DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Failure to descend, post-term pregnancy.
POSTOPERATIVE DIAGNOSIS: Failure to descend, post-term pregnancy.
OPERATION PERFORMED: Primary low segment transverse cesarean section.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: Epidural.
ESTIMATED BLOOD LOSS: 500 mL.
FLUIDS: Crystalloid.
DRAINS: Foley catheter to gravity.
PROCEDURE FINDINGS: Viable male infant with Apgars of 8 and 9, delivered vertex. Nuchal cord x1, reduced on abdomen. Moderate meconium appreciated at delivery. DeLee suctioned on abdomen. Birth weight 8 pounds 6 ounces. Cord gas pending at the time of dictation. Placenta manually removed. Uterine cavity explored. The patient to the recovery room in stable condition with good urinary output.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, prepped and draped in the usual fashion, placed in the dorsal supine position. A Pfannenstiel incision was made with a scalpel. The incision was extended to subcutaneous tissue with Bovie cauterization. The fascia was nicked on either side of midline and extended laterally with curved Mayo scissors. Kocher clamps were applied superiorly and inferiorly on the fascia. This was bluntly and sharply dissected to the underlying rectus muscle, which was then bluntly bisected. The peritoneum was bluntly entered in the superiormost aspect and bluntly extended. The bladder blade was placed at the lower portion of the incision and a bladder flap was created by grasping the cervix on the lower third of the uterus and incising laterally. Kelly clamps were used to grasp this edge and it was bluntly dissected from the underlying uterus. The bladder blade was placed to protect the bladder and an incision was made in the lower segment of the uterus with the scalpel until the cavity was entered. It was bluntly extended.
Fetal vertex delivered without difficulty. Nuchal cord x1 reduced. DeLee suction on abdomen. Cord clamp, baby to the delivery room. The placenta was manually removed. Uterine cavity was explored and T clamps placed on the inferior aspect of the incision and the uterus was closed in a running locking fashion with #1 chromic. Adequate hemostasis was appreciated. Uterus was delivered back into the abdomen. Paracolic gutters were inspected. No clots removed. Subfascial planes were hemostatic. Fascia was closed from lateral aspect to midline using running nonlocking stitch of 0-Vicryl. Subcutaneous tissue was closed in a running fashion with 2-0 Vicryl. Skin was closed in subcuticular fashion with 3-0 Vicryl on a Keith needle. Steri-Strips applied. The wound was dressed. Pelvic exam performed. The patient was taken to the recovery room in stable condition.
