SAWA .. SAWA .. SAWA . SAWA .. SAWA . SAWA .. SAWA . SAWA .. SAWA . SAWA .. SAWA . SAWA . . SAWA .. WA .. SAWA ..

SAWA . SAWA .. SAWA . SAWA .. SAWA . SAWA .. SAWA . SAWA .. SAWA . SAWA . SAW . SAWA ..

SAWA .. SAWA .. SAWA . SAWA .. SAWA . SAWA .. SAWA . SAWA .. SAWA . SAWA .. SAWA . SAWA .

WA ..

SAWA ..

SAWA ..

A ..

Gyne Morning Session - Topics

www.sawa2006.com sawagroup@hotmail.com

1. 2. 3. 4. 5. 6. 7.

Obs Examination Pelvic Examination Menstrual Cycle Normal CTG Normal Vaginal Delivery Partogram Pre & Postoperative Care

SAWA .. SAWA .. SAWA . SAWA .. SAWA . SAWA .. SAWA . SAWA .. SAWA . SAWA .. SAWA . SAWA .

1. Obs Examination ..
( this is only the Palpation part of the examination which ur gonna practice bel morning report, uve to know all d steps Inspection, palpation and even auscultation men el lecture )

1.

superficial palpation (ask for any tender areas before

touching the patient, start from the right iliac fossa and in anticlockwise fashion round the abdomen with constant eye contact )

feel for : 1. Tenderness 2. Fetal movement 3. Uterine contractions 4. To gain confidence.

2.

Fundal Height :
a. Use your left hand to feel the uterus abdominally and get a quick estimate of the height of the uterus. b. After 20 weeks GA measure in centimeters. fix the end of tape measure at the highest point on the fundus to the symphysis pubis (highest point is not always in the midline. To avoid bias do this with the blank or inches side of the tape facing you, so that you only see the measurement on lifting the tape ) measurement equals the weeks of the gestational age 3 cm and is an indicator of growth problems

3.

Leopolds maneuvers : ( to identify the position, lie, and presentation of the fetus )
a. Fundal Grip Palpate the fundal area gently to identify which pole of the fetus (breech or head) is occupying the fundus. b. Lateral Grip Slip your hands gently down the sides of the uterus, one hand pushes in and the other palpates and again using opposite hands, to try to identify on which side the firm back and irregular limbs of the fetus are positioned. c. First Pelvic Grip Turn to face the patient's feet and slide your hands gently on the lower part of the uterus, pressing down on each side to determine the presenting part. If it is the fetal head, it feels hard and may be balloted between your fingers.

4.

Pawlicks maneuver : (or Second Pelvic Grip )

While facing the ladys face, grasp the lower portion of the abdomen just above the
symphysis pubis with the thumb and fingers of the right hand (one hand only).

2. Pelvic Examination ..
The comprehensive pelvic examination is an essential part of periodic health maintenance, and an essential tool for disease screening in all adult women. It consists of Examination of the external genitalia, pap test, bimanual examination and rectovaginal examination

Indications of Pelvic Examination:

1. Vulvar and/or vaginal complaints such as : pain, discharge, abnormal bleeding, itching and/or m a mass 2. pregnancy is suspected or proven assess the size of the uterus (<12weeks of gestation) 3. exposure to STDs

Pap Testing:
is the main screening tool for detecting precancerous lesions of the cervix

American Cancer Society recommendations for cervical cancer screening:

should begin approximately 3 years after the onset of vaginal intercourse or no later than 21 years of age it should be performed annually till the age of 30 women with age 30 years or older who have had three consecutive normal pap results can be screened every three years unless they have risk factors (such as: infection with human immunodeficiency virus, immunosuppression, or a new sexual partner) pap testing can be discontinued in women who have had total hysterectomy for benign lesions or in low risk women once they have reached 65 to 70 years of age.

