DATE OF DELIVERY: MM/DD/YYYY
CLINICAL HISTORY: The patient is a (XX)-year-old Hispanic female, gravida 3, para 1, AB 1, status post vaginal delivery x1, and a spontaneous abortion x1. The patient presently is 39 and 1/7 weeks by an estimated date of confinement of MM/DD/YYYY, which was determined by an ultrasound performed, placing the patient at 8 and 4/7 weeks. The patient was admitted to the hospital earlier today for elective induction of labor.
On admission, the fetal heart pattern was noted to be reactive. The patient subsequently had the initiation of IV Pitocin to begin her induction. The patient’s cervix on admission was stated to be 2 cm dilated, -2 station, and 60% effaced. Fetus was also confirmed to be in cephalic presentation.
The patient’s pregnancy was complicated by the fact that her last pregnancy was delivered recently. The patient therefore conceived within a year. The patient’s pregnancy also was complicated by the fact that she is a carrier for cystic fibrosis. The patient’s husband has no insurance and was unable to be tested. The patient lastly does have a history of fast labors.
The patient subsequently had artificial rupture of membranes performed resulting in clear fluid. The patient’s cervix at that time was 3 cm dilated, -2 station, and 50% effaced. The patient became more uncomfortable at which time she expressed the desire to have an epidural anesthetic. Anesthesia was consulted and a labor epidural placed. The patient then was comfortable. The patient eventually progressed to 8-9 cm and then to complete dilation.
The patient was then directed to start pushing. When the fetal vertex began to crown, the patient was placed in a dorsal lithotomy position. The patient subsequently delivered the fetal vertex spontaneously in left occiput anterior position. No episiotomy was performed. The infant’s oral and nasopharynx were bulb suctioned. There was noted to be a nuchal cord x1, loose, which was easily reduced. The rest of the infant’s body also was delivered without difficulty, noting to be a viable female. There was noted to be a true knot x1 in the cord.
After it was noted that the infant was doing well, attention was directed back to the patient. The infant was noted to be vigorous with good tone. She also developed a strong spontaneous cry. Placenta next was delivered, noted to be grossly intact and with a 3-vessel cord.
The patient was then given infusion of IV Pitocin to aid in clamping down of the uterus. Cervix next was examined for lacerations and none were visualized. The uterus was explored and no membranes obtained. The examination of the patient’s vagina and perineum also revealed no lacerations.
The patient was then cleaned off and taken out of the dorsal lithotomy position. Pelvic examination also was performed to confirm that there were no sponges left in the vagina. Sponge and needle counts also were confirmed to be correct.
SIGNIFICANT FINDINGS: The patient underwent a spontaneous vaginal delivery of a viable female infant. The infant’s Apgars were 9 and 9 at one and five minutes respectively. Estimated infant’s weight was 7 pounds 2 ounces.
Examination of the patient afterwards revealed no lacerations. Estimated blood loss was 200 mL.
