DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Active labor.
POSTOPERATIVE DIAGNOSIS:
Active labor.
OPERATION PERFORMED:
Placement of an epidural catheter for labor.
SURGEON: John Doe, MD
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The patient is a pleasant (XX)-year-old gravida 1, para 0, AB 0 female in active labor at this time. According to the nurses, she is 3 cm dilated. Her obstetrician has requested placement of an epidural catheter to keep her comfortable for the duration of labor.
CONSENT: Informed consent was obtained earlier this evening with a thorough discussion of risks, complications, and alternatives. Referencing the informed consent sheet which she had previously signed she stated understanding and wished to proceed with an epidural at the appropriate time.
At this time, she had been prehydrated with approximately 800 mL of crystalloids. She was placed and was ready for an epidural.
The patient is currently 165 pounds. She normally weighs 110 pounds. She is 5 feet 2 inches tall.
She denies any allergies.
She takes prenatal vitamins.
Her only past surgical history is remarkable for tonsillectomy.
She states there is no family or personal history of problems with anesthesia. No history of malignant hyperthermia or high fevers.
Her obstetrical history is totally unremarkable.
Past medical history is remarkable only for an episode of hepatitis. There is no subsequent treatment of symptoms or therapy since that time.
DESCRIPTION OF PROCEDURE: The patient was prehydrated with 800 mL of crystalloids. She was placed in the same position. In this position, she was monitored with EKG, blood pressure cuff, pulse oximetry, and fetal heart rate monitoring. In this position, her vital signs remained stable and the fetal heart rate remained stable.
The area of her lumbar back was sterilely prepped with Betadine x3 and sterilely draped and a skin wheal with 1% plain lidocaine was then raised to an approximate level of L3-4. At this site, an 18 gauge Tuohy needle was then slowly advanced to the loss-of-resistance technique to obtain the epidural space atraumatically on the first attempt. There was no evidence of CSF. There was no evidence of blood, and 3 plus 3 plus 4 totaling 10 mL of a solution of 0.25% plain bupivacaine was then placed through the needle followed by placement of the epidural catheter to a depth of approximately 4 cm without any paresthesias. The needle was withdrawn. The catheter was securely taped to the patient’s back.
Aspirations for CSF and blood continued to be negative and 3 mL of a test dose of 1.5% Xylocaine with 1:200,000 dilution epinephrine was then placed through the catheter. Again, the patient’s vital signs remained stable and the fetal heart rate remained stable. There were no adverse symptoms. She was then placed in the left tilt supine position, connected to an infusion of a solution of 0.2% ropivacaine with 1.5 mL of fentanyl at 10 mL per hour with a PCA modality of 3, 20, and 3.
She described excellent relief from her contractions stating that on a 0-10 scale, they were on the 12 prior to placement of the epidural catheter and approximately 5 minutes after initiation of the catheter, she had stated that the pain was down to a 4 and was continuing to get less. She can still move her legs and feet without problem. She was otherwise totally comfortable. On a touch sensation exam, she had a T7 level to light touch. Her vital signs and fetal heart rate were stable throughout. We will try to keep her comfortable for the duration of labor.
