Inpatient Pregnancy chart 1 OP report

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DELIVERY REPORT

Delivery Note 

Vaginal Delivery Note: 38w3d

 

Male

Birth date/time:               4:36 AM 

Living status: Living

Sex: Male

Apgar 1min: 8    Apgar 5min: 9 

Delivery Type: Vaginal, Spontaneous

Presentation: Vertex       

Position: Middle               -: Occiput             -: Anterior

Shoulder dystocia present: No

Placenta Removal: Expressed

Placenta Appearance: Intact

Comment: marginal cord insertion

Cord Complications: Nuchal

Nuchal intervention: reduced

Nuchal cord description: loose nuchal cord

Number of loops: 1           

Delayed Cord Clamping: Yes         

Delayed (seconds): 60

Anesthesia Method: Local

Local Medication Used: Lidocaine 1%      Volume (mL): 10

                Delivery quantified blood loss (mL): 400

COMBINED delivery est. & quant. blood loss (mL): 400

Surgical est. blood loss (mL): 0

Episiotomy: Median        Repaired with: 3-0 Polysorb, 2-0 Polysorb

Episiotomy Laceration Comment: Anal sphincter evaluated by MD Chu, found intact

Perineal lacerations: None                            

Rectal Exam: Intact           

 

Rupture type: Artificial

Fluid color: Clear 

 

Based on the clinical risk factors present at the time of this note, the risk of Postpartum Hemorrhage is medium. 

Silvia L Torres pushed with approximately 5 contractions until delivery. Deep variables to the 90s prior to delivery, which became prolonged decels lasting 1.5-2 minutes. Pedi and MD Chu called to bedside for potential VAVD. Excellent maternal pushing effort, but strong perineal tissues impeding immediate delivery. I quickly consented pt for an episiotomy to due to terminal decel to the 90s lasting 4 minutes. 1.5cm midline episiotomy cut.  Uncomplicated delivery of head. There was a nuchal cord, reduced prior to delivery of body. Anterior and posterior shoulders delivered without difficulty. Baby born with cry and good tone. Cord clamping was delayed for approximately 5 minutes. Cord clamped x2 by me and cut by FOB. Active management of the third stage was performed. Pitocin was administered. Gentle, steady traction was applied to the umbilical cord. Intact placenta delivered. Upon inspection by MD Chu and myself, a 1.5cm episiotomy with intact anal sphincter was found. Laceration was repaired with 2-0 and 3-0 Polysorb in the standard fashion. Scant bleeding with repair, however several large clots expressed with fundal massage and then with bimanual exam. LUS firm. Fundus firm, midline. Persistent clots with fundal massage, EBL at this point 350mL. Given history of delayed PPH and rate of large clots expressed, administered Misoprostol 500mcg PR, methergine IM for bleeding. QBL 450mL. Instrument and lap counts performed and accurate.