POST OP LSCS PLAN
1. T/O postnatal ward
2. Lie Flat x 6 H
3. Monitor vs 1/2 hourly times 2, then 2 hourly till stable
4. Keep NBM till next review
5. IVD 5 pint over 24 H (3 pint IVD NS, 2 Pint IVD D5%)
6. Keep CBD x 1/7
7. Input Output Chart
8. Pad Chart - To inform if patient has active pervaginal bleeding
9. IV pitocin 40unit in 1 pint NS over 6-8 Hours
10. S/c Heparin 5000 unit BD (start 6 H post op) until ambulating well
11. Wound Inspection Day 3, no need STO
12. Encourage Breastfeed
13. TED Stockinette
14. Supp Voltaren 100mg BD x1/7 15. IV Ampicillin 500mg QID x 1/7
6 Hour kemudian, kita akan review pesakit ini, kemudian tulis post op review pula. Tak sampai 6 jam pun dah boleh tengok patient sebenarnya.
<Post Op Review>
6 Hour post EMLSCS for fetal distress, EBL 600ml
Delivered baby boy on 20/6/18 at 1200H AS 9 (1), BW 3.1kg Baby Discharge to Mother
ANC (antenatal care)
1. GDM on diet control 2. Hx UTI at 35w POA 3. ETC.
Currently, Patient well, Not ambulating yet
No fever No anaemic sx ( no palpitation, no dizziness)
No SOB, No Chest Pain Still NBM
O/E alert, concious, pink, BP 120/80 PR 80 Temp 37 C
Lungs clear CVS DRNM (dual rhythm, no murmur) PA soft, tender at Op site, dressing intact, minimal blood stain
No calves tenderness
CBD - Urine Concentrated
Plan
1. Allow CF, then soft diet as tolerated
2. Start SC Heparin 5000 unit BD
3. Cont other plan (kena salin balik plan yang berkaitan seperti plan di atas) Esoknya kita Day 1 kita buat am review, sama sahaja dengan post op review, cuma plan agak berubah
Plan
1. Off CBD
2. Change to T. Voltaren 50mg TDS
3. Cont other mx (salin semula management yang berkaitan)
Day 2 – Review general condition of the patient. Dressing soak ke tidak. Any sign anemia atau fever? Day 3 - Kita buka plaster yang dilekatkan pada lscs site,kita spray op site. Per abdomen: Soft, mild tender at op site, Wound inspection, no hematoma, no discharge, mild erythema, suture intact, no gapping.
Plan
1. Allow discharge after review by MO
2. MEMO for KK for Sc Heparin 5000 unit x 10/7 (to complete another 7/7)
3. TCA stat if increase PV bleed, abdominal pain.
4. Encourage Breasfeed and ambulation
5. TCA KK 6/52 for MOGTT and contraceptive
POST OP LSCS PLAN
1. T/O postnatal ward
2. Lie Flat x 6 H
3. Monitor vs 1/2 hourly times 2, then 2 hourly till stable
4. Keep NBM till next review
5. IVD 5 pint over 24 H (3 pint IVD NS, 2 Pint IVD D5%)
6. Keep CBD x 1/7
7. Input Output Chart
8. Pad Chart - To inform if patient has active pervaginal bleeding
9. IV pitocin 40unit in 1 pint NS over 6-8 Hours
10. S/c Heparin 5000 unit BD (start 6 H post op) until ambulating well
11. Wound Inspection Day 3, no need STO
12. Encourage Breastfeed
13. TED Stockinette
14. Supp Voltaren 100mg BD x1/7 15. IV Ampicillin 500mg QID x 1/7
6 Hour kemudian, kita akan review pesakit ini, kemudian tulis post op review pula. Tak sampai 6 jam pun dah boleh tengok patient sebenarnya.
<Post Op Review>
6 Hour post EMLSCS for fetal distress, EBL 600ml
Delivered baby boy on 20/6/18 at 1200H AS 9 (1), BW 3.1kg Baby Discharge to Mother
ANC (antenatal care)
1. GDM on diet control 2. Hx UTI at 35w POA 3. ETC.
Currently, Patient well, Not ambulating yet
No fever No anaemic sx ( no palpitation, no dizziness)
No SOB, No Chest Pain Still NBM
O/E alert, concious, pink, BP 120/80 PR 80 Temp 37 C
Lungs clear CVS DRNM (dual rhythm, no murmur) PA soft, tender at Op site, dressing intact, minimal blood stain
No calves tenderness
CBD - Urine Concentrated
Plan
1. Allow CF, then soft diet as tolerated
2. Start SC Heparin 5000 unit BD
3. Cont other plan (kena salin balik plan yang berkaitan seperti plan di atas) Esoknya kita Day 1 kita buat am review, sama sahaja dengan post op review, cuma plan agak berubah
Plan
1. Off CBD
2. Change to T. Voltaren 50mg TDS
3. Cont other mx (salin semula management yang berkaitan)
Day 2 – Review general condition of the patient. Dressing soak ke tidak. Any sign anemia atau fever? Day 3 - Kita buka plaster yang dilekatkan pada lscs site,kita spray op site. Per abdomen: Soft, mild tender at op site, Wound inspection, no hematoma, no discharge, mild erythema, suture intact, no gapping.
Plan
1. Allow discharge after review by MO
2. MEMO for KK for Sc Heparin 5000 unit x 10/7 (to complete another 7/7)
3. TCA stat if increase PV bleed, abdominal pain.
4. Encourage Breasfeed and ambulation
5. TCA KK 6/52 for MOGTT and contraceptive
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Nota Labour Room
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