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Operative Notes

Robotic Assisted Laparoscopic Hysterectomy(Work Type 78)

TAH / BSO

NAME:
PATIENT MR#:
DATE OF PROCEDURE:
PREOPERATIVE DIAGNOSIS:
POSTOPERATIVE DIAGNOSIS:
OPERATIVE PROCEDURE: Total abdominal hysterectomy with bilateral salpingo-oophorectomy
SURGEON:
ASSISTANTS:
ANESTHESIA: General Endotracheal
ESTIMATED BLOOD LOSS:
URINE OUTPUT: ___cc clear yellow urine at the end of the case.
IV FLUIDS:
COMPLICATIONS:
PATHOLOGY:
FINDINGS:
DESCRIPTION OF PROCEDURE: Following informed consent, the patient was taken to the operating room where she was placed under general anesthesia without difficulty. She was prepped and draped in a sterile fashion. After a timeout was performed, a pfannenstiel skin incision was made and carried down to the underlying fascia. Fascial incision was then extended laterally with Mayo scissors. Superior fascial edge was grasped with Kocher clamps. The rectus muscles were then dissected off with blunt dissection and Mayo scissors. Inferior fascial edges were then grasped with Kocher clamps and once again the rectus muscles were dissected off using blunt dissection and Mayo scissors as well. Muscles were separated in the midline. A peritoneal incision was then made and extended superiorly and inferiorly with Metzenbaum scissors with good visualization of the bladder.

The uterus was palpated and found to be mobile within the pelvis. A Balfour retractor was placed and the bowel packed to the upper abdomen with laparotomy sponges. The round ligaments, fallopian tube, and uteroovarian ligament were clamped with Kelley clamp x2, and the uterus lifted upward. The round ligament was clamped with right angle clamps x2, cut with metzenbahms and ligated with 0 vicryl. Anterior and posterior leaves of the broad ligament were opened up using metzenbahms and blunt dissection. Next, the ureters were visualized and peristalsis was noted bilaterally. A window was made in the posterior broad ligament and IP ligament was clamped with a curved R&N. The pedicle was transected and the pedicles were ligated using 0 Vicryl on a free tie followed by a fore-and-aft stitch. Curved R&Ns were then placed across the uterine arteries after skeletonization at the level of the internal os and ligated with 0 Vicryl in a Heaney stitch. Next, straight R-Ns were placed bilaterally, close to the cervix. Pedicles were transected and ligated with 0 Vicryl bilaterally. Bladder flap was then further created using sharp dissection with metzenbahms and a sponge on a stick. Cardinal ligaments were then transected using a straight R&N bilaterally. Each pedicle was transected and ligated with 0 Vicryl in a Heaney and this was continued until the distal portion of the cervix was reached. Curved R&Ns were placed just distal to the edge of the cervix. Pedicles were transected with Jorgenson scissors and uterus, tubes, ovaries, and cervix were removed from the abdominal cavity. The uterosacral pedicles were incorporated into the vaginal cuff with a Heaney stitch bilaterally. The cuff was identified with an allis clamp and a total of 3 figure of 8 sutures were used to close the cuff. Survey of the vaginal cuff revealed excellent hemostasis.

The abdomen was then irrigated. Survey revealed good hemostasis. The muscles were reapproximated with 0 Vicryl. The fascia was then reapproximated using 0 Vicryl in a running continuous fashion. The subcutaneous layer was irrigated and hemostasis was achieved with Bovie cautery and the skin was reapproximated with staples. Sponge, needle and lap counts were correct x2. The patient was taken to the recovery room in stable condition.

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TVH / BSO (Work Type 78)

NAME:
PATIENT MR#:
DATE OF PROCEDURE:
PREOPERATIVE DIAGNOSIS:
POSTOPERATIVE DIAGNOSIS:
OPERATIVE PROCEDURE: Total vaginal hysterectomy with bilateral salpingo-oophorectomy
SURGEON:
ASSISTANTS:
ANESTHESIA: General Endotracheal
ESTIMATED BLOOD LOSS:
URINE OUTPUT: ___cc clear yellow urine at the end of the case.
IV FLUIDS:
COMPLICATIONS:
PATHOLOGY:
FINDINGS:
DESCRIPTION OF PROCEDURE: After informed consent, the patient was taken to the operating room where anesthesia was induced without difficulty. She was placed in candy cane stirrups and prepped and draped in a sterile fashion. Next, a timeout was performed and 100cc of methylene blue was instilled in the bladder and foley catheter was clamped. Next, a weighted speculum was placed posteriorly, a Deaver anteriorly, and the cervix grasped with a thyroid tenaculum. Once the anterior and posterior reflections were identified, the cervix was injected circumferentially with vasopressin. Next, a scalpel was used to circumscribe around the cervix just proximal to the reflections and the reflection was then pushed up digitally. Next, using Metzenbaums, the posterior cul-de-sac was entered, and curved R&Ns were then used to grasp the uterosacrals which were clamped and tied with Vicryl and tagged. Next, the bladder reflection was identified. Using Metzenbaums, it was entered and palpation and direct visualization confirmed proper location. Next, using curved R&Ns, the uterine arteries were clamped, cut, and ligated bilaterally with vicryl in a heaney stitch. The pedicles were visualized after ligation and were hemostatic. Next, clamps were sequentially placed more cephalad and the pedicles cut and ligated with Vicryl. This was continued until only the round ligament and fallopian tubes remained. Then, the round ligament and fallopian tubes were grasped, cut, and ligated bilaterally with vicryl using a free tied followed by a fore-and-aft stitch. The pedicles were inspected and found to be hemostatic.

Next, each ovary was grasped with a Babcock and pulled to the surgical view. A clamp was placed around the IP. It was cut with curved Mayo's, and the pedicle ligated with Vicryl on a free tie followed by a fore-and-aft stitch. The clamp was removed and found to be hemostatic. This was repeated for the contralateral ovary.

All pedicles were then inspected and were found to be hemostatic. Next, the cuff was closed using a vertical mattress suture incorporating the uterosacrals at the angles. A total of 5 sutures were used to close the cuff. The cuff was irrigated and found to be hemostatic. The pt was taken to the recovery room in stable condition.

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TLH / BSO(Work Type 78)

NAME:
PATIENT MR#:
DATE OF PROCEDURE:
PREOPERATIVE DIAGNOSIS:
POSTOPERATIVE DIAGNOSIS:
OPERATIVE PROCEDURE: Total laparoscopic hysterectomy with bilateral salpingo-oophorectomy
SURGEON:
ASSISTANTS:
ANESTHESIA: General Endotracheal
ESTIMATED BLOOD LOSS:
URINE OUTPUT: ___cc clear yellow urine at the end of the case.
IV FLUIDS:
COMPLICATIONS:
PATHOLOGY:
FINDINGS:
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where general anesthesia was induced without difficulty. She was then placed in the dorsal lithotomy position with careful attention in positioning to avoid over extention, flexion, AB-duction or AD-duction of the lower extremities. She was prepped in a sterile fashion and after a timeout was performed, a RUMI manipulator was placed into the os after dilation to 25 French. The internal and external balloons were inflated. Next, gloves were changed and attention was turned to the patient's abdomen.

An incision was made in umbilicus after infiltration with marcaine and a Veres needle was inserted into the abdomen. Position confirmed by saline drop test. Next, pneumoperitoneum was created with carbon dioxide and position was further confirmed when the 5th abdominal pressure was less than 10. The Veres needle was removed and a 5mm trocar was placed in the umbilical incision followed by confirmation of proper placement by direct visualization with the camera. A survey of the abdomen showed no bleeding from the insertion sites, no injury to the structures below the insertion sites. Two additional 5mm ports were placed in a similar fashion approximately 3 cm superior to and 3 cm medial to the anterior superior iliac spine bilaterally and a 12 mm port was placed approximately 12cm superior to the port on the right. The ureters were identified bilaterally and the pelvis was surveyed and the findings were noted as above.

