OB/GYN


OB Post-Partum Note :

Pt feeling well w/o new complaints. 

Pain: located at lower abdomen, mild - controlled, improving.
Denies CP/SOB/ fever & chills.

Bleeding: = lochia, decreasing.
PO: +fluids, +solids w/o n/v. 
+Urine, +BM, +flatus.
Denies depression, energy is mod and improving. 
Ambulating w/o difficulty. 

BCM: 
Br/Bo; declines assistance from lactation consultant.

PE: 
General: no acute distress, comfortable
CV: rrr w/o murmurs - no heave
Pulm: ctab w/o w/r/r - good air movement
Abdo: fundus firm, at <<<<< umbilicus, mild TTP
MSK: 1+ b/l LE edema
Neuro: cn2-12 grossly intact
Psych: answers & affect appropriate

Incision site: w/o erythema, no sign infection, no drainage, healing appropriately. 


AP
_ yo GP_ s/p CS - NSVD. 
A
1. PPD / POD 1 : afebrile, VSS, meeting milestones
2. Pain: controlled
3. Baby: next to mom, doing well, Br/Bo feeding. 
4. PNLs: 
5. -

P
1. Cont routine post-partum care
2. Pain: continue ibuprofen, acetaminophen, norco PRN as appropriate
3.

Dispo: stable - improving - anticipate d/c __ to home pending approval from Dr. __

---------------------------------------

H&P



__ yo GP__ at __ by US__

CC: 

ROS: +FM, no LoF, no VB, no F/C, no HA/vision changes/ RUQ pain, no dysuria
PNLs: BT       ; 
GBS neg by ____ date

>>> all negs: Ab neg, RPR neg, RI, GC/CT neg, Hep B sAg neg, HIV neg, GBS neg 
Obhx: 


Gynhx: denies abnormal PAPs, denies STIs

Cx: denies any cx this pregnancy
PMHx: denies DM/ HTN/ thyroid dzs/ seizures/ asthma

PE: 
General: comfortable, afebrile, no distress
CV: rrr w/o murmurs - no heave
Pulm: CTAB w/o w/r/r - good air movement
Abdo: gravid - nonTTP all quadrants
MSK: __+edema b/l LE
Neuro: CN2-12 intact grossly , aox3
Psych: answers & affect appropriate

Leopolds: EFW :

FHTs: __ baseline - mod var - +accels - no decels
Toco: 
US: cephalic, +FM

__ yo GP__ @ __ by __ px __
A
1. Labor: latent vs active vs not in labor; cxt q___ min; SVE __ ; BOWI vs SROM __ time; pitocin / cervidil / cytotec
2. FWB: cat 1 - , +FM
3. Pain: none / mild / mod - controlled. 
4. PNLs: 

P
1. Admit for labor / eIOL / mIOL  ; continuous EFM/toco.
2. FWB: cont monitoring; O2, position changes, IVFs as indicated
3. Pain: cont stadol, epidural PRN as appropriate
4. -

Plan w/ Dr. __ , RN. 

------------
Mag Checks

Mg checks: 

PIH checks: 

------------
Vaginal Delivery Note

Performed by: 
Time of Delivery:

Procedure:
NSVD, no forceps / vacuum used. Cord clamped and cut at delivery. Fundus firm with IV pitocin and fundal massage, hemostasis achieved. Mother and baby recovering appropriately.

Anesthesia:
Presentation: cephalic
Lacerations:
EBL:
Complications: none

Infant: singleton
APGARs 9, 9
Wt:
Cord blood: not collected
Umbilical cord: 3 vessels
Placenta: intact
Nuchal cord: none

Other comments: none


Occiput Presentation 
wiki


Obstetrics Cheatsheet

• Text4baby
• Cervix: Bishops: <6 unfav, >8 fav.
1
2
3
Position
posterior
interm
anterior
-
Consistency
firm
interm
soft
-
Dilation
0
1-2
3-4
>5
Efface
0-30%
30-50%
50-80
>80
Station
-3
-2
-1,0
>+1 

0

• Px: US + AFI/deep pocket
• FWB: FHTs: definitions! mod var 6-25. accels 15x15 (10x10). 
• <6 = cervical ripening; cytotec >cervidil >ptiocin. >8 pit for ctx

