DATE OF DELIVERY: MM/DD/YYYY
PREDELIVERY DIAGNOSES:
1. A (XX)-year-old gravida 1, para 0 with intrauterine pregnancy at 39 weeks.
2. Term labor.
3. Spontaneous rupture of membranes.
4. Maternal fever.
POSTDELIVERY DIAGNOSES:
1. A (XX)-year-old gravida 1, para 0 with intrauterine pregnancy at 39 weeks.
2. Term labor.
3. Spontaneous rupture of membranes.
4. Maternal fever.
PROCEDURES PERFORMED:
1. Spontaneous vaginal delivery.
2. Right mediolateral episiotomy.
SURGEON: John Doe, MD
ANESTHESIA: Epidural and local with 1% lidocaine.
PROCEDURE FINDINGS:
1. Full-term female infant in right occipitoposterior presentation and position.
2. Apgars 9, 9 and 9.
3. Weight was 2982 grams and placenta delivered spontaneously intact.
LABOR COURSE: The patient is a (XX)-year-old G1, P0 female with IUP at 39 weeks by LMP and 6-week ultrasound, who was admitted on MM/DD/YYYY at 2130. The patient was admitted for induction of labor at term. On admission, the patient denied any leakage of fluid or vaginal bleeding and she had some mild contractions and fetal heart tones were in 130s, moderate variability with accelerations, no decelerations.
On tocometer, the patient was contracting every 4 to 6 minutes, and on vaginal exam, the patient was 2, 50, -2. Induction of labor with IV Pitocin was initiated. Later on, the patient was complaining of leakage of fluid. Fetal heart tones were in the 130s, moderate variability with accelerations, no decelerations. On tocometer, the patient was contracting every 2 to 4 minutes, and on vaginal exam, she was 3, 70, -2, clear fluid.
At 3:15 a.m., fetal heart tones were at 110, moderate variability with accelerations, occasional early decelerations. On tocometer, the patient was contracting every 2 to 4 minutes, and on vaginal exam, the patient was 3, 80, -2. At 5 a.m., fetal heart tones were at 110, moderate variability with accelerations, early decelerations down to 60s, good recovery to baseline.
On tocometer, the patient was contracting every 1 to 6 minutes, and on vaginal exam, the patient was 5, 90, -1. IV fluids were running. Pitocin was turned down and the patient was turned on her side. At 7:30 a.m., prolonged deceleration was noted down to 60s, recovered to baseline of 110-120s. Moderate variability, accelerations present too. On tocometer, the patient was contracting 1 to 3 minutes, and on vaginal exam, the patient was 6, 90, -1. The Pitocin was turned off, oxygen applied via mask.
At 9:45 a.m., fetal heart tones were at 130s to 140s, moderate variability with accelerations, no decelerations. On tocometer, the patient was contracting every 3 to 6 minutes. At 12:15, fetal heart tones were at 140s, moderate variability with accelerations, no decelerations. On tocometer, she was contracting 3 to 6 minutes, and on the vaginal exam, she was 7 to 8, 80, -1. The Pitocin was restarted at 11:15 a.m. and at 2:15 p.m., prolonged deceleration noted to 80s, with prolonged contraction and baseline was at 130s. Deceleration recovered to baseline and moderate variability, acceleration was still present. On tocometer, the patient was contracting every 2 to 3 minutes, and on vaginal exam, the patient was 9 to 10, 100, +1.
At 2:20, the temperature was noted to be up to 100.6. Therefore, she was started on IV ampicillin, and at 1630, a full-term female infant was delivered over right mediolateral episiotomy in right occipitoposterior position. Weight was 2982 grams. Apgars were 9, 9 and 9. Vertex delivered first and then anterior shoulder, posterior shoulder and the rest of the body delivered without any difficulties. Cord was clamped and cut and cord gas was sent. Cord blood sample was obtained and after that placenta delivered spontaneously, intact with 3 vessels. Hemostasis was achieved by external uterine massage and IV Pitocin. EBL was 350 mL and the right mediolateral episiotomy was repaired with 2-0 and 3-0 Vicryl in regular fashion. Mother and baby were stable at the end of the procedure.
