SCRIPT OBSTETRIK

1.       Reduce Fetal Movement

• Usually completed 10 kick by 2 pm, however

• today just 4 kicks until 2 pm

• Claimed reduce in intensity and frequency

• No h/o trauma or abdominal massage

2.       Leaking Liqour (PROM or PPROM)

• Feeling gushing of fluid

• Dribbling along thigh

• During sleeping

• 2 episode

• Soaked Sarung/ soaked 2 pad

• Clear fluid

• Not foul smelly

3.       Risk Of GDM (Age factor, Family History)

• Mogtt at 14 week : normal  - 4.3/5.1

• Mogtt at 28 week : normal - 4.2/4.4 4. GDM on insulin/ Diet Control

• Mogtt at ? Week : 4.2/ 7.8

• HBA1C at ? Week 5.3%

• BSP (Blood Sugar Profile) latest on 20/6/18 at 38w optimised

• Detail scan done at ? Week - Grossly normal fetus

                

4.       Gestational Hypertension  

• Booking BP 120/80  

• Dx at 30 w

• No impending eclampsia symptom

• Urine albumin negative

5.       Preeclampsia

• Noted BP at KK today 160/100

• Urine albumin 2+

• Given Tab Labetolol stat dose

• Repeated BP 140/90

• PE Profile at KK Hb/ PLT/ AST/ALT/UA

• No Impending Eclampsia symptoms

• Reflex present, not brisk

6.       Severe Pre- Eclampsia

• preeclampsia with impending eclampsia symptom (headache, epigastric pain, vomiting, blurring of vision) 8. Anaemia in pregnancy

• Hb booking 12

• Hb lowest at 20 w 9.0

• Hb latest at 38 w 10

• Compliance on T. Zincofer 1/1 OD, T. Iberet, T. Obimin, T. Maltofer. T hematinic



7 . Beta Thallasemia trait carrier  

• Dx since 1st pregnancy

• Hb 8-9 througout pregnancy

• Husband not investigated

• No history of blood tranfusion

• No history of Hosp admission for anaemia

7.        1 previous scar for acute fetal distress

-          EMLSCS (emergency lower segment caeserean section) in 2010 for fetal distress at Hosp X • Done under spinal anaest - uneventful

• Intraoperative - uneventful

• Followed by 2 VBAC (vaginal birth after caeserean section)

• Keen for VBAC 11. History of instrumental delivery (vacuum or forcep) in 2012 for fetal distress

• Done at Hosp Y

 • BW 3.8 Kg

• Complicated with extended tear

• Need blood tranfusion 1 pint pack cell 12. History of macrosomic baby in 2014

• Bw 4.2 Kg

• Delivered SVD • No history of PPH, no history of shoulder distocia • Uncomplicated



13. History of retained placenta in 2016

 • Done under General Anaesthesia at Hospital

• Uncomplicated

 • No PPH 14. Primary subfertility for 6 years

• married since 2012

• Not on contraception

• Spontaneous conception

• Ist child 1st union

14.   H/o treated Urinary Tract Infection

 • Completed T. Cephalexin for 1/52



15.  H/o treated vaginal candidiasis at 30w POA

• Completed Cannestan Pessary 200mg ON x 3/7



 17. History of excessive weight gain at 32 w POA

• Increase 2 kg in 2week

• Moggt x 2 normal

• Urine albumin negative

• No Impending Eclampsia sx

• EOD BP normotensive



18. Constitutional SGA( Small Gestational Age)

• Parameter 34-36w (39POA)

• Growth chart growing

• Doppler normal waveform • H/o BW 2.4Kg



19. H/o premature delivery at 36 week

• Bw 2.0 kg

• Baby healthy and well



20. Preterm labour

• Completed IM dexamethasone 2 dose on 20/6/18

• EFW 2.5kg

• os 3 cm

• Regular contraction • Ventilator booked

POST OP LSCS PLAN

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

Baca Juga :
Nota Labour Room
Dapat posting OnG?
How To Prepare Mgso4?

HOW TO PREPARE MGSO4

Macam mana nak prepare MgSo4 (Magnesium Sulphate) kalau ada MO suruh kita prepare? Biasa tengok MO buat, nampak macam senang, sekali kita kena suruh, baru terkapai-kapai, masa tulah sangat blur kalau time emergency baru nak ingat dose bagai. Haha.

Ini soalan bocor saya nak bagitahu korang ni. Boleh lah nak prepare in mind sedikit sebanyak. MgSo4 ni kita kena tahu ada dua jenis, satu untuk bagi secara slow bolus, satu lagi untuk maintainance dose.


1. Slow bolus (bagi dos 4 gram in 10-15 min)

 2. Maintainance (1 gram per hour)



Macam mana nak prepare? Di hospital saya 1 ampule MgSo4 ada 5ml yang mengandungi 2.5 gram (lebih kurang) So, macam mana nak dapatkan 4 gram?

