Archive for the ‘ 2-O&G ’ Category

Obstetric & Gynecology Department (6 Ogos-14 Ogos)


DOCUMENTATION IN OBSTETRIC

History Taking in Obstetric

1)Name / Age / Gravidity & Parity (G1P1 = first pregnancy)

2)Last Menstrual Period (LMP) / Expected Due Date (EDD) / Period of Amenorrhea (POA)

-sure of date (SOD) by previous scan

3)Presenting Complaint

-abdominal pain

-contraction / min

-leaking liquor (LL) / show (blood) / Fever

-Fetal Movement

4)Past Pregnancy Problem

-booking BP / hP for hypertension

-Meal Glucose Tolerance Test (MGTT) done for diabetes

5)Past Medical Problem / Surgical Problem

-Diabetes / Hypertension / Asthma

-Any Surgery

-family history (fHx) of above diseases

-any allergy of food or medication

6)Past Obstetric Hx

-process (spontaneous vaginal delivery (SVD) / Induced Vaginal Delivery (IVD) / Caeserian Delivery (CD)

-baby weight & sex

-baby status (Full Term (FT) / Preterm (PT)

7)Medication

-prescribed or recreational

General Examination

-Lung clear & same of both lungs

-CVS duorythms no murmur (DRNM)

Abdominal Exam

-cephalic or breech presentation

-fetal head over 5

Vaginal Exam

-cervix opening (1-10)

-fetal head engage

Spaculum Exam

-PreVaginal (PV) discharge

-colour of fluid

-pooling of fluid (rupture of membrane)

-Sign and Symptom of Urinary Tract Infection (S&S for UTI)

USS Scan Exam

-Head Circumference (HC)

-Abdominal Circumference (AC)

-Fetal Length (FL)

-Amount of amniotic fluid

-expected age due size

Physical Exam

-stable / alert / comfortable

-pink (healthy)

Social History

-occupation

Management

-strict FKC (Fetal Kick Chart)

-follow up (CTO) for any contraction / LL / show

-follow up (CTO) for BP / CTG / USS Scan

PROCEDURE IN OBSTETRIC

BASIC

1)Vaginal Exam

2)Abdominal Exam

3)Speculum Exam

4)CardioTocoGraph(CTG)

5)Artificial Rupture of Membrane (ARM)

Delivery

1)Spontaneous Vaginal

2)Vacuum Vaginal

3)Caeserian Section

Complication

1)Common Complication

2)Premature Rupture of Membrane (PROM)

3)Pre-Eclampsia

4)Breech Birth

5)Shoulder Dystocia Birth Injury

6)Preterm Labour