Medical Specialty:
Obstetrics / Gynecology

Sample Name: Delivery Note - 9

Description: She required augmentation with Pitocin to achieve a good active phase. She achieved complete cervical dilation.
(Medical Transcription Sample Report)

DELIVERY NOTE: This G1, P0 with EDC 12/23/08 presented with SROM about 7.30 this morning. Her prenatal care complicated by GBS screen positive and a transfer of care at 34 weeks from Idaho. Exam upon arrival 2 to 3 cm, 100% effaced, -1 station and by report pool of fluid was positive for Nitrazine and positive ferning.

She required augmentation with Pitocin to achieve a good active phase. She achieved complete cervical dilation at 1900 At this time, a bulging bag was noted, which ruptured and thick meconium was present. At 1937 hours, she delivered a viable male infant, left occiput, anterior. Mouth and nares suctioned well with a DeLee on the perineum. No nuchal cord present. Shoulders and body followed easily. Infant re-suctioned with the bulb and cord clamped x2 and cut and was taken to the warmer where the RN and RT were in attendance. Apgars 9 and 9. Pitocin 15 units infused via pump protocol. Placenta followed complete and intact with fundal massage and general traction on the cord. Three vessels are noted. She sustained a bilateral periurethral lax on the left side, this extended down to the labia minora, became a second degree in the inferior portion and did have some significant bleeding in this area. Therefore, this was repaired with #3-0 Vicryl after 1% lidocaine infiltrated approximately 5 mL. The remainder of the lacerations was not at all bleeding and no other lacerations present. Fundus required bimanual massage in a couple of occasions for recurrent atony with several larger clots; however, as the Pitocin infused and massage continued, this improved significantly. EBL was about 500 mL. Bleeding appears much better; however, Cytotec 400 mcg was placed per rectum apparently prophylactically. Mom and baby currently doing very well.

Keywords: obstetrics / gynecology, augmentation with pitocin, delivery, cervical, dilation, perineum, lacerations, pitocin, infant,