PREOPERATIVE DIAGNOSES:
1. Postdates intrauterine pregnancy.
2. Failure to progress in labor.
3. Failed induction of labor.
POSTOPERATIVE DIAGNOSES:
1. Postdates intrauterine pregnancy.
2. Failure to progress in labor.
3. Failed induction of labor.
4. Fetal macrosomia.
PROCEDURE PERFORMED: Primary low transverse cesarean section.
SURGEON: John Doe, MD
ANESTHESIA: Spinal.
ESTIMATED BLOOD LOSS: 600 mL.
COMPLICATIONS: None.
DISPOSITION: The patient was taken to the recovery room in good condition at the termination of the procedure.
DESCRIPTION OF PROCEDURE: The patient is a (XX)-year-old gravida 1, para 0, EDC is MM/DD/YYYY. She was admitted with complaints of decreased fetal movement. A biophysical profile returned with a score of 6 out of 8. The decision was made to proceed with an induction of labor. The risks and benefits were explained as well as the patient’s alternatives.
A Cervidil induction of labor was started. The afternoon of MM/DD/YYYY, the patient was having contractions and her membranes were ruptured. She was approximately 2 cm dilated and 80% effaced at a -2 station at 1 p.m. on MM/DD/YYYY. Pitocin was given with very careful labor monitoring. The afternoon of MM/DD/YYYY, an internal uterine monitor was placed to allow for careful monitoring of her labor. She was reassessed at 11 p.m., and at that time, the patient was 4 cm dilated, 80% effaced and at a -2 station. Despite excellent contractions, there was virtually no change in the cervix and no descent over the head over the several previous hours. The decision was made to proceed with a cesarean section. This was discussed with the patient and her husband.
The patient was taken to the operating room where spinal anesthesia was administered without complication. She was placed in the supine position with lateral displacement of the uterus. She was prepped and draped in the usual fashion. A Pfannenstiel skin incision was performed and carried down to the fascial layer. The fascia was transected, the rectus muscles were retracted laterally. The peritoneum was entered under direct visualization. The bladder was dissected off the lower uterine segment. A low transverse uterine incision was performed with a scalpel and carried laterally with curved scissors. A 9 pound 7 ounce healthy male infant was delivered and handed to the neonatal nurse in attendance. Cord bloods were obtained, and the placenta was extracted and the uterus delivered into the operative field for repair.
The uterine incision was repaired in two layers using 0 chromic sutures. The incision was hemostatic. The bladder flap was reapproximated with a running stitch of 3-0 Vicryl suture. The uterus, tubes, and ovaries all appeared normal. The uterus was placed back into the abdominal cavity. The abdominal cavity was cleaned of any remaining blood and amniotic fluid. The sponge, needle, and instrument counts were correct. The parietal peritoneum was reapproximated with interrupted 2-0 Vicryl suture. The rectus muscles were reapproximated with interrupted 0 Vicryl suture. The fascia was closed with 0 PDS suture. The subcutaneous tissue was reapproximated with interrupted 3-0 Vicryl suture. The skin was closed with a running subcuticular stitch of 4-0 Vicryl suture. A dry sterile dressing was placed over the incision. The patient was then transferred to the recovery room in good condition.
