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Obstetrics / Gynecology-Low-Transverse C-Section - 3 (Medical Transcr... https://www.mtsamples.com/site/pages/sample.asp?type=45-Obstetrics /...

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Sample Name: Low-
Transverse C-Section - 3
Description: Repeat low-transverse C-section, lysis of omental
adhesions, lysis of uterine adhesions with repair of uterine
defect, and bilateral tubal ligation.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES:
1. Intrauterine pregnancy at 33 weeks, twin gestation.
2. Active preterm labor.
3. Advanced dilation.
4. Multiparity.
5. Requested sterilization.

POSTOPERATIVE DIAGNOSIS:
1. Intrauterine pregnancy at 33 weeks, twin gestation.
2. Active preterm labor.
3. Advanced dilation.
4. Multiparity.
5. Requested sterilization.
6. Delivery of a viable female A weighing 4 pounds 7 ounces, Apgars were 8 and 9 at 1 and 5 minutes respectively
and female B weighing 4 pounds 9 ounces, Apgars 6 and 7 at 1 and 5 minutes respectively.
7. Uterine adhesions and omentum adhesions.

OPERATION PERFORMED: Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions
with repair of uterine defect, and bilateral tubal ligation.

ANESTHESIA: General.

ESTIMATED BLOOD LOSS: 500 mL.

DRAINS: Foley.

This is a 25-year-old white female gravida 3, para 2-0-0-2 with twin gestation at 33 weeks and previous C-section.
The patient presents to Labor and Delivery in active preterm labor and dilated approximately 4 to 6 cm. The
decision for C-section was made.

PROCEDURE: The patient was taken to the operating room and placed in a supine position with a slight left lateral
tilt and she was then prepped and draped in usual fashion for a low transverse incision. The patient was then given
general anesthesia and once this was completed, first knife was used to make a low transverse incision extending
down to the level of the fascia. The fascia was nicked in the center and extended in a transverse fashion with the
use of curved Mayo scissors. The edges of the fascia were grasped with Kocher and both blunt and sharp dissection

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was then completed both caudally and cephalically. The abdominal rectus muscle was divided in the center and
extended in a vertical fashion. Peritoneum was entered at a high point and extended in a vertical fashion as well.
The bladder blade was put in place. The bladder flap was created with the use of Metzenbaum scissors and dissected
away caudally. The second knife was used to make a low transverse incision with care being taken to avoid the
presenting part of the fetus. The first fetus was vertex. The fluid was clear. The head was delivered followed by the
remaining portion of the body. The cord was doubly clamped and cut. The newborn handed off to waiting
pediatrician and nursery personnel. The second fluid was ruptured. It was the clear fluid as well. The presenting part
was brought down to be vertex. The head was delivered followed by the rest of the body and the cord was doubly
clamped and cut, and newborn handed off to waiting pediatrician in addition of the nursery personnel. Cord pH
blood and cord blood was obtained from both of the cords with careful identification of A and B. Once this was
completed, the placenta was delivered and handed off for further inspection by Pathology. At this time, it was noted
at the uterus was adhered to the abdominal wall by approximately of 3 cm x 3 cm thick uterine adhesion and this
was needed to be released by sharp dissection. Then, there were multiple omental adhesions on the surface of the
uterus itself. This needed to be released as well as on the abdominal wall and then the uterus could be externalized.
The lining was wiped clean of any remaining blood and placental fragments and the edges of the uterus were
grasped in four quadrants with Kocher and continuous locking stitch of 0 chromic was used to re-approximate the
uterine incision, with the second layer used to imbricate the first. The bladder flap was re-approximated with 3-0
Vicryl and Gelfoam underneath. The right fallopian tube was grasped with a Babcock, it was doubly tied off with 0
chromic and the knuckle portion was then sharply incised and cauterized. The same technique was completed on
the left side with the knuckle portion cut off and cauterized as well. The defect on the uterine surface was reinforced
with 0 Vicryl in a baseball stitch to create adequate Hemostasis. Interceed was placed over this area as well. The
abdominal cavity was irrigated with copious amounts of saline and the uterus was placed back in its anatomical
position. The gutters were wiped clean of any remaining blood. The edges of the peritoneum were grasped with
hemostats and a continuous locking stitch was used to re-approximate abdominal rectus muscles as well as the
peritoneal edges. The abdominal rectus muscle was irrigated. The corners of the fascia grasped with hemostats and
continuous locking stitch of 0 Vicryl started on both corners and overlapped on the center. The subcutaneous tissue
was irrigated. Cautery was used to create adequate hemostasis and 3-0 Vicryl was used to re-approximate the
subcutaneous tissue. Skin edges were re-approximated with sterile staples. Sterile dressing was applied. Uterus was
evacuated of any remaining blood vaginally. The patient was taken to the recovery room in stable condition.
Instrument count, needle count, and sponge counts were all correct.

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Keywords: obstetrics / gynecology, intrauterine pregnancy, gestation, preterm labor, omentum adhesions, low
transverse c section, uterine adhesions, intrauterine, adhesions, abdominal, uterus, uterine,

NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference
purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample
reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and
dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else
to real world is purely incidental.

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Transcribed Medical Transcription Sample Reports and Examples

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