Obstetrics / Gynecology
Sample Name: Delivery Note - 6
Description: Her pregnancy is complicated by preterm contractions. She was on bedrest since her 34th week. She was admitted here and labor was confirmed with rupture of membranes.
(Medical Transcription Sample Report)
DELIVERY NOTE: This is an 18-year-old, G2, P0 at 35-4/7th weeks by a stated EDC of 01/21/09. The patient is a patient of Dr. X's. Her pregnancy is complicated by preterm contractions. She was on bedrest since her 34th week. She also has a history of tobacco abuse with asthma. She was admitted here and labor was confirmed with rupture of membranes. She was initially 5, 70%, -1. Her bag was ruptured, IUPC was placed. She received an epidural for pain control and Pitocin augmentation was performed. She progressed for several hours to complete and to push, then pushed for approximately 15 minutes to deliver a vigorous female infant from OA presentation. Delivery of the head was manual assisted. The shoulders and the rest of body then followed without difficulty. Baby was bulb suctioned, had a vigorous cry. Cord was clamped twice and cut and the infant was handed to the awaiting nursing team. Placenta then delivered spontaneously and intact, was noted to have a three-vessel cord. The inspection of the perineum revealed it to be intact. There was a hymenal remnant/skin tag that was protruding from the vaginal introitus. I discussed this with the patient. She opted to have it removed. This was performed and I put a single interrupted suture 3-0 Vicryl for hemostasis. Further inspection revealed bilateral superficial labial lacerations that were hemostatic and required no repair. Overall EBL is 300 mL. Mom and baby are currently doing well. Cord gases are being sent due to prematurity.
Keywords: obstetrics / gynecology, preterm, rupture of membranes, preterm contractions, contractions, pregnancy, delivery,