DATE OF DELIVERY: MM/DD/YYYY
1. Gravida 1, para 0.
2. Singleton intrauterine pregnancy at 41 and 2/7 weeks' gestation.
3. Prolonged rupture of membranes.
4. Meconium-stained amniotic fluid.
5. Active labor.
POSTDELIVERY DIAGNOSIS: Normal spontaneous vaginal delivery of a viable female in the left occipitoanterior position.
TYPE OF DELIVERY: Normal spontaneous vaginal delivery of viable female in the LOA position.
ESTIMATED BLOOD LOSS: 350 mL.
FINDINGS: Weight 7 pounds 12 ounces. Apgars 8, 9 and 9. Placenta delivered spontaneously intact with 3-vessel cord and meconium noticed. Second-degree perineal laceration repaired with 2-0 chromic under epidural and local anesthesia.
DELIVERY DETAILS: The patient is a (XX)-year-old female, gravida 1, para 0, at 41 and 2/7 weeks' gestation by LMP, dated by 7-week ultrasound. Her dates are consistent with last menstrual period. The patient presented to Labor and Delivery at 1630 with complaint of spontaneous rupture of membranes at 3 a.m. with regular contractions. Her vaginal exam at 1650 was 3, 100, -2. The patient desired natural childbirth. Due to prolonged rupture of membranes, penicillin prophylaxis was started at 1830. At 0130, she was 6, 100, -1. At 0450, bag was ruptured with meconium-stained amniotic fluid, and she was 8, 100, -1. At 0720, she was 8, 100, 0. At 0950, after epidural anesthesia, she was 10, 100, +1. She progressed to complete, 100 and +1 station at 1150 after resting for 4 hours after epidural anesthesia. Fetal heart tones in the second stage of labor were overall reassuring. She began pushing with direction. She pushed for 1 hour 20 minutes, delivered the head in the LOA position. Bulb suction of mouth and nose at the perineum. Shoulders delivered easily. Progressed to normal spontaneous vaginal delivery of viable female at 1310, delivered onto mom's abdomen. The cord was clamped x2 and cut. Baby was handed to the neonatologist with meconium-stained amniotic fluid. Apgars were 8, 9 and 9. Negative meconium below the cord. The weight was 7 pounds 12 ounces. Placenta delivered spontaneously intact with 3-vessel cord at 1315. Fundus massaged to firm. Hemostasis achieved easily with an estimated blood loss of 350 mL after Pitocin 30 units IV piggyback given. A second-degree perineal laceration was noted and repaired with 2-0 chromic with local anesthesia. The mother and baby tolerated delivery well.
Pediatric Discharge Summary Samples #1 Neonatal / Infant Discharge Summary Sample