and cut 1 cm above the 25. Transversalis fascia sutured with continuous stitches using vicryl 1-
bladder. 0.
10. Bladder pushed downward and a curvilinear incision is done on 26. Subcutaneous tissue closed with simple interrupted stitches with
the lower uterine segment using bandage scissors Plain 2-0.
11. Rupture of membranes. 27. Skin closed by subcuticular stitches using Monocryl 3-0.
12. Amniotic fluid suctioned and fetal head exposed. 28. Operative site painted with betadine
13. Delivery of live full term baby boy in left occiput transverse 29. Top dressing done.
position. 30. Specimen sent for Histopath.
14. Umbilical cord doubly clamped and cut. 31. End of procedure.
15. Manual extraction of placenta.
16. Closure of incision site done layer by layer
a. First (endometrial) layer closed by continuous VAGINAL HYSTERECTOMY
interlocking stitches using Chromic 1. 1. Induction of anesthesia.
b. Second (myometrial) layer closed by continuous 2. Patient is placed in dorsal lithotomy position.
interlocking stitches using Chromic 1. 3. Asepsis/Antisepsis
c. Third (Vesico-uterine folds) closed by simple 4. Drapings done leaving the operative site exposed
continuous stitches using chromic 2-0. 5. Evacuation of urine using straight catheter
17. Suction of blood and amniotic fluid and sponge done. 6. Vaginal mucosa is incised with a scalpel around the entire cervix.
18. Inspection of the ovaries, fallopian tubes and ligaments 7. Downward traction is applied using tenacula, Metzenbaum used
19. Parietal peritoneum closed with continuous suture using chromic to dissect the bladder off the anterior lower uterine segment.
2-0 8. A sponge covered finger dissects the bladder all the way up to the
20. Transversalis fascia sutured with continuous interlocking stitches vesicouterine fold, facilitates entry to anterior cul de sac.
using Vicryl 1-0 9. Right angle retractor is placed under the vaginal mucosa and
21. Subcutaneous tissue sutured simple interrupted stitches using bladder, elevating the bladder. Strong downward traction is
Plain 2-0 applied to the tenacula on the cervix, and the peritoneal
22. Skin closed by subcuticular stitches using Vicryl 4-0. vesicouterine fold is grasped with Allis clamps and incised with
23. Incision site painted with betadine sharp curved mayo scissors.
24. Top dressing applied. 10. Elevating the peritoneal vesicouterine fold with Allis clamps,
25. End of procedure. 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-de-sac
TAHBSO 12. The posterior vaginal retractor is removed. The broad ligament is
1. Induction of spinal/epidural anesthesia exposed from the uterosacral ligaments to the tuboovarian
2. Patient in supine position. ligament. A finger is placed in the posterior cul-de-sac and moved
3. Insertion of foley catheter done. laterally revealing the uterosacral ligament as it attaches to the
4. Asepsis/Antisepsis lower uterine cervix.
5. Drapings done leaving operative site exposed.
 13. With the cervix on upward and lateral retraction using the FRACTIONAL CURETTAGE
tenacula, a clamp is placed in the posterior cul-de-sac with one 1. Induction of anesthesia.
blade underneath the uterosacral ligament, and the opposite 2. Patient in dorsal lithotomy position.
blade over the uterosacral ligament. This is done to prevent 3. Asepsis/Antisepsis.
possible ureteral damage from clamping the ligaments in lateral 4. Drapings done leaving operative site exposed.
position. 5. Straight catheterization done.
14. Uterosacral ligament is cut using the mayo scissors. 6. Weight-bearing retractor applied at posterior vaginal wall. Cervix
15. Chromic 1-0 suture is used to suture ligate the uterosacral smooth with no erosions.
ligament. 7. Application of tenaculum forceps at 12 o’clock position of cervical
16. When tied, the suture is held with a Kelly clamp for traction. lip.
17. With uterus on upward and lateral retraction using the tenacula 8. Endocervical curettage done, evacuated minimal endocervical
on the cervix, cardinal ligaments is clamped adjacent to the lower scrapings.
uterine segment and incised. 9. Hysterometer inserted. Pre-curettage uterine depth measured
18. Cardinal ligaments is sutured ligated with Chromic 1-0 suture. 9cm.
Suture is held with a Kelly clamp for traction 10. Endometrial curettage done. Evacuated ½ teaspoon of
19. The remaining portion of the broad ligament attached to lower endometrial scrapings/tissues and placental tissues.
uterine cervix segment containing the uterine artery is clamped 11. Post curettage uterine depth measured, approximately 8 cm.
and ligated. 12. Tenaculum and retractors removed.
20. With all the ligaments on both sides, clamped and ligated, cervix is 13. Perineal wash done
retracted upward in midline with the tenacula. Posterior uterine 14. Specimen sent for histopath.
wall is grasped, the fundus is delivered posteriorly. 15. End of procedure.
21. Two cochers clamps are applied to the tubo ovarian round
ligaments, incised close to the fundus. COMPLETION CURETTAGE
22. Infundibulo-pelvic ligament is tied twice using Vicryl 1.0. Second 1. Induction of anesthesia.
suture ligation is tied in a fixation stitch, placing the suture in the 2. Patient in dorsal lithotomy position
mid portion of its pedicle. 3. Asepsis/Antisepsis
23. The anterior and posterior clamps right angle retractors are 4. Drapings done leaving operative site exposed
removed, and the weighted posterior retractor is placed in the 5. Insertion of straight catheter.
vagina. Any bleeding from any pedicle is clamped. 6. Speculum applied at posterior vaginal wall
24. Cardinal ligaments, uterosacral ligaments and utero ovarian 7. Application of tenaculum forceps at 12 o’clock position of cervical
ligaments anchored at the posterior vaginal mucosa. lip.
