DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Intrauterine pregnancy, 38 and 5 days.
2. Failure to progress from almost complete dilatation.
POSTOPERATIVE DIAGNOSES:
1. Intrauterine pregnancy, 38 and 5 days.
2. Failure to progress from almost complete dilatation.
PROCEDURE PERFORMED: Primary low transverse cesarean section.
SURGEON: John Doe, MD
ANESTHESIA: Epidural.
ESTIMATED BLOOD LOSS: 800 mL.
COMPLICATIONS: None.
FINDINGS: Male infant delivered from vertex presentation with Apgars of 8 and 9, clear amniotic fluid, normal pelvic organs and normal placenta, and three-vessel cord.
DESCRIPTION OF OPERATION: The patient was taken to the operating room, and after successful level of epidural anesthetic was obtained, she was placed on the table in the supine position. The abdomen and perineum were prepped and draped in the usual sterile fashion. A Pfannenstiel skin incision was made with a scalpel. The abdomen was entered in the normal Pfannenstiel way. Once inside the abdomen, the visceral peritoneum was bluntly and sharply dissected off the lower uterine segment. A transverse incision was made over the lower uterine segment and the incision extended laterally and curved upwards both ways with scissors.
Once inside the uterus, the infant was delivered from the vertex presentation in standard fashion without complications. Clear amniotic fluid was seen. Mouth and nose were suctioned with the bulb suction. The cord was doubly clamped and cut. The infant was handed off to the nursing staff in attendance. Routine cord bloods were obtained. The placenta was manually extracted from the uterus, and the uterus was exteriorized, covered with a moist lap sponge, and a dry sponge was used to wipe the uterine cavity of remaining blood clots and products of conception.
The uterine incision was closed with two layers of running interlocking 0 chromic sutures with a second layer imbricating the first. Subsequently, the visceral peritoneum overlying the lower uterine segment was approximated with a 2-0 running Vicryl suture. Hemostasis was adequate. The uterus was placed back in the abdomen. The paracolic gutters were vigorously irrigated, and the abdominal wall closed in layers in the standard fashion. The fascia was approximated with two #0 PDS sutures with each half of the incision being closed with a separate suture. Vicryl 3-0 interrupted sutures were used to approximate the subcutaneous tissues and Dermabond was used for the skin. A sterile dressing was applied. The uterus was expressed of any remaining blood clots. The patient was taken to the recovery room in good condition having tolerated the procedure well. At the end of the procedure, all sponge, needle and instrument counts were correct x 3.
Sample #2
DATE OF OPERATION: MM/DD/YYYY
PROCEDURE PERFORMED: Low transverse cervical cesarean section.
DESCRIPTION OF OPERATION: After informed consent was signed, the patient was taken to the operating suite and placed in the supine position. The table was tilted to the left. She had her abdomen appropriately prepped and draped. A low transverse skin incision was made and carried down to the anterior rectus fascia, which was divided transversely and dissected superiorly and inferiorly off the rectus muscle. The rectus muscle was bluntly divided in the midline, and the peritoneum was grasped, elevated, and divided and the peritoneal incision carried superiorly and inferiorly to the dome of the bladder. The bladder blade was placed. The bladder flap was developed. A second knife was used to make the initial uterine incision, and it was carried through the uterine cavity. Using a Kelly clamp, the incision was then extended laterally digitally. The first infant was dislodged from the pelvic brim. There was caput. It was asynclitic. The head was delivered and mouth and nose suctioned. The remainder of the infant was delivered. The cord was doubly clamped and cut. The bag of water of the second twin was ruptured. It was delivered breech to the umbilicus. The cord was lengthened, and it was delivered to the shoulders. The arms delivered across the chest and then the head gently delivered. Mouth and nose were suctioned. The cord was doubly clamped and cut. Cord blood samples were obtained. The placenta was delivered manually. The uterus was eviscerated. The cut edges of the uterus were grasped with T clamps. The uterus was injected with IU Pitocin. The uterus was closed using 0 Monocryl, the first one being a running locked stitched and the second being a running nonlocked, imbricating stitch. The uterus was placed into the abdomen. The abdominal gutters were cleaned of any free blood and clots. There was no bleeding from the uterine incision. The peritoneum of the bladder was reestablished using 0 Monocryl, the peritoneum closed with 2-0 Vicryl, and the fascia closed from left to right using 0 Vicryl. Subcutaneous tissues were irrigated and dried. There was no active bleeding. Scarpa’s fascia was reapproximated using 3-0 plain gut. Skin edges were reapproximated using 4-0 undyed Vicryl in a subcuticular manner. Steri-Strips were applied. The patient was taken to the recovery room in stable condition.
