DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Intrauterine pregnancy at 40 weeks.
2. Frank breech position.
POSTOPERATIVE DIAGNOSES:
1. Intrauterine pregnancy at 40 weeks.
2. Frank breech position.
OPERATION PERFORMED: Primary low transverse cesarean section with two-layer closure.
SURGEON: John Doe, MD
ANESTHESIA: Spinal anesthesia.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 500 mL.
URINE OUTPUT: 200 mL.
IV FLUIDS: 1300 mL crystalloid. Ancef 1 gram at cord clamp IV.
OPERATIVE FINDINGS: Normal male infant with Apgars of 8 and 9 at one and five minutes with weight of 6 pounds 8 ounces.
DESCRIPTION OF OPERATION: After informed consent, risks and benefits of the procedure was discussed with the patient. The patient was taken to the operating room where she was placed in the dorsal lithotomy position with leftward tilt. After placement of spinal anesthesia, which was found to be adequate, she was then prepped and draped in the usual sterile fashion.
A Pfannenstiel skin incision was made with a scalpel and carried through to the underlying layer of fascia. The fascia was then nicked in the midline, extending bilaterally and sparing the inferior aspects. The fascia was dissected off the rectus muscles bluntly. The rectus muscles were separated in the midline, and peritoneum was identified, entered with hemostat, and extended superiorly and inferiorly with good visualization of the bladder.
The bladder blade was then inserted. The vesicouterine peritoneum was identified and entered sharply with Metzenbaum scissors and extended bilaterally and then the bladder flap was created digitally. The uterine incision was then made with the scalpel and extended with bilateral index fingers in a crescent-shaped fashion. The fetal buttocks were then grasped and bilateral legs were delivered, and the infant was delivered in the usual fashion of a beech delivery, atraumatically. The cord was clamped and cut. The infant was then handed off to the awaiting pediatric staff. The placenta was then delivered spontaneously, intact.
The cervix was then dilated with ring forceps. The uterus was then exteriorized and cleared of all clots and debris. The uterine incision was then closed with 1-0 chromic in a running locked fashion. A second layer of the same suture was used in an imbricating fashion for hemostasis. The uterus was then returned to the abdomen. Bilateral gutters were cleared off all clots and debris. The uterine incision was noted to be hemostatic.
The subfascial layer was noted to be hemostatic, and the fascia was closed with 1-0 Vicryl in a running fashion. The subcutaneous layer was then closed with 3-0 Vicryl in a subcutaneous fashion. The skin was closed with 4-0 Vicryl in a subcuticular fashion. Steri-Strips, Telfa, and Tegaderm dressing were applied. All instruments, needle, and lap counts were correct x2. The patient was taken to the recovery room in stable condition.
