OBGYN Intern Manual

OB Triage Common OB Triage Complaints Ask all OB patients​: FM, VB, VD, LOF, CTXs (how often) Rule out labor at term (>37 WGA) ● Monitor for cervical change over 1-2 hours unless obviously in active labor ● May let patient walk after reactive NST ● Must have reactive NST before discharge ● Questions to ask:​ pain quality, location, dysuria, N/V Rule out ​preterm​ labor (<37 WGA) ● Always get Cxs & fetal fibronectin before cervical exam ● Cxs can be discarded later if not needed (MCC= infection) ● Cultures to get: DNA probe (cervical), aerobic cx (vaginal) r/o BV or yeast, GBS cx (vaginal/perineal), ureaplasma/ mycoplasma (vaginal) and UA ● Call attending for management and to assess need for Perinatology or NICU consultation ● Treatment may include oral or IV hydration, tocolytics (terbutaline, MgSO4, Indocin), steroids (BTMZ), antibiotics ● BSUS for presentation, EFW, AFl, placental locationif patient to be admitted or transferred ● No Tocolysis after 34 weeks!

Medications: ○ Terbutaline​ 0.25mg subQ (may repeat q 30min X3 doses) ○ Terbutaline​ p.o. 2.5-5.0 mg p.o. q4-6 hr ○ Procardia​ 30mg loading dose, then 10mg po q6-8hrs ○ Magnesium​ ​Sulfate​ 4-6 gram bolus in 10000 D5W, then 4 grams 500cc D5W @ 2-3.5 g/hr (must uid restrict to 125cc/hr total). Accurate ​l/Os, DTRs and breath sounds​q 2h while on MgSO4 ○ Indomethacin​ 50mg po load, then 25mg p.o. q 6h for max of 48 h (24-32wk) ● Specific questions to ask: ​PTL in prior pregnancy, dysuria, substance abuse?

Rule out rupture of membranes at term ● Perform SSE (Sterile Speculum Exam) for pooling (have patient cough or bear down), nitrazine (pH test- amniotic fluid is blue) and collect slide for ferning, then perform cervical exam ● If neg SSE, but convincing history, may have patient walk around after reactive NST, then put patient in Trendelenburg, re-spec and check AFI. ● Must have reactive NST before discharge ● Specific questions to ask​: time of rupture, color of fluid, urinary incontinence, fevers or chills?

Rule out rupture in the ​preterm​ patient (<37 WGA) ● Perform SSE for nitrazine, ferning, pooling ● Visually assess for cervical dilatation with speculum and perform cultures ● Do not check cervix digitally, may introduce infection ● If SSE negative, check AFl ● If SSE positive, assess for signs and symptoms of preterm labor or infection ● Call attending to discuss need for tocolytics, steroids, antibiotics ​(<34 weeks ampicillin and azithromycin, >34 weeks penicillin and delivery) ● Antibiotic doses → PCN 5 million units, then PCN 2.5 million units q4 hours ○ Alternative: ampicillin 2g IV initially, then 1g IV q4hrs and azithromycin 500mg IV q 24 hrs ● Perform BSUS for presentation, AFI, EFW, placenta location ● If cesarean and not on azithromycin, add to help with prophylaxis

Vaginal bleeding (R/O placenta previa/abruption) ● Pertinent HPl= recent intercourse, trauma, infection, placenta previa, CTXs, signs and symptoms of abruption (pain + bleeding, ctxs that don’t relax, decreased FM) ● Assess maternal vitals and FHTs ● If stable do BSUS initially to locate placenta look for retroplacental clot, consider official US ● Perform SSE → try to determine the origin of bleed (cervix, uterus, vagina, bladder), assess for signs and symptoms of rupture of membranes (pooling, ferning, + nitrazine). ● Determine Rh status for Rhogam eligibility (suppresses immune system from making antibodies) ● Call attending to discuss management plan ● Severe bleeding may need IVx2 access large bore, Kleihauer Betke test (​blood test used to measure the amount of fetal hemoglobin transferred from a fetus to a mother's bloodstream​)​, CBC, Coagulation panel (PT, PTT, plt, fibrinogen), DIC panel(based on plt, PT, D-dimer, & fibrinogen), T&S or T&C ● May require tocolysis depending on cause ● 2​nd​ episode of bleeding with placenta previa must be hospitalized until delivery ● May be discharged from hospital when there is no bleeding for 7 days per local MFM ● Vaginal spotting is often caused by labor/PTL/ROM/ prior cervical exam/sex/STD ● Specific questions to ask:​ onset, amount, last intercourse, trauma, prior c/s, drug or tobacco use, h/o prior abruption, Rh status, exam earlier that day?

Decreased fetal movement ● Perform Non-Stress Test (NST) ● If reactive, patient may be discharged home with kick sheet ○ 10 movements within an hour if not drink or eat something and count for another hour baby could have been sleeping ● If nonreactive continue NST for 20 additional minutes ● If still not reactive after 40 total minutes, perform BPP ● Definitions of Non-Stress Test: ​2 or more fetal heart rate accelerations at least 15 bpm above baseline, lasting for at least 15 secs in a 20-min period ● NST statistics: ○ 24-28 weeks 50% nonreactive ○ 28-32 weeks 15% nonreactive ○ >32 weeks usually reactive ● Once fetus is called reactive, must always be reactive ● BPP​ – Five Components ○ Non-Stress Test ○ Fetal breathing​ (at least one sustained episode for 30 secs in 30 minute period ○ Fetal movement​ (at least 3 gross body movements in 30-minute period) ○ Fetal tone​ (at least one episode of exion/extension of an extremity or open/close hand in 30-minute period) ○ AFl ​(at least a vertical pocket of 2cm) ○ 2 points for each if present, 0 if not present ○ Score​= 8-10 WNL, 6 must repeat in 24 hours, 4 or less must deliver ● Modified BPP= NST + AFl ● Contraction Stress Test → ​Pitocin until 3 contractions lasting at least 40 secs in 10 min ○ Negative = no decelerations ○ Positive = late decels following 50% or > of ctxs ○ equivocal/suspicious = intermittent late decels or significant variable decelerations ● Specific questions to ask:​ accurate gestational age, trauma, contractions, bleeding?

Rule out Preeclampsia ● Onset after 20 weeks gestation ● Prior to 20 weeks = chronic Hypertension ● Dened as sustained BP increase to 140/90 four hours apart ● HPI- HA, visual changes, RUQ pain, hyperreflexia. ○ *edema is no longer included in criteria ● VS- serial BP, NST ● PE- abdominal, extremities, reexes ● Labs- urine dip protein, UA, HELLP labs: AST, ALT, Bun, Cr, uric acid, CBC, consider LDH and DIC panel ○ Plt <100,000, spot P/C ratio > 0.3, 2x ULN AST/ALT, creatinine 1.1 or 2x baseline ● Urine protein/creatinine ratio greater than .3 or 24-hour urine protein greater than 300mg ● Protein level is not part of the criteria for Preeclampsia with Severe Features ● Definitions Preeclampsia without Severe Features ○ BP > 140/90 but < 160/110 ○ 24-hour urine protein >300mg or P/C ratio greater than .3 Preeclampsia with Severe Features ■ BP >160-180/110 ■ 24-hour urine protein > 300mg ■ HELLP syndrome ■ Eclampsia ■ Evidence of end-organ involvement ■ S/S of Neurological involvement (Headache, Blurred Vision, Disorientation, Altered Mental Status) ○ Severe Ranges = > or = 160 and/or > or = 110 in antepartum ■ > or = 150 and or > or = 100 postpartum ○ Mild ranges <160/<110 to >140/>90 antepartum ■ <150/<100 to >140/>90 postpartum ○ Normal <140/<90 ● BP to treat- persistent elevation >160/110

Meds ○ Labetalol​ max= 300mg drip: 0.5-2mg/min ○ MgSO4​= 4g bolus in 100cc DSW, then 40g in 500cc DSW @ 2g/hr (must uid restrict 125cc/h total), accurate l/O, DTRs and breath sounds q 2 hrs ● Specific questions to ask​: HA, vision changes, RUQ pain, SOB, CP, h/o HTN or gHTN, recent tobacco or drug use, taking BP medication and if so did you take it today?

HTN urgency/pre-e medication protocols > or = 160 and/or > or = 110 notify attending and repeat in 15 minutes; get fetal monitor on Labetalol​: 20 mg IV → 40 mg IV → 80 mg → ​hydralazine 10 mg IV ○ After each dose of labetalol measure BP in 10 mins ○ After hydralazine measure BP in 20 mins ○ If BP is still > 160/>110 give next dose ○ Contraindications: asthma, heart disease, CHF Hydralazine​: 5-10 mg IV → 10 mg IV → 20 mg IV → 40 mg IV labetalol ○ After each hydralazine dose measure BP in 20 mins ○ After labetalol dose measure BP in 10 mins ○ If BP is still > 160/>110 give next dose Nifedipine​: 10 mg PO → 20 mg PO → 20 mg PO → 40 mg labetalol IV ○ Short acting only NOT XL ○ After each Nifedipine dose measure BP in 20 mins ○ After labetalol dose measure BP in 10 mins ○ If BP is still > 160/>110 give next dose If BP still high after performing protocol consult MFM, ICU and anesthesia If BP <160 and <110 → monitor next dose not needed Labor​: once BP goal is reached repeat BP q 10 mins for 1 hour then q 15 minutes until delivery Antepartum/postpartum​: once BP goal is reached, repeat BP q 10 mins for 1 hour then q 15 mins for 1 hour then q 30 mins for 1 hour and then q 4 hours

MVA or trauma ● First must be cleared by ER for signicant injury ● In absence of significant injury and ctxs EFM/toco for 4 hours ● Perform BSUS assess for signs of abruption/placenta previa, may get official ultrasound ● Consider T&S, Kleihauer Betke, DIC Panel, speculum exam, CBC ● If no signs or symptoms of abruption or contractions may DC home after 4 hours ● If any signs or symptoms of abruption or contractions, monitor 24 hours ● Specific questions to ask​: description of trauma, direct abdominal trauma, abuse, drug use?

N/V in pregnancy (R/O hyperemesis gravidarum) ● If severe gets labs: LFTs, CMP, Amylase, Lipase, UA (check for ketones), CBC ● Will need to tolerate PO prior to d/c ● Consider other ddx: appendicitis, pancreatitis, hepatitis, cholecystitis, UTI, pyelonephritis, fatty liver of pregnancy ● Specific questions to ask: ​duration, abdominal pain, F/C, last time ate or drank something, weight loss.

