Obstetrics / Gynecology
Sample Name: Cesarean Section
Description: Cesarean Section. An incision was made as noted above in the findings and carried down through the subcutaneous tissue, muscular fascia and peritoneum.
(Medical Transcription Sample Report)
The patient was prepared and draped in the usual sterile manner for an abdominal procedure. An incision was made as noted above in the findings and carried down through the subcutaneous tissue, muscular fascia and peritoneum. Once inside the abdominal cavity, a low cervical transverse incision was made in the lower uterine segment after creating a bladder flap by both blunt and sharp dissection. With creation of the bladder flap, a transverse incision was made and the infant was delivered as a vertex. The placenta was then removed as well. With removal of the placenta and baby, cord blood was obtained. The infant was handed off to the nurses in attendance. The uterus was then exteriorized and brought out through the abdominal incision. We then closed the uterine incision in the usual manner with #1 Chromic suture in a running continuous manner. The bladder flap was inspected for hemostasis and closed with #2-0 Chromic in a running continuous manner as well. We then began closure of the abdominal incision. Number 0 Vicryl was used to close the fascia in a running continuous manner. The subcutaneous tissue and peritoneum were closed with #2-0 Vicryl suture in a running continuous manner. The skin was closed as noted above. A Foley catheter had been inserted. Clear urine was noted. The sponge count was correct times 2. There were no complications at this point. The patient was then awakened and taken to the Recovery Room in good condition.
Keywords: obstetrics / gynecology, peritoneum, cesarean section, abdominal incision, subcutaneous tissue, bladder flap, incision, cesarean, fascia, flap, abdominal,