Preparation:
Before you perform this procedure elicit the patients recent history ask about: -

the date of LMP review her gynecological and obstetrical history including History of abnormal pap smears , and the type of contraception she is using or has used for women undergoing routine screening, inquire about issues relevant to vulva and vagina whether she has itching, abnormal discharge or dyspareunia ask about total number of sexual partners , patient sexual orientation if there is concern about the possibility of STDs or has experienced prior discomfort during the pelvic examination

Equipment of Pelvic Examination

1. Speculum: we have two types a. Bivalve Speculum (mainly)
Comes in different sizes & Lengths Metal specula may be sterilized & reused while plastic ones are always disposable, a metal speculum is cold so its recommended to be warmed under hot tap

b. Sims Speculum used to examine the walls of the vagina, useful for visualising vaginal prolapse and fistulae 2. Gloves

3. Water-Soluble Lubricant 4. Materials for the pap test (brush and liquid-based fixative or wooden spatula, cervical brush and glass slide with fixative) 5. wet-mount materials (pH papers, Glass slides, cotton swabs, potassium hydroxide and normal saline) 6. materials for testing for STDs depending on your clinic setting, testing for gonorrhea and Chlamydia may include: DNA probes, culture media and/or PCR wash your hands and put on gloves & Ensure that the examination light is working, that the speculum blades approximate where the speculum is closed and the screw on the speculum thumb piece is functional.

Procedure:
Make sure that the patient has emptied her bladder before the exam, as a full bladder may compress the vaginal canal and obstruct the view of the cervix Provide some privacy as the patient changes into a gown Ask her to sit on the examination table with a drape covering her legs Make sure she has been offered the opportunity to have a chaperone in the room during the examination Help guide the patient into lithotomy position by placing her feet in the stirrups, having her slide her buttocks to the edge of the examining table, and having her relax her legs into abduction.

She should be draped in a way that allows minimal exposure, and you should be able to easily visualize her vulva but still keep her knees covered. Examine the entire vulva, peri-anal area, vaginal canal, and Bartholin glands.

Observe for

Discharge Erythema Rashes Trauma

Swelling Lesions Masses Excoriation or ulceration

If you noted any prolapse ask the patient to cough or strain down, to note the position and extent of the prolapsed and watch for involuntary urine leak (stress incontinence)

Palpate
Examine the Bartholin glands separate the labia with your non-dominant hand and then place the index finger of your dominant hand into the introitus. Gently compress the anteriolateral tissue bilaterally (the area of the Bartholin gland) Examine the patient for areas of discomfort, irritation, or pain. Some of the common findings include (next page)

1- Bartholins Absess

2- lichen sclerosus a chronic inflammatory dermatosis that results in white plaques with epidermal atrophy

3- vulvar dermatitis results in redness and excoriation

4- vulvar ulceration

5- condyloma is seen here as multiple, cauliflower-like eruptions

6- vaginal varicosities, often associated with pregnancy.

Speculum Insertion :
-

Put on a clean pair of gloves and warm the speculum with warm water ensure the temperature is comfortable for her by touching it to her thigh Apply a water-based lubricant to the speculum. If a patient finds speculum examination difficult offer her the chance to insert it herself. Insert the speculum gently and slowly at a slight downward angle through the introitus. Once past the introitus, insert the speculum further into the vagina using a downward pressure to a depth of 4 to 5 cm. The speculum handle should be approximately 2 cm away from the introitus before opening the speculum blades. After inserting the speculum, if the cervix is not visualized, identify the folds of the vagina in front of the speculum opening. These vaginal folds aid in identifying the cervix. Close the speculum, back up 1 to 2 cm, and then gently insert the speculum further into the vagina using downward pressure in the direction of the vaginal folds. Reopen the speculum slightly and search again for the cervix. This maneuver may need to be repeated several times. After inserting the speculum, open the speculum slightly and look for the cervix. The cervix has a smooth, firm appearance (no vaginal rugae). You may only see the anterior or posterior portion of the cervix.

If the cervix is visualized immediately, open the speculum further to encircle the cervix and then lock the speculum in place by turning down the screw on the speculum thumb piece. and look for cervical polyps, or a malignancy which would appear vascular and irregular in appearance

NOTE : In obese patients the cervix can be difficult to visualize secondary to excess vaginal tissue. To visualize the cervix in this case cut off the distal thumb tip of a large latex-free examination glove to create a sleeve; place the sleeve around the speculum. As the speculum is opened in the vaginal canal, the excess vaginal tissue will be kept out of the line of sight by the sleeve

Papanicolaou test (Pap Test) :

There are several methods used to obtain cervical cells for examination - the liquid-based cytologic screening technique - the traditional glass-slide sampling technique It is unnecessary to perform both at the same patient In both techniques, it is important to obtain samples of both the endocervix and exocervix. The traditional glass-slide sample technique place the wooden spatula on the face of the cervix and rotate 360 degrees, then place the endobrush in the cervical os and turn 360 degrees. Transfer specimen to the slide by rolling or twisting the spatula and brush on the slide then Apply fixative. liquid-based cytologic screening use a broom-shaped brush to obtain the samples. place the brush against the cervix and gently rotate the brush several times. Remove the brush from the vagina. Disconnect the brush tip and place it in the liquid-based Pap container.

Specimen for wet-mount and cervical cultures

Can be done before or after obtaining the Pap smear Using a cotton-tipped swab, obtain a sample of the vaginal discharge in the posterior or anterior fornix or along the vaginal walls. Swab it onto a piece of pH paper to determine the vaginal pH. A healthy adult female vaginal pH is 4, this will appear yellow on the pH paper. If the vaginal pH is > 4 (blue) you should be concerned about vaginal infections such as: bacterial vaginosis Note : if its acidic with suspected infection you must think of Candidal infection confirm it with KOH test (dissolves skin cells leaving the Candida cells intact) Then swab the sample onto a glass slide, apply potassium hydroxide and saline to opposite sides of the slide, and then cover the slide with coverslips. Using the microscope: Examine the saline prep sample for clue cells (bacterial vaginosis) and trichomonads (trichomonads will appear to vibrate on the slide). Examine the potassium hydroxide prep sample for budding hyphae (Candida). To perform DNA gonococcal or chlamydia probe, position a cotton-tipped swab in the cervical os for 30 seconds. Place this end in the medium provided, and then secure the top.

Removing the Speculum :

Warn the patient before unlocking and removing the speculum. Unscrew the lock in the speculum handle and gently detach the blades from the cervix. As you are removing the speculum slowly close the blades the blades should be completely closed when exiting the introitus. Make sure you examine the walls of the vagina as you are retracting the speculum. Let the patient know she may have a small amount of bleeding after Pap smear sampling.

Bimanual Examination :
Place the index finger and middle finger of your dominant hand into the vagina to examine the vagina, cervix, uterus, and adnexae. The abdominal hand should be used to sweep the pelvic organs downward, while the vaginal hand is simultaneously elevating them. 1- the size, shape, symmetry, mobility, position, and consistency of the uterus. 2- Check the adnexal regions for the presence of appropriately sized, mobile ovaries (about 2 by 3 cm). This can cause her some mild discomfort. Adnexal masses should be described as to location, size, consistency, mobility, and degree of tenderness. 3- Move the cervix from side to side and note any tenderness (Cervical Excitation) may indicate pelvic inflammatory disease (PID), ectopic pregnancy and is of some use to help differentiate PID and appendicitis Note: 20-33% of women in their forties have uterine fibroid, most are asymptomatic

Rectovaginal Examination :
performed after the bimanual examination if indicated. Indications: 1- better assessment (size and shape) of a retroverted uretus, 2- screening for colorectal cancer in women 50 years or older 3- if there is a concern for pelvic pathology. -

place the index finger of your dominant hand into the vagina, and concurrently place your middle finger of the same hand into the rectum. Apply pressure with these fingers laterally and anteriorly to palpate structures. To assist in palpating structures, use your nondominant hand to apply downward pressure on the abdomen.

Contraindications of Pelvic Examination :

1. Physical and/or mental disability 2. Abnormal Anatomy, 3. Physical Immaturity with an intact hymen an examination under anesthesia should be considered if you had to examine. 4. In a heavily menstruating patient (at the time of the examination) & you are using the traditional glassslide technique for pap test (e.g. because the liquid-based Pap technology is unavailable): in this case the Pap smear should be delayed, as red blood cells can obscure the cervical cells on a traditional slide, whereas with the liquid-based technology, they can be filtered out.

3. Menstrual Cycle :
I . Ovarian Cycle
1. 2. 3. Follicular phase. Ovulation. Luteal phase.

1. Follicular Phase :
In this phase FSH & LH are released, and stimulate group of follicles. You know the follicle consist of theca cells, and granulosa cells.

A. Rule

Two cells, two gonadotrophine: which means .. (Two cells = theca & granulosa , two gonadotrophine = FSH & LH) o LH stimulate THECA CELLS to convert cholesterol to ANDROGEN. o FSH stimulate GRANULOSA CELLS to convert androgen to ESTROGEN (this mechanism called aromatization), and release inhibin & activin. NOTES : Without FSH follicular atresia will occur. Inhibin inhibit FSH , activin increase FSH. In PCOS (poly-cystic ovarian syndrome) theres increase in LH level which lead to increase androgen level.

B.

Selection of the dominant follicle: o The increase in estrogen & inhibin level cause negative feedback on the pituitary gland which lead to decrease in FSH & LH level. o that survive at low level of FSH, is called THE DOMINANT FOLLICLE, which has the following characteristics: 1. The largest follicle. 2. Well-developed. 3. Has the highest aromatase activity. 2. Ovulation : In late follicular phase FSH increase the LH receptors on the dominant follicle .. 1. The dominant follicle will secrete very high level of estrogen that will cause POSITIVE feedback on hypothalamus, which lead to increase in LH level. 2. LH cause luteinization of the granulosa cells so they start secreting progesterone which has POSITIVE feedback on the pituitary.

1 + 2 = LH peak 36 hrs after the onset of the LH surge, ovulation will occur. 12 hrs after the peak, ovulation will occur.

NOTE : o In ovulation all hormones increase (FSH, LH, Progesterone, Estrogen, Androgen). o The role of Androgen here is to increase libido around the time of ovulation. Mechanism of ovulation : LH peak : Stimulate the resumption of meiosis of the follicle. Increase macrophage chemotactic factor & IL8 which lead to recruitment of macrophages & neutrophiles which in turn secret proteinases & prostaglandins that destruct the follicular wall releasing the oocyte.

3. Luteal Phase :
After ovulation the remaining granulose cells & theca lutea cells from the corpus luteum. Corpus luteum secretes progesterone (in high level), estradiol & inhibin which all together inhibit FSH & LH. If no pregnancy occurs luteulysis of corpus luteum will happen which lead to decrease in progesterone & estrogen level which lead to increase in FSH & LH follicular phase will start again. If pregnancy occurs -HCG (which is secreted by trophoblast) will preserve the corpus luteum for 12 weeks till placenta takes over. This phase is 14 days duration. o Estrogen in low level has ve feedback on the pituitary, but in high level has +ve feedback on hypothalamus. o Progesterone in low level has +ve feedback, but in high level has ve feedback.

NOTE :

II. Uterine Cycle

1. 2. 3. Proliferative phase. Secretory phase. Menstruation.

1. Proliferative phase : under the effect of Estrogen mainly

o Epithelial glands lining converts from single layer columnar epithelium to pseudo-stratified epithelium. o Stroma re-expands. o The thickness increase from 0.5 mm to 3.5-5 mm.

2. Secretory phase : under the effect of Progesterone mainly

o The endometrial glands increase their secretory activity. o The glands & spiral arteries become tortuous. o In late secretory progesterone makes decidualization.

3. Menstruation :
When corpus luteum dies, estrogen & progesterone levels drop, this lead to apoptosis of the decidua so shedding occur (menstruation).

Mechanism of shedding (menstruation):

Progesterone withdrawal will lead to: - Spiral arteries vasoconstriction. - Inflammation. - Vascular growth factor secretion angiogenesis new dicediua formation. NOTE : Homeostasis is achieved by: - Spiral arteries vasoconstriction. - Fibrinolytic activity. - Prostaglandin (F2).

NOTE : (Important) Day of ovulation period length 14 (luteal phase) Highest level of progesterone at day = period length 7 (when progesterone test done)

As you can see below @ the first line (the 35-day cycle); ovulation happened later than the 28-day While ovulation in 21-day cycle happened before 28-day cycle. Baby in 35-day cycle will be conceived after 7 days we have to add 7 days to the EDD .. while it happened 7 days earlier than normal in 21-day cycle; so we subtract 7 days from the EDD of 28-day If you want to calculate the GA for 21-day or 35-day cycles, consider it a 28-day cycle then do the math ! Elli beddu yefhamha ye7seb ennu el fetus ta3 el 35-day cycle met2a55er 3an 97abo e66abee3eyyeen oboo3 .. 3ashan heak benzeedlo eyyah bel a5er .. wel 3aks bel 21-day cycle !

