OB-GYN Study

DISCHARGE SUMMARY

HISTORY

The patient is a 21-year-old gravida 1, para 0, who was admitted to Labor and Delivery after spontaneous rupture of membranes.  The patient initially had no spontaneous labor, and Pitocin augmentation was initiated.  Her labor progressed initially quite slowly and then rapidly to complete and pushing, and she was taken to the delivery room.  Over a pudendal anesthetic and with use of elective low forceps for prolonged variable decelerations, the patient was delivered, and she delivered a viable male infant with Apgars of 8 and 9, estimated at term.  The episiotomy was midline with fourth-degree extension, repaired with 2-0 and
3-0 chromic suture.  The placenta was delivered spontaneously and intact.  Estimated blood loss 300 cc.  There were no complications.

Postpartum course was uneventful with a postpartum hemoglobin of 10.8, hematocrit 32.9.

CONDITION AT DISCHARGE

Improved.    

PROCEDURES

1. Elective low forceps delivery after augmentation of labor.

2. Midline episiotomy with fourth-degree extension, repaired.

3. Placement of internal monitor.

FINAL DIAGNOSES

1. Intrauterine pregnancy, term, delivered.

2. Viable male infant.

PLAN

The patient is to be discharged to be followed in the office at approximately 2 weeks postpartum.  Her discharge medication will include Colace 100 mg 2 at h.s.  She may continue to take her iron and vitamins at home.  She will also receive Parlodel 2.5 mg p.o. b.i.d. for the next 4 days.  Darvocet-N 100 one p.o. q.4-6h. will also be given.

FOOTNOTE

Line 9 (Page 1).  Alternative:  Labor and delivery.

Line 12 (Page 1).  The phrase complete and pushing refers to complete dilations and effacement of the cervix, with the patient pushing.

Line 14 (Page 1).  The slang term decels was edited to decelerations.

Line 29 (Page 1).  Forceps is always plural; forcep was edited to forceps.

Line 34 (Page 1).  The abbreviation IUP was expanded for clarity in the Final Diagnoses.