The harmonic scalpel was used to grasp the right infundibulopelvic ligament where it was coapted and cut. The harmonic scalpel was then used to take down the broad ligament down to the level of the cervix and bladder flap was created with the harmonic scalpel and uterine arteries were skeletonized. The uterine arteries were then cut after coapting the tissue thoroughly. All of these pedicles were hemostatic. Next, attention was turned to the contralateral side which was dissected in a similar fashion and bladder flap created to join the other side. Blunt dissection was used to help dissect off the bladder past the internal os where the metal cup of the RUMI could be felt. Using the harmonic scalpel active blade, the vagina was cut circumferentially above the uterosacral ligaments using the metal cup of the RUMI as a guide. The uterus was pulled down through the cuff to help tamponade the air from escaping from the abdomen.

The cuff was closed with an Endostitch device using 6 interrupted stitches and the cuff was found to be hemostatic. Next, the suction irrigator was used to thoroughly irrigate the pelvis and pedicles were inspected and found to be hemostatic. At this point, the specimen was totally removed from the patient's vagina and sent for pathology. The insufflation was let down to less than 5mmHg and the pedicles were once again visualized and found to be hemostatic. Next, using the fascial closure device, the 12 mm trocar site was brought back together and the other trocars were removed under direct visualization. The skin was reapproximated with Dermabond. Sponge, lap and needle counts were correct times two. The patient was taken to the recovery room in stable condition.

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LSH(Work Type 78)

NAME:
PATIENT MR#:
DATE OF PROCEDURE:
PREOPERATIVE DIAGNOSIS:
POSTOPERATIVE DIAGNOSIS:
OPERATIVE PROCEDURE: Laparoscopic supracervical hysterectomy
SURGEON:
ASSISTANTS:
ANESTHESIA: General Endotracheal
ESTIMATED BLOOD LOSS:
URINE OUTPUT: ___cc clear yellow urine at the end of the case.
IV FLUIDS:
COMPLICATIONS:
PATHOLOGY:
FINDINGS:
DESCRIPTION OF PROCEDURE: After informed consent, the patient was taken to the operating room where she was placed under general endotracheal anesthesia without difficulty. The patient was prepped and draped in a sterile fashion. After a timeout was performed, an infraumbilical incision was made after infiltration with marcaine and a Veres needle was inserted into the abdomen. Position confirmed by saline drop test. Next, pneumoperitoneum was created with carbon dioxide and position was further confirmed when the 5th abdominal pressure was less than 10. The Veres needle was removed and a 12-mm trocar was placed in the umbilical incision followed by confirmation of proper placement by direct visualization with the camera. A survey of the abdomen showed no bleeding from the insertion sites, no injury to the structures below the insertion sites. Three additional 5mm ports were placed in a similar fashion approximately 3 cm superior to and 3 cm medial to the anterior superior iliac spine bilaterally and 3cm above the symphysis pubis under direct visualization with the camera. The ureters were identified bilaterally and the pelvis was surveyed and the findings were noted as above.

The harmonic scalpel was used to grasp the round ligament where it was coapted and cut. The harmonic scalpel was then used to take down the broad ligament down to the level of the cervix and a bladder flap was created with the harmonic scalpel and uterine arteries were skeletonized. The uterine arteries were then cut after coapting the tissue thoroughly. All of these pedicles were hemostatic. Next, attention was turned to the contralateral side which was dissected in a similar fashion and bladder flap created to join the other side. Next, at a site approximately 2cm distal to the internal os, the harmonic scalpel was used cut the cervix and the uterus amputated. The morcellator was introduced and the uterus was morcellated and sent to pathology for review. Pelvis was irrigated and all pedicles were noted to be hemostatic. The insufflation was let down to less than 5mmHg and the pedicles were once again inspected and found to be hemostatic. The 12mm port was removed and the defect closed with a facial closure device. The pneumoperitoneum was released and all remaining ports were removed from the abdomen. The skin was closed with Dermabond. The patient tolerated the procedure well. Sponge, lap, and needle were correct times two. She was taken to the recovery room in stable condition.

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Laparoscopic BSO(Work Type 78)

NAME:
PATIENT MR#:
DATE OF PROCEDURE:
PREOPERATIVE DIAGNOSIS:
POSTOPERATIVE DIAGNOSIS:
OPERATIVE PROCEDURE: Laparoscopic bilateral salpingo-oophorectomy
SURGEON:
ASSISTANTS:
ANESTHESIA: General Endotracheal
ESTIMATED BLOOD LOSS:
URINE OUTPUT: ___cc clear yellow urine at the end of the case.
IV FLUIDS:
COMPLICATIONS:
PATHOLOGY:
FINDINGS:
DESCRIPTION OF PROCEDURE: After informed consent, the patient was taken to the operating room where general anesthesia was obtained without difficulty. She was then placed in the dorsal lithotomy position with careful attention in positioning to avoid over extention, flexion, AB-duction or AD-duction of the lower extremities. She was then prepped and draped in a sterile fashion. The patient was then examined under anesthesia and found to have a small anteverted uterus with normal adnexa. An open sided speculum was placed in the patient's posterior vagina, and the anterior lip of the cervix was grasped with the single-tooth tenaculum. The cervix was dilated to 23 french and a ZUMI minipulator inserted without difficulty and inflated.

Attention was then turned to the patient's abdomen where after local infiltration of marcaine, a 5 mm skin incision was made in the umbilical fold. A Veress needle was inserted into the abdomen and position confirmed by saline drop test. Next, pneumoperitoneum was created with carbon dioxide and the position was further confirmed on the fifth abdominal pressure was less than 10. The Veress needle was removed and a 10 mm trocar was placed in the umbilical incision followed by confirmation of placement by direct visualization with the camera. A second skin incision was then made and a trocar placed in the right lower quadrant approximately 3 cm superior to and 3cm medial to the anterior superior iliac spine under direct visualization. Survey of the abdomen showed no bleeding from the insertion sites and no injury to the structures below the insertion sites. An additional port was placed on the contralateral side in a similar fashion under direct visualization with the camera. The ureters were identified bilaterally and the pelvis was surveyed and the findings were noted as above.

The left ovary was then grasped, the IP ligament identified, coagulated, and cut using the gyrus. The plane was continued to contain the ovary, utero-ovarian ligament, and fallopian tube. This was placed in the anterior cul-de-sac and attention turned to the contralateral side where a similar disection was done. An Endocatch bag was introduced into the abdomen and both ovaries were placed into the bag and carefully removed from the abdomen. Final survey of the abdomen revealed no bleeding. Ureteral peristalsis was visualized bilaterally. The insufflation was let down to 5mmHg and the pedicles were once again visualized and found to be hemostatic. Instruments were then removed from the patient's abdomen. The 10 mm incision was closed with a facial closure device and the skin was closed with dermabond. Sponge, lap and needle counts were correct times two. The patient was taken to the recovery room in stable condition.

DISPOSITION: The results of the operation were discussed with the patient's family. The patient will be discharged home when stable per PACU protocol. She was then given a prescription for Lortab 7.5 mg, #30 and Phenergan #20. The patient will be followed up in the GYN clinic in two weeks for a postoperative check. We will followup with the pathology of the patient's bilateral tubes and ovaries.