Induction: 
Pitocin: 2-2; max 6 for ripening, max 20 for induction. low dose vs high dose.
Cervidil (dinoprostone, PGE2): 10mg vag insert; 12hr release; pit ok 1hr post removal
Prepidil: 0.5 mg q2 hr gels; hold if ctx >3/10min. 
Cytotec (misoprostol): initial 25mcg q3-6hr, placed in post fornix: 1x. 86% PROM induced w/ 1x miso. if miso, wait 4hr -> pit.
> both cervidil, prepidil, cytotec absolue c/i if hx cs or major uterine surg.
> must have good dating prior!! > don't stack rx at same time. allow ~4 hr between (?) 

note: before mech methods, ?where is placenta/vasa previa?
Foley : 26,Fr: 
AROM: only when Bishop >8 (favorable). Never use alone! ROM if Bishop>8. Absolute c/i = HIV (inc vertical transmission).
• Membrane stripping: risk AROM!

Indications for induction: 
PROM/PPROM, placenta abruption, chorio, IUFD, gHTN/PIH, post-term, fetal compromise
C/i for induction: vasa previa, complete placenta previa, transverse lie, cord prolapse, acute HSV, hx classic cs. 
> why induciton after ROM?? reduce chorio/endometritis, reduce NICU need

Managing Intrapartum Strip
Describing variables: 

Tachysystole: >5 ctx/10 min avg/30 min. <5 nl.
• O2 + position ∆ + IVFs + slow /dc pitocin
Terbulatine: IV 2.5-5 mcg/min (incr by 2.5-5/min; max 17.5-30); SQ 0.25 mg q20min-3hr

Infections:
Chorioamnonitis: (amp 2g q6hr / gent 1.5mg/kg q8hr) ==> if c/s :+ clinda 900mg q8 or metro 500mg q 12hr
-> px:(T>38.0) or (uterineTTP/HR>110/fHR>160/foul odor) or (WBC+Lshift)
Endometritis
GBS ppx: penicillin G 5millionU loading + 3millU q4hr until delivery; goal = 4hr cover.
-> indications? : GBS+, GBS unk + (<37wk, ROM>18hr, or >100.4). -> alt: vanco, ancef
• STI: Chlamydia azithro 1g x1 (or doxy 100mg BIDx7d); Gonorrhea; ceftriaxone 1g IM

PPH: definition NSVD 500, CS 1000
pitocin: 10-40u in 1000cc LR/NS. or 10u IM into uterus. 
methergine: 0.2mg IM or 0.2 mg tab PO x1; c/i if HTN. 
carboprost: 0.25 mg IM q15 min up to 8x dose, typical <4x dose; c/i if asthma
misoprostol: 1000mcg PR or 600mcg PO/SL

Transfusion: H <7; <8-9 +sx; cardiac hx <10. 1U=1hgb
• Consent: transfusion rxn, HepB 1/1mill, HIV 1/600k. 
• 2U PRBC cerner: 'blood transfusion; leukoreduced'; H/H ~12hr post

Steroid Window
• indications: risk of pre-term @ 24-34 weeks.
• betamethasone 12mg IM q24hr x2
• or dexamethasone 6mg IM q12 x4.

Tocolysis

• nifedipine: 30mg POx1 loading -> 10-20mg q4-6hr.
• Mg: 4-6 IV bolus / 20 min --> 2-3g IV/hr. goal 4- mg/dl. fetal lethargy, low tones, resp depression.
• Terbulatine: 0.25 mg SC q20min -3hr (hold if HR >120); c/i in any arrhythmias hx. blackbox >48-72hrs use.

PIH:
• gHTN: SBP>140/DBP>90; usually T3, final dx only post-partu, resolve within 3mo. 
• mild pre-eclampsia: SBP>140/DBP>90 x2 after 20wk gestation, w/o hx HTN.
• severe pre-eclampsia: SBP>160/DBP>110 x2 6hr apart, proteinuria (>5g in 24hr urine or 3+ x2 random UAs), oliguria (<500cc/24hr), cerebral/vision changes, pulm edema, epigastric/RUQ pain, impaired liver fxn, thrombocytopenia (<100), fetal growth restriciton
• eclampsia: +seizures, w/o hx. 
• Risk stratification? >35 yo, twins, DM, Renal dz, cHTN, obese, AA, latino, auto-immune dzs. 

