Obstetrics / Gynecology
Sample Name: Delivery Note - 5
Description: Artificial rupture of membrane was performed for clear fluid. She did receive epidural anesthesia. She progressed to complete and pushing.
(Medical Transcription Sample Report)
DELIVERY NOTE: This is a 30-year-old G7, P5 female at 39-4/7th weeks who presents to Labor and Delivery for induction for history of large babies and living far away. She was admitted and started on Pitocin. Her cervix is 3 cm, 50% effaced and -2 station. Artificial rupture of membrane was performed for clear fluid. She did receive epidural anesthesia. She progressed to complete and pushing. She pushed to approximately one contraction and delivered a live-born female infant at 1524 hours. Apgars were 8 at 1 minute and 9 at 5 minutes. Placenta was delivered intact with three-vessel cord. The cervix was visualized. No lacerations were noted. Perineum remained intact. Estimated blood loss is 300 mL. Complications were none. Mother and baby remained in the birthing room in good condition.
Keywords: obstetrics / gynecology, perineum, placenta, rupture of membrane, artificial rupture, cervix, delivery, induction,