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Diagnostic Laparoscopy / Hysteroscopy(Work Type 78)

NAME:
PATIENT MR#:
DATE OF PROCEDURE:
PREOPERATIVE DIAGNOSIS:
POSTOPERATIVE DIAGNOSIS:
OPERATIVE PROCEDURE: Diagnostic hysteroscopy and diagnostic laparoscopy
SURGEON:
ASSISTANTS:
ANESTHESIA: General Endotracheal
ESTIMATED BLOOD LOSS:
URINE OUTPUT: ___cc clear yellow urine at the end of the case.
IV FLUIDS:
COMPLICATIONS:
PATHOLOGY:
FINDINGS: Normal cervix, normal internal uterine anatomy. Normal uterus, tubes, and ovaries. Normal appearing liver edge, gallbladder, and appendix
DESCRIPTION OF PROCEDURE: After informed consent, the patient was taken to the operating room where general anesthesia was obtained without difficulty. She was then placed in the dorsal lithotomy position with careful attention in positioning to avoid over extention, flexion, AB-duction or AD-duction of the lower extremities The patient was then examined under anesthesia and found to have a small anteverted uterus with normal adnexa. An open sided speculum was placed in the patient's posterior vagina, and the anterior lip of the cervix was grasped with the single-tooth tenaculum.

Next, the hysteroscope was advanced under direct visualization without complication. The fundus was examined and found to be within normal limits. Both ostia were visualized. The hysteroscope was removed and the the cervix examined during withdrawal and found to be normal in appearance.

Next, the uterus was gently sounded to 8cm and dilated to 23 french with pratt cervical dilators. A ZUMI uterine manipulator was then advanced into the uterus without issue. The speculum was removed from the vagina. Attention was then turned to the patient's abdomen where after local infiltration with marcaine, a 5-mm skin incision was made just inferior to the umbilicus. A Veres needle was inserted into the abdomen via Z technique and postion confirmed by saline drop test. Next, pneumoperitoneum was created with carbon dioxide and position was further confirmed when the 5th abdominal pressure was less than 10. The Veres needle was removed and a 5-mm trocar was placed in the umbilical incision followed by confirmation of proper placement by direct visualization with the camera. A second skin incision was made approximately 3 cm above the symphysis pubis in the midline after infiltration with marcaine. A second trocar and sleeve were advanced under direct visualization of the laparoscope. A survey of the abdomen showed no bleeding from the insertion sites, no injury to the structures below the insertion sites, a grossly normal appendix, and a normal appearing gallbladder and liver. Survey of the abdomen revealed a normal appearing posterior cul de sac, normal uterine anatomy, normal appearing ovaries, and fallopian tubes. A final survey of the abdomen revealed no bleeding. The instruments were then removed from the patient's abdomen and the incisions were closed using Dermabond. The ZUMI uterine manipulator was then removed from the cervix and hemostasis of the cervix was assured. The patient tolerated the procedure well. Sponge, lap, and needle counts were correct x2. The patient was taken to the recovery room in stable condition.

DISPOSITION: The results of the operation were discussed with the patient's family. Patient will be discharged home when stable per PACU protocol. She has been given a script for oxycodone. She will be followed up in the GYN clinic in two weeks for a postoperative check.

Postpartum Tubal Ligation


(Work Type 78)

PATIENT NAME:
PATIENT MR#:
DATE OF PROCEDURE:
PREOPERATIVE DIAGNOSIS:
POSTOPERATIVE DIAGNOSIS:
OPERATIVE PROCEDURE: Bilateral tubal ligation via modified Pomeroy procedure
SURGEON:
ASSISTANTS:
ANESTHESIA: General Endotracheal
ESTIMATED BLOOD LOSS:
IV FLUIDS:
COMPLICATIONS:
FINDINGS: Normal uterine fundus, tubes & ovaries.
PATHOLOGY: Bilateral tubal segments.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where she was placed in a dorsal supine position and she was prepped and draped in a sterile fashion. After anesthesia was found to be adequate, Allis clamps were used to pick up the skin in the infraumbilical area, and a scalpel was used to make an approximately 3 cm incision which was carried down to the underlying layer of fascia. Army-Navy retractors were then inserted into the skin incision. The patient was put in Trendelenburg. The patient's right tube was then identified, grasped with a Babcock clamp and carried out to the fimbria and then approximately 3 cm from the cornual region was doubly tied with plain gut and excised with excellent hemostasis. Ostia were visualized on both ends of the excised portions. After hemostasis was assured, the tube was returned to the abdomen. Attention was then turned to the patient's left tube which was identified, picked up with Babcock clamps and carried out to the fimbria. Approximately 3 cm from the cornual region was doubly tied with plain gut. It was excised with excellent hemostasis. Both ostia were visualized. After ensuring hemostasis of the tube, the suture was cut and the tube was returned to the abdomen. The fascia was then closed with Vicryl in a running fashion and the skin was closed with Vicryl in a subcuticular fashion. The patient tolerated the procedure well and was taken to the recovery room in stable condition.

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Interval Laparascopic Tubal Ligation (Work Type 78)

PATIENT NAME:
PATIENT MR#:
DATE OF PROCEDURE:
PREOPERATIVE DIAGNOSIS:
POSTOPERATIVE DIAGNOSIS:
OPERATIVE PROCEDURE: Laparoscopic bilateral tubal ligation via dessication of oviducts
SURGEON:
ASSISTANTS:
ANESTHESIA: General Endotracheal
ESTIMATED BLOOD LOSS:
URINE OUTPUT: ___cc clear yellow urine at the conclusion of the procedure.
IV FLUIDS:
COMPLICATIONS:
FINDINGS: Normal uterine fundus, tubes & ovaries.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where general anesthesia was obtained without difficulty. The patient was placed in dorsal lithotomy position and examined under anesthesia and found to have a small anteverted uterus with normal adnexa. She prepped and draped in sterile fashion. A weighted speculum was placed in the patient's posterior vagina, and the anterior lip of the cervix was grasped with the single-tooth tenaculum. A ZUMI uterine manipulator was then advanced into the uterus. The speculum was removed from the vagina.

Attention was then turned to the patient's abdomen where after local infiltration with marcaine, 5-mm skin incision was made in the umbilical fold. A Veres needle was inserted into the abdomen via Z technique and postion confirmed by saline drop test. Next, pneumoperitoneum was created with carbon dioxide and position was further confirmed when the 5th abdominal pressure was less than 10. The Veres needle was removed and a 5-mm trocar was placed in the umbilical incision followed by confirmation of proper placement by direct visualization with the camera. A second skin incision was made approximately 3 cm above the symphysis pubis in the midline after infiltration with marcaine. A second trocar and sleeve were advanced under direct visualization of the laparoscope. A survey of the abdomen showed no bleeding from the insertion sites, no injury to the structures below the insertion sites, a grossly normal appendix, and a normal appearing gallbladder and liver edge. Gyrus applicator was then advanced through the suprapubic trocar sleeve, and the patient's left fallopian tube was identified and followed out to the fimbriated end. The Gyrus applicator was applied 3 cm from the cornual region, and the fallopian tube was cauterized until adequate blanching was noted. Three contiguous sites of the tube were dessicated in total. There was no bleeding noted in the mesosalpinx. The right fallopian tube was identified and dessicated in a similar fashion. A final survey of the abdomen revealed no bleeding. The instruments were then removed from the patient's abdomen and the incisions were closed using Dermabond. The uterine manipulator was removed from the cervix and hemostasis of the cervix was assured. The patient tolerated the procedure well. Sponge and lap counts were correct x2.

