By Dr. Irish-Clardy
Date of Birth:

Date of surgery:

Procedure: Spontaneous Vaginal Delivery

Pre-op Diagnosis:  A __ years old, G2 P1001 at 39W 2D. GBS (-)

Post-Op Diagnosis: A __ years old, G2 P2002 at 39W 2D.

Primary Surgeon:

Supervising Surgeon:

Attending Physician

Anesthesia:  Epidural

Findings: Term female neonate with APGAR 9 at 1 minute and 10 at 5 minutes. Birth Weight 6 lb, 9oz

Estimated Blood Loss:  250cc

Complications:   None


Description of procedure:

At [Time] this 22 yo G2 now P2002 delivered vaginally under epidural anesthesia. The anterior shoulder was delivered with gentle downward traction. The posterior shoulder was delivered with gentle upward traction. Infant was suctioned with bulb on perineum. There was nuchal cord x1. The infant was placed on the patient's abdomen after delivery.  The cord was clamped and cut, and the baby was handed off to the awaiting pediatric team. Placenta was delivered intact with normal 3-vessel cord. The fundus was firm with  massage and IV Pitocin. There were no cervical, vaginal, or perineal lacerations. [gender] infant weighs 3,486 grams (7#11oz), & APGAR score 7 at 1 min and 9 at 5 min. Both mom and infant are recovering well. Dr. Attending was present for the delivery and Dr. Resident assisted with the delivery. At the time of my departure, the mother and neonate were in stable condition.

Other info to add: