DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. A 40 and 3/7 weeks’ intrauterine pregnancy.
2. Active labor.
3. Poor maternal expulsive effort.
POSTOPERATIVE DIAGNOSES:
1. A 40 and 3/7 weeks’ intrauterine pregnancy.
2. Active labor.
3. Poor maternal expulsive effort.
OPERATIONS PERFORMED:
1. Attempted vacuum extraction.
2. Low forceps delivery.
3. Repair of midline episiotomy.
SURGEON: John Doe, MD
ANESTHESIA: Epidural.
ESTIMATED BLOOD LOSS: 300 mL.
OPERATIVE FINDINGS:
1. Viable female infant, Apgars 8 and 9, weight 2830 grams.
2. Intact external anal sphincter.
3. The fetus was in the right occiput anterior position.
DESCRIPTION OF OPERATION: The patient is a (XX)-year-old gravida 1, para 0, at 40 and 3/7 weeks who presents in labor. The patient progressed to completely dilated, +1 station, and left occiput transverse position after pushing. The Mityvac was placed on the fetal head, and in an attempt to rotate the fetal head, the fetal head was brought down to the +3 station, however no further rotation from the left occiput transverse position.
The patient commenced pushing again for approximately 15 minutes, and the fetal head was manually rotated to the right occiput anterior position. The bladder was catheterized. The epidural was adequate. Luikart-Simpson forceps were placed on the fetal head, and with one contraction, the fetal head was delivered. The mouth and nose were suctioned with the bulb suction, and the remainder of the infant delivered without difficulty. The cord was then doubly clamped and cut, and the infant handed off to the waiting nursery staff. Cord blood was then obtained and the placenta delivered with fundal pressure.
Inspection of the midline episiotomy revealed an intact external anal sphincter. The vagina was reapproximated in running fashion with 2-0 Vicryl. The bulbocavernosus muscles were then reapproximated with interrupted sutures of 2-0 Vicryl. The skin was closed in a subcuticular fashion with 3-0 Vicryl. The patient and the infant were in stable condition.
