DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Term pregnancy and fetal macrosomia.
POSTOPERATIVE DIAGNOSES:
1. Term pregnancy and fetal macrosomia.
2. Fetal malposition plus one loop of cord around the baby’s neck.
PROCEDURE PERFORMED: Cesarean section.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: Epidural.
DESCRIPTION OF PROCEDURE: This (XX)-year-old gravida 1, para 0 was prepped and draped in the supine position with a right wedge in place under epidural analgesia. A Foley catheter was in place in the bladder. A Pfannenstiel incision was made, and the layers of the abdominal wall were taken down in the usual fashion. The peritoneal cavity was entered through a combination of sharp and blunt dissection without difficulty. The uterovesical peritoneum was incised laterally, and the bladder flap was created.
A lower uterine segment transverse incision was made with a knife and extended laterally with bandage scissors. Clear amniotic fluid was noted. Head of the baby boy was delivered in the left occiput posterior position and the rest of the delivery followed without difficulty. One loop of cord was noted around the baby’s neck. Keeping loose, it was released prior to delivery. Complete placenta was delivered shortly thereafter. The uterus was closed with two layers of running suture, the first one interlocking.
The cord pH was sent and came back at 7.334 with a base excess of 1.4. The baby’s Apgars were 9, 9, and 9 at one, five, and ten minutes respectively, and the weight was 9 pounds and 10 ounces.
The uterus and both adnexa were checked and found to be normal. The abdominal peritoneum was closed with a running suture after excellent hemostasis in the pelvis was obtained. The fascia was closed with a running suture. The subcutaneous fat was reapproximated with a running suture. Steri-Strips and staples were used to close the skin.
Estimated blood loss for the procedure was approximately 700 mL. There were no complications. The patient left the postanesthetic room in stable condition. Instrument, needle and sponge counts were correct x2 at the end of the procedure.