Fever ● UA to r/o pyelonephritis, CBC and may need further workup depending on patient’s symptoms

Nausea and Vomiting of pregnancy Acute without volume depletion Should have ​conservative management ● Dietary modifications such as small frequent bland meals with high carbohydrate and low fat content, salty foods better tolerated in early morning and sour and tart liquids such as lemonade are often better tolerated than water. ● Acupressure ● Acupuncture and/or ● Ginger 250 mg PO QID Acute w/out volume depletion but failed conservative First line: ● Pyridoxine​ (Vitamin B6) 10-25 mg orally TID ● and/or ● Doxylamine​ (Unisom) 12.5 mg orally QID PRN ● Diclegis​ (doxylamine/pyridoxine 10/10) start 2 tabs po qhs, then 1 tab PO q am and 2 tabs PO qhs up to: 1 tab PO q am and midafternoon and 2 tabs PO qhs​. Not covered by many insurances and is very expensive.

Second line: ● Meclizine​ (Antivert) 25 mg PO QID (max 100 mg/day) ● Dimenhydrinate​ (Dramamine) 50-100 mg PO QID (max 400 mg/day) ● Diphenhydramine​ (Benadryl) 25-50 mg PO QID (max 300 mg/day) ● Metoclopramide​ (Reglan) 5-10 mg PO TID for maximum of 5 days, maximum 30 mg/day ● Chlorpromazine​ (Thorazine) 10-25 mg PO QID prn ● Promethazine​ (Phenergan) 12.5 to 25 mg PO TID-QID prn

Acute with volume depletion from Hyperemesis Gravidarum ● IV hydration with ringer lactate +/- KCL and added thiamine (vitamin B1) ● Parenteral or rectal antiemetics: ○ Zofran​ 4-8 mg IV TID (if > 10 weeks) ○ Reglan​ 5-10 mg IV or IM TID for max 5 days ○ Thorazine​ 12.5-25 mg IM q 6 hrs ○ Phenergan​ 12.5-25 mg IM or rectal suppository TID Adjuncts ● Omeprazole 20-40 mg IV daily ● Methylprednisolone 16 mg IV TID for 3 days, then taper gradually over 2 weeks (use if > 10 weeks gestation) The birth defects purported (alleged) by the lawsuit is cleft lip and palate and cardiac malformations (embryologically this can only happen in the first trimester) therefore ​giving Zofran after the first trimester is as safe as giving steroids which also has supposed association with oral cleft defects.​ According to the CDC women that smoke, are diabetic, or use epilepsy meds in the first trimester are most at risk for oral cleft defects.

Please try to avoid causing patient confusion and do not pit one provider against another. There are times when even known teratogens such as Coumadin are necessary in pregnancy and risk of maternal problems outweighs risk of birth defects (for Coumadin it is metal heart valves in the mother).

Protocol for Pyelonephritis in Pregnancy ● 30-40% of pregnant women with untreated asymptomatic bacteriuria will develop symptomatic UTI including pyelonephritis ● As many as 20% of women with severe pyelonephritis develop complications that include septic shock syndrome or acute respiratory distress syndrome (ARDS) Acute pyelonephritis is suggested by: ● Flank pain ● Nausea/vomiting ● Fever ● Costovertebral angle tenderness ● May occur in the presence or absence of cystitis symptoms Treatment ● Pregnant pts should be hospitalized and treated w/ IV abx until 24-48hrs afebrile and symptomatically improved ● First line → Ceftriaxone​ 1gm IV q 24 hrs (3rd generation cephalosporin) (Category B) ● Second line → ​If resistant or recurrence occurs consider: Cefepime​ 1-2gm IV q 12 hrs (4th generation cephalosporin) (Category B) ● PCN allergic → Aztreonam 1gm IV q8 hrs (Category B) ● Avoid​ Ancef (cefazolin) (secondary to increased resistance) and Ampicillin/Gentamicin (Aminoglycosides, category C or D, have been associated with ototoxicity following prolonged fetal exposure). ● Duration of Treatment: After 24-48 hrs afebrile transition to oral antibiotics ○ First line​ → ​Keflex​ 500mg PO q6 hrs x 14 days and then 500mg PO at HS for remainder of pregnancy ○ Second line ​→ ​Macrobid​ 100mg PO BID x 14 days and then 100mg PO HS for remainder of the pregnancy ● Periodic urinary surveillance for infection is recommended for the remainder of the pregnancy.

Sample OB Triage Note Dated by LMP alone; LMP confirmed with US; or by US only and inconsistent with LMP CC​: HPI​: Pt is a 25-year-old G2P1001 AA female @ 38 1/7 weeks by LMP confirmed by 7 wk US presents c/o increased ctxs, -LOF,-VB, +FM, no s/s of Preeclampsia (HA, RUQ pain, change in vision).

Antenatal course c/w 1​st​ trimester bleeding.

Prenatal care with ______.

OBhx​: SVDx1 in 2018, Full term, male 8lbs, 11oz, no complications (if c/s what was the reason) GYNhx​: -STDs, -abnormal paps, ● Menarche/Time between cycles/Cycle duration ● Abnormal pap, if so when and did they ever have biopsies, cryotherapy (freezing) or surgery on their cervix (CKC/LEEP)?

Were their follow-up pap smears normal? ● STD’s, if so when and if treated? Make sure you name them all: (GC, Chl, HIV, Herpes, Hepatitis, Trichomonas, Syphilis) ● LMP ● Sexual history ● (ex: 12/28day/7days; no abnormal paps; h/o chlamydia this pregnancy- treated) PMH​: HTN/DM/Asthma (any recent hospitalizations), lung, heart, liver or kidney problems, bleeding disorders?

PSH​: C/S? Gyn surgery - open or laparoscopic and the indication Meds​: PNV/Fe (dosage and frequency) All​: NKDA (what is the reaction) SH​: -Tob, -EtOH, -Drugs FH​: health problems, birth defects, multiple births, any family members with breast cancer, uterine cancer, ovarian cancer, or colon cancer? Age at diagnosis?

PE VS​ 100/70, 80, 12, 98.7 FHTs-​ 130s reactive, Toco CTXs q4-5min CV/Lungs​ if pertinent to HPI Abd​: Soft, Gravid, NT, FH=37 cm Ext​: no edema, no calf tenderness, 2+patellar reflex b/l Cvx​: dilation/effacement/station (4/50%/0) Prenatal Labs​: ● Type & Screen ● CBC ● Sickle cell ● HIV ● Hep B ● GC/Chl ● Rubella ● RPR, ● Group B strep ● Urine culture ● PAP ● 1hr glucose US​: cephalic, etc Assessment​: 1. IUP@38 1/7 weeks 2. r/o labor Plan​: Monitor for cervical change for 1-2 hours. d/w Dr. _______________________

Labor and Delivery Admitting laboring patients, inductions, scheduled Cesarean ● ● ● ●

● ● ● ●

Scheduled C-sections should already have H&P and consent Always obtain and review prenatal records and labs Determine 36-week GBS status for laboring patient GBS Prophylaxis Medications: ○ PCN-G​ 5 million units IV initially, then PCN 2.5 million lV q4h until delivery ○ Alternative ​Ampicillin​ 2g IV initially, then 1g IV q4 unil delivery ○ if PCN allergic (anaphylaxis, angioedema, respiratory distress, urticaria) Clindamycin​ 900mg lV q8h until delivery (if sensitivities done on GBS Culture), Alternative Vancomycin​ 1 gram IV q 12 hrs until delivery ■ If allergy isn't severe ​cefazolin​ 2g IV initially then 1 g IV q 8 hrs until delivery Inquire about ​history of HSV​, prodromal signs and symptoms, last outbreak History of HSV​ must have Sterile Speculum Exam (​SSE​) to rule out active lesions Routine labs for the laboring patient= T&S, CBC; Cesarean= T&S, CBC Always do ​BSUS for presentation, placental location, EFW​ for all patients including scheduled C-sections- can be done by ultrasound or Leopold maneuvers.

Management of Preterm Labor Preterm delivery complicates approximately ​12% of deliveries.

While some of these are indicated because of maternal or fetal indications, the majority occur because of ​spontaneous preterm labor or PROM​. Preterm infants are at ​risk for respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and death.​ Administration of antenatal​ steroids decreases the risk​ of these complications. ​Tocolysis is effective for only a short time, 2-7 days, but will often allow time for steroid administration.

Diagnosis​: preterm labor is defined as ● Regular contractions accompanied by cervical change ● Initial presentation with regular contractions and cervix > 2 cm ● Women with preterm contractions, but without cervical change (especially < 2 cm), generally should not undergo tocolysis Fetal fibronectin​: ● Useful for its ​negative predictive value​ (~95% with a negative test will not deliver in subsequent 7-14 days) ● Should NOT be performed unless test will change management Choice of tocolytic agent: First-line tocolytics ● NSAIDs (​indomethacin​) 50mg po load, then 25mg p.o. q 6h for max of 48 h (24-32wk) ● CCB (nifedipine (Procardia)): ​Procardia​ 30mg loading dose, then Procardia 10mg po q 6-8 hrs ● Beta-agonists: ○ Terbutaline​ 0.25mg subQ (may repeat q 30 min X3 doses) ○ Terbutaline​ p.o. 2.5-5.0 mg p.o. q4-6 hr

● Magnesium sulfate:​ 4-6 gram bolus in 10000 D5W, then 4 grams 500cc D5W @ 2-3.5 g/hr (must uid restrict to 125cc/hr total. ​Accurate l/Os, DTRs and breath sounds q 2h while on MgSO4 Tocolysis contraindications: All tocolytics​: ● Fetal demise or lethal anomaly ● Non-reassuring fetal status ● Severe preeclampsia or eclampsia ● Maternal bleeding with hemodynamic instability ● Chorioamnionitis ● PROM (except for initial 48 hours to administer steroids) ● Agent-specific contraindications (see below) ○ Indomethacin ■ Platelet or bleeding disorder ■ Hepatic dysfunction ■ GI ulcers ■ Renal disease ■ Aspirin-sensitive asthma ■ PROM or oligohydramnios ● Calcium channel blockers ○ Hypotension ○ Pre-load sensitive cardiac disease (i.e. aortic insufficiency) ● Beta-agonists ○ Poorly controlled diabetes (use with caution in any patient with diabetes) ○ Tachycardia-sensitive cardiac disease ● Magnesium sulfate ○ Myasthenia gravis ○ (use with caution in patients with renal insufficiency)

