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Forceps Delivery Medical Transcription Operative Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PRE-DELIVERY DIAGNOSES:
1.  Term pregnancy.
2.  Nonreassuring fetal heart strip.

POST-DELIVERY DIAGNOSES:
1.  Term pregnancy.
2.  Nonreassuring fetal heart strip.

PROCEDURE PERFORMED:
Forceps delivery.

ESTIMATED BLOOD LOSS:  300 mL

BRIEF HISTORY:  This (XX)-year-old gravida 1 presented at 38 weeks and 1 day gestation with history of spontaneous contractions. There was no history of ruptured membranes. No bleeding. The cervix was 2 cm dilated in the office earlier that day. This pregnancy was uneventful except for the abnormal quadruple screen for which the patient declined to have amniocentesis.

PAST MEDICAL HISTORY:  Noncontributory.

MEDICATIONS:  None except for vitamins.

ALLERGIES:  None.

PHYSICAL EXAMINATION:  On examination, vital signs are stable. Cardiovascular and chest examination normal. Abdomen is soft. Palpable contractions are noted. Cervix is 3 cm dilated with the presenting part at station 0 and 90% cervical effacement. Fetal heart rate was reactive.

COURSE AND DELIVERY NOTE:
The patient was admitted and mildly elevated temperature was noted. She was given ampicillin and Tylenol, and Pitocin was started for augmentation. The patient progressed with contractions and artificial rupture of membranes revealed clear fluid. Once fully dilated, the patient began pushing. During the second stage of labor, the patient developed some decelerations. The cervix was completely dilated. The fetal scalp was visible between labor in-between contractions. In view of the nonreassuring fetal heart rate tracing, the patient was presented with an option of a forceps delivery and explained the pros and cons and risks of the procedure, which the patient found acceptable. The bladder was drained. Between contractions, solid McLane forceps were applied and the position was rechecked and found to be appropriate. Over the next contraction, with the patient pushing and minimal amount of traction on the forceps, the head of the baby girl was delivered and suctioned and the rest of the delivery followed without difficulty. A pudendal block was used in addition to the epidural prior to forceps delivery. Complete placenta was delivered shortly thereafter. The baby's weight was 6 pounds 4 ounces and the Apgars were 9, 9 and 9 at one, five and ten minutes respectively. The cord gases were sent and the pH came back as 7.24 with base excess of -2.4. A right mediolateral episiotomy was performed to facilitate the delivery. This was later repaired with 2-0 chromic suture. There were no extensions. The rectum was checked post repair and found to be intact. Estimated blood loss for the procedure was approximately 300 mL. There were no complications. Both the baby and the patient were stable postdelivery. The instrument, needle and sponge counts were correct x2 at the end of the delivery.

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