LMP

Luteal phase (fixed = 7 days)

35 28 21 ovulation

MOLA55A9 MOFEED : For 35-day cycle EDD = EDD of 28-day cycle + 7 days GA = GA of 28-day cycle 7 days For 21-day cycle EDD = EDD of 28-day cycle - 7 days GA = GA of 28-day cycle + 7 days

4. Cardiotocography (CTG) ..
is a technical means of recording (-graphy) the fetal heartbeat (cardio-) and the uterine contractions (-toco-) during pregnancy, typically in the third trimester. The machine used to perform the monitoring is called a cardiotocograph, more commonly known as an electronic fetal monitor (EFM).

Indications for Electronic Fetal Monitoring

Oligohydramnios Hypertension. Abnormal FHR detected. Malpresentation and in labour. DM, Multiple Gestation. Previous CS. Abdominal Trauma. Prolonged ROM. Meconium Liquor

Indications for the continuous EFM : 1. 2. 3. 4. 5. High risk pregnancies IOL and Augmentation of Labour. Reduced FM. Premature labour/TPL. APH/IPH

Make sure that you can read : 1. 2. 3. 4. 5. Name Date Time GA Calibration 11

o Parameters
1. Baseline of Fetal Heart Rate (FHR) :
Mean level of FHR when this is stable, excluding Accelerations and Decelerations. Normally in term (110 150) Preterm (120 160)

If < 110 = Bradycardia If > 160 = Tachycardia

2.

Variability of Baseline :
Normally between 5 15 bpm Non-reassuring less than 5 bpm (less than 30 min) Abnormal less than 5 bpm (for 90 min or more)

What you have to know is only Good variability Poor variability Bad variability 12

Poor Variability is due to :

1. 2. 3. 4. Hypoxia Sleeping phase (40 min) Drugs (Penthedine) Preterm

3.

Accelerations :
transient increase in FHR of 15 bpm or more lasting for 15 sec. from onset of the acceleration (2 10 min. = prolonged) Presence of FHR Accelerations have good outcome.

4. 5.

Uterine Activity : Decelerations :

transient slowing of FHR below the baseline level of more than 15 bpm and lasting for 15 sec. or more. Normally NOT seen. 1. Early Due to Head compression Begins on the onset of contraction and returns to baseline as the contraction ends.

13

2. Late Due to Placental insufficiency (Uteroplacental or Fetoplacental vascular insufficiency) Associated with respiratory and metabolic acidosis. Repetitive late decelerations increases risk of Umbilical artery acidosis and Apgar score of less than 7 at 5 mins and Increased risk of CP.

3. Variable (vagal activity) Variable intermittent periodic slowing of FHR with rapid onset recovery and isolation Not related to uterine contractions. Caused by compression of the umbilical cord Often associated with Oligo-hydroaminos with or without ROM Can cause short lived RDS if they MILD Acidosis if prolonged and Recurrent.

14

o According to these Parameters, we can classify CTGs into 4 categories

1- Reactive CTG : All parameters are normal (present acceleration, absent deceleration) 2- Reassuring CTG : No accelerations (still normal) 3- Suspicious CTG : There is 1 abnormal parameter. (abnormal baseline , abnormal variability or presence of decelerations) 4- Pathologic CTG : 2 abnormal parameters.

In reassuring CTG we do PH test and normally its > 7.25 In the pathologic CTG we should interfere:
In the first stage its only cesarean interfering. And in second stage, either by cesarean (high head) or instrumental (low head ). NOTE : We have 2 types of monitoring : 1- Continuous (CTG) for the high risk patient (record) 2- Intermittent auscultation (sonicaid) for low risk patients (without a record) In intermittent auscultation we hear fetal heart for 1 min after uterine contraction. o We hear fetal heart every 30 min first stage. o We hear fetal heart every 5-15 min second stage. Causes for fetal Bradycardia :
1. 2. 3. 4. Hypoxia SLE Supine hypotension Congenital heart block

Causes for fetal Tachycardia :

1. Maternal tachycardia 2. Maternal fever 3. Infection / Chorioamnionitis

15

5. Normal Vaginal Delivery ..

1. 2. 3. 4. 5. 6. 7. 8. 9. Descent Engagement Flexion Internal Rotation Extension Restitution External Rotation Shoulder Delivery Delivery of the baby

16

1.

Descent :
during first stage and first phase of second stage of labor descent occurs secondary to uterine contractions. In the active phase of second stage it is helped by voluntary use of abdominal muscles and the Valsava maneuver (pushing).

2.

Engagement :
when the widest part of the presenting part has passed successfully through the inlet.

3.