Suggested tocolytic protocol: 23w0d – 31w6d ● Begin ​magnesium sulfate for fetal neuroprotection ● 6 gram bolus followed by 2gm/hr for 12 hours ● If contractions stop with magnesium sulfate, no other tocolytic is needed ● Use magnesium sulfate at 2 grams/hour for 12 hours only; do not increase dose ● If contractions persist with magnesium sulfate or resume after magnesium stopped at 12 hours: ○ Indocin, 50 mg per rectum followed by 25 mg orally or per rectum every 6 hours (48 hour max) 32w0d – 34w0d ● Procardia​ 20-30 mg initial dose followed by 10 mg every 6 hours for up to 48 hours ● Use immediate release preparation (not XL) Maintenance tocolytics ● Use of oral tocolytics after steroid administration is complete has not been proven effective ● Oral terbutaline should not be used (FDA warning) Steroid therapy​: ● EGA: ​23w0d – 33w6d ● patients at risk for preterm delivery should receive steroid therapy with betamethasone or dexamethasone ○ betamethasone​: 12 mg IM followed by 2nd dose in 24 hours (no data to support earlier dosing) ○ dexamethasone​: 6 mg IM followed by 3 additional doses every 12 hours

Rescue dosing of steroids: ● A 2nd course may be administered if: ○ At risk for preterm delivery (recurrent preterm labor or new risk factor) ○ Initial course > 14 days ago ○ Current EGA < 32w6d ● Multiple courses (> 2) are not recommended GBS prophylaxis: ● Obtain vaginal-rectal swab for GBS and begin prophylaxis ● If patient’s labor stops, discontinue prophylaxis ● Patients with PROM: continue antibiotics for 7 days (recommended agents are Amoxicillin and azithromycin) ● If patient begins preterm labor again, resume GBS prophylaxis, unless culture was negative ● If culture is negative, repeat culture at 35-37 weeks Steroids for Late Preterm Births (34w0d-36w6d) Recommendation​: ● Course of ​betamethasone​ (12 mg, 2 doses 24 hours apart) for late preterm (34w0d-36w6d) at risk of delivery w/in 7d ● At risk for delivery includes: ○ Preterm labor ○ PROM ○ Med/ob indications that allow for 24-48 hr delay Exclusions to steroids for late preterm births (NEJM study): ● Prior steroid course; Pregestational diabetes; Multiple gestations; Chorioamnionitis; Non-reassuring fetal status Benefits​: ● Decreased need for respiratory support ● Increased rate of neonatal hypoglycemia, but this is easily detected & treated under current Ped/NICU procedures. ● For late preterm patients (34w0d-36w6d) that are in preterm labor, tocolysis is NOT recommended.

Labor Induction Induction of labor ​occurs in approximately 25%​ of all deliveries in the U.S. Induction of labor is valuable when the benefits of delivery outweigh the risks of continuing the pregnancy. The benefits of induction should be weighed against the potential maternal and/or fetal risks. Increasing rates of labor ​induction are associated with increased risks for Cesarean, preterm birth, and NICU admissions. ​ Labor inductions utilize L&D beds longer than typical laboring patients. Therefore, prior to initiating an induction, the provider should review the indications, risks/benefits, and the necessity of the induction. ​If the Bishop score is < 7, consider cervical ripening is recommended​.

Prior to induction: ● Counsel patient regarding indication for induction, risks/benefits, and possible need for Cesarean delivery ● Assess pelvis for adequacy ● Examine cervix and perform Bishop score (if < 7, cervical ripening is recommended prior to oxytocin)

● Evaluate FHR status

● Confirm gestational age: ○ Labor should not be electively induced (non-medical indication) prior to 39 weeks​.

Labor should not be electively induced after 39 weeks in patients with an ​unfavorable cervix because of the increased risk for a Cesarean delivery. ○ For inductions that occur at > 39 weeks, a gestational age of 39 weeks (presumption of lung maturity) ​can be confirmed​ by one or more of the following: ■ Ultrasound at < 20 weeks that establishes/ confirms gestational age ■ 30 weeks since fetal heart tones were documented by doppler ■ 36 weeks since documented positive hCG (urine or serum) Indications for Inductions (not all inclusive): ● Medically-indicated ​inductions may be necessary prior to 39​ weeks in the presence of certain maternal or fetal indications, which include, but are not limited to: ○ Preeclampsia (> 37 weeks) ○ Fetal growth restriction: ■ other coexisting conditions such as HTN or diabetes: (37 weeks) ■ no other complicating factors (38 weeks) ○ Twins ■ monochorionic/diamniotic (37 weeks) ■ dichorionic/diamniotic (38 weeks) ○ Chronic hypertension ■ no medications (37-38 weeks) ■ with medications (37-38 weeks) ○ Gestational hypertension (37-38 weeks) ○ Oligohydramnios, AFI < 5 cm (> 37 weeks) ○ PROM (> 34 weeks)

● Unless maternal/fetal indications are present, induction for postdates is at > 41 weeks ● Logistical reasons may be an indication for induction after 39 weeks with good dating criteria and a favorable cervix ○ Example: Patient lives a long distance from hospital ● Suspected fetal macrosomia is not an indication for induction Document all of the following in patient’s chart: ● Counseling of risks/benefits of induction ● Indication for induction ● Gestational age ● Cervical exam to include Bishop’s score ● Adequacy of pelvis ● FHR status ● Estimated fetal weight (SGA, AGA, or LGA) ● Method for induction or cervical ripening Medications​: ● Cervidil​ (Dinoprostone) 10 mg PV for up to 12h ● Cytotec​ (misoprostol) 25 mcg PV q3-6h (can do 50 mcg doses); wait >4 h before adding oxytocin ● Pitocin/oxytocin​ 0.5-2 milliunits/min IV, increase 1-2 milliunits/min q15-40 minutes until ctx pattern established; Max 40 milliunits/min for induction and 20 milliunits/min for augmentation

Situations in Labor and Delivery Deceleration in the Term Patient ● Notify the Attending ● Initially change position (left side, right side, knee chest, or even at if it works) ● Oxygen by mask ● Fluid bolus (500cc) ● Check patient- cord prolapse, large amount of cervical change or descent of fetal part, scalp stim? ● Place internal leads, rupture if not ruptured ● Turn off the Pitocin ● Tetanic contraction, persistent decelerations, or just prior to emergent cesarean section give Terbutaline 0.25mg subQ ● If 8-10 cm dilation and severe deceleration try having the patient trial push ● If resuscitative efforts fail proceed to emergent Cesarean Deceleration in the ​Preterm​ Patient ● Notify the Attending ● Membranes intact → position change, O2, fluid bolus, check cervix ● Membranes ruptured → position change, O2, uid bolus, SSE ● Even when preterm if decelerations severe and persistent may still have to check patient, rupture and place internal leads for fetal distress ● If decelerations subtle and nonpersistent → perform BPP Pain Med Regimens ● Stadol​ (​Butorphanol (opioid))​ 1-2 mg IV q3-4 hours ● Dilaudid​ (hydromorphone (opioid)) 0.5-1 mg IV q3-4 hours ● Demerol​ (meperidine (opioid)) 25mg IV, 50mg IM with Phenergan 25mg lV ● Nubain​ (nalbuphine (opioid)) 10mg IM, 10mg IV doses may be repeat q3-4 hrs -caution near delivery due neonatal depression ● Fentanyl​ 25-50 mcg IV q 2 hrs

Amnioinfusion ● Indicated for meconium (can be used to clear meconium, no clear research to support) and variable type decelerations ● 300c bolus NS, then 125cc/hr warmed uid Labor management of GDMA2 or pre-existing Diabetics ● Accucheck q 2h when in active labor ● Adjust insulin ​sliding scale​ and uid type per protocol ● *​Dilution is 25 Units of Regular insulin in 250cc of NS with 25cc ushed through the line IV -when insulin is initiated accucheck q 1hour Circumcisions ● Bottle fed- wait 90min before circumcision ● Breast fed- wait 30 min before circumcision ● Local anesthetic-inject 0.3cc each side (total 0.600) Montevideo Units ● Calculated by obtaining the peak uterine pressure amplitude And subtracting the resting tone, then add up those numbers Generated by each contraction within a 10 minute period >= 200 is adequate

Sample Admit Note Pt is a 24y/o AA female GZP1001 @ 39 2/7 wks by LMP c/w 18 wk US who presented to L&D c/o increased CTXs found to be dilated to 6cm. No LOF, VB, or s/s of Pre-e. +FM. Antenatal course uncomplicated PNH​: registered at ___ wks at __________ clinic/practice LMP​ ________ ​EDD​ _________ OB hx​: GZP1001, full term SVD 7lbs 11oz. No complications Gyn hx:​ no history STDs or abnormal paps, menses reg PMH​: denies PSH​: T&A Meds​: PNVs, FeSO4 All​: PCN (anaphylaxis) SH​: no tob, EtOH, or illicit drug use, FOB involved?, occupation VS​ 98.6 88 120/70 18 FHTs-​ 130’s reactive with accels and no decels, CTXs q 4m CV Lungs Abd​: FH, EFW Ext​: DTR/edema SVE​: dil/eff/stat/pres/membr Prenatal Labs​: O+, RPR NR, HBS-ag neg, Rub lmm, 36 wk GBS neg BSUS—​ cephalic, placenta anterior, EFW= 3500g, AFI 110mm Assessment 1. lUP@ 39 2/7 wks 2. Active labor Plan 1. Admit to service of (ATSO) Dr. Management 2. NPO except ice chips 3. IVFs- D5LR at 125 cc/hr 4. EFM/Toco

6. Expectant 7. Pt desires epidural 8. Anticipate NVSD 9. D/W Dr.

5. CBC, T&S, RPR

Patients admitted on L&D Sample Labor Note​ (q 2-3 hrs)

Pt comfortable with epidural, CTX q 3min, FHTs 130’s reactive with accels and no decels.

SVE​ 5/90/0/C/R, will continue to follow. *If patient is on Magnesium Sulfate for preterm labor or pre-eclampsia in addition should have DTRs, breath sounds, and urine output documented q 2 hours

Sample Delivery Note

Pt progressed to complete, pushed effectively and delivered.

A viable male neonate over an RML episiotomy, no nuchal cord, no meconium, ROA position. Infant bulb suction on perineum, spontaneous breath & cry, cord doubly clamped and cut, infant handed off to waiting pediatrician/NICU staff/Nurse attendant. No complications. EBL 500 cc Wt 7#11oz., APGARs 9 at 1min, 9 at 5min. Placenta delivered spontaneously and intact with three vessel cord. Cervix and vagina without evidence of laceration. RML episiotomy repaired with 3-0 vicryl in the usual fashion.

Mother and Infant went to recovery in stable condition.

Sample Infant Admit Note A viable male neonate was delivered via SVD without complication. No nuchal cord. No meconium. GBS neg.

Infant bulb suctioned on the perineum. Wt 7#11oz.