DISPOSITION: The patient was taken to the recovery room in stable condition. She was given a script for darvocet 650/100 #20. She will be followed up in the GYN clinic in two weeks for a postoperative check.

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C Section (Work Type 78)

PATIENT NAME:
PATIENT MR#:
DATE OF PROCEDURE:
PREOPERATIVE DIAGNOSIS: A 33-year-old G2, P1 at 39 and 5 weeks for cesarean section secondary to ( prior c-section with request for repeat c-section / arrest of descent / nonreassuring fetal heart tracing / etc...) and desire for permanent female sterilization
POSTOPERATIVE DIAGNOSIS: Same as above
OPERATIVE PROCEDURE: Primary low transverse cesarean section via Pfannenstiel incision with bilateral tubal ligation via modified Pomeroy procedure.
SURGEON:
ASSISTANTS:
ANESTHESIA: General Endotracheal
ESTIMATED BLOOD LOSS:
URINE OUTPUT: ___cc clear yellow urine and the conclusion of the case
IV FLUIDS:
COMPLICATIONS:
FINDINGS: Normal Tubes, ovaries, & uterus. No abdominal adhesions identified. Viable male infant at 12:26, 6 pounds 9 ounces, Apgars 9 and 9.
PATHOLOGY: Bilateral tubal segments.
DESCRIPTION OF PROCEDURE: Patient was taken to the operating room where spinal anesthesia administered. She was then placed in the dorsal supine position with a leftward tilt. She was then prepped and draped in a sterile fashion. A timeout was performed and after assuring adequate anethesia, a pfannenstiel skin incision was then made and the incision was carried down to the underlying layer of fascia. Fascia was then extended laterally with the Mayo scissors. The superior aspect of the fascia was then grasped with Kocher clamps, tented up, and the rectus muscles were dissected off using the Mayo scissors. Kochers were then placed on the inferior aspect of the fascia and the rectus muscles were dissected off using the Mayo scissors as well. The rectus muscles were then entered in the midline. The peritoneum was identified and entered. Bladder blade was then inserted. Vesicouterine peritoneum was then identified, tented up with pickups and extended laterally with the Metzenbahm scissors. Bladder flap was created digitally. The bladder blade was removed, and reinserted behind the bladder flap. A transverse incision was then made in a curvilinear fachion in the lower uterine segment and extended laterally digitally. Baby's head and body were delivered atraumatically. Nose and mouth were suctioned. Cord was cut and clamped. Baby was handed off to the awaiting nurses. Cord gases were sent. The placenta was then removed after manually massaging the uterus. Uterus was exteriorized, wrapped in a wet lap, cleared of all clots and debris using a dry lap. The uterine incision was then closed with #1 vicryl in a running, locked fashion. A second layer closure was then done with horizontal mattress sutures. Hysterotomy repair was inspected and found to have excellent hemostasis. A lap pad was placed over the hysterotomy site and the uterus moved forward

Attention was then turned to the tubes. The tube was picked up approximately 3 cm from the cornual region with the Babcock clamp. It was then doubly tied with plain gut and excised with excellent hemostasis. The tube on the other side of the uterus was then grasped with Babcocks as well, doubly tied with plain gut and excised with excellent hemostasis.

The posterior aspect of the uterus was irrigated and the uterus moved back. And the lap pad over the hysterotomy repair was removed. The site again was inspected, and the uterus was then returned to the abdomen. Gutters were irrigated. (Tubal sites were visualized by both surgeons and were hemostatic with suture intact.) The rectus muscled were reapproximated with 2 interrupted sutures. Fascia was closed in a running fashion with vicryl. A subcutaneous fat layer closure was done after ensuring hemostasis The skin was closed in a subcuticular fashion with vicryl. Patient tolerated the procedure well. Sponge, lap, and needle counts were correct x2. Mother was taken to the recovery room in stable condition.

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Suction Dilation & Curettage(Work Type 78)

NAME:
PATIENT MR#:
DATE OF PROCEDURE:
PREOPERATIVE DIAGNOSIS:
POSTOPERATIVE DIAGNOSIS:
OPERATIVE PROCEDURE: Dilation and suction curettage
SURGEON:
ASSISTANTS:
ANESTHESIA: General Endotracheal
ESTIMATED BLOOD LOSS:
IV FLUIDS:
COMPLICATIONS:
PATHOLOGY: Probable products of conception
FINDINGS:
DESCRIPTION OF PROCEDURE: The patient was taken to the OR where general anesthesia was induced. The patient prepped and draped in a sterile fashion. A timeout was performed and a bimanual exam was done which showed a 8wk sized anteverted uterus. A sterile speculum was inserted and the cervix was easily visualized. A single-tooth tenaculum was applied to the anterior lip of the cervix. The uterus was then gently sounded to 9 cm, and an 8-mm suction curette was advanced gently to the uterine fundus. Suction device was then activated and the curette rotated to clear the uterus of products of conception. A sharp curettage was then performed until a gritty texture was noted. The suction curette was then reintroduced to clear the uterus of all remaining products of conception. There was minimal bleeding, and a tenaculum was removed with good hemostasis. The patient tolerated the procedure well and was taken to the recovery area in stable condition.

DISPOSITION:She will be discharged home when stable per PACU protocol. The patient is blood type O positive so no Rhogam is necessary. She was also counseled regarding birth control. Please discuss what method she chooses at her postop followup visit and give her a prescription for the birth control. The patient received the following medications: Doxycycline 100mg 1hr prior to the case and 200mg after the case (OR Pt received Flagyl 500 b.i.d. x7 days).
            (if heavier bleeding or anemia give Methergine 0.2 q.6 hours x24 hours and/or Iron sulfate 325mg BID for 2 months.)

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Postpartum Problems:

-Bleeding: (any problems with pregnancy or delivery?)
-Fever: Defined as temp greater than 101.5 at any time OR two temps greater than 100.4 outside of 1^st 24 hours

-Pain           PO:          Lortab 7.5 1 to 2 q4h
                                    Oxycontin 10mg q12h(sustained release analgesia)
                                    Roxicodone 5mg 1-2 po q4h
            Injectable:        Toradol 30mg IV/IM q6h
                                    Morphine 2-10mg IV q4h
                                    Fentanyl 1mcg/kg slow IVP q1h prn
                                    Demerol 50-75mg IM q4h

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Hormone Replacement Regimens

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Estrogen Preparations used for postmenopausal hormone replacement therapy

Acceptable HRT regimens for women with a uterus

Equivalent estrogen doses: Premarin 0.625 po; Ortho-Est .625 po; Nevest 0.625 po; Ogen 0.625 po; Estrace 1 mg po; Estinyl 0.05 mg; Estraderm 0.05 mg biweekly; Alera 0.05 biweekly; Fempatch 0.05 biweekly; Climera 0.05 weekly.

Equivalent low dose progestins: Provera (MPA) 2.5 mgs qd; Norethindrone .035 mg qd; Aygestin 2.5 mg qd.

Equivalent intermittent progestin doses; Provera 10m; Aygestin 5 or 10 mg; Micronor 0.07

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Emergency Contraception:

Notes:
1) Ella, Plan B, Plan B One-Step and Next Choice are the only dedicated product specifically marketed for emergency contraception.
2) Lo/Ovral, LoSeasonique, Low-Ogestrel, Lybrel, Nordette, Ogestrel, Seasonale, and Seasonique have been declared safe and effective for use as ECPs by the FDA.
3) Plan B One-Step and Next Choice are available OTC to women and men aged 17 and older; Plan B is available OTC to women and men aged 18 and older. You can buy these pills by prescription if you are younger. Ella is available by prescripion only.

