OB+Dictations

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DELIVERY NOTE -- use smart text CCHS Vaginal Delivery Note
Fill in the blanks keeping it brief and to the point. Think about what you would want to know if you were requesting records later.

CESAREAN DICTATION
PREOP DIAGNOSES: 1. Term intrauterine pregnancy. 2. Labor. 3. Late decelerations.

POSTOP DIAGNOSES: 1. Term intrauterine pregnancy. 2. Labor. 3. Late decelerations.

OPERATION: Low-transverse C-section.

POSTOP FINDINGS: 1. Term infant male with Apgars of 9 and 10. 2. Body cord. 3. Normal uterus, tubes and ovaries.

SURGEON: AAA, MD. ASSISTANTS: BBB, MD. ANESTHESIOLOGIST: CCC, M.D.

ANESTHETIC: Spinal. DRAINS: 150 mL. ESTIMATED BLOOD LOSS: 1000 mL. REPLACEMENT: 1600 mL.

INDICATIONS: This is a 27-year-old G3, P2 with intrauterine pregnancy at 40 weeks who was admitted for labor. She was noted to have late decelerations, which did not improved with intravenous fluids, oxygen, postural changes, or ephedrine. Cervical exam at the time of decelerations was 7 cm. Patient was consented for C-section for fetal bradycardia.

DESCRIPTION OF PROCEDURE: After informed consent obtained, the patient was taken to the operating room where the epidural anesthesia was found to be adequate. The patient was placed in the supine position with a leftward tilt. She was then prepped and draped in a normal sterile fashion. A Pfannenstiel skin incision was made with the scalpel, and this was carried down to the underlying layer of fascia with a scalpel. The fascia was then incised in the midline and the incision extended laterally with the Mayo scissors. The superior aspect of the fascial incision was then grasped with Kocher clamps, elevated, and underlying rectus muscle dissected off the fascia using sharp and blunt dissections. Attention was then turned to the inferior aspect of the fascia. It was then grasped with Kocher clamp, elevated, and again the underlying rectus muscle dissected off the fascia using sharp and blunt dissections. The rectus muscle was then separated in the midline. The peritoneum was entered bluntly. This incision was then extended superiorly and inferiorly with good visualization of the bladder. The bladder blade was then inserted, and the vesicouterine peritoneum identified and grasped with the pickups and entered sharply with the Metzenbaum scissors. This incision was then extended laterally, and the bladder flap was created digitally. The bladder blade was then replaced. The lower uterine segment was incised in a transverse fashion with a scalpel. This incision was then extended laterally bluntly. The bladder blade was removed, and the infant was delivered through the hysterotomy atraumatically. The infant's nose and mouth were suctioned with the bulb suction. The cord was then clamped and cut. The infant was handed off to the awaiting pediatrician. The placenta was manually removed, and the uterus exteriorized and cleared of all clots and debris. The uterine incision was then repaired with 0-Monocryl in a running-locked fashion. Excellent hemostasis was noted. The uterus was then returned to the abdomen. The gutters were irrigated, suctioned, and cleared of all clots. All instrument counts were correct times 2. The fascia was then reapproximated with 1-Vicryl in a running fashion, and the skin was closed with staples. The patient tolerated the procedure well. The patient was then taken to recovery in good condition.