25. Reperitonealization of the pelvis, carried out with purse string 8. Sharp/blunt curette done. Evacuated 1 tablespoon cup of
sutures. products of conception.
26. Perineal wash done. 9. Betadine wash done.
27. End of procedure. 10. End of procedure.
11. Specimen sent for histopathology.
EVACUATION CURETTAGE
1. Induction of spinal anesthesia. VAGINAL BIRTH AFTER A CESAREAN SECTION (VBAC)
2. Patient in dorsal lithotomy position.  Allow a trial of labor under double set-up for all previous cesarean
3. Asepsis/Antisepsis. of one low segment incision after excluding an inadequate pelvis
4. Drapings done leaving the operative site exposed. and unless a new indication arises
5. Straight Catheterization done.  Selection Criteria:
6. Right angle retractor applied to expose cervix. o 1 or 2 prior low-transverse cesarean section delivery
7. Anterior cervical lip grasped with tenaculum forceps at 12 0’clock o Clinically adequate pelvic
position. o No other uterine scars or previous rupture
8. Hysterometer inserted. o Physicians immediately available throughout active
9. Pre-curettage uterine depth measured 9 cms. labor capable of monitoring labor and performing an
10. Sharp and dull curettage done in a clockwise manner, evacuated ½ emergency cesarean section delivery
cup of products of conception and placental tissues. o Availability of anesthesiologist and personnel for
11. Post curettage uterine depth was not measured. emergency cesarean section delivery
12. Perineal washing done.
13. Specimen for histopathology. 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
DIAGNOSTIC CURETTAGE  It has been 36 weeks since a (+) serum/urine hCG pregnancy test
1. Induction of anesthesia. was performed by a reliable laboratory
2. Patient in dorsal lithotomy position  An UTZ measurement of the CRL obtained at 6-11 weeks supports
3. Asepsis/Antisepsis a gestational age at least 39 weeks
4. Drapings done leaving operative site exposed  UTZ obtained at 12-20 weeks confirms the gestational age of at
5. Straight catheter was inserted. least 39 weeks determined by clinical history and PE
6. Cervix dilated with Goodell’s dilator
7. Retractor applied at posterior & anterior vaginal wall CP STATUS
8. Application of tenaculum forceps at 12 o’clock position of cervical  CP status assessed
lip.  Pls. transfuse available ___ “u” PRBC of px blood after proper
9. Insertion of hysterometer to measure pre-curettage uterine depth crossmatching
of 3 inches.  BT to run initially @ 5-10 gtts/min x 30min then ↑ to 15-20
10. Blunt curette done in a clockwise manner. Evacuated scanty gtts/min if with no BT rxn
endometrial scrapings.
 Maintain IVF x KVO while on BT
11. Perineal wash done
 BT precautions please
12. Specimen sent for histopath
 Watch for any untoward s/sx such as DOB, pruritus, fever
 Refer prn
 Thank you.
ADMITTING NOTES (Ectopic Pregnancy) DYDROGESTERONE (Duphaston)
 Cc: Mode of Action:
 Imp:  Orally active progesterone
 Please admit pc to ROC under the service of Dr. ___  Promotes pregnancy in case of luteal insufficiency for maintaining
 TPR q 4 hours and record pregnancy in threatened and habitual abortions
 NPO temporarily Indications:
 Labs:  Dysfunctional uterine bleeding, irregular cycles, threatened and
o CBC, APC habitual abortion, infertility, premenstrual syndrome,
o CT, BT, PT endometriosis, dysmenorrheal
o BT w/ Rh Side effects:
o U/A  Breakthrough bleedings, hemolytic anemia, edema, asthenia or
o S. Preg test malaise, jaundice and abdominal pain
 IVF: D5LR 1L X 8 Hrs
 Meds: None temporarily METOCLOPRAMIDE (Plasil)
 SO: Mode of Action:
o Monitor VS, abdominal status hourly  Stimulates motility of the upper GIT w/o stimulating gastric,
o Refer once lab result is in biliary or pancreatic secretions
o Dr. ___ seen px at ER  Sensitization of tissues to action of acetylcholine
o Watch out for any untoward s/sx Indications:
o Refer prn  For disturbances of GIT motility, GERD, diabetic gastroporesis,
nausea, vomiting, migraine HA
ANESTHESIA Side effects:
Pre-meds:  Restlessness, drowsiness, fatigue, lassitude
 Cefuroxime (Zegen) 1.5 gms IV
 Omeprazole 20mg IV
 Metoclopramide (Plasil) 10mg IV Ranson’s Criteria ( objective sign’s of severity of acute pancreatitis)
Anesthetic Agent: Bupivacaine 15mg + MgSO4 16mg On Admission:
Detailed Technique: RA-SAB Age > 55 y.o
 X-LLDP, SAS Glucose > 200mg/dl
 LA w/ 2% Lidocain WBC > 16,000/cumm
 LP at L3 L4 LDH > 350 IU/L
 CSF clear and free flowing AST > 250 U/L
 Intrathecal administration of anesthetic
After Initial 48 hrs
SIGNS OF MALIGNANCY UTZ: Serum Ca++ < 8mg/dl
Arterial PO2 < 60mmHg
 Septations
Base Deficit > 4meq/L
 Internal echoes
BUN Increase > 5mg/dl
 Ascites
Hematocrit fall > 10%
 Multiple daughter cysts
Fluid Sequestration > 6,000ml
<5 cm cyst  in postmenopausal women expectant management

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

CaMg (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