Biasanya kita akan ambil 8 ml, ia mengandungi 4 gram dah. So lebih kurang 1 ampule setengah kita kena syringe out. Kita masukkan 8 ml tu dalam syringe 20 cc, (8 ml Mgso4 + 12 ml Normal Saline)



Kita bagi dalam slow bolus, sebab ubat ni agak “panas”, kita masukkan 3 way di branulla, kita bagi infusion Mgso4,pada masa yang sama kita run Normal Saline, kita kena pakai glove ya! Panas kan?

Ok settle dah yang tu.  dalam 15 minit kita bagi kat pesakit.

 *Kena tekan syringe slow-slow, jangan laju sangat, jangan tak bergerak sangat - jangan lupa tengok jam juga.



Nak prepare maintainance kita kena guna Syringe yang 50 cc. Masukkan 10 Ampule MgSo4, so kita akan ada 50ml Mgso4 (di dalamnya ada 25gram mgSo4)

 Kita set infusion 2 cc per hour (for 24 Hour), so jadilah 1 Hour kita sedang bagi 1 gram kan?  50ml : 25 gram  -  2 ml : 1 gram Complete mgso4 in 24 Hour.

1 Ampule yang ada 5ml tu mengandungi 2.47 gram sahaja, bukan 2.5 g ya. Itu untuk memudahkan pemahaman.

DAPAT POSTING ONG?

Kalau tak sempat baca yang lain, at least must read apa yang ada dalam list ini terlebih dahulu. Ada sesetengah masa, mereka meletakkan taggers sepenuhnya 2 minggu di Labour Room. Sangat tertekan kalau perkara yang saya listkan ini anda tak pernah ‘sentuh’ sebelum masuk tagging. Sangatlah stress! Serius sis tak tipu. Ini homework ya untuk anda. Boleh juga tanya senior untuk lebih memudahkan pemahaman. Saya sempat buat soalan je, nota tak sempat tulis masa saya ONG sebagai first poster dulu. Kini, kurang ingat dah. Huhu.


Banyak kan kita belajar masa kita jadi student masa posting OnG?
Untuk tak nak terkejut sangat kalau masuk posting ONG nanti, antara benda yang kita kena revise sebelum masuk Labour Room adalah:


1. Macam mana nak inteprete CTG?

Acceleration. Deceleration. Variability. Normal fetal heart. Tacycardia. Bradycardia. Secondary arrest. Type 1 and Type 2 Deceleration.

2. How to plot Partogram
Os. Head decent. Station. Action line. Etc

3. Common drug untuk Gestational HPT, apa beza Gestational HPT, Preeclampsia, Impending Eclampsia, Eclampsia etc

     
 4. How to dilute MgSo4 (magnesium sulphate)
Slow bolus vs maintainance dose

5. Apa beza syntocinon vs syntometrine

6. Definition PPROM vs PROM

7. Apa beza SROM vs PROM?

8. Nak tengok apa Perspeculum Examination kalau pt datang dengan Leaking Liqour
9. How to Dx chorioamnionitis, how to manage postpartum haemorrage. Cause? Commonest cause PPH?



PART 2

1. What is hemabate? Maximum dose?

2. What is DIVC regime?

3. Macam mana nak dilute Ampicillin

4. How to differentiate nak ambil EDD ke REDD?
5. Dating scan dgn date verify at tu adalah benda berbeza?

6. Cara buat VE (sepatutnya kena berlatih ukur bukaan jari)

7. Normal labour process
1st stage, 2nd stage, 3rd stage.

8. Cara buat Artificial Rupture of Membrane apa tips and trick

                 
 9. Sign and sx scar dehiscence

• Factor influence labour passage/passenger/ power

• What to monitor in patient with preeclampsia?

• MgSo4 toxicity monitoring.

• Macam mana nak bezakan LMSL/ moderate/ thick MSL?

• CTG kena buat berapa lama untuk kita kata ia reactive atau tidak?

• Dose IM Dexamethasone? How many hour apart? Why? Theorically kena bagi berapa minggu POA? In practice berapa minggu kita dah bagi?

• Apa kerja seorang houseman masa Assist caeser
- Kalau masih jadi student, cuba tengok apa step yang houseman tu buat

• Bagaimana nak scrub?
» How to sambungkan forchet semasa kita
nak repair episiotomy? Macam mana nak buat supaya takde hematoma atau suture loose?

» Jenis-jenis menjahit - dekat mucosa kita jahit macam mana? Dekat skin kita jahit macam mana? Guna continous suture atau interupted? Atau buried continous interupted?
Cari dalam youtube ye!

» Kes macam mana kena bagitahu MO, kes yang macam mana kita boleh manage sendiri tanpa inform MO? Tanya senior anda!

» Kalau nampak deceleration, sebelum nak bagitahu MO tu, kita kena try bagi oxygen dulu, hydration, put in left lateral position, buat VE dulu. Kalau masih CTG tak cantik, baru inform MO.

Bagaimana nak move on apabila kena marah
» Ini sangat memerlukan inner strength yang tinggi. Boleh beli buku Cerita Dalam Hospital. Banyak saya cerita.

» Berapa nilai significant Albumin nak cakap yang patient ada preeclampsia?

» Macam mana nak tahu VE finding by cervical lip?

