Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Obstetrics / Gynecology

The OB/GYN profession cares for women who are pregnant, during the prenatal, delivery and postnatal stages of pregnancy. Also treats diseases and provides routine physical care of the female reproductive system.



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Delivery Note
Delivery is a normal spontaneous vaginal delivery of an intrauterine fetal demise. Fetal position is right occiput anterior.

Delivery Note - 1
Spontaneous controlled sterile vaginal delivery performed without episiotomy.

Delivery Note - 10
The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks. The patient progressed to a normal spontaneous vaginal delivery over an intact perineum.

Delivery Note - 2
Pitocin was started quickly to allow for delivery as quickly as possible. Baby was delivered with a single maternal pushing effort with retraction by the forceps.

Delivery Note - 3
Delivery was via spontaneous vaginal delivery. Nuchal cord x1 were tight and reduced. Infant was DeLee suctioned at perineum.

Delivery Note - 4
She progressed in labor throughout the day. Finally getting the complete and began pushing. Pushed for about an hour and a half when she was starting to crown.

Delivery Note - 5
Artificial rupture of membrane was performed for clear fluid. She did receive epidural anesthesia. She progressed to complete and pushing.

Delivery Note - 6
Her pregnancy is complicated by preterm contractions. She was on bedrest since her 34th week. She was admitted here and labor was confirmed with rupture of membranes.

Delivery Note - 7
The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes. She was found to be positive for Nitrazine pull and fern. At that time, she was not actually contracting.

Delivery Note - 8
Her cervix on admission was not ripe, so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring. At a later time, Pitocin was started.

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NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples