Medical Specialty:
Obstetrics / Gynecology
Sample Name: Spontaneous Vaginal Delivery - 1
Description: Spontaneous vaginal delivery. Male infant, cephalic presentation, ROA. Apgars 2 and 7. Weight 8 pounds and 1 ounce. Intact placenta. Three-vessel cord. Third degree midline tear.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES
1. Intrauterine pregnancy at 39 plus weeks gestation.
2. Gestational hypertension.
3. Thick meconium.
4. Failed vacuum attempted delivery.
POSTOPERATIVE DIAGNOSES
1. Intrauterine pregnancy at 39 plus weeks gestation.
2. Gestational hypertension.
3. Thick meconium.
OPERATION PERFORMED: Spontaneous vaginal delivery.
ANESTHESIA: Epidural was placed x2.
ESTIMATED BLOOD LOSS: 500 mL.
COMPLICATIONS: Thick meconium. Severe variables, Apgars were 2 and 7. Respiratory therapy and ICN nurse at delivery. Baby went to Newborn Nursery.
DESCRIPTION OF OPERATION: The patient was admitted this morning for induction of labor secondary to elevated blood pressure, especially for the last three weeks. She was already 3 cm dilated. She had artificial rupture of membranes. Pitocin was started and she actually went to complete dilation. While pushing, there was sudden onset of thick meconium, and she was having some severe variables and several late decelerations. When she was complete +2, vacuum attempted delivery, three pop-offs were done. The vacuum was then no longer used after the three pop-offs. The patient pushed for a little bit longer and had a delivery, ROA, of a male infant, cephalic, over a third-degree midline tear. Secondary to the thick meconium, DeLee suctioned nose and mouth before the anterior shoulder was delivered and again after delivery. Baby was delivered floppy. Cord was clamped x2 and cut, and the baby was handed off to awaiting ICN nurse and respiratory therapist. Delivery of intact placenta and three-vessel cord. Third-degree midline tear was repaired with Vicryl without any complications. Baby initially did well and went to Newborn Nursery, where they are observing him a little bit longer there. Again, mother and baby are both doing well. Mother will go to Postpartum and baby is already in Newborn Nursery.
Keywords: obstetrics / gynecology, thick meconium, cephalic presentation, intrauterine pregnancy, gestational hypertension, spontaneous vaginal delivery, delivery, vaginal, placenta, newborn, meconium, apgars,