CESAREAN WITH TUBAL DICTATION
DESCRIPTION OF PROCEDURE: After informed consent obtained, the patient was taken to the operating room and given spinal anesthesia. The patient was placed in the supine position with a leftward tilt. She was then prepped and draped in a normal sterile fashion. A Pfannenstiel skin incision was made with the scalpel, and this was carried down to the underlying layer of fascia with a Bovie. The fascia was then incised in the midline and the incision extended laterally with the Mayo scissors. The superior aspect of the fascial incision was then grasped with Kocher clamps, elevated, and underlying rectus muscle dissected off the fascia using sharp and blunt dissections. Attention was then turned to the inferior aspect of the fascia. It was then grasped with Kocher clamp, elevated, and again the underlying rectus muscle dissected off the fascia using sharp and blunt dissections. The rectus muscle was then separated in the midline.The peritoneum was entered bluntly. This incision was then extended superiorly and inferiorly with good visualization of the bladder. The bladder blade was then inserted, and the vesicouterine peritoneum identified and grasped with the pickups and entered sharply with the Metzenbaum scissors. This incision was then extended laterally, and the bladder flap was created digitally. The bladder blade was then replaced. The lower uterine segment was incised in a transverse fashion with a scalpel. This incision was then extended laterally bluntly. The bladder blade was removed and the infant was delivered through the hysterotomy easily. The infant's nose and mouth were suctioned with the bulb suction. The cord was then clamped and cut. The infant was handed off to the awaiting pediatrician. The placenta was spontaneously removed. The uterus exteriorized and cleared of all clots and debris. The uterine incision was then repaired with 0-Monocryl in a running locked fashion. Excellent hemostasis was noted.

The left fallopian tube was identified and followed out to the fimbriated. The Babcock clamp was then used to grasp the tube. A window was created in the mesosalpinx. A 3 cm segment of the tube was then clamped, excised, and ligated with a free tie of 0 chromic gut. Excellent hemostasis was noted. The right fallopian tube was identified and followed out to the fimbriated. Again, it was grasped with a Babcock clamp and a window was created in the mesosalpinx. A 3 cm segment of the tube was then clamped, excised, and ligated with a free tie of 0 chromic gut. Excellent hemostasis was noted. The uterus was then returned to the abdomen. The gutters were irrigated, suctioned, and cleared of all clots. All instrument counts were correct times 2. The fascia was then reapproximated with 1-Vicryl in a running fashion, and the skin was closed with staples. The patient tolerated the procedure well. The patient was then taken to recovery in good condition.

TUBAL LIGATION DICTATION
SPECIMEN SENT: Include segments of right and left tubes. POSTOP FINDINGS: Uterine fundus at umbilicus, normal-appearing tubes. DESCRIPTION: Patient is a 31-year-old gravida 3, para 3, who expressed the desire for future infertility. Patient was given all contraceptive options. The risks, benefits, and complications were discussed. Patient verbalized she understood these options, risks, and benefits and want to have tubal ligation done. Patient was told of the specific risks with a tubal ligations including but not limited to bleeding, infections, injury to close by organs, and 2 percent failure rate. After informed consent obtained, patient was taken to the operating room and given general anesthesia. She was placed in the supine position. She was then prepped and draped in a normal sterile fashion. Her infraumbilical incision area was anesthetized with 0.25 percent Marcaine, and an infraumbilical incision was then made with a scalpel and carried down to the underlying layer of fascia. The fascia was then grasped with Kocher, elevated, and incised with Mayo scissors. The peritoneum was then entered bluntly. Upon inspection, the patient was found to have uterine fundus at the umbilicus. The left fallopian tube was identified and followed out to the fimbriated end. Babcock clamps were then used to grasp the tube in middle 3rd segment. A window was created in the mesosalpinx. A 3-cm segment of the tube was then clamped, excised, and ligated with free tie of 0 chromic gut. Excellent hemostasis was noted. The left tubes were then returned to the patient's abdomen. The right tube was then identified and followed out to the fimbriated end. Again, it was grasped with a Babcock clamps, and a window was created in the mesosalpinx. A 3-cm segment of the tube was then clamped, excised, and ligated with free tie 0 chromic gut. Excellent hemostasis was noted. The right tube was then returned to the patient's abdomen. All instrument counts were correct x2. The fascia was then re-approximated with number 1 Vicryl in a running fashion and the skin was closed with 4-0 Monocryl in the subcu fashion. Patient tolerated the procedure well. She was then awakened and taken to recovery room in good condition.

VACUUM DELIVERY DICTATION -- be sure to review with Attending and Nursing staff. Double check delivery summary.
Include: Indication Patient verbally consented Fetal Station (if not +2 or lower then say why --ask Attending) Number of pullsets (each set is one contraction) Number of pop-offs (goal is 0) Total Vacuum pull time.

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