The labels for Plan B and Next Choice say to take one pill within 72 hours after unprotected intercourse, and another pill 12 hours later. However, recent research has found that both pills can be taken at the same time. Research has also shown that that all of the brands listed here are effective when used within 120 hours after unprotected sex.

The progestin in Cryselle, Lo/Ovral, Low-Ogestrel and Ogestrel is norgestrel, which contains two isomers, only one of which (levonorgestrel) is bioactive; the amount of norgestrel in each tablet is twice the amount of levonorgestrel.

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Oral Contraception Components:

TRADE NAME	GENERIC NAME	ESTROGEN (DOSE)	PROGESTIN (DOSE)
MONOPHASIC
Alesse, Levlite	Aviane, Lessina	Ethinyl estradiol (20 μg)	Levonorgestrel (0.1 mg)
Mircette	Kariva	Ethinyl estradiol (20 μg×21 days +10 μg×5 days during placebo week)	Desogestrel (0.15 mg)
Loestrin FE	Microgestin FE 1/20, June FE 1/20	Ethinyl estradiol (20 μg)	Norethindrone acetate (1 mg)
Yaz		Ethinyl estradiol (20 μg)	Drospirenone (3 mg)
Levlen, Nordette	Levora, Portia	Ethinyl estradiol (30 μg)	Levonorgestrel (0.15 mg)
Lo/Ovral	Low-ogestrel, Cryselle	Ethinyl estradiol (30 μg)	Norgestrel (0.3 mg)
Desogen, Ortho-cept	Apri	Ethinyl estradiol (30 μg)	Desogestrel (0.15 mg)
Loestrin 211/5/30	Microgestin, Junel Fe	Ethinyl estradiol (30 μg)	Norethindrone acetate (1.5 mg)
Yasmin		Ethinyl estradiol (30 μg)	Drospirenone (3 mg)
Ovcon 35		Ethinyl estradiol (35 μg)	Norethindrone (0.4 mg)
Ortho-Cyclen	Mononesessa, Sprintec	Ethinyl estradiol (35 μg)	Norgestimate (0.25 mg)
Brevicon, Modicon	Nortrel, Necon 0.5/35	Ethinyl estradiol (35 μg)	Norethindrone (0.5 mg)
Demulen 1/35	Zovia 1/35	Ethinyl estradiol (35 μg)	Ethynodiol diacetate (1 mg)
Ortho-Novum 1/35, Norinyl 1+35	Necon 1/35, Nortrel	Ethinyl estradiol (35 μg)	Norethindrone (1 mg)
Ortho-Novum 1/50	Necon 1/50	Ethinyl estradiol (50 μg)	Norethindrone (1 mg)
Ovral	Ogestrel	Ethinyl estradiol (50 μg)	Norgestrel (0.5 mg)
Ovcon 50		Ethinyl estradiol (50 μg)	Norethindrone (1 mg)
Demulen 1/50	Zovia 1/50	Ethinyl estradiol (50 μg)	Ethynodiol diacetate (1 mg)
Norinyl 1/50		Mestranol (50 μg)	Norethindrone (1 mg)
Alesse, Levlite	Aviane, Lessina	Ethinyl estradiol (20 μg)	Levonorgestrel (0.1 mg)
Ortho-Novum 10/11, Jenest	Necon 10/11, Nelova 10/11	Ethinyl estradiol (35 μg)	Norethindrone (0.5 mg×10 days, 1 mg×11 days)
TRIPHASIC
Ortho Tri-Cyclen Lo		Ethinyl estradiol (25 μg)	Norgestimate (0.18 mg×7 days, 0.215 mg×7 days, 0.25 mg×7 days)
Cyclessa	Velivet	Ethinyl estradiol (25 μg)	Desogestrel (0.1 mg×7 days, 0.125×7 days, 0.15 mg×7 days)
Triphasil, Tri-Levlen	Trivora, Enpresse	Ethinyl estradiol (30 μg×6 days, 40 μg×5 days, 30 μg×10 days)	Levonorgestrel (0.05 mg×6 days, 0.075 mg×5 days, 0.125 mg×10 days)
Tri-Norinyl		Ethinyl estradiol (35 μg)	Norethindrone (0.5 mg×7 days, 1 mg×9 days, 0.5 mg×5 days)
Ortho Tri-Cyclen	Tri-Sprintec, Trinessa *	Ethinyl estradiol (35 μg)	Norgestimate (0.18 mg×7 days, 0.215 mg×7 days, 0.25 mg×7 days)
Ortho-Novum 7/7/7	Nortrel 7/7/7, Necon 7/7/7	Ethinyl estradiol (35 μg)	Norethindrone (0.5 mg×7 days, 0.75 mg×7 days, 1 mg×7 days)
Estrostep FE		Ethinyl estradiol (20 μg×5 days, 30 μg×7 days, 35 μg×9 days)	Norethindrone acetate (1 mg)
EXTENDED CYCLE
Seasonale		Ethinyl estradiol (30 μg×84 days followed by 7 placebo pills)	Levonorgestrel (0.15 mg)
Seasonique		Ethinyl estradiol (30 μg×84 days followed by 10 μg×7 days)	Levonorgestrel (0.15 mg)

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Commonly Used Medications:

Ambien 10mg Qhs
Amoxicillin 500mg PO TIDx 10d (UTI)
Ampicillin 2gm IV Q6
Bactrim DS 160/800 BIDx7d (less resistance)
Brethine 0.25mg subQx1
Ceftriaxone 125mg IM (GC)
Cipro 100-250BIDx3d, 500 Qdayx3d (nonpreg UTI)
Clindamycin 900mg IV Q8
Cytotec 25mcg PV
Darvocet N-100 1-2 po q4hrs prn pain
Depo Provera 150mg IMx1, rep 11wks
Fentanyl 1mcg/kg IV q2hrs
FeSO4 325mg PO BID
Fiorcet ( 50mg butalbital, 325mg acetaminophen, 40mg caffeine) 1-2 PO Q4 prn h/a
Flagyl 500mg PO BIDx10d (BV)
Gentamicin 1.5mg/kg load then 1mg/kg Q8, pharmacy to dose
Ketamine 2mg/kg IVP slow over 1 minute Macrobid 100mg BIDx7d (preg UTI)
Mag Oxide 400mg PO BID (migraine prophylaxis)
Methergine 0.2mg Q6x24hrs
Midrin (65mg Isometheptene Mucate, 100mg Dichloralphenazone, 100 mg, 325mg Acetaminophen) 2 immediately, then 1Qhr, max 5/12hrs (migraine)
Naprosyn 250 PO BIDx5d (migraine)
OrthoEvra 1patch Qwkx3wk, 1wk off
PCN 5million units IVx1, then 2.5 million units Q4 till delivery (GBS)
Phenergan 25mg PO/PR/IM Q6hr nausea
Pitocin 2 mU per minute; increase by 2mU q20 minutes until adequate. max dose 20mU
Pyridium 100-200mg Q8 (urinary analgesic) OTC- (Uristat, Azostandard)
Rhogam 1 vial per 0.3%, 2for .4-.6
Roxicodone 5mg 1-2 PO Q4hrs prn
Stadol 1mg
Tobramycin 120mgx1 then pharm to dose
Toradol 15-30mg IM q6hrs prn (pp pain)
Tylenol 325mg 1-2tabs , or 1000q8
Triamcinolone 0.1% 60g tube (pupps)
Unisom 12.5 PO BID (n/v)
Versed 2 mg slow IV, then 1-2mg IV every 5 minutes as needed VitB6 50mg PO BID (n/v)
Zithromax 1gm (2 tab 500mg) x1 (for chlamydia)
Zofran 4-8mg PO Q6 prn nausea

