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Delivery Note Medical Transcription Sample Report / Example

DATE OF DELIVERY:  MM/DD/YYYY 

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old G1, P0 at 39-3/7 weeks with an EDD of MM/DD/YYYY based on a 6-week ultrasound. The patient presented to L and D with complaints of contractions every 3 minutes and leaking of fluid since 0400 on MM/DD/YYYY. The patient reports positive fetal movement and denies vaginal bleeding. Prenatal care began at 9 weeks x15 visits. Total weight gain was 37 pounds. The patient is A positive, rubella immune, GBS positive. She has no known drug allergies.

Upon admission, vaginal exam was 1, 80% and -1 station per the RN. Fetal heart tones were 124, positive long term variability, positive acceleration and no decelerations. Uterine contractions every 2 to 3 minutes, 60 to 80 seconds and moderate to palpation.

ASSESSMENT:
1.  Term pregnancy. 
2.  Spontaneous rupture of membranes. 
3.  Spontaneous labor. 
4.  Reassuring fetal status.

PLAN:  Admit the patient to the labor and delivery unit. Dr. Doe informed and agrees with plan. GBS protocol, ampicillin. The patient encouraged to ambulate, shower, use the birth ball. Reassess in 3 to 4 hours or p.r.n.

At 1500 hours on MM/DD/YYYY, the patient continued to breathe with contractions. Her husband was at her side and was quite supportive. Vital signs were stable. Fetal heart tones were in the 120s with average long term variability, positive accelerations, no decelerations. Uterine contractions were every 2 to 5 minutes for 50 to 90 seconds, moderate to palpation. Vaginal exam at that time was 2, 80%, -1 station. There had been minimal cervical change; however, fetal heart tones remained reassuring. Plan was to start Pitocin per protocol after having reviewed the options with the patient, who was agreeable to the plan. Continue to ambulate, use the birth ball or shower, and reevaluate after 3 to 4 hours. Dr. Doe was made aware of the plan and agreed.

At 2100 hours, the patient reported being more uncomfortable during the contractions but able to rest between. She was feeling most of her pain in her back. Her husband was at the bedside providing support. The patient was ambulating and using the birthing ball and showering but was requesting an epidural. Vital signs remained stable, as did the fetal heart tones. The vaginal exam was 5, 80%, 0 to -1 station. 

At 2300 hours, the patient was resting comfortably with her epidural. Temperature at that time was 99.6 and Tylenol per rectum was given. Fetal heart tones were 120s with average long term variability but prolonged decelerations down to the 90s and sometimes 60s x3 minutes with prolonged uterine contractions. Uterine contractions were every 1-1/2 to 5 minutes and there was coupling and they were lasting 50 to 70 seconds and moderate to palpation. The vaginal exam was 7 to 8 cm, 80%, 0 to -1 station and caput was forming. Pitocin was at 16 mU. Dr. Doe was informed of decelerations, which seemed to be eliminated by maternal position changes and agreed with the plan to continue Pitocin augmentation.

At 0400 hours, the patient was reporting increased vaginal and rectal pressure and had an urge to push. She was still comfortable with her epidural. Vital signs:  Temperature was 98.8, fetal heart tones were 144 with minimal long term variability but positive accelerations and early decelerations with contractions. Uterine contractions were every 1-1/2 to 5 minutes with coupling and lasted 60 to 100 seconds long, strong to palpation. The Pitocin was at 10 mU. Vaginal exam was complete, +1 station with caput. The patient was only feeling mild urges to push and so the plan was to continue laboring down and to begin pushing efforts when there was a stronger urge.

At 0600, the patient was complete and laboring down. She reported a strong urge to push and pushing was begun. The patient pushed effectively. Fetal heart tones were 130s with minimal to moderate long term variability with no accelerations. There were variable decelerations down to the 70s x 1-1/2 to 2 minutes with pushing efforts with a slow return to baseline after the contraction. O2 was applied and Pitocin was turned off. Dr. Doe was paged and Dr. Jane Doe, the house officer, was requested to evaluate the patient for possible vacuum extraction. Dr. Jane Doe presented at the patient's bedside for evaluation of fetal station which was 0 with caput at +1 in LOA position. Dr. Jane Doe recommended restarting the Pitocin after 30 minutes of rest at 4 to 5 mU and then increase slowly to allow the fetus to labor down. After turning on the Pitocin, fetal heart tones were in the 130s with moderate long term variability, positive accelerations and no decelerations. Uterine contractions were every 3 to 5 minutes, lasting 60 to 90 seconds and strong. The patient was resting comfortably with the epidural. Dr. Doe was aware and continued to agree with the plan. At 0830 hours, report was given to certified nurse midwife, who resumed the care of the patient.

LABOR PROGRESS:  At 0900, the patient was pushing with contractions. She was feeling pressure but was still comfortable with the epidural. The patient stated that she was exhausted. The Pitocin was restarted at 2 mU as the RN realized that the catheter had come loose from the patient's IV and the Pitocin was not being delivered to the patient. Pitocin currently now at 18 mU per minute. Contractions were every 2 to 6 minutes, 50 to 60 seconds long. Fetal heart tones were 125, average variability, 15 x 15 accelerations with mild variable decelerations with good return to baseline. Vaginal exam at 0830 hours was complete, 100%, with the head at the 0 station and the caput at +2 station. The patient appeared to be making some progress with pushing; however, Dr. Doe was consulted and was asked by the CNM to assess the patient after leaving an OR case. The plan was that the patient would continue pushing provided fetal heart tones remained stable until Dr. Doe was able to get out of the OR to evaluate her. The plan was to consider vacuum extraction.

DELIVERY NOTE:  The patient pushed extremely well and through excellent maternal efforts and frequent position changes, the infant rotated and descended and normal spontaneous vaginal delivery occurred at 0950 hours in the LOA position over intact perineum. Meconium-stained fluid was noted as the head came over the perineum and Neonatology was called to the room. The mouth and nose were bulb suctioned on the perineum by the CNM. The shoulders delivered easily and a nuchal cord loose x1 was noted and reduced with the delivery of the body. The cord was immediately clamped x2 and cut by the father of the baby and the infant was taken to the warmer for evaluation by Neonatology. The placenta delivered spontaneously at 0958 hours, was complete, had a 3-vessel cord, and was in the Schultz fashion. EBL was 200 mL. Pitocin was run open after the delivery of the placenta. The vagina was inspected and a first-degree vaginal and left first-degree labial laceration were repaired with 2-0 chromic and 3-0 Vicryl respectively. The fundus was firm, midline, and -2. There was light lochia. Infant’s Apgars were 6, 8 and 9. Weight was 7 pounds 16 ounces. The mother and the infant were left in stable condition.