POSTPARTUM ORDERS

NSVD Admitting Notes

Back to room/ward
Full diet once full awake
Side notes Please admit to ROC under the service of Present IVF to run at 30 gtts/min, D/C if with minimal VB
TPR _____
IVF to ff: D5LR + 10 u Oxy to run at 30 gtts/min
BP TPR q 4 hours and record
Meds:
Weight Full diet, NPO once in active labor
Antibiotics
LMP (Last Menstrual Period) Labs: Mefenamic Acid 500 mg/cap q 8 H RTC x 24 H, then
EDC (Expected Date of CBC prn for pain
Confinement) HBsAg Methergine 1 tab TID x 3 days
AOG (Age of Gestation) Urinalysis
FH (Fundic Height) Vitamins
IVF: D5LR + 10 u oxytocin to run at 10- SO:
FHB (Fetal Heart Beat) 15 gtts/min
CD (Cervical Dilatation) Monitor VS q 15 min until stable
Meds: Massage uterus prn
Effacement Ampicillin 2g IV ANST if
Station Ice pack on hypogastrium
PROM Perilight x 15 min OD
BOW (Bag of Water)
None if no OB Routine perineal care
Leopolds
complications Watch out for profuse vaginal bleeding
Special Order: Refer accordingly
Monitor FHB and Thank you
progress of labor
Puboperineal shave
please
Inform NROD
Will inform service
consultant on deck
Refer prn

DISCHARGE ORDERS (Normal OB)

CS ADMITTING NOTES MGH
Please admit to ROC under the service of _____ Home Meds
TPR q 4 hours and record OPD follow-up on Saturday @ OB service clinic
Full diet, NPO post-midnight with photocopy of D/S
Labs: Discharge IE and summary c/o ___
CBC, APC TCB anytime if with profuse VB, HA, blurring of vision,
CT, BT, PT any untoward s/sx
Urinalysis
Venoclysis:
Meds:
Cefazolin 500mg IVTT q8H x 3 doses then shift to TRANS-OUT ORDERS
Side notes the ff: Orders
Co-Amox 625mg/tab, 1 tab BID Stable VS May refer back to room
Famotidine 20mg IVTT q8H x 3 doses Able to flex both legs D/C O2 and pulse oximeter
Ketomed 30mg IVTT q8H x 3 doses (-) vomiting Monitor V/S q 15 min until
Ketomed 10mg q8H to start if px is on soft diet stable
Blurring of vision
Special Order: MIO q Hly (+ FC) or shift (- FC)
Inform OR and refer if UO <30 cc/H
Secure signed consent Watch out for profuse vaginal
Abdominoperineal prep please bleeding, hypotension,
Request 500cc FWB of patients blood type as tachycardia or any untoward s/sx
standby Refer accordingly
Dr. ___ for anesthesia
Inform NROD
Refer accordingly
Thank you
POST-OP ORDERS NUMBER OF DAYS IN EACH MONTH
To RR
Monitor VS q15 mins. until stable SOLVING OF EXPECTED DATE OF CONFINEMENT(EDC) Month Number of days
NPO x 6 H, then may have sips of Clear liquids By Last Menstrual Period (LMP) January 31
O2 at 2-3 LPM via nasal prong o Nigels Rule (-3,+7, +1) February 28
Run present IVF @ 30 gtts/min Example: LMP May 2,2014 or 5/2/14 29-Leap year 2016,2020,2024...
IVF to ff: 5 2 14 March 31
D5LR -3 +7 +1 April 30
D5NM 2 9 15 or Feb 9,2015=EDC May 31
D5LR x 8 H June 30
Meds: SOLVING OF AGE OF GESTATION July 31
Antibiotics By Last Menstrual Period August 31
Example: Today is April 5, 2015, LMP is Feb 10, 2014
Ranitidine (Zantac) 50mg IVTT q8H x 3 doses September 30
Feb 28-10 =18 days
SO: October 31
March =31 days
Attach px to O2 at 2-3 LPM via nasal prong November 30
April = 5 days
Attach pc to pulse ox December 31
54 days/7(7days a week)=
MIO q H and record refer if UO is <30cc/H
7 weeks and 5/7 days
Remove FC 24H post op
Standby available blood By Ultrasound
DECIMAL POINT CONVERSION TO DAYS
Apply abdominal binder Example: UTZ result AOG is 23 4/7 days(convert to
Morphine precaution please days)=165 days. Today is April 16 2014. Utz is taken last .1 1 days
Specimen for histopathology March 12 2015. .2 2 days
Watch out for profuse vaginal bleeding, April 30 days-16 =14days .4 3 days
hypotension, tachycardia or any untoward s/sx March 31 days-12=19 days .5 4 days
Refer PRN 33 days + 165 days = 198 days .7 5 days
Thank you .8 6 days
198/7(convert to weeks)=28 weeks 2/7 days Whole number 7 days
PELVIC EXAM 1. Fetal Breathing Movements
Inspection 2. Gross Body Movement
Grossly N external genitalia 3. Fetal Tone
Masses, discharges, bleeding 4. Reactive FHR(not included in Modified BPS)
Speculum 5. Amniotic Fluid
Cervix hyperemic/nonhyperemic; *Perfect Score is 10/10 or 8/8
Fish-mouth deformity/ping pong
IE NON-STRESS TEST
Cervical dilatation Test of fetal condition
Cervical effacement REACTIVE
Station At least 2 accelerations of the FHR occurs for at least 15
BOW (intact/leaking) bpm, lasting for 15 sec w/in 20 min period of observation
Amniotic membrane PROM x days/hours NONREACTIVE
Presenting part May imply that the fetus is acidotic, asleep, or drugs was
Clinical pelvimetry administered to the mother
Inlet B. EARLY DECELERATION
Midplane Head compression
Ischial spines C. LATE DECELERATION
Sacrum Utero-placental insufficiency
Sidewalls Most common ; Most ominous
Outlet

