Sample Type / Medical Specialty: Obstetrics / Gynecology
Sample Name: Delivery Note - 1
Description: Spontaneous controlled sterile vaginal delivery performed without episiotomy.
(Medical Transcription Sample Report)
The patient is a 29-year-old, Caucasian, para 0, 40 weeks' pregnant who presented with contractions. Prenatal care has been in my office since the first trimester. Ultrasounds have been consistent with menstrual history. Factors identified for consideration during prenatal care included maternal history of Gilbert's syndrome.
The patient presented in the early morning hours of February 12, 2007, with contractions. The patient was found to be in false versus early labor and managed as an outpatient. The patient returned to labor and delivery approximately 12 hours later with regular painful contractions. There was minimal cervical dilation, but 80% effacement by nurse examination. The patient was admitted. Expected management was utilized initially. Stadol was used for analgesia. Examination did not reveal vulvar lesions. Epidural was administered. Membranes ruptured spontaneously. Cervical dilation progressed. Acceleration-deceleration complexes were seen. Overall, fetal heart tones remained reassuring during the progress of labor. The patient was allowed to "labor down" during second stage. Early decelerations were seen as well as acceleration-deceleration complexes. Overall, fetal heart tones were reassuring. Good maternal pushing effort produced progressive descent.
Spontaneous controlled sterile vaginal delivery was performed without episiotomy and accomplished without difficulty. Fetal arm was wrapped at the level of the neck with the fetal hand and also at the level of the neck. There was no loop or coil of cord. Infant was vigorous female sex. Oropharynx was aggressively aspirated. Cord blood was obtained. Placenta delivered spontaneously.
Following delivery, uterus was explored without findings of significant tissue. Examination of the cervix did not reveal lacerations. Upper vaginal lacerations were not seen. Multiple first-degree lacerations were present. Specific locations included the vestibula at 5 o'clock, left labia minora with short extension up the left sulcus, right anterior labia minora at the vestibule, and midline of the vestibule. All mucosal lacerations were reapproximated with interrupted simple sutures of 4-0 Vicryl with the knots being buried. Post-approximation examination of the rectum showed smooth, intact mucosa. Blood loss with the delivery was 400 mL.
Plans for postpartum care include routine postpartum orders. Nursing personnel will be notified of Gilbert's syndrome.
Keywords: obstetrics / gynecology, delivery, gilbert's syndrome, membranes, cervical dilation, contractions, labia minora, labor, labor and delivery, trimester, uterus, vaginal delivery, vaginal lacerations, vulvar, fetal heart tones, fetal heart, heart tones, postpartum, vaginal, fetal, lacerations,