APGARs 9 at 1 min, 9 at 5 min. Infant to recovery in stable condition.

Sample Brief Op Note Preop dx: Post op dx: Procedure: Surgeon: Asst: Anesthesia: Complications: Specimens: EBL: Fluids: U/O: Drains: Findings: S/N/l ct correct x2 Disposition: Dictation: IV abx prophylaxis:

Admit Orders

A: Admit to floor, attending D: Diagnosis C: Condition V: Vitals, how often, daily weights A: Allergies N: Nursing: I/O’s including foley/NGT/drains D: Diet: NPO ice chips/clears/regular A: Activity OOB--chair in PM/amb with assist/as tol L: Labs I: IVF - D​5​1/2 NS w/20 meq KCL/L @ 125 cc/hr S: Special studies/instructions: EKG/CXR TEDS SCDs M: Medications Notify HO if …

Sample Post-op C/S Orders Admit to Recovery Room, then postpartum floor Diagnosis: ​Status post (s/p) C/S for failure to progress (FTP) Condition: ​Stable Vitals: ​Routine, q shift Allergies: ​None Activity: ​Ambulate with assistance this PM, then up ad lib Nursing​: Strict I&Os, Foley to catheter drainage, Call MD for Temp >38.4, pulse >110, BP <90/60 or >140/90, encourage breastfeeding, pad count, dressing checks and TEDs until ambulating Diet​: Regular as tolerated; some hospitals only allow ice chips or clear liquids IV​: Lactated ringers (LR) or D5LR at 125 cc/hr, with 20 units of Pitocin x 1-2 Liters Labs: ​CBC in AM Medications: ● Morphine sulfate PCA (patient controlled analgesia) per protocol (1 mg per dose with 10 minute lockout, not exceed 20 mg/4hrs) ● Percocet 1-2 tabs PO q 4-6 hours prn pain, when tolerating PO well ● Vistaril 25 mg IM or PO q 6 hours prn nausea ● Ibuprofen 800 mg PO q 8 hours prn pain, when tolerating PO well ● Prophylactic antibiotics if indicated ● Thromboprohylaxis for high-risk patients ● Rhogam, if Rh-negative

ER Calls Rule out spontaneous abortion ● If the patient is stable, have E.R. do labs (BHCG, CBC, T&S) and ultrasound before you go to see the patient ● Pertinent history​= GsPs, LMP, amount of bleeding (pad count), passage of tissue ● Pertinent P.E.​= perform SSE, have 4x4s and ring forceps handy, visualize cervix, if products of conceptions are visible at the cervical os remove them with ring forceps and put in formalin for pathology, perform bimanual exam to estimate uterine size in weeks, cervix open or closed ● Ultrasound findings Discriminatory zone ○ transvaginal B-hcg 1500-2000 ○ transabdominal B-hcg 6500 Gestational sac​= 1st US nding (4 weeks) Yolk sac within gest sac (5 weeks, B-hcg 7200) 3 yolk sac/embryo with FHM (6 weeks, B-hcg 10,800) Yolk sac seen when mean gest sac diameter= 8mm Embryo seen when mean gest sac diameter= 16mm ● Definitions Threatened ab​- any VB in 1st trimester Inevitable ab​- VB, cervix open, no tissue passed Incomplete ab​- VB, cervix open, passage of part POC Missed ab​- no bleeding, cervix closed, embryonic death Septic ab​- presence of infection with any of the above Blighted ovum​- gestational sac only develops ● If ​Rh neg​ must give ​Rhogam​ within 72 hours ● If stable may be discharged home and followed with serial B-hcg and US (B-hcg doubles approx. every 48 hours) ● After D&C → home with ○ Methergine​ 0.2 mg tid for 3 days ○ Motrin​ 600 mg every 6-8 hr prn pain ○ Doxycycline​ 100mg bid for 7 days ● After instrumentation in ER → patient discharge home with Doxycycline 100 mg BID for 7 days

​Rule out ectopic ● If the patient is stable, have ER do labs (CBC, B-hcg, T&S) and US before you see the patient. ● Pertinent history= GsPs, LMP, vaginal bleeding, abdominal pain, presence of risk factors (history PID, history IUD, h/o ectopic, etc.) ● Pertinent P.E. = abdominal exam, SSE if bleeding, bimanual exam, cervical exam ● Dx= correlate P.E. with B-hcg and US ndings ● Possible ultrasound ndings ○ no IUP ○ pseudo-gestational sac (uid lled collection in uterus, no double decidual sign) ○ adnexal mass ○ ring enhancing lesion in adnexa ○ embryo with FHM in the adnexa ○ free uid in cul de sac ○ + lUP (heterotopic pregnancy) ● With no ultrasound ndings and +B-hcg ○ B-hcg ​less than​ discriminatory level could be early IUP or ectopic (transvag 2000 & transabd 6500) ○ B-hcg ​greater than ​discriminatory level: likely ectopic if unsure of dx and patient stable may follow serial B-hcg and US. (transvag 2000 & transabd 6500) ● If patient unstable → surgery ● If patient unreliable → hospitalize ● If patient stable and sure of dx, consider ​methotrexate ○ patient must be stable ○ desires future fertility ○ patient reliable and will follow up appropriately ○ absolute contraindications = breastfeeding, immunodeficiency, liver disease, renal disease, hematologic disease, peptic ulcer disease, active pulmonary disease, sensitivity to MTX ○ relative contraindications = mass > 3.5 cm, fetal cardiac activity, B-hcg >6500

MTX protocol ● Obtain baseline labs (CBC, BhCG, AST/ALT, Bun Cr,T&S) ● Dose methotrexate 50mg/m​2​ IM ● Give patient Rx/Orders to have labs: B-hcg drawn on day 4, then repeat B-hCG, Bun/Cr, AST, ALT, CBC on day 7 ● Want to see 15% decline of B-hCG from days 4 to 7

Rule out PID ● Have E.R. do labs (CBC, B-hcg) and appropriate radiographic studies before you see patient ● Pertinent history​- GsPs, LMP, F/C, abdominal/pelvic pain, VD, pain w/ intercourse, h/o STDs/PID, sexual hx. ● Pertinent P.E​.- abd exam, spec exam w/ cultures before starting antibiotics (DNA probe, wet prep for trichomonas, aerobic cx r/o bacterial vaginosis, yeast), bimanual exam for cervical motion tenderness, uterine size, adnexal mass ● Lab findings​- +/- Leukocytosis ● US findings​-adnexal mass (tubo-ovarian abscess} free uid, or normal ● Admission criteria​- Leukocytosis, +/- rst episode of PlD, pregnancy (rare), tubo-ovarian abscess, intractable pain, failed outpatient treatment Parental regimen A ​→ ​Cefoxitin​ 2gm IV q6 hrs ​PLUS Doxycycline​ 100mg PO or IV q12 hrs Parenteral regimen B​→ ​Clindamycin​ 900mg IV q8 hrs ​PLUS Gentamicin​ loading dose IV or IM (2mg/kg of body weight) followed by a maintenance dose (1.5mg/kg) every 8 hrs. Single daily dosing may be substituted Parental regimen C​ → ​Ampicillin/Sulbactam ​3mg IV q6 hrs PLUS Doxycycline​ 100mg PO or IV q12 hrs Oral treatment ​recommended regimen ● Ceftriaxone​ 250mg IM in a single dose ​PLUS Doxycycline​ 100mg PO BID x 14 days ● with or without ​Metronidazole​ 500mg PO BID x 14 days

Vaginal bleeding ● Pertinent history​- age, GsPs, LMP, onset and duration of bleeding, quantity (pad count), menstrual history (timing of bleeding in relation to menses), ​postmenopausal? ● Pertinent P.E.​- abd exam; spec exam to quantify bleeding, visualize cervix, and vagina; bimanual exam for-uterine size and contour, uterine mass, adnexal mass, cervical mass ● Pertinent labs​- CBC, B-hcg, T&S and/or T&C if signicant bleed, coags panel if history or suspicion of coagulopathy ● Ultrasound​- uterine size & contour, broids, endometrial stripe, mass (adnexal/uterine/cervical), ovaries ● abnormal uterine bleeding​= excessive, prolonged, or irregular menstrual bleeding in which there is an identiable cause ● Treatment ○ Depo Provera​ 200mg IMx1 ○ Oral Contraceptive Pills ○ Megace​ 40mg p.o. qid (broids, polyps, thickened end) ○ Motrin or Anaprox​ at scheduled doses (prostaglandin hypothesis) ○ Premarin​ 25mg IV q 4hr for 24 h or until bleeding stops, works best with atrophic endometrium (Cl with any history of thromboembolic disease, breast ca, uterine ca) ● May want EMB before initiating hormonal treatment ● Surgery- D&C ● PALM: structural causes ○ Polyp (AUB-P) & Adenomyosis (AUB-A) ○ Leiomyoma (AUB-L) (submucosal vs other myoma) ○ Malignancy & hyperplasia (AUB-M) ● COEIN: nonstructural causes ○ Coagulopathy (AUB-C) ○ Ovulatory dysfunction (AUB-O) ○ Endometrial (AUB-E) ○ Iatrogenic (AUB-I) & Not yet classified (AUB-N)

Pelvic pain Differential Diagnosis ● Gyn → ​endometriosis, rupture ovarian cyst, pelvic adhesions, PID, ectopic pregnancy, degenerating broids, adenomyosis, pelvic congestion, pelvic/ovarian mass, pelvic support defects, ovarian torsion, ovarian remnant syndrome ● Urologic​- UTI, interstitial cystitis, nephrolithiasis ● GI​- appendicitis, diverticular disease, irritable bowel, inammatory bowel, gastroenteritis, constipation, hernias ● Musculoskeletal​- coccydynia, degenerative, joint disease, disk disease, low back pain

Rule out ovarian torsion

● Pertinent history​- age, GsPs, LMP ○ acute onset, severe, unilateral lower abdominal/pelvic pain ○ associated N/V common -fever with necrosis of ovary ○ may describe intermittent previous pain as ovary (as ovary undergoes partial torsion with spontaneous reversal) ○ may have no ovarian cysts ● Pertinent labs​- CBC (leukocytosis with necrosis ovary) ● Ultrasound​ -commonly associated with adnexal mass ○ rare if ovary less than 4-5cm ○ edematous ovary ○ abnormal color ow doppler (not diagnostic) ● Diagnosis​- based on clinical findings in conjunction with radiographic studies ● Tx -​surgical emergency