• Pre-E: non-severe = monitor PIH labs, BPs + sx, fetal growth
• Pre-E: severe = deliver regardless of best age since high risk maternal morbidity; possible MFM override
• Pre-E: severe = MgSo4 6mg => 2mg maintenance, until 24 hrs postpartum

PIH Labs: 
• CBC (plates); CMP (BUN/Cr; LFTs); uric acid; LDH; 24hr urine protein / random urine protein
• Urine protein/Cr ratio: <0.2 effectively excludes significant proteinuria.
• may repeat q 6-12hrs. 
• Strict I/Os = UOP >4L/day indicate resolution

 
Tx PIH
• Labetalol / Hydralazine if >160/100
Mg: load 4g -> 2g maintenance, cont 24hr post-partum; Reversal = Ca gluconate 1g IV /5-10min
- Mg fx: drop serum Ca, min FHTs
• Best indicator resolution = >4L/day UOP

Mg Checks: q4hr
- Mg goal is 4-8 mg/dL
- somnolence/lethargy, SOB, weakness, resp difficulty. Mg goal: 
- DTRs, clonus, pulm CTAB, UOP
-
PIH: HA, n/v, RUQ pain,vision changes,

Labs: normals in pregnancy

Post-Partum
D/c Rx: 
Standard: Ibuprofen 600 mg TID-QID, cont home PNVs
S/p CS: + Norco 5/325 q6hr x7 days
Anemia: FeSo4 325 mg TID + Vit C 250 mg TID x2-3 months
BCM: 
Easy sheet for options (reproductiveaccess.org)

Intrapartum
HTN: methyldopa, nicardipine, labetalol, hydralazine
UTI: 
DM: glipizide, insulin
Pain: acetaminophen

KB Test Kleinhauer Bettke: 
MVA:  4 things FHTs, abdo pain, ctx, --- watch 24 hrs otherwise 6hr

GDM
1hr gtt: 130-140
3hr gtt : fast >95, 1hr >180, 2hr >155, 3hr >140

BPP: = AFI + NST, plus some extra
Tone: 2; Breath: 2; Move: 2; AFI: 2 -> 4 quadrants; NST : 2

FHT Category 1,2,3 : only to be used when pt is in labor. 
NST + AFI is antenatal testing
If pt <32 weeks, variable decels are wnl. 
If pt >32 weeks, and see non-reassuring strip -> then get BPP, typically trumps a bad initial NST done

High Risk pts? AMA, GDM, HTN, PIH, thyroid, obese, GDM -> 32 week : 2 NSTs / week, AFI; so NST q 3-4 days, AFI q 7 days
If high risk, and <32 weeks -> nonviable for our hospital; this number is different in every state. 

<32 week
>32 week
accels = 10x10
accel = 15x15
(+) variable decels
(-) variable decels
reassuring or not
reactive vs. non-reactive

SSE: FFN, pooling, dilation
Swabs: GBS, GC/CT, wet prep
US
Cervical length 

FFN: r/o PTL when unclear
- leaks when tissue ∆; indicated for 22-34 wks
- if (+): inconclusive; soon or weeks.
- if (-): 95% øPTL x2 wks
- false (+)? sex, cervical stim, etc.

ROM+: 

Amnisure: 

Pre-term Labor / Ctx
• Px ctx: SSE-> dilation <2 = PTCtx; >2 = PTL
• PTCtx: can monitor x4 hr; hydrate etc. 
• PTL: stop ctx (<32 wks: indomethacin; >32 wk nicardipine ); GBX ppx (ampicillin 4g-2g); <32 wks (neuro protection w/ mag)
• terb: old-school rx; don’t use anymore

Common Infxn/Abx Courses: 
Candida VV: diflucan 150 mg x1; miconazole (monistat) 2% 5g  x7days
Trichomonas vaginitis: metronidazole 2g x1(or 500mg BID x7days)
BV: metronidazole 500mg BID x7days
GC: (ceftriaxone 250mg 1x IM) + (azithro 1g PO x1)
CT: azithro 1g x1; doxy 100mg po BID x7d
PID: 
UTI cx: macrobid (c/i if Preg T3)
UTI non-cx: 
Pyelo: 