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Preventive Care / screening guidelines
- Mammograms: Screening mammogram starting at 40 every year. If a 1st degree relative had breast cancer, 5 years before their age at diagnosis.
- Pap Smears:
               
- Cholesterol Checks: every 5 years starting at age 35. Smokers, Diabetics, or a strong family history of heart disease, start cholesterol checks at age 20.
- Blood Pressure: Have your blood pressure checked at least every 2 years.
- Colorectal Cancer Tests: Colorectal cancer starting at age 50.
            -Fecal Occult Blood test and DRE every year
            -Colonoscopy every 10 years
            -Flexible sigmoidoscopy every five years
            -Double contrast barium enema every five years
            -Computed tomographic colonography every 5 years (not recommended/not likely covered by insurance)

- Diabetes Tests: Fasting glucose every 2 years if obese, have high blood pressure, family history of diabetes, or high cholesterol.
- Depression:
            -Felt "down," sad, or hopeless
            -Felt little interest or pleasure in doing things for 2 wks straight
            -(Sleep Interests Guilt Energy Concentration Appetite Psychomotor retardation or agitation Suicide Mood)
- Osteoporosis Tests: Bone density test at age 65 to screen for osteoporosis. Test at 50-64 if have 2 of the following: weight <155 lbs., postmenopausal, decreased Vit D or Ca intake, smoker, Family history of osteoporosis, Autoimmune disease, or a chronic disease
- Chl/GC, HIV, RPR: if < 25 and sexually active. Screen after 25 for high risk populations
- Thyroid disease: TSH by age 45
- Optional Screening: Sexual Satisfaction, domestic abuse, dementia, routine skin exams.

- Immunizations:        Flu shot: If pregnant. Yearly for all persons at 6m and older.  
                                    Tetanus-diphtheria- Pertussis: every 10 years.
                                    Pneumovax: Chronic Illnesses, chronic diseases of pulmonary system, immunosuppressive conditions. Otherwise, once at age 65.
                                    HepB: High Risk populations (health care, gay male, < 45 years old, or if can't discern high risk). Three doses (at 0m, 1m, 4m from first dose)

                                    Herpes Zoster: A single dose for all adults ≥60yo

                                    MMR: Two doses given at 0m and a minimum of 26d later.

                                    Varicella: everyone > 13yo who are unexposed (2 doses 4-8 wks apart)
                                    Menigococcus: Single dose for military, college, incarcerated
                                    Tuberculosis: Health care workers, incarcerated
                                    HPV: <27yo. (3 doses- 0m, 2m, 6m from first dose)

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Diabetes Mellitus

	Insulin Type	Onset	Peaks	Duration
Rapid Acting	Humalog	15-20 mins	30-90 mins	3-4 hours
	Novolog	15-20 mins	40-50 mins	3-4 hours
	Regular	30-60 mins	80-120 mins	4-6 hours
Intermediate Acting	NPH	2-4 hours	6-10 hours	14-16 hours
	Lente	3-4 hours	6-12 hours	16-18 hours
Long Acting	Ultralente	4-6 hours	10-16 hours	18-20 hours
	Lantus	2-3 hours	almost no peak	18-26 hours
	Levemir	45-60 mins	almost no peak	24 hours
Mixed Preparations	NPH/Lispro 75/25	<15-20 mins	30-90 mins	24 hours
	NPH/Regular 70/30	30-60min	2-12 hours	24 hours
	NPH/Regular (50/50)	30-60 mins	2-12 hours	24 hours
	NPH/Aspart 70/30	15-20 mins	1-3 hours	24 hours

Early pregnancy evaluation in Class B-H Diabetes.
    A 24-hour urine for creatinine clearance and total protein.
    B Serum TSH
    C EKG for DM > 15 years duration
    D Ophthalmology consult
    E Hemoglobin A1C (consider checking each trimester)
    F Urine culture (check each trimester)
    G Diet Orders: 2000 calorie ADA diet. No juices, milk, or peanut butter.

Blood Sugar Goals

	Setting		Preprandial		Postprandial
	Non-Critical		110		180
	Pregnancy		95		125

HgBA1C goal < 7.0 %

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Screening
    24-28 weeks with 50g Glucola
    Blood Glucose after 1hr GREATER THAN OR EQUAL TO 140 gets 3hr GTT.
    Glucose Tolerance Test - Draw fasting glucose then give 100g glucose load      

	Criteria		Fasting		1 hour		2 Hour		3 Hour
	ADA		105		190		165		145
	Carpenter/Coustan		95		180		155		140

        2 values EQUAL TO OR HIGHER makes the diagnosis

Classes:br>     A1 = Diet Controlled Gestational DM
    A2 = Glyburide or Insulin Controlled Gest. DM

Monitoring
     - Fasting & 2hr postprandial (goal is 95 fasting & 120 postprandial)
     - Begin 2x weekly testing for all A2 as well as A1 if they have other issues (PreE, macroomia, polyhydramnios)
     - Follow-up - 2hr 75g GTT at 6-10 weeks postpartum

			Fasting		2 hours
	Normal		< 100		< 140
	Impaired		100-124		141-199
	Diabetic		≥125		≥200

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White's Classification

Class	Description
A	Gestational Diabetic
B	Onset at >20 AND duration < 10 years
C	Onset at age 10-19 OR duration of 10-19 years
D	Onset before age 10 OR duration over 20 years OR benign retinopathy (microaneurysms aka dot hemorrhages)
R	Proliferative Retinopathy or Viteous Hemorrhage
F	Nephropathy with > 500 mg/day proteinuria
RF	Criteria for both R & F
G	Many pregnancy failures
H	Evidence of Arteriosclerotic heart disease
T	Prior Renal transplant

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Diabetic Ketoacidosis

Biochemical Definition>
    Plasma glucose > 250 mg/dl
    Plasma HC0₃ < 18 mEq/l
    Arterial pH < 7.30
    Positive serum or urine ketones
    High anion gap (> 12 mEq/l)

Management
    1. IV fluids
         a) 0.5 or 1 normal saline
         b) One liter over first hour and 300 - 500 ml/hr afterwards
         c) When plasma glucose below 250 mg/dl, 5% glucose in water should be infused.
         d) Total IV fluid replacement in first 12 hours about 5 liters.
    2. Regular insulin IV
         a) Initially give 5-10 units IV push over 10 min
         b) 50 units in 500 ml of 0.5 or 1.0 normal saline, run at 50-100 ml/hr to yield 5-10 units/hr.
         c) If the glucose does not fall by at least 10% in one hour or 30% in two hours, the insulin infusion should be doubled.
    3. Laboratory monitoring
         a) Plasma glucose - q1 to 2hrs
         b) Arterial pH - as needed
         c) Serum electrolyte - q4hrs
         d) Serum / urine ketones-4hrs
    4. Half the insulin dose when the glucose reaches 200-250 mg/dl. Half the dose again when the glucose falls below 150 mg/dl. Usually 1-2 units/hr will suffice at this time.
    5. If arterial pH remains below 7.30 and is not rising, the insulin infusion should be increased even though the glucose level is falling. (5% glucose should be infused to avoid hypoglycemia.)
    6. Bicarbonate: If pH <7.00, 44 mEq sodium bicarbonate to each liter. If pH ><6.9, 88 mEq sodium bicarbonate to each liter. Stop infusion when pH reaches 7.20. >
    7. Potassium (KCL):
         40 mEq over 1 hour if K < 3
         30 mEq over 1 hour if K < 4
         20 mEq over 1 hour if K < 5
    8. Keep in L & D on IV insulin for minimum of 12 hrs after acidosis and hyperglycemia corrected.
    9. Search for underlying cause of diabetic ketoacidosis - infection, vomiting, dehydration, etc.
    10. External fetal monitoring at fetal viability: Decreased reactivity and late decelerations may occur but no intervention should be taken while mother is unstable. Correction of maternal acidosis and hyperglycemia usually will result in improvement of FHR tracing.