Bartholin cyst/abscess ● Located at the entrance of the vagina at 5 and 7 o'clock ● Need to decide if cyst or abscess is uctuant and ready for I&D ● If not, may discharge patient home with Rx for ​Keex 500mg p.o. qid, for 7-10d, sitz baths, warm compresses, pain meds ● If yes, will need the following instruments ○ 1% lidocaine with epi ○ 10cc syringe, 18 gauge and 22 gauge needles ○ no. 11 blade ○ Hemostat ○ aerobic/anaerobic cultures ○ Hydrogen Peroxide and NS for irrigation ○ Irrigation syringe ○ 4X4s ○ 1” iodoform gauze or Word catheter ○ may need to premedicate patient with pain meds and/or versed ○ home with ​Keex​ 500 mg p.o. qid for 7-10d and 1 pain med ● Enlargement of the Bartholin’s gland in ​postmenopausal patient requires biopsy​ to rule out carcinoma of the gland

Hyperemesis gravidarum Admission criteria ● Evidence of signicant dehydration or malnutrition (persistent ketonuria despite hydration in ER, increased urine S.G., decreased skin turgor, etc.) ● Failed outpatient treatment work-up= UA, electrolytes, Bun, Cr, B-hcg, TSH, AST, ALT, Tbili, Dbili, ofcial fetal ultrasound to r/o molar pregnancy if no US yet ● With this pregnancy usual initial treatment ○ 1-2 liter uid bolus normal saline, then D5NS@150-2000cc/hr with 50 mg p ​ yridoxine​ (B6) and 50 mg D ​ ramamine​ or ​Benadryl​ in each Liter ○ may add an amp of multivitamin injection (MVl) to one of the liters daily ● Antiemetic options ○ Phenergan​ 25mg IV/lM/po q 4-6h ○ Tigan​ 200 mg PR/lM q 6-8h or 250mg po q 6-8h ○ Zofran​ 4 mg IV q 12 or ​Anzemet​ 12.5 mg IV q 24 ○ Zofran​ 8mg po bid ● Initially should be scheduled dose then prn ● Initially NPO, then Hyperemesis Diet (BRAT dietbananas, rice, apples, toast) ● Nutrition consult ● Diet diary once eating ● Urine dip for ketones q shift

Hospitalization for tx of PID is recommended if: ● Pregnant, Severely ill (nausea, vomiting, fever), Does not respond to or cannot take oral medication and needs intravenous antibiotics, Has a tubo-ovarian abscess ● Needs to be monitored to be sure her symptoms are not due to another condition that would require emergency surgery (i.e. appendicitis) Transition from IV to oral therapy can usually be initiated within 24 hrs of clinical improvement Parenteral Treatment Regimen A ○ Cefoxitin​ 2gm IV q6 hrs ​PLUS ○ Doxycycline​ 100mg PO or IV q12 hrs Parenteral Regimen B ○ Clindamycin​ 900mg IV q8 hrs ​ PLUS ○ Gentamicin​ loading dose IV or IM (2mg/kg of body weight) followed by a maintenance dose (1.5mg/kg) every 8 hrs. Single daily dosing may be substituted Parental Regimen C ● Ampicillin/Sulbactam​ 3mg IV q6 hrs ​PLUS ● Doxycycline​ 100mg PO or IV q12 hrs Oral Treatment ● Ceftriaxone​ 250mg IM in a single dose ​PLUS ● Doxycycline​ 100mg PO BID x 14 days ● With or without ​Metronidazole​ 500mg PO BID x 14 days USE OF FLUOROQUINOLONES should only be used​ if the test for gonorrhea is negative​. If negative then an alternative regimen is: ● Levofloxacin​ 500mg PO daily x14 days (​Ofloxacin 400mg PO BID may be used as an alternative) With or without ​Metronidazole​ 500mg PO BID x 14 days Cases of ​PCN allergy​: ​Azithromycin​ 2gm PO x1, limit d/t macrolide resistance. Consider TOC, if still pos need consult w/ allergy/ID for cephalosporin tx following desensitization.

Rounding Post-partum/Post-op Rounding HPI ● How do you feel today? Any fevers or chills overnight? ● Pain adequately controlled? ● Have you been up moving around (basically are you ambulating?) ● Passed flatus or BM ● VB (lochia) < = or > than your normal period ● Dizzy, fatigued, lightheaded upon standing, palpitations, SOB? (looking for s/s anemia) ● Breastfeeding, bottle feeding or both? ● Pain in breasts, engorgement? ● Birth Control? ● Itchy, painful urination, increased frequency, blood in urine (check if she had an episiotomy or catheter) ● HA, vision changes? ● Physical Exam ○ Uterus: fundus firm, NT and at the level of the umbilicus ○ Lochia: less than normal menses ○ Ext: calf tenderness and homan’s sign (DVT)

Managing a PP patient ● C/S pts with a pfannenstiel incision, remove bandage on POD#1. Counsel pt she can shower and use dove/dial antibacterial soap to clean it. Keep the incision clean and dry. Steri strips will fall off on their own. Incision should heal around 2 weeks. ● POD#1 orders for C-section patients ○ Discontinue foley ○ Activity: Ambulate TID with assistance; Patient may shower ○ Diet: Advance as tolerated ○ Heplock IV when tolerating po ○ D/C IV/IM pain meds when tolerating po, then switch to po pain meds ■ Percocet​ 5/325 mg 1 po q4hrs prn pain level 1-5 ■ Percocet​ 5/325 mg 2 po q 6 hours prn pain level 6-10 ○ Motrin​ 800mg 1 po q 8 hours prn pain ○ MOM​ 30 ml po q 6 hours prn constipation ○ Mylicon​ 80mg po q 6 hours prn gas ○ May have ​Toradol​ 30 mg IV/IM q 6 hours prn pain (Max 4 doses) rd ​ ● For 3​ and 4​th ​degree tears we add: ○ Colace​ 100mg 1 po BID to prevent constipation ● If pt wants OCP’s write prescription to ​start 6 weeks PP b/c increased risk of blood clots with the estrogen. ○ If pt is breastfeeding use ​micronor​ OCPs 6 weeks PP or ​Depo provera​ at discharge → progesterone only BC

Sample Postpartum Note Pt is PPD/POD #1 who is s/p uncomplicated RLTCS (h/o previous c/s x2) or SVD. No complaints this AM. Moderate lochia with no passage of clots. Perineal/abdominal pain adequately controlled. Endorses passing flatus and denies BM. Tolerating regular diet vs ice chips vs clear liquids. Breast or bottle feeding.

Ambulating without difficulty, voiding spontaneously without difficulty vs foley in place. Denies calf tenderness.

VS​: Tmax: 98.1 BP: 120-134/80-86 P: 78-94 R: 16 Uop (if catheter still in, prefer hourly output with > 30 cc/hr is adequate) Gen​: A&Ox3 CV​: RRR Lungs​:CTAB Breast​: nontender/non-engorged Abd​: soft, +BS Incision​: C/D/I (+staples or steri-strips in place) Uterus​: fundus rm 2cm below the umbilicus, NT Lochia​: moderate Ext​: no edema, no calf tenderness, negative Homan’s Assessment 1. PPD/POD #1 s/p RLTCS (LTCS d/t arrest of dilation at 3 cm) or SVD (VD with forceps or vacuum), doing well 2. Rh+, Rub Imm, RPR (Rhogam and Rubella prn) 3. Pre-delivery Hbg and PP Hbg 4. Others like preeclampsia or DM or cHTN

Vaginal delivery Plan 1. Routine pp care 2. Continue PO pain control 3. Encourage ambulation 4. Advance diet as tolerated 5. Anemia- asymptomatic, will d/c with PO iron and colace 6. Contraception- desires nexplanon placement 7. Circumcision to be scheduled (if baby boy) 8. Rhogam prn (if mom is Rh- and baby is Rh+)/Rubella prn 9. Consider d/c 24-48 hours postpartum 10. F/U in 4-6 weeks for PP visit (sooner if HTN- 1 week for BP check) C section Plan 1. AM CBC pending 2. d/c foley catheter 3. Advance diet as tolerated 4. Encourage ambulation 5. Encourage IS use 6. Contraception 7. Consider d/c 48-72 hours postpartum 8. F/U in 1-2 weeks for incision check (sooner if HTN for BP check)

Sample Post-op Note Pt is a 34 yo G2P2 with _______ s/p TAH/BSO/Cysto POD1.

Pain control is adequate, no complaints this AM. Tolerating clears, no N/V, + atus, -BM, ambulating, +urinating. No calf tenderness, no CP/SOB, Iochia VS​ Tmax, TCurrent, BP, P RR, UO over the last 8hrs Gen ​O&Ax3 CV​ RRR Lungs​ CTAB Abd​ soft appropriately tender, incision C/D/I, +BS, fundus if CS Ext​ no edema, no calf tenderness, SCD’s in place, neg Homan’s GU​ foley, urine clear Labs​ pre-op CBC and post-op CBC Assessment and Plan​: 34 yo G2P2 s/p TAH/BSO/cysto POD #1- doing well ● Advance to POD#1 orders- good urine output ● d/c foley ● encourage ambulation TID with assistance, pt can shower ● advance diet as tolerated ● heplock IV when tolerating PO ● D/C IV/IM pain meds when tolerating PO, then switch to PO pain meds ● Lortab 7.5/500mg 1 PO every 4 to 6hrs prn pain ● Lortab 7.5/500mg 2 PO every 4 to 6hrs prn pain ● **also can use Percocet 5/325mg ● Motrin 800mg 1 PO every 8hrs prn pain ● MOM 30ml PO every 6hrs prn constipation ● Mylicon 80mg PO every 6hrs prn gas ● May have Toradol 30mg IV/IM every 6hrs prn pain (Max 4doses) ● Bedside IS to use 10x/hour while awake

What are the MC causes of post-op fever?

Fever is defined as an increase in temp ​≥100.4​ on 2 occasions at least 4hrs apart, excluding the 1​st ​24hrs OR temperature >101.5.

If a patient has a fever, the most likely cause is determined by the POD. Remember the ​7W’s: Wind, Water, Womb, Wound, Walking, Wonder Drugs, and Watermelons (Breast) POD 1-2: ​Wind (Atelectasis): ​often causes fever secondary to inadequate deep breathing after surgery and incisional pain on deep breathing. Treated with Incentive Spirometry b/c deep breathing prevents atelectasis.

POD 3-5: ● Water (UTIs): ​secondary to Foley catheters. ● Womb (Uterus)​: secondary to endometritis. Predisposing factors: C/S, prolonged labor, PROM, chorio, internal monitors, multiple vaginal exams, meconium, manual placenta extraction, anemia, poor nutrition. ● Watermelons (Breast): ​Always check breasts during each exam. Keep breasts bound if not breastfeeding.