Huhu. Sangat banyak kan?

NOTA LABOUR ROOM

Di hospital saya, biasanya pesakit yang ingin bersalin, akan datang ke PAC. 

Bergantung pada bukaan os nya, kita akan decide samadia akan naik ke wad antenatal ataupun terus dimasukkan kedalam labour room. Ibu yang os nya 4 cm dan keatas akan terus ke labour room manakala yang kecil daripada itu akan menunggu di wad sahaja. 

Ini contoh situasi yang saya reka: 

Patient came with active phase of labour, di PAC (patient assessment centre), selepas selesai clerking…

 1. IMPRESSION - Active Phase of Labour ( atau Latent Phase of Labour)

 - Os 4cm  - Cx (cervix) 1 cm

2. INVESTIGATIONS - Full Blood Count, GSH (Group Save & Hold)

3. PLAN - Admit Labour Room For ARM (Artificial Rupture of Membrane) and Delivery.

Time : 11pm 

Kita buat labour room entry.

                                                 < Labour Room Entry >

29 year old Malay Lady, G2P1 at 39w POA  (verified at 11w POG)

 1. Problem : Active Phase of Labour 

2. Other issue : GDM, HPT 

3. Currently, 

comfortable under room air, 

regular pain 3 in 10 for 20 seconds,

 no SOB, no chest pain

 4. On examination – alert conscious, not pale, good hydration 

BP/PR/Temp 

5. Vaginal Examination  : 

VV NAD, 

Os,

 Cx,

 Station, 

Membrane Intact etc

 6. Bladder catheterized 100cc Clear Urine

 7. ARM (artificial rupture of membrane) done at 11 pm - Clear Liqour

 Plan 

• To Plot Partogram (Os 4cm, Station -2, action line, alert line, Blood Ix, Last meal, Ht,Wt, BMI)

 • CTG post ARM - If reactive, to give IM Nubain 10mg stat (analgesic) 

• IV Hydration 

• Confirm GSH (trace blood group dan rhesus setelah blood tadi diproses blood bank)

• NRC (Next Review Contraction) in 2 Hour at 1am, aim contraction 4 in 10 min (>45s), if suboptimised to give IV pitocin augmentation 3cc/ H (primid max 96cc/H, others 48cc/H, grandmultip and 1 Previaous Scar max 24cc/H) 

• NRVE (Next Review Vaginal Examination) in 4 Hour at 3 am 

• CTG monitoring with intermittent tracing.

Others 

• Patient GDM - CBS 2 Hourly, to start insulin sliding scale if CBS >7

 • PROM - If patient not delivered by 7 am (leaking pada 7 pm : 12 jam leaking ), to give IV ampicillin 1 g stat then 500mg QID 

• GBS positive  - Give IV Ampicillin 2g stat then 1g 4 Hourly

 • PROM - Watchout signs and symptoms of chorioamnionitis

 • 1 previous scar - Watch out signs and symptoms of scar dehisences (fetal distress, vaginal bleeding, severe abdominal pain)

 • Preeclampsia -Watch out sign and symptom Impending Eclampsia (headache, nausea, epigastric pain, visual disturbance etc)

Kita pun tulislah PARTOGRAM. Kemudian kita update di whiteboard.

Labor Room 1 

33 yo G2P1 at 39w POA, 

Aanaemia in pregnancy,

 os 4 cm, ARM Clear Liqour, NRC at 1 am, NRVE at 3 am

* Kita perlu update whiteboard sebab tak semestinya kita yang ada masa nak review patient tersebut pukul 1 am dan 3 am kelak, masa tu mungkin kita sedang suture orang lain, conduct atau clerk pesakit lain, so mana-mana HO atau MO yang free ketika itu akan review patient berdasarkan time yang tertera di whiteboard.

Kemudian 2 hour later at 1 am kita akan time contraction dia, how frequent contraction dalam masa 10 minit. Kita aim 4 in 10 for 45 seconds. 

Kalau contraction masih 3 in 10 minutes, kita start IV pitocin augmentation 

(Kita tulis dalam plan, Misi tolong start IV infusion) 

Setiap setengah jam, Misi akan naikkan sampai tahap maxima yang kita dah tulis dalam plan. Mereka akan mulakan dengan 3cc/Hour dose using drop mat (mereka akan masukkan 1 ampule pitocin yang mengandungi 10 unit pitocin dalam 1 pint normal saline), then titrate accordingly.

 • 3cc/ Hour • 6cc/Hour • 12cc/Hour • 24cc/Hour • 48cc/Hour • 98cc/Hour

 4 jam kemudian (at 3 am) kita akan tulis VE REVIEW.

<VE Review>

Check VE, banyak mana dah bukaan Os. Kemudian plot partogram bacaan os yang terbaru, juga decend of the head. 

Kalau os baru 6 cm, NRVE in 4 Hour later 

Kalau 7 Cm, NRVE in 3 Hour 

Kalau 8 Cm, NRVE in 2 Hour

*4, 3 or 2 Hour later, kita pun buat entry baru. Update new VE finding.