Cesarean Delivery Dictation

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

Date of procedure:

Dx: [pre]term intrauterine pregnancy at X weeks gestational age with [indication]

Post Op Dx: same as preoperative diagnosis s/p procedure performed

Procedure Performed: [primary/repeat] [low transverse/classical] cesarean delivery with [Pfannenstiel/midline] incision

Indication (HPI): Patient is a X yo GXPX who presented to Tulane Lakeside Labor and delivery at X weeks gestational age for [ ].

Surgeon:

Primary Assistant:

Secondary Assistant:

Anesthesia:

QBL:

IV Fluids:

UOP:

Infant findings and Apgar score: Viable [male/female] infant with Apgars of X and X

Procedure in Detail:

The patient was taken to the operating room. After adequate anesthesia, patient was prepped and draped in the usual manner in the dorsal supine position with a leftward tilt. A time-out was performed.

A Pfannenstiel incision was made with the knife and taken down to the level of the rectus fascia (with Bovie cautery). The fascia was incised and the incision was extended laterally (with Mayo scissors/Bovie). The superior portion of the rectus fascia was grasped with Kocher clamps x2 and reflected upward. The rectus abdominus muscles were dissected off the fascia using (Bovie/Mayo scissors). The same procedure was repeated on the inferior portion of the rectus fascia, dissecting off the pyramidalis muscles.

The rectus abdominus muscles were separated in the midline (bluntly/with Mayo scissors). The peritoneal cavity was entered (bluntly/sharply with Metzenbaum scissors) and the incision was extended (with Metzenbaum scissors). The bladder blade was then inserted. (The vesicouterine peritoneum was tented up and entered sharply with Metzenbaum scissors and extended laterally. The bladder flap was created digitally. The bladder blade was then replaced.)

A low transverse (low vertical/classical) incision was made into the uterus, and extended laterally using finger fraction in the cephalo-caudad plane. (Amniotomy was performed and) clear/meconium/bloody/minimal fluid was noted. The infant was noted to be in (OA/OP/transverse/breech) position. The head of the infant was elevated to the hysterotomy and delivered atraumatically while fundal pressure was applied. Nuchal cord was present/not present. The remainder of the infant was then delivered without difficulty. Mouth and nares were suctioned. The cord was clamped x2 and cut in between, and the baby was handed to the awaiting pediatric team. Cord blood was then collected.

The infant received Apgar scores of X at 1 minute and X at 5 minutes. The placenta was delivered (spontaneously or manually) and intact (or not). The uterus was ***WIPED / NOT WIPED*** and cleared of all clots and debris. (The uterus was delivered through the incision for repair.) The incision was closed with (one layer of 1 chromic suture in a locking fashion). Hemostasis was noted.

Inspection of the pelvic cavity revealed grossly normal tubes and ovaries. (The pelvis was then thoroughly irrigated and suctioned of all irrigation and blood clots.) (The uterus was returned to the abdominal cavity.) (The parietal peritoneum was closed with a running layer of 2-0 chromic suture.) (The muscle layer was reapproximated with 1 chromic suture.) The fascia was closed with 0-Vicryl suture. (The subcutaneous tissue was reapproximated with 2-0 plain gut.) The skin was closed with 4-0 Monocryl in a subcuticular fashion (or staples).

Sponge, lap and needle counts were correct x 2. The patient was doing well and transferred to recovery in stable condition.

Dr. Attending was present and scrubbed for the entire procedure.