POD 4-6: ​Walking (DVT): ​due to venous stasis. Venous compression devices or low dose heparin reduce the incidence of venous thromboembolism. Early ambulation of the patient on POD#1 is the best way to prevent this complication.

POD 5-7: ​Wound​: Most wound infections occur during this period, especially in obese patients. Preoperative antibiotics are important to prevent or reduce the risk of infection.

POD 7: ​Wonder Drugs​: If all other sources of fever are ruled out after careful physical exam and laboratory evaluation. Check the meds that the patient is taking. Also, look at the temperature chart for characteristic spiking pattern (CBC may show elevated eosinophils).

Discharging Patients after Delivery Postpartum Patients​: Patient with NSVD without complication 1. FU in ​4 weeks​ where the patient had her prenatal care Cesarean Section Patients​: 1. All patient follow-up ​1-2 weeks​ where they did their prenatal care Blood Pressure Checkups​: Patients that need a blood pressure checkup due to Gestational Hypertension, Preeclampsia etc.

1. All patient follow-up in ​1-week​ blood pressure checkup Discharge Medication after Delivery Postpartum Patients​: 1. Motrin​ 800mg, one po every 6-8 hours, Dispense 30 2. FeSo4​ 325mg, one po every day, Dispense 30 3. Colace​ 100mg, one po twice a day, Dispense 60 4. Any other medication determined by the condition (HTN, DM etc.)

Cesarean Section Patients​: 1. Motrin​ 800mg, one po every 6-8 hours, Dispense 30 2. FeSo4​ 325mg, one po every day, Dispense 30 3. Colace​ 100mg, one po twice a day, Dispense 60 4. Percocet​ 5/325, one po every 6 hours, Dispense 16 5. Any other medication determined by the condition (HTN, DM etc.)

Boarding Case for Surgery During Day from ER ● place orders in EMR ● call scheduling or main OR to add on case must know: patient's name, age, type of case, surgeon, patient's location, account number ● if emergent may have to bump scheduled cases ● if non-emergent nd out estimated time and location of case During Day from floor ● If emergent call main OR ● place orders in EMR ● if not emergent call the boarding ofce ● to add on case must know patient's name, age, type of case, surgeon, patient's location At night or on the weekend ● Same process as calling from ER Transferring a Patient to another Facility ● After discussing with attending and determining if the patient is stable for transfer, contact the resident or attending at the receiving hospital and nd out their name ● Call Transfer line to initiate transfer ● Usually done by calling transfer line of the accepting facility ● After hospital accepts, have ambulance called for transfer ● Complete and have patient sign transfer form and release of information ● Complete EMS form ● Write transfer note (similar to admit note) ● Complete discharge/transfer summary-needs to be dictated ● Copy pertinent medical records for receiving hospital

Floor Calls Postpartum Hemorrhage

● Greater than or = to 500cc blood loss in the 1st 24 hours (1000cc in c/s) Etiology ● uterine atony​- multiparty, overdistention of uterus (twins, macrosomia, hydramnios), prolonged labor, Pitocin augmentation, general anesthesia, chorioamnionitis, Magnesium Sulfate, rapid labor ● Retained placenta​- usually delayed hemorrhage (accreta, succenturiate lobe, manual extraction of placenta, etc.) ● Genital tract laceration​- operative vaginal delivery, precipitous labor, improper epis repair ● Uterine inversion Medications ● Vigorous fundal massage ● Oxytocin​ 10-40 units in 1 L of IV saline infusion ● Oxytocin​ 10 units IM ● Methylergonovine (​methergine​) 0.2 mg given IM q2-5h ○ Contraindicated in HTN ○ If given IV can cause severe HTN ● Carboprost (​Hemabate​) 0.25 mg IM OR intramyometrial 0.25 mg q 15-90 minutes with a max of 8 doses ○ Contraindicated in asthma ● Misoprostol (​cytotec​) 600-1,000 micrograms PO, sublingual or rectal once only ● Tranexamic Acid (​Lysteda​) 1g IV over 10 minutes can be before section or after cord clamping ○ Can be used as prophylaxis or treatment

Pain Control ● Always​ see the patient and evaluate for possible post-op or postpartum complications ● Pain meds ○ Dilaudid/Hydromorphone​ 0.5-1 mg IV q4-6 hours prn pain ○ Demerol​ (lV/lM/PCA) 75-100 mg IM q 3-4h prn pain ○ Phenergan​ 25mg IM with each dose 25mg IV q3-4h prn ○ Morphine​ (lV,lM,sub Q/PCA) ■ 5-10mg lM/sub Q q 3-4h pm pain ■ 2—4rng W q 3-4h prn pain ○ Toradol​ (IV/IM) ■ 30 mg W q 6-8h prn ■ 30-60 mg IM q 6-8h prn ■ caution with asthma/bleeding ● PO pain meds ○ Tylenol​ 325-650 mg one po q 4-6 h prn pain ○ Motrin​ 600-800 mg one po q 6-8h prn pain ○ Percocet​ 5/325 mg one-two po q 4-6 h prn pain ○ Tylenol​ #3 one-two po q 4-6h prn pain ○ Vicodin​ 5-325 mg one-two po q 4-6 h prn pain

Blood Loss anemia

● Symptomatic or asymptomatic ● Pertinent history​= CP, SOB, lightheadedness, determine source ● Pertinent P.E.​ = VS: tachycardia? hypotensive? check orthostatic pulse and BP, heart, lungs, abdominal, extremities ● Consider patient’s age and comorbidities when determining need for transfusion

Post-op or postpartum fever

● Two increased temps greater than 100.4 ● Always evaluate patient for etiology ○ wound (post-op) ○ wind (atelectasis, pneumonia) ○ water (UTl, pyelonephritis) ○ walk (DVT, PE, septic pelvic thrombophlebitis) ○ womb (endometritis) ○ weaning (breast engorgement) ○ wonder (drug fever) ● Pertinent history​= cough, SOB, CP, dysuria, fever/chills, abdominal pain, uterine tenderness, calf tenderness ● Pertinent P.E.​= directed to complaint plus heart, lungs, abdomen, incision (erythema, warmth, exudate), extremities (Homan’s, calf tenderness), bimanual exam if postpartum ● Possible Iabs​- CBC, UA C&S, blood cx X 2 15 min apart (before starting antibiotics) ● Possible studies​- CXR, CT or pelvic US (abscess) -initially always best to present case to attending and discuss labs and X-rays to be ordered and/or empiric antibiotic treatment ● Common Antibiotic Treatment Regimens: ​Directed at source or empiric ○ Triples= ​Ampicillin​ 2g IV q 6, ​Gentamicin​ PTD (pharm to dose), Clindamycin 900 mg IV q 8 ​or Flagyl​ 500 g IV q12 ○ Kefzol/Ancef​ 1g IV q8 ● Treatment until afebrile 24 hours ● If fever persists 48-72 h after treatment, consider abscess or septic pelvic thrombophlebitis

Chest Pain

● Cardiac or noncardiac etiology ● Differential diagnosis​= musculoskeletal, MI, P.E., GERD ● If suspect MI order stat ECG, cardiac enzymes, may give O2, NTG SL, Morphine, IM/Cardiology consult ● If suspect P.E. start Heparin/Lovenox ASAP, order pulse Ox, ABG, ECG, CT angiogram, lM/pulmonary consult

Hypotension ● Differential diagnosis= hypovolemic, septic, cardiogenic ● Pertinent history​- review PMH and current hospitalization, fever, chills, s/s blood loss, CP, SOB ● Pertinent PE​- VS, UO, determine uid status, heart, lung, abdominal, extremities ● Treatment​- depending on cause if suspect hypovolemia or sepsis (250-500 cc uid bolus NS, IV @125 cc/hr, blood products as necessary), if cardiogenic (notify lM/Cardiology)

Hypertension

● Pertinent history​= PMH, history HTN, current BP meds, any CP, SOB, HA, neuro s/s ● Pertinent PE​: verify BP reading (cuff size, manual reading) and HR ● Meds ○ Catapres​ 0.1mg po (may repeat up to 0.4mg) ○ Vasotec​ 0.625—1.25mg IVP (IV push) ○ Labetalol​ 20mg SIVP (slow IV push) ○ Hydralazine​ 10mg SIVP ○ Procardia​ 10 mg po

SOB/Difficulty in breathing

● Differential diagnosis​= cardiac (MI, CHF), asthma/COPD, P.E. ● Pertinent history​- review PMH and current hospitalization, any CP ● Pertinent PE= VS, pulse ox, heart, lungs, assess uid status (edema, JVD, etc.), extremities (calf tenderness) ● If wheezing, administer Nebulized Mist Tx (NMT) (0.5 cc Albuterol with IUD Atrovent STAT and q4h as needed) Call respiratory for pulmonary treatments ● Hypoxia ○ O2 by NC each L/min adds 4% RA (21%) ○ Venti-mask 25-55% O2 ○ Nonrebreather mask 70-100 % O2 ○ if suspect uid overload → heplock IV, and give Lasix 10-40mg IV ○ If you suspect PE, start Lovenox/Heparin, see P.E. section ● Labs- ABG (depending on severity) ● Studies— CXR ● IM/pulmonary consult as needed

Decreased urine output ● ● ● ●

Pertinent history​- PMH, current hospitalization Assess uid status overload: JVD, rales, peripheral edema Lasix 10-40mg IV and determine cause No signs or symptoms of overload, skin turgor, recent surgery, N/V/D, etc. ● 250-500cc uid bolus NS IV @ 125cc/hr

Electrolyte replacement

● Potassium → KCL 10 meq/100 cc NS (10 mEq w/ central line) run for 1 hour x 4 runs ● K-dur → 10-20mEQ p.o. ● Phosphate → K​2​PO​4​ 20 mmol /250 NS IV (or Na PO​4​) Run over 4 hours ● Magnesium → MgSO4 2g/100cc NS over 1h ● Calcium → 2 amps calcium gluconate in 250cc D5W or NS over 1h (do not mix with Phos, may be mixed w/ KCL)

Insulin

● Non pregnant patients ○ Accucheck ac (before a meal) and hs or q6h if NPO ○ Insulin Reg by SS

Pregnant patients

● Accucheck fasting and 2h pp ● GDMA2 arbitrary starting dose = 20 NPH/10 R in am and 10 NPH/10 R in om ​OR ● 6-18 wks 0.7 U/kg ● 18-26 wks 0.8 U/kg ● 26-36 wks 0.9 U/kg ● 36-30 wks 1.0 U/kg ● Am ⅔ total → ⅔ NPH, ⅓ R ● Pm ⅓ total → ½ NPH, ½ R ● Goal FBS <90, 2h pp <120 ● *begin at ½ dose

Clinic OB patients Timing of OB visits ● Q 4 weeks until 28 wks ● Q 2 weeks 28-36 wks ● Weekly from 36 wks until delivery

1st tri 0-14 w 2nd tri 14-28 w 3rd tri 28-42 w

New OB visit ● Review info and labs completed at new OB visit with nurse ● Determine gestational age by LMP and exam correlate with US if patient has had one ● Always compare LMP with the earliest US ● If the patient conceived with assisted reproductive technology (ART), the ART-derived EDC should be used. ● If there is a concern about the correct EDC for a given pregnancy, an ultrasound exam should be performed as early in the pregnancy as possible. Ideally, this would occur between 6-12 weeks gestation. ● If the patient is uncertain about her last menstrual period, the ultrasound gestational age should be used. ● The earliest ultrasound at which an EDC is established or confirmed should be used. ● If a patient’s EDC is changed after 24 weeks to a lower gestational age, a follow-up study in 2-3 weeks should be considered to evaluate interval growth. This will aid in excluding fetal growth restriction as a possibility for the initial discrepancy in pregnancy dating.

