DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Intrauterine pregnancy at 42 weeks’ gestation, fetal distress.
POSTOPERATIVE DIAGNOSIS: Intrauterine pregnancy at 42 weeks’ gestation, fetal distress, delivered.
PROCEDURE PERFORMED: Emergency primary low transverse cesarean section.
SURGEON: John Doe, MD
FIRST ASSISTANT: Jane Doe, MD
ANESTHESIA: Epidural.
ESTIMATED BLOOD LOSS: 800 mL.
IV FLUIDS: 1500 mL.
URINE OUTPUT: 300 mL.
COUNTS: Correct.
SPECIMENS: Placenta.
COMPLICATIONS: None.
DISPOSITION: The patient returned to the postanesthesia care unit with infant, both in stable condition.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old primigravida at 42 weeks’ gestation, who had been admitted 1-1/2 days previously for induction of labor. The patient initially received Cervidil overnight followed by Oxytocin induction. The patient had been making gradual progress in her labor. She developed fetal distress with fetal heart tones in the 90s to 110s for 10 minutes with small amount of bleeding noted. At this time, the patient is approximately 6 to 7 cm dilated and -2 station. A diagnosis of fetal distress was made, and the decision was made to proceed with emergency cesarean section. We were notified by telephone and Dr. (XX) and Dr. (XY) performed the initial part of the surgery until we could arrive at the hospital, which was immediately after the infant was delivered.
OPERATIVE FINDINGS: A viable female infant weighing 8 pounds 13 ounces with Apgars of 8 at one minute and 9 at five minutes with the umbilical cord wrapped around the infant’s body. The uterus, tubes, and ovaries were normal.
DESCRIPTION OF OPERATION: After induction of epidural anesthesia, the patient was placed in the supine position with left lateral uterine displacement. A Foley catheter had previously been placed. The patient was prepped and draped in the usual sterile fashion.
A Pfannenstiel skin incision was then made and extended to the fascia. The fascial incision was extended bilaterally. The vesicouterine peritoneum was entered while tenting it upwards, and the incision was extended bilaterally. A bladder flap was created. A low transverse uterine incision was made and extended bilaterally.
The operator’s hand was inserted and the fetal vertex delivered through the incision with gentle fundal pressure. The mouth and nose were bulb suctioned. The remainder of the infant was delivered atraumatically. The cord was doubly clamped and cut.
The infant was handed to the awaiting nursery staff. A segment of cord was isolated, so that cord blood gases could be obtained. The placenta was delivered and was noted to be intact. The uterus was then exteriorized and wrapped with a moist sponge.
The uterine incision was closed in two layers using 0 chromic suture in a running fashion, and the second layer in an imbricating fashion. Additional figure-of-eight sutures were used as needed for hemostasis. The posterior cul-de-sac was irrigated. The uterus was returned to its anatomic position. The pelvic gutters were irrigated. The uterine incision was reinspected and hemostasis confirmed. The fascia was closed using 0 Vicryl suture in a running fashion. The subcutaneous tissues were irrigated. Hemostasis was achieved with electrocautery. Subcutaneous tissues were closed using 2-0 Vicryl in a running fashion. The skin was closed with staples. A sterile dressing was applied. The patient tolerated the procedure well.