Endometritis: 
• PP: endometrial tissue @ other sites; 50% ovaries  /pelvic peritoneum
• 10% all women; MC ~28yo
• Px: non-specific; chronic cyclical pain; 4Ds (dysmenorrhea, dysparunia, dysuria, dyschezia)
• Dx: Pelvic US (r/o cysts, fibroids); UA/SSE r/o;r/o GI issues; gold = laparoscopic + bx
• Tx: goal = pain reduce; 1st line NSAID (naproxen) + OCP (non-cyclical); 2nd GnRH q3 mo (leuprolide depo IM, most effective)
• Surgical: ablation; rec for advanced endometriosis
• Lesions can go anywhere, can self-resolve w/ tx over time; pregnancy/OCP will shut it down

Dysmenorrhea: 
• 1º vs 2º: 1º painful menses ø obvious pathology; MC at 3yrs post-menarche; better after 1st pregnancy
• px just like endometriosis!
• tx: NSAID (2days prior to menses to 3days post); OCPs
• 2º etios: 3MC = ectopic, endometriosis, PID; also fibroids, interstitial cystisis; preg, UA, wet prep, GC/CT, US cyst/fibroids

Uterine Fibroids
• inc w/ age (>40 yo); mc solid tumor in F
• PP: arise from myometrium - benign
• sx: px menorrhagia (fibroids is MC cause!); pelvic pressure + sensation if big enough
• Dx: TVUS 
• Tx: 33% hysterectomies are for fibroids; indications for surgery = size, sx; via myomectomy, embolization, TAH-BSO; rx are not good option

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C-section Template

Patient was taken to the operating room decision was found to be adequate. 2 g of cancer given for infection prophylaxis. She was paired dorsal supine leftward tilt. A Pfannenstiel incision was made with scalpel. Incision was carried down to the fascia with a bovie. The fascia was incised and extended laterally. The inferior aspect of the fascia was grasped with the Kocher clamps. The underlying rectus muscle and pyramidal was dissected off sharply with Mayo scissors. In a similar fashion, the superior aspect of the fascia was elevated with Kocher, and the the rectus muscle was dissected off. Hemostasis was achieved with the movie. The rectus muscle was separated in the midline down to the level of the pubic symphysis. Pre-peritoneal fatty tissue was bluntly dissected to expose the peritoneum. Peritoneum was found to be free of adherent bowel and entered sharply with scissors. The peritoneal incision was extended superiorly and inferiorly to the bladder reflection with good visualization of the bladder.

The bladder blade was inserted and vesicouterine peritoneum identified. Intra-abdominal survey revealed scant, clear peritoneal fluid and the thinned out lower uterine segment. The vesicouterine peritoneum was opened with scissors and the bladder flap was developed. Bladder blade was repositioned to keep the bladder out of the operative field. The lower uterine segment was incised with a scalpel. The amniotic sac was ruptured with an Allis clamp and clear fluid was noted. The uterine incision was extended bluntly with lateral and upward traction.

Fetus was found in cephalic presentation. Head was elevated out of the pelvis with special attention paid to avoid using the uterine incision was fulcrum. Gentle fundal pressure was applied once the head was brought into incision. The infant was delivered with no difficulty. the mouth and nose were suctioned with a bulb. The cord was clamped and cut. The infants was handed off the pediatrician. IV oxytocin was initiated to facilitate uterine contractions. The placenta was delivered intact with manual massage of uterine funds. Uterus was the exteriorized. The inside of the uterus was gently wiped with a lap sponge to assure complete removal of placental membranes. The uterine incision was closed with a 0-vicryl for 2 layers - 1st running locking, 2nd closure umbilicating. The ovaries and tubes were found to be normal. The uterus, tubes, and ovaries were then returned to the abdominal cavity. The blood clots and fluid were wiped out of the abdomen and pelvis with moist laparotomy sponges. The uterine incision was re-inspected and good hemostasis and good hemostasis was noted.

The peritoneum was closed with 1 vicryl in continuous running fashion. The skin was closed with Keith subcutaneous. Patient tolerated the procedure well. All the counts were correct times two. Patient was taken to the recovery room in a stable condition.

Attending _____ was present for the entire procedure.