Obtain full history ● OB hx GsPs, type of delivery, gest age, any complications ● Gyn hx- history STDs, abnormal paps, menstrual cycle ● PMH, PSH, FH, Meds, All, SH, Genetic hx, drug or environmental exposures -identify risk factors and note in chart ● Perform full P.E.-​ heart, Iungs, breast exam, abdominal exam, fundal height if >15 weeks, pap smear, cultures, pelvic exam (assess adequacy of pelvis), cervical exam, FHTs (rst audible by doppler around 11 weeks) ● Discuss: contraception, breastfeeding, anesthesia ● If not already start PNV; iron and colace if anemic Routine OB visits ● Review chart for risk factors and things to follow up on ○ Gs/Ps, prior pregnancy complications ● Calculated patient gestational age based on EDC ● Review labs or tests completed since last visit ● Inquire about fetal movement (>18/19 weeks), vaginal bleeding, vaginal discharge, LOF, cramping or CTXs, s/s Pre-eclampsia (headache, vision changes, RUQ pain), mood and support at home ○ If pt is complaining of contractions may need to do a cervical check ● Review BP, FHTs and perform fundal height, abdominal exam, extremities ● Determine if due for any tests and next appt ○ Cervix is checked from 37 weeks until delivery ● Later in pregnancy you can inquire about: PP birth control plans, epidural?, breast or bottle feeding ● Labor precautions: ○ If no FM or decreased from normal (10/hr), ○ Ctx q10 min if <38 and q 5-10 if >38 if ctx are strong and regular ○ Big gush of fluid ○ Vaginal bleeding

ROB visits 8-12 weeks - New OB ● Review dating US ● FHT may be hard to find ● Offer genetic testing ○ 1st trimester screening 10-13.6w ○ Cell free DNA 10+w ○ 2nd trimester screening aka Quad screen 15-22w ● Labs ○ PAP (21+) ○ T&S, Rh, Antibody screen ○ CBC, BHCG, Varicella titer, Rubella titer, HepBsAg ○ GC/Chlamydia, HIV, RPR, HSV ○ UDS, UA and urine culture ○ Hg electrophoresis if African American 16 week ROB ● BP, weight, UA ● FHTs ● Review initial OB labs ● Offer genetic testing ○ Cell free DNA 10+w ○ 2nd trimester screening aka Quad screen 15-22w ● Order 20 w anatomy scan to be completed between 18-22wks 20 week ROB ● BP, weight, UA ● FHTs and FH ● Review anatomy scan ● PTL precautions

24 week ROB ● BP, weight, UA ● FHTs and FH ● Can discuss feeding method, childbirth classes, doctor for the baby, anesthesia, birth control ● Order 1 hr GTT to be completed 24-28 WGA ● PTL precautions 28 week ROB ● BP, weight, UA ● FHTs and FH ● 1 hour GTT during this visit ○ Non-fasting and if blood glucose is > 140 she needs a 3 hr GTT ■ 3 hr GTT ● Fasting <95 ● 1 hr <180 ● 2 hr <155 ● 3 hour <140 ● Order Rhogam if mom is Rh- and baby is Rh+ ● Offer Tdap ● Labs ○ Repeat CBC and urine cx ○ Repeat HIV, RPR, CG/Chlamydia ● Edinburgh postnatal depression scale (EPDS) ● Schedule anesthesia consult appointment is patient desires epidural ● Possible growth US for high risk ● PTL precautions 30 week ROB ● BP, weight, UA ● FHTs and FH ● PTL precautions

32 week ROB ● BP, weight, UA ● FHTs and FH ● Possible growth US for high risk ● PTL precautions 34 week ROB ● BP, weight, UA ● FHTs and FH ● PTL precautions 36 week ROB ● BP, weight, UA ● FHTs and FH ● Possible growth US for high risk ● Labs ○ GBS culture (vag/rectal swab), GC/Chlamydia Cultures, syphilis, HIV, CBC ● Anesthesia options, BC options, repeat pelvimetry ● PTL precautions 37 week ROB ● BP, weight, UA ● FHTs and FH ● Optional cervical check ● PTL precautions 38 and 39 week ROB ● BP, weight, UA, FHTs and FH ● SVE and BSUS for presentation ● PTL precautions 40 week ROB ● BP, weight, UA, FHTs and FH ● SVE and BSUS for presentation ● Schedule IOL by 41 weeks ● PTL precautions

Prenatal genetic screening

● 1st trimester screening​: ​10-13 6/7 weeks​, blood test and NT US exam which screens for Downs and trisomy 18, 85% sensitive NT (1.1to 3 mm is normal) and PAPPA (> 0.5 is normal), hCG also measured ○ 82-87% sensitive for Down syndrome ● Cell free DNA screening: 10+ weeks:​ (trisomy 21,13, and 18 as well as can tell sex and sec chromosomal abnormalities) ● Second trimester screen​ (quad screen- hCG, AFP, estradiol, inhibit A): ​15-22 weeks​, blood test that screens for downs, trisomy 18 and NTDs ○ 81% sensitive for Down syndrome ● Standard US exam: 18-22 weeks​: screens for physical defects

Prenatal diagnostic genetic testing

● CVS: 10-13 weeks​, tests fetal cells in a sample of chorionic villi; detects downs, trisomy 13, trisomy 18 and inherited disorders you request testing but not NTDs ● Amniocentesis: 15+ weeks​; tests fetal cells in a sample of amniotic fluid. Detects downs, trisomy 13, trisomy 18, inherited disorders for which you request testing and certain types of NTDs

Sample Prenatal Note 21 yo G3P2002 at 30 6/7 WGA by LMP c/w 12 wk US here for ____ wk ROB visit. Pt is without complaints. +FM, no LOF, no VB/VD and no ctxs.

VS: BP HR weight UA: protein/glucose/nitrite FH FHTs A/P: 21 yo G3P2002 at 30 6/7 WGA by LMP c/w 12 wk US 1. Size = dates 2. Note anything from problem list and how it is being managed (GDM, cHTN) 3. h/o c/s x2 for RLTCS 4. Continue PNV and iron 5. Kick counts/PTL precautions given 6. Collected all prenatal labs today 7. Given flu shot (or Rhogam or other vaccine- Tdap) 8. RTC in ____ weeks for next ROB visit

Scheduling of Elective Cesarean Delivery The U.S. ​Cesarean rate is approximately 34% ​and almost 40% of all Cesarean deliveries are repeat procedures. Elective deliveries prior to the onset of labor (primary and repeat) comprise 50% of all Cesareans. Recent investigators have shown that ​elective Cesarean delivery prior to 39 weeks is associated with an increased risk of neonatal respiratory complications, NICU admission, and increased neonatal length of stay. ​The rate of ​NICU admission ​with scheduled elective delivery at 37, 38, and 39 weeks is approximately 12%, 8%, and 5%. ● Elective​ Cesarean delivery is a delivery that occurs in the absence of medical or fetal indications. The most common indication for elective Cesarean is ​repeat Cesarean delivery. ● Elective delivery prior to the onset of labor ​should not occur until > 39 weeks​. Gestational age of 39 weeks can be confirmed by one or more of the following: ○ Ultrasound at < 20 weeks that establishes/confirms gestational age ○ 30 weeks since fetal heart tones were documented

by Doppler ○ 36 weeks since documented positive hCG (urine or serum) ○ For women with poor dating criteria or if elective delivery is planned prior to 39 weeks, an amniocentesis for fetal lung maturity is advised ● This guideline is not intended to address the scheduling of medically-indicated Cesarean deliveries​, but a few of these conditions are worthy of mention: ○ HIV positive​ patients scheduled for elective Cesarean delivery can be scheduled at > 38 weeks

○ Twin​ gestations ■ monochorionic/diamniotic: > 37 weeks ■ dichorionic/diamniotic:​ > 38 weeks ○ Placenta previa:​ ​36-37 weeks (amniocentesis is not necessary prior to procedure) ○ Prior Classical Cesarean​- 36-37 weeks (amniocentesis is not necessary prior to procedure) ○ Pre-gestational diabetes​: Amniocentesis for fetal lung maturity is advised for delivery before 39 weeks of gestation, unless there are additional maternal indications or nonreassuring fetal testing. ○ Gestational diabetes​: Prior to 39 weeks, or when control is poor or undocumented, pulmonary maturity should be assessed before delivery.

However, when early delivery is planned because of maternal or fetal compromise, the urgency of the indication should be considered in the decision to perform amniocentesis.