Bimanual Examination(BME)
I (introitus) admits 2 fingers with ease/snugly
C (cervix) open/closed,; firm, doughy
U (uterus) level of umbilicus
A (adnexae) firm/fullness; w/ adnexal masses
D (discharges) (+) (-); scanty or minimal bleeding
E (episiotomy) with blood/well coaptated wound

Rectal Vault Exam(RVE)

Intact rectovaginal septum
Good sphincter tone
Abdomen
Inspection: globular/gravid; linea nigra, striae
Auscultation: NABS
Palpation: Leopolds
FH, FHB R/L

BIOPHYSICAL SCORING PARAMETERS

CONTRACTION STRESS TEST/OXYTOCIN CHALLENGE TEST Bloody vaginal discharge or bleeding appears L1 (Fundal Grip)
A measure of utero-placental function Closed vaginal os What fetal pole occupies the fundus
Contraction induced by using IV oxytocin Low abdominal pain
Record FHB Bleeding first, cramping follows L2 (Umbilical grip)
Fetal back
POSITIVE INEVITABLE ABORTION
Consistent and persistent late deceleration (50%) of the FHB Gross rupture of membrane L3 (Pawlicks grip)
in the absence of uterine hypertonus or supine hypotension Leaking amniotic fluid (+) engagement of head or (-) engagement
Cervical dilatation
NEGATIVE L4 (Pelvic grip)
atleast 3 contractions in 10 mins, each lasting 40 secs, w/o Side of cephalic prominence
COMPLETE ABORTION
late deceleration Complete detachment
FUNDIC HEIGHT
Int. cervical os closes
SUSPICIOUS 12wks-1st felt; above the symphysis pubis
Inconstant late deceleration patterns 16wks- bet. Symphysis and umbilicus
INCOMPLETE ABORTION
20wks- umbilicus
Int. cervical os opens and allows passage of blood
HYPERSTIMULATION 36wks- below ensiform cartilage
Uterine contractions occur more frequent than every 2 mins, FHB Monitoring
FETAL DEATH
or lasting longer than 90 secs, or presence of hypertonus Every 30mins= low risk
Tobacco-stained amniotic fluid
UNSATISFACTORY Every 15mins= high risk
Spaldings sign significant overlapping of fetal skull bones
Frequency of contractions is <3 per minute
Roberts sign Demonstration of gas bubbles in the fetus
Exaggeration of fetal spinal curvature

