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Primary Low Transverse Cesarean Delivery Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
A (XX)-year-old with footling breech at term.

POSTOPERATIVE DIAGNOSIS:
A (XX)-year-old with footling breech at term.

PROCEDURE PERFORMED:  Primary low transverse cesarean delivery.

SURGEON:  John Doe, MD

ANESTHESIA:  Spinal.

COMPLICATIONS:  None.

ESTIMATED BLOOD LOSS:  500 mL.

ANTIBIOTICS:  Two grams Ancef intraoperatively.

OPERATIVE FINDINGS:  Normal male infant, 3450 grams.

DESCRIPTION OF PROCEDURE:  The patient was taken to the operating room after having a previous Foley catheter placed and clipper shave. The patient was then given anesthesia. She had a normal fetal heart tracing prior to this. She was then placed in a left uterine tilt and prepped and draped. A Pfannenstiel incision was made and taken down to the rectus sheath with sharp dissection. This was then extended laterally using sharp dissection. Rectus muscles were separated sharply cephalad and caudad. The peritoneum was tented, entered sharply and extended bluntly. After this, the bladder blade was inserted, visceral peritoneum was tented off of the uterus and cut in order to create a vesicouterine reflection and the bladder blade was then reinserted over this. A hysterotomy was done. After this, an amniotomy was done and it was clear fluid. Hysterotomy incision was then extended bluntly. The infant was then slightly rotated to get to the buttocks in the presentation. This was then elevated. After doing this, a nontraumatic delivery to the shoulders was effected, upon which the patient's right shoulder was then brought across midline and out. The baby rotated and the left shoulder was brought out subsequently. At this time, we could easily see there was a nuchal cord x1. The head was easily delivered at this point in time. Nuchal cord reduced. The cord was doubly clamped and cut in between and the infant was bulb suctioned and then handed off to the nurses for warming. Baby was spontaneously crying at this point in time. Cord blood was obtained. Placenta was manually removed. Uterus was wiped free of remaining fragments and closed with 2 layers of #1 Vicryl. Irrigation was applied and removed. It was hemostatic. Fascia was then closed with 0-Vicryl suture followed by a 3-0 subcutaneous followed by a 4-0 subcuticular Monocryl. Steri-Strips placed. The patient tolerated the procedure well. Instrument, sponge and needle counts were correct x2. The patient was taken to the recovery room in stable condition.