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Calculating Starting Insulin Dose

    1) Calculate the Total Daily Insulin Dose by multiplying weight in kg by:
         0.7 in 1^st trimester
         0.8 in 2^nd trimester
         0.9 in 3^rd trimester
    2) Give 66% of the total dose in the morning.
         Divide this dose so 33% is rapid acting and 66% is intermediate acting
    3) Give 33% of the total dose in the evening.
         Divide this dose so 50% is short acting and 50% is intermediate acting

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Example Sliding Scale Insulin

     Regular Insulin Sub Q

	FSBG		Regular Insulin SubQ
	< 60		Hypoglycemia Protocol
	61-100		0 units
	101-120		2 units
	121-140		4 units
	141-160		6 units
	161-180		8 units
	181-200		10 units
	> 201		Call M.D.

 Peri-Operative Management of Diabetes

Schedule surgery as early in the morning as possible.
Monitor BS q 1-2 hrs before, during and after surgery.
 

Orally controlled
>old oral diabetic medications after midnight
Use regular insulin sliding scale, prn for BS > 180
 

Insulin controlled
Short / Early Procedure- Delay am insulin until after surgery & administer after with late breakfast
Missed Breakfast- Give 1/2 to 2/3 of am NPH dose
Missed Breakfast and Lunch or Late Procedures- Give 1/3 to 1/2 of am NPH dose and use D5W @ 100 cc/hr. Continue insulin pumps at the basal rate
Give usual dose of Lantus
Long Procedures- Use an insulin drip with D5W at 100 cc/hr

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Herpes in Pregnancy

      Primary or First Episode
         Acycolvir (Zovirax) - 400mg TID x 7-10d
         Valacyclovir (Valtrex) - 1g BID x 7-10d

          Symptomatic recurrent episode

         Zovirax - 400mg TID x 5d OR 800mg BID x 5d
         Valtrex - 500mg BID x 3d OR 1g qd x 5

      Daily Suppression
         Zovirax - 400mg TID after 36 weeks
         Valtrex - 500mg BID after 36weeks

      Severe or Disseminated Disease
         Zovirax - 5-10mg/kg q8h x 2-7d then oral therapy for primary infection to complete 10d course

      Rates of Vertical Transmission from SVD
         Primary Outbreak at delivery = 30-60%
         Recurrent lesions at time of delivery = 3%
         History of but no visible lesions = 0.02%

 

 

 

 

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 Anemia

Iron Stores Analysis

	Normal	Iron Deficiency	Anemia of Chronic Dz	Iron Overload
Iron	60 - 150 mcg/dL	Decreased	Normal or decreased	Increased
Ferritin (Iron Stores)	40 - 200 ng/mL	≤ 15 mcg/L	Increased	W > 300, M >400
TIBC	250 - 450 mcg/dL	Increased	Normal or decreased	Decreased
Transferrin	10 - 30 nM/L	Increased	Normal	Normal

 

Workup of anemia

 

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General Medicine

Death Pronouncement Note: I was called to the bedside to pronounce death for ____, MRN ___. Family was present/ absent. Pt had no spontaneous movements or breaths. Pt was unresponsive to voice command or deep sternal rub. Pupils were fixed and dilated. Corneal reflex was absent. No ausculatory breath or heart sounds. Time and date of death is ________. Signature, CC.

Death Summary: Dictate a full note. Use the Discharge Summary template above, except instead of discharge date, dictate date of death, and add a Death Pronouncement Note paragraph.

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Chest Pain

MONA (morphine if no recent use of Viagra, Oxygen, Nitro, ASA).
Also, beta blocker, ACE, statin.
If high suspicion for MI (very typical presentation with risk factors +/- elevated enzymes, EKG changes) call Cardiology
Consider therapeutic dose of anticoagulation (Heparin gtt +/- glycoprotein IIb/IIIa inhibitors).
If significant ST elevation on EKG consistent with acute MI or new left BBB, then call Cardiology stat for emergent cath.
Check baseline LFT's and FLP.
Check CXR to rule out aortic dissection and pneumothorax.
Consider PE.

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Labor Dysfunctions

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Drug	Dose/Route	Frequency	Comments
Oxytocin (Pitocin)	IV: 10-40 units in 1L normal saline or LR solution ; IM: 10 units	Continuous	Avoid undiluted rapid IV infusion, which causes hypotension.
Methylergonovine (Methergine)	IM: 0.2 mg	q2-4 h	Avoid if hypertensive
15-methyl PGF2α (Hemabate)	IM: 0.25 mg	q15-90 min, 8 doses max	Avoid in asthmatic patients; relative contraindication if hepatic, renal, and cardiac disease.
Misoprostol (Cytotec, PGE1)	800-1000 mcg rectally	----	----

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Etiology of Postpartum Hemorrhage

Primary
     -Uterine atony
     -Retained placenta-especially accreta
     -Defects in coagulation
     -Uterine inversion

Secondary
     -Subinvolution of placental site
     -Retained products of conception
     -Infection
     -Inherited coagulation defects

Risk Factors for Postpartum Hemorrhage

     -Prolonged OR Rapid labor
     -Augmented labor
     -History of postpartum hemorrhage
     -Episiotomy, especially mediolateral
     -Preeclampsia
     -Overdistended uterus (macrosomia, twins, hydramnios)
     -Operative delivery
     -Asian or Hispanic ethnicity
     -Chorioamnionitis

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3 Tier Classification of Fetal Heart Rate Monitoring

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Admission Orders -

A - dmit                                      &nbs p;	A -Admit
D -Diagnosis	D –Diagnosis
C -Condition	C –Condition
V -Vitals	V -Vitals
A –Activity	A -Activity
N -Nursing ( SBP>160 or 110 or 100.4. Pulse >110.	N -Nursing ( SBP>160 or 110 or 100.4. Pulse >110.
C -Consults	D -Diet
L -Laboratory Studies	I -IV Fluids
A -Allergies	M -Medication
I -IV Fluids	L -Laboratory Studies
M -Medication
I -Ins & Outs
D -Diet
I -Imaging
O -other (daily weights, breast pump to bedside, etc...)
M- Monitoring

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Dictation Guide

Phone:  (inside) Dial 1900,   (outside) Dial 512-1900 OR 1-800-379-3019

Welcome to Precise. Enter your 4 digit ID number:   (enter your physician ID#)

Enter the 2 digit report type:    (  Enter the number and then the # sign  )
            1  #  - Surgical H&P
            2  #  - History & Physical
            3  #  - Operative Note
            4  #  - Consultation Note
            5  #  - Discharge Summary
            6  #  - Transfer Summary

Enter the patients 7 digit account number:

Begin dictating after the tone

     Dictate:
         1 - Listen                       6 - Go to end of file
         2 = Dictate                    7 - Fast Forward
         3 - Short Rewind          8 - Go to beginning of file
         4 - Pause                      9 - Disconnect
         5 - End

Listen to reports:
Phone:  (inside) Dial 1900,   (outside) Dial 512-1900 OR 1-800-379-3019

Enter your: Physician ID number

Press * & 2 to listen
Press 3 and enter the patient account number
The most recent report will start playing
Press 5 to skip to the next report on the same patient.

