Vaginal Delivery Dictation

"This is an operative note for patient name ____, MRN/Unit number ____. This is [your name] dictating for [Attending]."

Date of procedure:

Preop Dx: [pre]term intrauterine pregnancy in active labor at X weeks

Post Op Dx: same as preoperative diagnosis s/p [spontaneous/operative] vaginal delivery

Procedure Performed: [spontaneous/operative] vaginal delivery

Indication (HPI): Patient is a X year old G_P_ who presented to Tulane Lakeside labor and delivery at X weeks with ___. She was admitted in anticipation of delivery. Her labor course was augmented/induced with ___, and was otherwise [un]complicated.

Surgeon:

Assistant:

Anesthesia:

EBL:

Findings/Infant and Apgar score: viable [fe]male infant with Apgars of [] and []

Procedure Detail:

I was at the bedside of this X yo G_P_ at X weeks gestational age in active labor when the vaginal exam was completely dilated, completely effaced and +2 of 3 station. The patient was placed in dorsal lithotomy position and prepared and draped in the normal fashion. Under continuous external/internal fetal heart rate monitoring, the patient was encouraged to push. With good maternal effort [or dicate operative below], she delivered a viable [fe]male infant with APGARs of X and X.

[Vacuum: Due to maternal/fetal indications, delivery assisted by Kiwi vacuum was offered. The patient was counseled and indications and risks were discussed. Questions were answered and the patient's consent was obtained. At this point, the cervix was completely dilated. Nursey and anesthesia were notified. Maternal fetal sizes were determined appropriate for application and the bladder had been emptied. The fetal station was noted to be low +3 and the fetal head was noted to be in the OA position. Kiwi vacuum was applied to the fetal head. Cup placement was determined to be appropriate and maternal tissue was noted to be excluded from the cup. The vacuum was placed on the fetal head and the pressure was kept in the recommended range per manufacture's instructions. Station was advanced with each pull. Total traction time was ___ minute with ___ pulls and ___ pop offs. Vacuum extraction of the head was successful and neonatal head assessment was normal.]

[Forceps: Due to maternal/fetal indications, delivery assisted by forceps was offered. The patient was counseled and indications and risks were discussed. Questions were answered and the patient's consent was obtained. At this point, the cervix was completely dilated. Nursey and anesthesia were notified. Maternal fetal sizes were determined appropriate for application and the bladder had been emptied. The fetal station was noted to be low +3 and the fetal head was noted to be in the OA position. Tucker-McLane forceps were opened and each blade was lubricated with gel. Vaginal examination reconfirmed direct OA position and outlet station. The handle of the left branch was held in the left had and the tip of the blade was gently introduced into the left side of the vagina with the right hand. In a similar fashion, the right blade was placed into the right side of the vagina. Biparietal application was confirmed and the two branches were locked with ease. Gentle traction in the axis of the pelvis was applied in coordination with uterine contraction and maternal pushing effort. Station was noted to be advanced with each pull. Total traction time was ___ minute with ___ pulls over ___ contractions. The handles of the forceps were gradually elevated when the occiput was delivered under the pubic symphysis. The forceps then disarticulated and removed.]

The fetal head delivered first in ROA/LOA/OP position. Nuchal cord was reduced/cut/not present. Then, with gentle downward guidance, the (L or R) anterior fetal shoulder was delivered, followed by the (L or R) posterior fetal shoulder, followed by the remainder of the infant without difficulty.

The umbilical cord was clamped x 2 and cut in between [by the baby’s father]. The infant was vigorous and placed on the mother’s abdomen/handed to awaiting nurses/pediatric team.

Cord blood/cord gasses were then collected. The placenta delivered spontaneously/manually and intact (or not). Three-vessel cord was noted. Pitocin infusion was started immediately after the delivery of the placenta. Uterine massage was given until the fundus was firm.

The cervix, perineum, vagina, and rectum were then carefully inspected for lacerations. None were noted (or what types and the repairs performed). Hemostasis was noted. No sponges were left in the vagina and all counts were correct.

Mother and baby were bonding well at the end of the procedure.

Dr. Attending was present for the entire delivery.