DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. A 41-week intrauterine pregnancy.
2. Labor.
3. Fetal bradycardia.
4. Poor maternal expulsive effort.
POSTOPERATIVE DIAGNOSES:
1. A 41-week intrauterine pregnancy.
2. Labor.
3. Fetal bradycardia.
4. Poor maternal expulsive effort.
OPERATIONS PERFORMED:
1. Low forceps delivery.
2. Repair of midline episiotomy with third-degree extension.
SURGEON: John Doe, MD
ANESTHESIA: Epidural.
ESTIMATED BLOOD LOSS: 300 mL.
OPERATIVE FINDINGS:
1. Viable male infant with Apgars 8 and 9, weight 7 pounds 9 ounces.
2. Midline episiotomy with third-degree extension with intact rectum.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old gravida 1, para 0 at 41 weeks who presents in labor. The patient progressed to completely dilated and pushed for approximately 1-1/2 hours to a +3 station. The fetal heart rate tracing showed severe variable decelerations. Due to the poor maternal expulsive effort, forceps delivery was discussed with the patient, and verbal consent was obtained.
DESCRIPTION OF OPERATION: The bladder was catheterized. The epidural was found to be adequate. The Luikart-Simpson forceps was placed on the fetal head at the left occiput anterior position at a +3 station. With two contractions, the fetal head was delivered atraumatically. There was a tight nuchal cord, which was reduced, and the remainder of the infant delivered without difficulty. The mouth and nose were suctioned with the bulb suction. The cord was doubly clamped and cut, and the infant handed off to the awaiting nursery staff. Cord blood was then obtained.
Inspection of the perineal body showed a midline episiotomy with a third-degree extension. The rectum was examined and noted to be intact. The external anal sphincter was then reapproximated with interrupted figure-of-eight sutures of 2-0 Vicryl. The vaginal mucosa was then reapproximated with running interlocking suture with 2-0 Vicryl. The bulbocavernosus muscles were then reapproximated with interrupted sutures of 2-0 Vicryl. The skin was closed in subcuticular fashion with 3-0 Vicryl. The placenta was delivered with fundal pressure prior to the repair of the episiotomy. There was noted to be excellent hemostasis. The infant and the mom were in stable condition.
