Obstetrics / Gynecology
Sample Name: Spontaneous Vaginal Delivery
Description: Spontaneous vaginal delivery. Term pregnancy at 40 and 3/7th weeks. On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Term pregnancy at 40 and 3/7th weeks.
PROCEDURE PERFORMED: Spontaneous vaginal delivery.
HISTORY OF PRESENT ILLNESS: The patient is a 36-year-old African-American female who is a G-2, P-2-0-0-2 with an EDC of 08/30/2003. She is blood type AB -ve with antibody screen negative and is also rubella immune, VDRL nonreactive, hepatitis B surface antigen negative, and HIV nonreactive. She does have a history of sickle cell trait. She presented to Labor and Delivery Triage at 40 and 3/7th weeks gestation with complaint of contractions every ten minutes. She also stated that she has lost her mucous plug. She did have fetal movement, noted no leak of fluid, did have some spotting. On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions. She was evaluated by sterile vaginal exam and was noted to be 4 cm dilated, 70% effaced, and -3 station. This was a change from her last office exam, at which she was 1 cm to 2 cm dilated.
PROCEDURE DETAILS: The patient was admitted to Labor and Delivery for expected management of labor and AROM was performed and the amniotic fluid was noted to be meconium stained. After her membranes were ruptured, contractions did increase to every two to three minutes as well as the intensity increased. She was given Nubain for discomfort with good result.
She had a spontaneous vaginal delivery of a live born female at 11:37 with meconium stained fluid as noted from ROA position. After controlled delivery of the head, tight nuchal cord was noted, which was quickly double clamped and cut and the shoulders and body were delivered without difficulty. The infant was taken to the awaiting pediatrician. Weight was 2870 gm, length was 51 cm. The Apgars were 6 at 1 minute and 9 at 5 minutes. There was initial neonatal depression, which was treated by positive pressure ventilation and the administration of Narcan.
Keywords: obstetrics / gynecology, roa position, arom, labor and delivery, spontaneous vaginal delivery, term pregnancy, contracting, meconium, lacerations, pregnancy, contractions, vaginal,