HIV Pregnancy Management ● Begin Kaletra and Combivir (400/100) twice daily ● Infectious disease consultation for long term management ● Labs ○ CD4 labs every 3 months ○ Viral Load monthly until undetectable ○ Resistance testing should be done for patients who viral loads do not respond appropriately to therapy (HIV Genotype) ○ Baseline liver function test, creatinine, BUN ○ Hepatitis A antibody, Hepatitis B surface antibody and Hepatitis C antibody ○ Toxoplasmosis IgG ○ PPD (considered positive if >5mm) ○ Pap smear: Colposcopy for ASCUS or Dysplasia ● Immunizations​, if not up to date: ○ Hepatitis A, if antibody test is negative ○ Hepatitis B, if Hepatitis B surface antigen and antibody are negative ○ Pneumococcal vaccine & Influenza vaccine ● Prophylaxis​ for opportunistic diseases at appropriate CD4 values: ○ <200 ​PCP​ prophylaxis w/ Bactrim DS, 1 po qd ○ <100 ​toxoplasmosis​ proph w/ Bactrim DS, 1 po qd ○ <50 ​MAC​ prophylaxis w/ Azithromycin 1200 mg PO qwk or 600 mg PO 2x/wk ○ If viral load is > 1,000 near the time of delivery, elective Cesarean at 38 weeks to reduce the risk of neonatal infection ○ If Viral lost is <1,000 then vaginal delivery can be attempted; intravenous ​Zidovudine​ (AZT) during labor/delivery is recommended: Loading does: 2 mg/kg over 1 hour ■ Maintenance: 1 mg/kg/hr until delivery (for elective Cesarean, give maintenance dose for 3 hours after loading dose)

Gyn visits ● New patient​: obtain a full history ● Established patient with ​CC​ investigate the patient’s chief complaint similar to how you would in medicine (​OLDCARTS​) ○ For menstrual period complaints:​ regular or irregular, how many pads per day, how many days of bleeding, hormonal therapy use, any medicines used and if they worked. Any patient over 35 with menometrorrhagia (heavy periods and bleeding between periods) will likely require an ​EMB (endometrial biopsy) to rule out a pathologic source. Always look to see if the patient has had an ultrasound​, and what their ​h/h​ is most recently. ● Annual exam ○ Begin when sexually active or 21 (PAP 21+) ○ ask the patient if she has ​any recent concerns or questions since she was last seen or any changes to medical hx, recent hospitalizations, surgeries or changes to medications. ● Always ask: LMP, any new sexual partners since last visit, methods of contraception (& h/o contraceptive use including any AE or reasons for stopping), condom use, inquire about any desire for STD testing, or discuss future fertility plans if patient indicates she is planning on getting pregnant ● If​ post/peri-menopausal ​ask about vaginal bleeding, menopausal signs or symptoms, HRT use, Calcium 1500mg/d, with no HRT, 1000mg/d with HRT (in divided doses), vit D 400-800IU/d

● PE​: heart, lungs, thyroid, breast, abdominal, pap smear (21+), cultures if indicated, bimanual exam, extremities, rectal exam if 50 ● Screening Intervals/ Health Maintenance ○ Yearly pelvic exam & breast exam for all women ○ PAP​ (21+) every 3 years for under age 30, every 5 years for over age 30 w/ HPV co test ○ Breast self awareness ○ Mammograms​ yearly beginning age 40 if patient desires (can also do biannual), but recommended at 50 ○ Rectal exam & hemoccults yearly beginning age 50 ○ Colonoscopy​ starting at 50 ○ DEXA​ scan ■ recommended for all postmenopausal women beginning at age 65 ■ may be performed for postmenopausal women <65 with one/more risk factors ■ do not repeat more often than every 2 years ○ Calcium/Vit D supplementation ○ Immunizations ○ Screening labs-​ cholesterol, CBC, TSH, fasting blood sugar q 5yrs

GYN H&P Outline: CC HPI​ (OLDCARTS) OB History:​ Number of pregnancies including miscarriages/abortions, when the baby was delivered, term/preterm, vaginal vs. C-section, and any pregnancy complications/infections/NICU stay GYN History​: Age at menarche, regular periods, Last Pap, history of abnormal Pap, history of ovarian cysts, fibroids, or STIs Past Medical History​: HTN, DM, heart, lung, liver, kidney, or bleeding problems Past Surgical History​: It is important to find out when and where any surgeries were done Medications Allergies Family History​: HTN, DM, bleeding disorders, history of birth defects, history of breast, uterine, ovarian, or colon cancers Social History​: EtOH, Tobacco products, illicit substances (“Or any other drugs that aren’t prescribed to you?”)

VS Breasts​: No masses, adenopathy, skin changes Abd​: No masses, soft, NT Ext genitalia​: Normal Vagina​: pink, moist, well rugated Cervix​: multiparous, no lesions Bimanual​: uterus small, anteverted, NT, no adnexal masses or tenderness Assessment/Plan

Gyn Ultrasound ● Order transvaginal and transabdominal as some structures are seen better from different views ● May need to insert Foley catheter to ll patient's bladder if unable to drink -things to note: 1. uterus- size, contour, mass 2. endometrial stripe (>4mm post-menopausal female requires eval) 3. ovaries- size, ow to ovaries ● presence of cyst/mass ● indications for surgical eval ● simple ovarian cyst >5cm persistent for 6-8 weeks ● any solid mass ● any cyst with palpitations ● any adnexal mass >10cm ● Ascites ● any mass in pre-menarchal or postmenopausal female 4. presence of free uid

Antenatal assessment of thromboprophylaxis

Postnatal assessment of thromboprophylaxis

Reference Material EKGs

1. Check for rhythm strip and calibration (10mm/mV/25mm/sec) 2. Rate​: 300, 150, 100, 75, 60, 50, 43, 38, 32 3. Rhythm​: sinus = p wave is up in I, II, aVF and down in aVR 4. Axis​: normal = -30 degrees to +90 degrees and up in I, aVF a. LAD i. <-30 degrees = up in I, down in aVF ii.

Indeterminate?

1. Check II down = left 2. Up = leftward iii. QRS 0.08-0.12 or > → small Q’s in I, aVL → LAFB b. RAD i. > +90 degrees = decrease in I ii.

QRS 0.08-0.12 or > → small Q’s in II, III, aVF → LPFB 5. Interval a. PR = 120-200 msec b. QRS <80 i.

Mild = 80-120 ii.

Large => 120 iii. QTc = 380-420 6. V1 a. Terminal P wave is negative & >1 box x 1 box = LAE 7. II, III, AVF a. P wave peaked >2.5 boxes = RAE

8. V2 a. Tall R or R’ → QRS >0.12 → RSR’ in V1, V2 → deep/wide S in I, aVL, V5, V6 → RBBB b. Deep wide S in V1, V2 → QRS >0.12 → RR’ in I, aVL, V5, V6 → no septal Q or S wave in I, aVL = LBBB (cannot dx LVH, also +/- LAD) c. Deep wide S in V1, V2 → QRS >0.12 → RR’ in I, aVL, V5, V6 → + septal Q or S wave in I, aVL → atypical LBBB 9. LVH​ → romhit and estes criteria 10. Low voltage (heinz 57) a. <5mm limb leads b. <7 mm precordial leads 11. Infarction​: pathologic Q waves >1 box x1 box a. Inferior leads: II, III, aVF b. anterior leads: V1-4 c. Lateral leads: I, aVL, V5-6 d. Anterolateral leads: I, aVL, 1-6 e. Anteroseptal leads: V1-2 f. Posterior leads: V1-2 (reciprocal) 12. Ischemia​ → 1st ST-T vs (2nd ST-T wave ^ = opposite the main deflection of the QRS (DDX: RBBB, LBBB, LVH, RVH)

Common OB/GYN Abbreviations AROM = artificial rupture of membranes AFI = amniotic fluid index BPP = biophysical profile BSO = bilateral salpingo-oophorectomy BTL = bilateral tubal ligation CKC = cold knife conization

LAVH = laparoscopic-assisted vaginal hysterectomy LEEP = loop electrocautery excision procedure LMP = last menstrual period NST = non stress test NT/NE = non-tender non engorged NSVD = normal spontaneous vaginal delivery

D&C = dilation and curettage MLE = midline episiotomy EDC = estimated date of confinement (due date) EAB = elective abortion FAVD = forcep assisted vaginal delivery FHT = fetal heart tones FM = fetal movement FTP = failure to progress FM = fetal movement FSE = fetal scalp electrode GDM = gestational diabetes mellitus IUPC = intrauterine pressure catheter IUFD = intrauterine fetal demise LOF = leakage of fluid

PLTCS = primary low-transverse cesarean section PTL = preterm labor PPROM = preterm premature rupture of membranes PIH = pregnancy induced hypertension PNC = prenatal care POC = products of contraception RLTCS = repeat low-transverse cesarean section RTC = return to clinic

SVE = sterile vaginal exam SSE = sterile speculum exam SROM = spontaneous rupture of membranes SAB = spontaneous abortion SLIUP = single live intrauterine pregnancy

VAVD = vacuum-assisted vaginal delivery VB = vaginal bleeding VBAC = vaginal birth after cesarean VFI = viable female infant VMI = viable male infant

TOCO = tocometer (measures contractions) TVH = total vaginal hysterectomy TLH = total laparoscopic hysterectomy TAH = total abdominal hysterectomy TOA = tubo-ovarian abscess TOLAC = trial of labor after cesarean section

WGA = weeks gestational age

TOD = time of delivery US = ultrasound

Commonly used medications ● Norco​ 5/325mg (Hydrocodone 5mg/Acetaminophen 325mg) sig: 1-2 tabs PO q4 hrs PRN pain, disp: #30 tabs, no refills ● Percocet​ 5/325mg (Oxycodone 5mg/Acetaminophen 325mg) sig: 1-2 tabs PO q4 hours PRN pain, disp: #30 tabs, no refills ● Oxycodone​ IR (immediate release) 5mg sig: 1-2 tabs PO q4 hrs PRN pain, disp: #30 tabs, no refills ● Motrin​ 800 mg sig: 1 tab PO q8 hrs PRN pain, disp: #30 tabs, no refills (Dr. Ashby gives 600mg PO q6 hrs, disp: #60 tabs) ● Ferrous sulfate​ 325mg sig: 1 tab PO daily for anemia, disp: #30 tabs (if Hgb <10 take daily; Hgb <8 take BID) ● Colace​ 100mg sig: 1 tab PO daily PRN for constipation, disp: #30 tabs ● Vistaril​ 50-100mg sig: 1-2 tabs PO q8 hrs PRN uterine discomfort/anxiety/sleep, disp: #30 tabs ● Macrobid​ 100mg sig: 1 tab PO BID x7 days for UTI, disp: #14 tabs, no refills ● Keflex​ 500mg sig: 1 tab PO qid (4x/day) x7 days for UTI, disp: #28 tabs, no refills ● Azithromycin​ 1g 1 tablet PO x1 ● Ceftriaxone​ 125 mg IM x1 ● Metronidazole​ (flagyl) 500mg sig: 1 tab PO BID x7 days, disp: #14 tabs, no refills ● Diflucan​ 150mg sig: 1 tab PO once for yeast infection, disp: #1 tab

Commonly used medications ● Maalox​ 30 cc PO q4-6hr prn ● Metamucil​ 1 TBSP in 4 oz juice PO BID ● Milk of magnesia​ (MOM) 30 mL 1 po q 6 hrs prn constipation ● Dulcolax​ suppository 10 mg suppository per rectum x1 ● Mylicon​ 80 mg 1 po q 6 hrs prn gas ● Zofran​ 4-8 mg IV q8h prn ● Reglan​ 10 mg IV/PO QID prn