Obstetrics / Gynecology
Sample Name: Delivery Note - 10
Description: 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.
(Medical Transcription Sample Report)
DELIVERY NOTE: This is a 30-year-old G6, P5-0-0-5 with unknown LMP and no prenatal care, who came in complaining of contractions and active labor. 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. Rupture of membranes occurred on 12/25/08 at 2008 hours via artificial rupture of membranes. No meconium was noted. Infant was delivered on 12/25/08 at 2154 hours. Two doses of ampicillin was given prior to rupture of membranes. GBS status unknown. Intrapartum events, no prenatal care. The patient had epidural for anesthesia. No observed abnormalities were noted on initial newborn exam. Apgar scores were 9 and 9 at one and five minutes respectively. There was a nuchal cord x1, nonreducible, which was cut with two clamps and scissors prior to delivery of body of child. Placenta was delivered spontaneously and was normal and intact. There was a three-vessel cord. Baby was bulb suctioned and then sent to newborn nursery. Mother and baby were in stable condition. EBL was approximately 500 mL, NSVD with postpartum hemorrhage. No active bleeding was noted upon deliverance of the placenta. Dr. X attended the delivery with second year resident, Dr. X. Upon deliverance of the placenta, the uterus was massaged and there was good tone. Pitocin was started following deliverance of the placenta. Baby delivered vertex from OA position. Mother following delivery had a temperature of 100.7, denied any specific complaints and was stable following delivery.
Keywords: obstetrics / gynecology, spontaneous vaginal delivery, rupture of membranes, gestational age, vaginal delivery, intact perineum, prenatal care, gestational, placenta,