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Elements of a Written Transfer Summary

Admission diagnosis:
Discharge diagnosis:
Hospital course:
Disposition at discharge: (patient status, code status)
Pending studies:
Pending issues for followup:

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Management of Abnormal Paps and CIN

2012 Pap Test Screening Recommendations

Journal article- 2012 Updated Consensus Guidelines for the Management of Abnormal Cervical Cancer Screening Tests and Cancer Precursors

Unsatisfactory Cytology

Cytology Normal but EC/TZ Absent/Insufficient

Management of Women greater than or equal to Age 30, who are Cytology Negative, but HPV Positive

Management of Women with ASCUS on Cytology

Management of Women Ages 21 to 24 years with either ASCUS or LSIL

Management of Women with LSIL

Management of Pregnant Women with LSIL

Management of Women with ASC-H

Management of Women Ages 21 to 24 yrs with ASC-H and HSIL

Management of Women with HSIL

Initial Workup of Women with Atypical Glandular Cells (AGC)

Subsequent Management of Women with Atypical Glandular Cells (AGC)

Management of Women with No Lesion or Biopsy-confirmed Cervical Intraepithelial Neoplasia - Grade 1 (CIN1) Preceded by Lesser Abnormalities

Management of Women with No Lesion or Biopsy-confirmed Cervical Intraepithelial Neoplasia - Grade 1 (CIN1) Preceded by ASC-H or HSIL Cytology

Management of Women with No lesion or Biopsy-confirmed Cervical Intraepithelial Neoplasia - Grade 1 (CIN1) in Women Ages 21 to 24

Management of Women with Biopsy-confirmed Cervical Intraepithelial Neoplasia - Grade 2 and 3 (CIN2,3)

Management of Young Women with Biopsy-confirmed Cervical Intraepithelial Neoplasia - Grade 2,3 (CIN2,3) in Special Circumstances

Management of Women Diagnosed with Adenocarcinoma in-situ (AIS) during a Diagnostic Excisional Procedure

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9 Steps in preparing obese pt for surgery (BMI >30)

1.) BMP, CBC, Coags, ABG, T&S (only if blood loss is expected)
2.) CXR & EKG
3.) Pulmonary Function Tests if h/o of or suspected obstructive lung disease
4.) Echo if abnormal EKG or suggested history of cardiac compromise
5.) Instruct use of Incentive Spirometry
6.) Bowel Prep if injury or adhesions are possible
7.) Antibiotic prophylaxis plus redose after 3hr procedure or after 1500cc blood loss
8.) Heparin 2hrs before surgery and q8hrs until discharge OR Lovenox 12hrs before and q12hrs until discharge
9.) SCDs in OR

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Intrauterine Fetal Demise

Protocol for diagnosis and management

I. Etiology:
      a) Fetal (25-40%) - chromosomal abnormalities 5-10%
    b) Placental (25-35%)
    c) Maternal (5-10%)
    d) Unexplained (25-35%)
II. Document thorough history and physical exam
    a) History:
         1) Last perceived movement, bleeding, contractions, ROM, GI/febrile illness, S/Sx of pre-eclampsia, trauma, domestic violence
         2) review chart carefully for PNC issues, obstetric history
         3) Physical: document temperature, presence or absence of fundal tenderness
         4) Labs:
              CBC
              Type & screen
              Coags
              fibrinogen
              K-B Test
              UDS
              Glucose ( if no glucola)
              Hgb A₁C
              Consider:
                   Thyroid Studies
                   RPR if no PNC
                   TORCH titers
                   Consider amnio for karyotype (esp. if patient opting for expectant mgt). May also obtain fluid from IUPC during induction.

III. Management:
    A) Offer pt expectant management vs. immediate delivery. Document discussion.
    B)Discuss options of autopsy.
    C)Consider genetics consult.
    D)Counsel the patient:
         Autopsy may provide cause of death up to 70% of time.
         Baseline recurrence risk of IUFD of unknown etiology is 3%.
         May change prenatal diagnostic assessment in next pregnancy.
         May add important information even if feasible cause already identified.
         May change preconceptual counseling/treatment for next pregnancy.
    E) Expectant management:
         1) Most (80-90%) will deliver within 2 weeks
         2) Time from demise to delivery is longer for earlier gestations.
         3) Coagulopathy - caused by release of tissue thromboplastin from fetus into maternal blood stream
              a) check serial CBC and fibrinogen (q week in clinic).
              b) Coagulopathy rarely develops in 1st month after demise
              c) 25% will develop DIC after 5 weeks.
         4) Prolonged time in utero will worsen maceration and autolysis making autopsy and tissue culture more difficult. This may be a reason for amniocentesis.
         5) Patient can select delivery at any point in surveillance.
    F) Active management (see Misoprostol guidelines and Concentrated Oxytocin guidelines):
         1) Misoprostol
              a) <23weeks
                   1) 400mcg pv q4h
                   2) If no response after first dose, increase to 600 mcg. (max dose 1200mcg in 24 hr.)
                   3) Alternative 200 mcg po q 4hr
              b) > 23 weeks, <28 weeks
                   1. 25-50mcg pv q4-6h
                   2. if no response after two doses, increase to 100-200mcg
              c) > 28 weeks
                   1. 25-50mcg pv q4-6h
                   2. higher doses increase risk of uterine rupture
    G) Concentrated Oxytocin (see guidelines)
    H) Indications for cesarean delivery
         1) complete previa
         2) if previous scar, may labor with IUPC. Discuss with attending on call.
    I) Retained placenta -Remember cord is fragile.
         A) 50U in 250cc NS, run over 1 hr. Then rest 1hr
         B) 100U in 250cc NS, run over 1 hr. Then rest 1hr
         C) D&C - indicated if no spontaneous delivery after 3 Hours OR excessive bleeding

IV. Delivery:
    A) Document appearance of fluid, membranes, placenta, cord (no. of vessels), fetus (condition, consistency w/ dates, anatomical anomalies).
    B) Placenta - send to surgical pathology if autopsy declined or if fetus going to Greenwood. 1x1 cm (full-thickness) specimen for culture if infection suspected.
    C) Cord blood - for karyotype to Greenwood if delivery within 24 hrs of demise or unknown (green top tube).

V. Autopsy:
    A) Obvious anomaly - fetus to genetic Center and discuss with on call geneticist. Take full-thickness placenta biopsy for cell culture (culture medium or sterile saline).     B) No apparent anomaly - fetus to pathology
         1) <20w or ><500g to surgical path><20w or <500g to surgical path
         2) >20 weeks goes to autopsy (done by forensic pathologists)
              a) send fetus and placenta together
              b) if sending tissue for genetics, take specimen immediately after delivery (sterile saline or culture medium).
    C) if patient declines autopsy may consider MRI.

VI. Postpartum care:     A) Patients on a floor away from nursery.
    B) Consult Grief Team.
    C) Offer chaplain services.
    D) Consult social work if appropriate/necessary.

VII.Follow-up:
    A) Arrange 2 week follow-up. Discuss coping mechanisms, look for signs of depression. Offer appropriate referrals. Dictate visit in detail.
    B) 6 week postpartum visit to discuss findings of evaluation of IUFD.
         1) Identify behaviors that may improve risk in future, and counsel accordingly (smoking/drug cessation, folic acid supplementation, controlling DM).
         2) Refer to geneticist if relevant.
         3) If abnormal placenta/pre-eclampsia, consider work-up for maternal thrombophilia.
         4) Dictate visit.

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