Flexion :
passive movement due to resistance from the cervix, pelvic walls, and pelvic floor. It minimizes the presenting diameter (from occipitofrontal to suboccipitobregmatic).

4.

Internal Rotation :
the occiput rotates anteriorly sagittal suture lies in AP diameter of pelvic outlet (widest diameter) this probably occurs as the fetal head meets the muscular sling of the pelvic floor.

5.

Extension :
occiput escapes from underneath the symphysis pubis and distends through the vulva. Episiotomy might be needed to reduce pernial resistance. Crowning when the largest diameter of fetal head is encircled by the vulvar ring (vertex reached a +5 station). Further extension, using the symphysis pubis as a fulcrum, leads to appearance of the bregma, followed by the face and the chin.

6.

Restitution :
As soon as head escapes from the vulva it aligns itself with the shoulders. The occiput rotates one eighth of a circle (neck untwists turning the head sideways).

7.

External Rotation :
Shoulders rotate to the AP plane. Occiput rotates a further one eighth of a circle to the transverse position.

8. Shoulder Delivery 9. Delivery of the baby

17

Diameters of Fetal Skull @ Delivery :

18

The important diameters of the fetal head (in cm) : 1. 2. 3. 4. 5. 6. Suboccipito bregmatic Suboccipito frontal Occipito frontal Submento bregmatic Mento vertical Biparietal 9.5 10 11.5 9.5 13 10

Pelvic Types :

1. Gynecoid 50%
(most favorable)

2. Anthropoid 20% 3. Platypelloid 3%

(Risk of obstructed labor)

4. Android 30%
(Typical male pelvis)

6. Partogram ..

Partogram is a chart taken for any lady in labor to asses : 1.fetal wellbeing 2.progress of labor 3.maternal well being.

20

Partogram Sections & Parameters :

1.patients profile :
It should contain patients name , gravidity and parity , her hospital number , date of admission ,time of admission , time of ruptured membranes and the time now .

2. fetal part :

It consists of 3 parts fetal heart rate status of the liquor .. and it is expressed as the following : I = stands for intact membranes C = stands for clear liquor M = stands for meconium stained liquor B = stands for bloody stained liquor NOTE : Signs of obstructed labour : 1. Moulding 2. cuppot

degree of moulding .. and it is expressed as following : 0 = no moulding + = sutures approximate each other (but not overlapping) ++ = bones overlap each other but reducible +++ = they overlap each other and irreducible

3. Progression of labor:
It consists of

1. A chart that has on its X axis the hours and on its Y axis numbers from 1 10 ; and we
blot on it : o the cervical dilatation (it is represented by an x) o the descent of the head (how many fifth is palpable abdominally and it is represented by o)

 If the line connecting the Xs or the Os doesnt cross the alert line everything is going well just reevaluate every 4 hours in primiparous and every 2 hours in multiparous . If it crosses the alert line then something is wrong check her vital signs, her contractions, if she needs Oxytocin, IV fluid or analgesia then : if in the first stage re-evaluate every 1-2 hr (according to the condition of the patient) if she is in the second stage re-evaluate every an hour. If it crosses the action line you should take an action; which means you should deliver the baby.. o If she is not fully dilated then by C/S . o If she is fully dilated then : if the head is engaged by instrumental delivery if the head is still high by C/S.

2. Number of contractions per 10 minutes :

21

You count how many contractions the patient has in 10 minutes each square represents a contraction. The intensity of the contractions is expressed as the following: o if it lasts < 20 seconds then put dots. o if it lasts from 20 to 40 seconds then put dashes (as the picture above). o if it lasts > 40 seconds then color the whole box (as the picture above).

3. Oxytocin & Drugs :

Oxytocin how many U/L and how many drops/minute. Drugs used during labor (analgesic, antihypertensive, insulin ..) & IV fluids.

4. Maternal Part : 1. Maternal blood pressure & pulse :

The pulse is represented by a dot and the BP is represented by a vertical line with 2 horizontal endings presenting the systolic (the upper end) and diastolic (the lower end) as you can see in the picture above 110 / 70 for example !

2. Maternal Temperature :

3. Urine :
we look for its volume its content of protein and acetone (remember acetone indicates dehydration)

22

7. Pre & Post-operative Assessment ..

A. Preoperative Assessment :
1. patients profile. 2. chief complaint (type of surgery) 3. any risk factors that may affect the surgery ; o previous same surgeries . o chronic medical illness ; thyroid, DM, HTN. 4. drug history. (and you have to know the antidote for each drug; mentioned later) 5. family history. 6. social history.

