Spontaneous Vaginal Delivery
NORMAL SPONTANEOUS VAGINAL DELIVERY
Date of Procedure: Preop Dx: 38 week IUP in active labor (with-‐list any other diagnosis). Postop DX: Same with delivery of viable male infant at 1400 hours weighing 7#12oz with Apgars of 9 @ 1 min and 9 @ 5 min. Procedure: Spontaneous Vaginal Delivery Surgeon: (list staff physician name) Assistants: Junior Resident and Senior Resident Anesthesia: Local infiltration of _____/pudendal infiltration of _____/epidural EBL: Indications: This 19 y/o G1P0 presents at 39 4/7 weeks gestation by LMP with an EDC of 04/06/12, c/o regular uterine contractions. Her prenatal course was complicated by ___. Prenatal lab data includes blood type O+ with a negative Ab screen, Rubella Immune, VDRL NR, HepBsAg neg, HIV NR, GBS neg. She presented at 0400 hours this am complaining of UCs q 5 minutes. At that time, her cervix was 2 cm, 90% effaced and at a –1 station. FHR was reactive and reassuring. She remained normotensive throughout the course of her labor. Slow progress was made initially, and at 0800 hours artificial rupture of membranes was performed with a return of clear fluid. At that time, her cervix was 5cm, 100% effaced and the fetal
Date of Procedure: Preop Dx: 38 week IUP in active labor (with-‐list any other diagnosis). Postop DX: Same with delivery of viable male infant at 1400 hours weighing 7#12oz with Apgars of 9 @ 1 min and 9 @ 5 min. Procedure: Spontaneous Vaginal Delivery Surgeon: (list staff physician name) Assistants: Junior Resident and Senior Resident Anesthesia: Local infiltration of _____/pudendal infiltration of _____/epidural EBL: Indications: This 19 y/o G1P0 presents at 39 4/7 weeks gestation by LMP with an EDC of 04/06/12, c/o regular uterine contractions. Her prenatal course was complicated by ___. Prenatal lab data includes blood type O+ with a negative Ab screen, Rubella Immune, VDRL NR, HepBsAg neg, HIV NR, GBS neg. She presented at 0400 hours this am complaining of UCs q 5 minutes. At that time, her cervix was 2 cm, 90% effaced and at a –1 station. FHR was reactive and reassuring. She remained normotensive throughout the course of her labor. Slow progress was made initially, and at 0800 hours artificial rupture of membranes was performed with a return of clear fluid. At that time, her cervix was 5cm, 100% effaced and the fetal