Spontaneous Vaginal Delivery

Topics: Childbirth, Uterus, Pregnancy Pages: 17 (512 words) Published: February 24, 2014
NORMAL
 SPONTANEOUS
 VAGINAL
 DELIVERY
 

 
Date
 of
 Procedure:
 
Preop
 Dx:
 38
 week
 IUP
 in
 active
 labor
 (with-­‐list
 any
 other
 diagnosis).
 
Postop
 DX:
 Same
 with
 delivery
 of
 viable
 male
 infant
 at
 1400
 hours
 weighing
 7#12oz
 with
 Apgars
 of
 9
 
@
 1
 min
 and
 9
 @
 5
 min.
 
Procedure:
 Spontaneous
 Vaginal
 Delivery
 
Surgeon:
 (list
 staff
 physician
 name)
 
Assistants:
 Junior
 Resident
 and
 Senior
 Resident
 
Anesthesia:
 Local
 infiltration
 of
 _____/pudendal
 infiltration
 of
 _____/epidural
 
EBL:
 
Indications:
 This
 19
 y/o
 G1P0
 presents
 at
 39
 4/7
 weeks
 gestation
 by
 LMP
 with
 an
 EDC
 of
 04/06/12,
 
c/o
 regular
 uterine
 contractions.
 Her
 prenatal
 course
 was
 complicated
 by
 ___.
 Prenatal
 lab
 data
 
includes
 blood
 type
 O+
 with
 a
 negative
 Ab
 screen,
 Rubella
 Immune,
 VDRL
 NR,
 HepBsAg
 neg,
 HIV
 NR,
 
GBS
 neg.
 She
 presented
 at
 0400
 hours
 this
 am
 complaining
 of
 UCs
 q
 5
 minutes.
 At
 that
 time,
 her
 
cervix
 was
 2
 cm,
 90%
 effaced
 and
 at
 a
 –1
 station.
 FHR
 was
 reactive
 and
 reassuring.
 She
 remained
 
normotensive
 throughout
 the
 course
 of
 her
 labor.
 Slow
 progress
 was
 made
 initially,
 and
 at
 0800
 hours
 
artificial
 rupture
 of
 membranes
 was
 performed
 with
 a
 return
 of
 clear
 fluid.
 At
 that
 time,
 her
 cervix
 
was
 5cm,
 100%
 effaced
 and
 the
 fetal
 vertex
 was
 at
 a
 0
 station.
 An
 epidural
 was
 placed
 for
 analgesia
 at
 
this
 time.
 She
 progressed
 to
 complete
 by
 1200
 hours
 and
 was
 allowed
 to
 push,
 bringing
 the
 infant’s
 
vertex
 to
 the
 perineum.
 
Procedure:
 The
 patient
 was
 noted
 to
 be
 complete
 and
 pushing,
 so
 was
 placed
 in
 the
 dorsal
 lithotomy
 
position,
 prepped
 and
 draped
 in
 the
 usual
 sterile
 fashion
 for
 a
 vaginal
 delivery.
 (Pt.
 Noted
 to
 have
 
epidural
 anesthesia/1%
 Lidocaine
 was
 infiltrated
 into
 the
 perineum/a
 pudendal
 block
 was
 placed).
 
The
 patient
 was
 asked
 to
 push
 and
 the
 head
 delivered
 spontaneously
 in
 the
 (LOA/ROA/OP,
 etc.)
 
position,
 over
 (an
 intact
 perineum/a
 midline
 episiotomy).
 The
 oropharynx
 and
 nasopharynx
 were
 then
 
(bulb/DeLee)
 suctioned
 on
 the
 perineum.
 A
 nuchal
 cord
 was
 checked
 and
 (none/one)
 noted,
 and
 
(relieved/delivered
 through/clamped
 and
 cut)
 around
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