1. Full history

2. Full physical examination. 3. Investigations.

If the age is < 40 minor surgery: 1. CBC ( Hb , Plts, WBCs ) 2. Blood group. 3. Consent form 4. Control the chronic diseases (HTN,DM,thyroid disease.) major surgery: all of the above + cross match 2 units of blood . If the age is > 40 follow the same steps but you also have to do : 1234KFT Random blood sugar. ECG Chest X ray.

23
If the patient is diabetic : You follow the steps above; then you have to do the following : 1. 2. 3. 4. Check HBA1c (must be maintained <6 ) Know the type of diabetes . Know the medications. The night before surgery give the patient his evening dose then keep the patient NPO In the morning dont give him/her the morning dose instead subcutaneous insulin must be given and the dose is determined according to the (sliding scale).

Sliding scales Insulin prescriptions generally specify fixed amounts of long-acting insulin to be given
routinely, and fixed amounts of short-acting insulin prior to every meal (the 'sliding scale' approach). However, the amount of short-acting insulin may be varied depending on the patient's preprandial fingerstick glucose, in order to correct pre-existing hyperglycemia. The so-called "sliding-scale" is still widely taught, although it is controversial.

 If the patient has hypothyroidism or HTN : The patient must continue taking his medications with sips of water. If the surgery is laparoscopy / hysteroscopy : Must be done after a period to make sure that there is no pregnancy (or check BhCG level before the surgery) If it is major surgery like ovarian cancer : You have to do bowel preparation ; fluid diet + laxatives + caster oil +flagyl

When to stop the drugs before the surgery ?

1Anticoagulants : Warfarin: stop the drug. Daily INR till normal . Then give LMWH. LMWH : must be stopped 12 hours prior to surgery. Anti platelets (aspirin) 7-10 days prior to surgery. Oral contraceptives 2-3 months prior to surgery.

23-

Antidotes :
1. 2. 3. 4. Warfarin FFP + vitamin K Heparin Protamiesulfate Paracetamol N- acetyl cystiene Medazolam (Diazepam) flumazil

B. Postoperative Assessment :
1. Minor Surgeries :
1. NPO till full recovery (full recovery is known if the patient can tolerate normal diet & simple analgesia). 2. Take antibiotics . 3. If the patient has DM can return back to her drugs when she is able to take her regular diet . And if the patient has HTN/thyroid disease She can take her drugs directly.

2. Major Surgeries :
@Day #0 (the same day of surgery)

24

1. Keep the patient NPO (if he was under GA during the operation) Or start with soft diet (if he was under epidural anesthesia) 2. Take her drugs with sips of water 3. IV fluids 4. Antibiotics are given according to the type of surgery and its complications : Chorioamnionitis triple therapy. PROM flagyl. Bowel perforation flagyl.

Note : in our hospital they usually give 3rd generation cephalosporins, flagyl, gentamycin. 5. Good analgesia opiods, tramadol, paracetamol 6. Prophylactic anticoagulants depending on the BMI : o if the patient has low BMI no need for prophylactic anticoagulants; only hydration and exercise . o if the patient has high BMI You have to give prophylactic anticoagulants and it is given according to the type of analgesia : GA : give the drug directly after the surgery Spinal anesthesia : give the drug 6 hours after the injection; Because if given before that you may cause spinal hematoma Epidural : give the drug 6 hours after the removal of the injection.
@Day #1 (first day after the surgery)

1. 2. 3. 4.

You have to check if the patient is in pain or not Check the vitals Check the blood sugar Listen to the bowel sounds o if u hear bowel sounds then you allow the patient to start with fluid diet then if she passed flatus you can convert her soft diet, then her regular diet o if not : Early mobilization if still there is no bowel sounds then check her K level : you may find hypokalemia indicating paralytic ilius 5. Repeat CBC and blood sugar.

Note : Post operative assessment for obese patients:

1. Prophylactic anticoagulants. 2. Leg exercise (early mobilization and ankle rolls) 3. Breathing exercise by a spirometer (to avoid atelactasis)

Note : Patients who had recurrent blood transfusions :

1. Check CBC. 2. KFT ; because they are at high risk of acute renal failure and hyperkalemia

25

www.sawa2006.com sawagroup@hotmail.com