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Kiwi Vacuum Delivery Medical Transcription Procedure Sample

DATE OF DELIVERY:  MM/DD/YYYY 

PRE-DELIVERY DIAGNOSES:
1.  Term pregnancy.
2.  Nonreassuring fetal heart rate tracing, mainly variable decelerations.

POST-DELIVERY DIAGNOSES:
1.  Term pregnancy.
2.  Nonreassuring fetal heart rate tracing, mainly variable decelerations.

TYPE OF DELIVERY:  Kiwi vacuum delivery.

ESTIMATED BLOOD LOSS:  200 mL

BRIEF HISTORY:  This (XX)-year-old gravida 2, para 1 presented at 39 weeks' gestation for induction of labor because of history of cervical dilation and a discussed risk of precipitous labor and a cord prolapse. This pregnancy was uneventful. The patient was GBS negative.
PAST SURGICAL HISTORY:  Noncontributory. The patient had one spontaneous vaginal delivery.

MEDICATIONS:  None except for vitamins.

ALLERGIES:  None.

PHYSICAL EXAMINATION:  VITAL SIGNS:  Stable. ABDOMEN:  Soft, nontender, and nondistended. CERVIX:  Initially 4-5 cm dilated, but quickly progressed to 9 cm cervical dilatation with Pitocin.

COURSE AND DELIVERY NOTE:
The patient required epidural for pain control. Once fully dilated, she began pushing. She had a relatively short second stage of labor. Towards the end of the second stage of labor, she developed variable decelerations, some with late component. This nonreassuring fetal heart rate tracing was discussed with the patient and her partner, as were the delivery options including a Kiwi vacuum delivery. The pros and cons and the risks of the vacuum delivery were discussed in detail, as were the alternative approaches. The patient and her partner decided to proceed with a Kiwi vacuum delivery. The cervix was completely dilated. The fetal scalp was visible between labor in-between contractions. The bladder was empty. The position was right occiput anterior. Between contractions, a flat Kiwi vacuum was applied and its position was rechecked and found to be appropriate. Over the next contraction, with the patient pushing and minimal amount of traction on the vacuum, the head of the baby boy was delivered and suctioned and the rest of the delivery followed without difficulty. A right mediolateral episiotomy was first performed to facilitate delivery. This was later repaired with 2-0 chromic suture. The rectum was checked post repair and found to be intact. Complete placenta with a 3-vessel cord was delivered. The baby's Apgars were 9, 9 and 9 at one, five and ten minutes respectively and the weight was 6 pounds 10 ounces. The cord pH was sent and it came back at 7.33 with a base excess of -3.2. Estimated blood loss for the procedure was approximately 200 mL. There were no complications. Both the patient and the baby were stable postdelivery. Instrument, needle and sponge counts were correct x2 at the end of the delivery.