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Low Transverse C Section Medical Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Intrauterine pregnancy at 39 weeks and 6 days.
2.  Nonreassuring fetal heart tracing, remote from delivery.
3.  Spontaneous rupture of the membranes at 2150 hours on MM/DD/YYYY.
4.  Limited prenatal care.

POSTOPERATIVE DIAGNOSES:
1.  Intrauterine pregnancy at 39 weeks and 6 days.
2.  Nonreassuring fetal heart tracing, remote from delivery.
3.  Spontaneous rupture of the membrane at 2150 hours on MM/DD/YYYY.
4.  Limited prenatal care.

OPERATION PERFORMED:
Emergent low transverse cesarean section with an extension.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  Spinal.

ANESTHESIOLOGIST:  Jean Doe, MD

INTRAVENOUS FLUIDS:  1200 mL.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  After appropriate informed consent was obtained, the patient was taken to the operating suite and given spinal anesthesia.  A Pfannenstiel skin incision was made through the lower section of the abdomen, taken down to the fascia.  The fascia was then incised in a bilateral curvilinear fashion using the curved Mayo scissors and pickups with teeth.  The fascia was dissected off the underlying rectus muscles bluntly and sharply using the curved Mayo scissors.  The rectus muscles were identified in the midline and were  separated using sharp dissection with the Mayo scissors.

The peritoneum was elevated with hemostats quite cephalad and entered sharply after transillumination using the Metzenbaum scissors.  The peritoneum was incised vertically and care was taken not to damage the bladder.  A bladder blade was placed and then the vesicouterine peritoneum was elevated.  It was entered sharply with the Metzenbaum scissors and excised in a bilateral curvilinear fashion.  It was then dissected carefully using blunt and sharp dissection off the lower uterine segment, the bladder blade was repositioned to protect.

A low transverse uterine incision was made and then expanded bilaterally using bandage scissors with fingers to protect the fetus.  The water bag was already ruptured.  A small extension occurred on the right side of the uterus.  The vertex was elevated and the fetal head was delivered atraumatic and without difficulty.  A DeLee suction catheter was used to clear the oral and nasopharynx and then the remainder of the infant was delivered without difficulty.  The umbilical cord was doubly clamped and cut and the male infant was handed to the waiting pediatricians.

Of note, there was a loose nuchal cord upon extraction of the newborn.  There was a spontaneous cry in the operative field.  The uterus was exteriorized and the placenta was removed manually and intact after appropriate cord blood samples were obtained.  The intrauterine area was curetted gently with a dry laparotomy cloth, while wet laparotomy cloth was used to protect the fundus.  The incision was inspected and found to have a small 2 cm extension on the right side of the incision.  The apices of the incisions were grasped with the Pennington clamps, and incision was closed with a standard two-layer closure of #1 chromic, the first being a running locking layer and the second being a running imbricating layer.

The incision line was hemostatic and the lower uterine segment was inspected and found to be hemostatic.  Therefore, the bladder flap was reapproximated with a 3-0 Vicryl running suture.  The uterus and its structure were inspected and found to be normal except for the filmy adhesions between the fallopian tubes and the ovaries.  There was no evidence of damage in intestines and the posterior segment was intact.  Therefore, the uterus was reperitonealized and irrigation was used in the paracolic gutters, and then the peritoneum was closed with the running 3-0 Vicryl suture in a vertical fashion.  Irrigation was used and the subfascial area was inspected carefully for hemostasis.

Then, the fascia was closed by beginning at each apex and sewing to the midline with #0 Vicryl suture.  Copious irrigation was used in the superficial fat pad and a few bleeders were coagulated with electrocautery.  The skin was reapproximated with sterile staples, and a pressure dressing was applied.  The patient was then taken to the recovery suite after tolerating the procedure without difficulty.  Instruments and sponge counts were correct.  The patient received 900 mg of clindamycin intravenously at cord clamp and a Foley catheter was previously placed and was there throughout the procedure.

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