Misc OB

Pregnancy Work Limits:

NIOSH Guidelines Recommend: Max lifting weight <20 weeks (36 lbs). >20 weeks (26 lbs). For repetitive lifting longer than 1 hr per day, limit lifting to 30lbs <20 weeks, and 22lbs >20 weeks.

She should also limit weekly work hours to 40 hrs, and have breaks for hydration/bathroom every 2 hours.

If S/D ratio is less than 3 at greater than 28 weeks, then cord dopplers are good.

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Circumcision (Mogen):

(WHO Manual - http://apps.who.int/iris/bitstream/handle/10665/44478/9789241500753_eng.pdf;jsessionid=2EA232EB70A6E2C6445E0C27F024B477?sequence=1)

1. Same setup as Gomco below.

2. Inject local anesthetic (1% lidocaine w/out epic) at 11 and 2 o'clock (0.4ml)

3. Sterilize penis and place drapes.

4. Palpate and mark corona of penis with marking pen.

5. Place hemostats at 3 and 9 o'clock to apply traction to foreskin, and use straight hemostat or probe to remove adhesions between inner foreskin layer and glans. Adhesions should be removed below the layer of corona marking (step 4).

6. Use a hemostat to dilate the foreskin opening (Instead of a dorsal slit).

7. Pull foreskin down while pushing glans up to expose the corona and ensure normal anatomy and adhesion lysis.

8. Pull foreskin back over glans and clamp straight hemostat at 12 o'clock (approx. 1/3 down length of foreskin).

9. Pinch foreskin between index finger and thumb to push glans down out of way of mogen clamp.

10. Slide mogen clamp into place with hemostat at leading edge of foreskin, and angling distal as it approaches the ventral side.

11. Skin above the clamp (to be removed) should be wedge shaped with more skin near the clamp (dorsal), and less on the ventral side.

12. Use the coronal mark to guide the mogen placement, clamp mogen down and palpate glans.

13. Use scalpel to excise foreskin, and leave clamp in place for 5 minutes before removing.

14. Push remaining foreskin down below the corona and apply barrier ointment.

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Circumcision (Gomco):

(UpToDate)

- Place the patient in a restraint device with padded leg straps and cover him with a blanket to maintain normothermia.

- Examine the patient, exclude penile and scrotal abnormalities, plan the amount of foreskin to be removed, and mark the corona.

- Apply or infiltrate local anesthetic as discussed in detail above and wait the appropriate amount of time for onset of action. Of note, as topical local anesthetics require at least 20 to 30 minutes for onset of action, these agents are typically applied before the infant is restrained.

- Sterilize the penis and surrounding area with antiseptic (betadine or chlorhexidine gluconate). Place a sterile fenestrated drape allowing visualization of the entire phallus including the base.

- Pass a straight clamp into the preputial orifice and gently sweep from side to side across the distal glans to disrupt adhesions. Open the jaws of the clamp and retract the clamp to gently stretch the preputial opening, allow access to the glans, and visualize the urethral meatus to ensure there are no abnormalities. Of note, it is important to angle the clamp dorsally when traversing the preputial orifice so the tips of the clamp do not enter the meatus of the glans. Spreading the hemostat within the meatus can lead to troublesome bleeding and injury to the glans.

- Grasp the foreskin at the 3 and 9 o'clock positions with two hemostats. With the foreskin on stretch from traction on the hemostats, a straight clamp is placed and engaged in the midline of the dorsal foreskin. The clamp is allowed to remain for approximately 10 seconds to devitalize a strip of foreskin. Divide the devitalized strip with straight scissors to complete a dorsal slit (just distal to the coronal margin - within 2 to 3 mm).

- Fully retract the foreskin, completely lyse any adhesions, and clearly visualize the coronal sulcus.

- Insert the bell of the Gomco clamp under the foreskin and cover the glans. A correctly fit bell should just cover the glans without excessively stretching of the foreskin. If not adequately covered, then the glans could sustain injury during amputation of the foreskin. Most commonly used size is 1.3, but a range of sizes are available.

- Insert a sterile safety pin placed through the cut edges of the dorsal slit at 12 o'clock. Thread the foreskin with safety pin in place through the hole in the base plate.

-The skin should be flat and supple, but without folds of skin or on stretch. Excessive traction leads to excision of too much shaft skin, whereas folds of foreskin below the base plate results in an incomplete circumcision with excess skin.

- Use the markings for the corona (made at the beginning of the procedure) to guide how much foreskin to remove.

- Leaving a little excess foreskin is better than removing too much, which will often result in denuded area of the shaft. If excessive foreskin is removed, these patients should be referred to an urologist for evaluation (Fortunately, most will heal by secondary intention).

- Once the clamp is properly positioned, release the traction on the foreskin and tighten the nut firmly.

- The clamp remains locked in place for 5 minutes, timed by the clock. Removing the clamp prior to the 5-minute mark can result in bleeding.

- Excise all foreskin above the base plate using a scalpel.

- Loosen the nut and disassemble the device.

- The bell will be stuck to the remaining shaft skin and prepuce. Sweep the skin gently off the bell with gauze or blunt probe.

- Evaluate for cosmetic appearance and apply the dressing of choice. Some options are antibiotic ointment, petroleum-impregnated gauze, and compressive wrap.