HYPERTENSION
AMONIOTIC FLUID INDEX
140/90mmHg
Normal: 6-24 cm
Etiology (Williams) BISHOPS Scoring
Oligohydramnios: <5 cm
Exposed chorionic villi
Low normal: 9-10 BISHOP 0 1 2 3
Twin pregnancy (Multiple gestation)
Polyhydramnios: >24 SCORE
Vascular dses
PRENATAL CHECK-UPS Dilatatio 0 1-2cm 3-4cm 5-6cm
Family hx
0-27 wks q4wks n
Proteinuria
28 wks q 2wks Effaceme 0-30% 31-50% 51-70% >70%
>300mg/24H urine sample
29-35 wks q2wks 36 wks and beyond q week nt
> 1000mg/random sample 6H apart OGTT (Oral Glucose Tolerance Test) Station -5/-3 -2 -1 +1/+2
1+ = mild proteinuria 24-28wks Cervical Posteri Midline Anterior -----
2+ to 4+ = heavy proteinuruia Complete Blood COunt Position or
*Edema DOES NOT validate Preeclampsia repeated at 28-32 AOG Cervical firm medium soft -----
HbsAg Consiste
GESTATIONAL HPN last trimester ncy
HPN w/o Proteinuria (after 20 weeks gestation) Alpha fetoprotein Favorable induction: ? 6(recheck!)
Confirm 12 wks Postpartum 16-18 wks AOG Unfavorable induction: ?
PREECLAMPSIA
(+) HPN, (+) Proteinuria after 20th week PLASMA GLUCOSE NDDG Coustan &
ECLAMPSIA RESULTS: Time Capenter(mg/dL)
(+) convulsions, (+) Preeclampsia Fasting 105 95
CHRONIC HPN 1st Hr 190 180
140/90mmHg before 20 weeks AOG 2nd Hr 165 155
SUPERIMPOSED PREECLAMPSIA 3rd Hr 145 140
Inc diastole and systole
Proteinuria
S/Sx of end organ damage

THREATENED ABORTION LEOPOLDS MANEUVER AUGMENTATION OF LABOR

 amniotic fluid 1st Degree
Oligohydramnios (causes) Fourchette, perineal skin, vaginal mucosa but not the underlying
Cord compression fascia and muscle
2nd Degree
Macrosomia
Fascia and muscles of the perineal body but not the anal sphincter
Deformations 3rd Degree
Fetal distress Extend from vaginal mucosa, perineal skin and fascia up to anal
sphincter but not the rectal mucosa
Induction of labor 4th Degree
Oxy drip but not in labor Encompasses extension up to rectal mucosa

Augmentation of Labor BRAXTON HICKS CONTRACTION

Oxy drip however in labor The uterus undergoes palpable but originally painless
contractions at irregular intervals from the early stages of
MYOMA gestation
causes soft tissue dystocia 20 weeks-primigravida
etiology: unopposed estrogen stimulation 18 weeks-multipara
types: Subserous, Intramural, Submucous INDICATIONS FOR CESAREAN SECTION
Prior CS
EXCISION OF BARTHOLINS CYST Labor dystocia (most frequent indication for 1 CS)
Hyperplasia (uterus) provera Fetal distress
Endocervical Breech presentation
Endometrial POST OP COMPLICATIONS OF CS DELIVERY
Endometrial for D & C Hysterectomy
Operative injury to pelvic structures
Infection
PLACENTA PREVIA Puerperal fever
Placenta increta invades Transfusion
Placenta percreta penetrates
Placenta accrete attaches
PLACENTA PREVIA Types:
Totalis placenta covers cervical os completely
Partialis internal os partially covered by placenta
Marginal edge of the placenta is at margin of internal os
Etiology: (P2ALM2)
Previous CS
Puerperal Endometritis
Advancing age
Multiparity
Multiple induced abortions
Diagnosis:
Painless third trimester bleeding
UTZ for placental localization
Placental Migration (placenta close to the internal os during
2nd trimester migrate to fundus as pregnancy advances

PLACENTA ABRUPTION
premature separation of the normally implanted placenta after the
20th week of pregnancy and before birth of fetus
Etiology: (PECSS)
Pre-eclampsia
External trauma
Chronic hypertension
Short umbilical cord
Sudden uterine decompression
LACERATIONS
STAGES OF LABOR
I: Active labor to full cervical dilatation (4-10 cm)
II: Full cervical dilatation to delivery of baby
II: Delivery of baby to expulsion of placenta
IV: Delivery of placenta to 1 hour after

CARDINAL MOVEMENTS
Engagement-Pelvic Inlet
Descent
Flexion
Internal rotation
Extension
External rotation
Expulsion

ASYNCLITISM such lateral deflection of the head to a more

anterior or posterior position of the pelvis

DELIVERY OF PLACENTA
SHULTZE MECHANISM
Peripheral
Shiny portion

DUNCAN MECHANISM
Central
Dirty part

Normal Rotation of Umbilical Cord:

Counter clockwise or Left-handed maneuver

SIGNS OF PLACENTAL SEPARATION

Calkins Sign (uterus becomes globular and firmer from
discoid)
Sudden gush of blood
Uterus rises in the abdomen as the detached placenta
drops to the lower segment and vagina
Lengthening of the cord
SIGNS OF MALIGNANCY UTZ:
Septations
Internal echoes
Ascites
Multiple daughter cysts
<5 cm cyst postmenopausal women expectant
management
VAGINAL BIRTH AFTER A CESAREAN SECTION (VBAC) Stimulates motility of the upper GIT w/o stimulating
Allow a trial of labor under double set-up for all previous cesarean *CaMg (CALMAG) gastric, biliary or pancreatic secretions
of one low segment incision after excluding an inadequate pelvis and Calcium: Sensitization of tissues to action of acetylcholine
unless a new indication arises Regulates heartbeat and prevents heart disease
Selection Criteria: Aids the growth and contraction of muscles Indications:
1 or 2 prior low-transverse cesarean section delivery Combats cholesterol by increasing HDL For disturbances of GIT motility, GERD, diabetic
Clinically adequate pelvic Reduces the occurrence of kidney stones gastroporesis, nausea, vomiting, migraine HA
No other uterine scars or previous rupture Reduces high blood pressure
Physicians immediately available throughout active labor Prevents muscle cramping Side effects:
capable of monitoring labor and performing an Restlessness, drowsiness, fatigue, lassitude
Transmits nerve impulses
emergency cesarean section delivery
Availability of anesthesiologist and personnel for *PIPERACILLIN TAZOBACTAM
Magnesium:
emergency cesarean section delivery Highly active against piperacillin-sensitive microorganisms
Assists calcium metabolism
as wells as B-lactamase-producing piperacillin-resistant
Helps maintain arterial health, normal blood pressure
CRITERIA FOR TIMING OF ELECTIVE REPEAT CS DELIVERY microorganisms
and normal heart rhythm
(At least 1):
Works with calcium to form the structure of the bone Indication:
Fetal heart sounds documented for 20 weeks by non-
Indication:
electronic fetoscope or for 30 weeks by Doppler For UTI, lower resp tract, intraabdominal & skin infections
Calcium deficiency, nutritional supplement to prevent osteoporosis
It has been 36 weeks since a (+) serum/urine hCG & septicemia
pregnancy test was performed by a reliable laboratory
Side effects:
An UTZ measurement of the CRL obtained at 6-11 weeks Side effects:
Diarrhea
supports a gestational age at least 39 weeks Upset stomach, vomiting, unpleasant or abnormal taste,
UTZ obtained at 12-20 weeks confirms the gestational age diarrhea, gas, headache, constipation, insomnia, rash,
of at least 39 weeks determined by clinical history and PE itching skin, swelling, shortness of breath, unusual
bruising or bleeding

TETANUS TOXOID
1st- 20 wks AOG
2nd- 1 month after birth
*ISOXUPRINE HCl (Duvadilan)
3rd- 6 months
Mode of Action:
ADMITTING NOTES (Ectopic Pregnancy) 4th- 1 year
beta-adrenergic agonist that causes direct relaxation of
Please admit pc to ROC under the service of Dr. ___ 5th- 1 year
uterine and vascular smooth muscle via beta-2 receptors
TPR q 4 hours and record
IVF: D5LR 1L X 8 Hrs Indication:
NPO temporarily *STEROIDS (Prematurity)
Treatment of circulatory disorders and uterine
Labs: 1 dose 28-32 wks
hypermotility
CBC, APC 3 doses q 2 wks
CT, BT, PT *MAGNESIUM SULFATE DOSES (Eclampsia)
Side effects:
BT w/ Rh Loading dose:
Transient palpitations, fall in BP, dizziness
U/A 4gms slow IV
5gms each buttocks deep IM
S. Preg test *DYDROGESTERONE (Duphaston)
Maintenance dose:
Meds: None temporarily Orally active progesterone
5gms IM/IV q 6hrs
SO: Promotes pregnancy in case of luteal insufficiency for
Monitor BP, U/O, DTRs hyporeflexia
Monitor VS, abdominal status hourly maintaining pregnancy in threatened and habitual
Monitor RR
Refer once lab result is in abortions
MgSO4 drip:
Dr. ___ seen px at ER
1-2gms/hr
Watch out for any untoward s/sx Indications:
1L = 10gm given 100cc/hr
Refer prn Dysfunctional uterine bleeding, irregular cycles,
threatened and habitual abortion, infertility, premenstrual 10meq/L(about 12mg/dL) respiratory depression
syndrome, endometriosis, dysmenorrheal 12meq/L respiratory paralysis and arrest
Antidote: Calcium gluconate 1g IV
Side effects:
Breakthrough bleedings, hemolytic anemia, edema, *HYOSCINE N-BUTYL BROMIDE (Buscopan) for softening of the
asthenia or malaise, jaundice and abdominal pain cervix

MEDICATIONS *METOCLOPRAMIDE (Plasil)