DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Intrauterine gestation at 41 weeks, in active labor, second stage.
2. Arrest of descent.
3. Persistent occiput posterior position.
POSTOPERATIVE DIAGNOSES:
1. Intrauterine gestation at 41 weeks, in active labor, second stage.
2. Arrest of descent.
3. Persistent occiput posterior position.
4. Delivery of viable, large-for-gestational-age male infant.
OPERATION PERFORMED:
Primary low transverse cesarean section.
SURGEON: John Doe, MD
ANESTHESIA:
COMPLICATIONS:
None.
ESTIMATED BLOOD LOSS:
800 mL.
DRAINS:
Foley catheter to the bladder.
SPECIMENS TO PATHOLOGY:
Cord blood for routine testing.
OPERATIVE FINDINGS:
A viable male infant with Apgars of 8 and 9 and birthweight of 9 pounds 9 ounces was delivered from a cephalic presentation, persistent occiput posterior position. There was marked caput and molding present on the head. Cord pH was 7.42. The cord contained 3 vessels. There was normal anterior fundal placenta. The amniotic fluid was clear. The uterus, fallopian tubes and ovaries were normal.
DESCRIPTION OF OPERATION:
The patient was brought to the operating suite in stable condition for primary low transverse cesarean section with epidural anesthesia on board and an indwelling catheter in place in the bladder. The patient was placed supine on the operating room table and rolled to her left side with a wedge. The abdomen was prepped and draped in standard fashion for cesarean section. After testing with forceps to assure an adequate anesthetic level, the surgery was commenced. We had counseled the patient extensively regarding the risks of the surgery including but not limited to stroke, embolus, phlebitis, pain, infection, hemorrhage, as well as injury to the infant and the internal organs such as the bowel, bladder, blood vessels, nerves, kidneys, ureters and pelvic organs. The patient was aware of the postoperative morbidity issues and recovery timeframes. The patient was aware she can form adhesions, which can result in obstruction of loop of bowel or ureter or chronic pain. She was aware that should she have hemorrhage and require blood transfusion, there was a small chance for exposure to hepatitis or HIV disease.
With the scalpel, a Pfannenstiel skin incision was made. Dissection was carried down sharply through the subcutaneous tissues and fascia in a transverse plane with the scalpel, electrocautery and curved Mayo scissors. The fascia was sharply freed up superiorly and inferiorly from the underlying rectus muscles, which were bluntly and sharply divided. The peritoneum was entered carefully in a clear space with a curved hemostat. The peritoneal incision was then extended vertically with Metzenbaum scissors. A retractor and bladder blade were placed. A bladder flap was created by incising transversely through the peritoneum and vesicouterine fold and then bluntly dissecting the bladder distally. With the scalpel, a low transverse hysterotomy was commenced. The serosa and myometrium were scored with the scalpel. The uterine cavity was actually entered bluntly with a curved hemostat. The uterine incision was then extended laterally with the operator’s fingers.
An intrauterine hand was placed and the head of the infant was brought up out of the pelvis into the uterine incision. With fundal pressure, he was delivered without difficulty. The nasopharynx and oropharynx were suctioned. The cord was doubly clamped and transected. The infant was then handed off to the nursery personnel. Apgars were good at 8 and 9. A cord pH was obtained, which subsequently revealed a normal value. Further cord blood was collected for routine testing. Intravenous Pitocin and antibiotics were administered.
The placenta was manually removed. The uterine cavity was then curetted with a dry sponge and freed of the remaining membranes. The edges of the uterine incision were grasped with Pennington clamps. With the massage and the Pitocin, the uterus began to firm up normally. The uterine incision was then closed in 2 layers of 0 Vicryl sutures. The first suture was placed to the endometrium and myometrium. The second suture was placed through the endopelvic fascia and also reincorporated the bladder flap peritoneum. Peritoneal lavage was then performed. The pelvis and gutters were irrigated and suctioned and cleared of all blood and clots and amniotic fluid. The uterine incision was reinspected to assure hemostasis. The uterus, tubes and ovaries were inspected and were normal. Once we were satisfied with the hemostasis, attention was turned to closure of the abdominal incision. The peritoneum, muscles and fascia were closed in layers using 0-Vicryl sutures. The subcutaneous tissue was closed with 3-0 plain sutures. The skin was closed with a subcuticular suture of 4-0 Vicryl followed by benzoin, Steri-Strips and a Telfa dressing. The patient was moved to the recovery room in stable condition with the Foley catheter draining clear urine. Instruments, sponge and needle counts were reported as correct. Estimated blood loss was 800 mL. There were no complications.
