Explain: Baby Delivery

Content: Cesarean Section

Clinical Information:

The female patient had the chief complaint of pregnancy at -------weeks.

This baby was her (G----P-----AA-----SA-----).

Her EDC was: ------/-----/------. Her birth day was:------/------/------.

She underwent prenatal examination at -------------.

She is {{ married, unmarried, divorced, widowed }}.

She had past history of {{ DM, PIH, Abortion, Previous myomectomy, Previous laparoscopic surgery, Premature baby, IUFD, Ectopic pregnancy, -------------}}.

Her body weight are:------------Kg (before pregnant).; ------------Kg (While delivered).

Her body height was -----------cm. So, her BMI (Body Mass Index) is :-------------.

The week at her first prenatal care was ----------------(Gestational weeks).

Number of Total Prenatal Visits:--------------.

Number of Ultrasound Examination: {{ 1,2,3,4,5,6,>6}}.

Substance exposure {{Nil, Tobacco, Alcohol, Herb drug, Narcotics, Sedatives, Amphetamine, X-ray, ---------------}}.

This birth is {{Singleton, Twin, Triplet, IVF, -----------}}.

Her Down syndrome risk is:------------.

Her DM screen: {{ unknown, screen (+), OGTT(-), OGTT(+) }}.

Her NST findings was : {{ N/L, Early deceleration, Variable deceleration, Late, Deceleration, Sinusoid pattern, Absence of variability, Uterine hypertonus }}.

Her prenatal diagnosis and treatment: {{ Nuchal translucency, CVS, Amniocentesis, Fetoechocardiography, Cordocentesis, FISH, CGH, Fetal therapy, Gene therapy }}.

Her pre-C/S lab data were: Hb:--------- , MCV:---------, Platelet:---------, CRP:---------GOT:----------, LDH:------------, Albumin:----------, Sugar (AC):-----------(PC)---------.

Other abnormal data:-------------------------------------------------------------------------

She had {{ previous C/S, Acute Fetal Distress, CPD, Malpresentation, Arrest of labor, Medical disease, Surgical disease, Congenital anomalies, -----------------------------.}}.

Therefore, C/S is indicated.

Operative Procedures:

Type of Operation: {{ Regular C/S, Elective C/S, Emergency C/S, Extraperitoneal C/S, Cesarean Hysterectomy (Porro’s). }}

The woman was brought to the operating room. After {{spinal, epidural, general anesthesia}}, the patient was put in supine position. The abdomen was prepared with soap and beta-iodine and draped as usual. A {{pfannestial incision, median longitudinal incision }} was made. The abdomen was opened layer by layer. {{After the oeritoneum was opened, two pads were put into the peritoneal cavity to push the intestine upward, a third blade was put in the caudal aspect to expose the lower segments of the uterus, by dissecting through the space of Retzius and then along one side and beneath the bladder to reach the lower uterine segment.}}. A transverse incision of the lower segment of the uterus was made. A baby was delivered smoothly. The placenta was removed manually. Then the uterus was closed by two layers sutures with 1-O {{vicryl, catgut}} The serosa was approximated. {{The right fallopian tube was grasped, ligated with 1-O chromic catgut and cut. Then the left tube was ligated and cut }} The abdomen wall was closed layer by layer. The skin was approximated with 3-O Dexon.

Pregnancy Outcome:

Baby: {{Male, Female, Ambiguous}}

Apgar Score(1) {{1.2.3.4.5}} ; Apgar Score(5) {{1,2,3,4,5}}

Grossly :{{ Normal, Abnormal}}; Birth weight:------------------Kg

If Abnormal gross findings, congenital anomalies were: {{CNS, Chest, Heart, GI, Limbs, ---------------------}}. Baby sent to NICU {{ yes, no}}, Neonatal death: {{+,-}}.

Placenta :{{ N/L, Abruption, Infarction, Bulky, Accessary lobe, other------------}}

Amniotic Fluid Amount: {{ N/L, Ologohydramnios, Polyhydramnios }}.

Amniotic Fluid color: {{ Clear, Bloody, Foul turbid, Meconium stain }}

Blood loss (including amniotic fluid):----------------------- ml.

Other significant findings:----------------------------------------------------------------------.

Complications: {{ Nil, PPH, DIC, Post-op Fever, Wound infection, Ureter injury, Bladder injury, ---------------------------}}

Dr----------------------------------------------- Date:-----------------------------------------

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