Labor and Delivery Summary Estimated gestational age (weeks/days): 36w6d Intrapartum events: Preterm labor (less than 37 weeks) and multiple variable decelerations Monitor: Fetal heart tones -external, fetal heart tones – internal, uterine contractions – external and uterine contractions – internal Labor Events Preterm: Yes Induction: None Augmentation: AROM Fluid Color: Clear Rupture Date and Time: 07-17-XX 3:45pm Rupture Type: Artificial Procedures Episiotomy: None Lacerations: None Blood loss in ml(s): No information available Remarks: Primary LTCS for cat 2 fetal tracing remote from delivery. At the conclusion of the procedure I examined the vagina and have determined that there are no retained sponges. Delivery Information Delivery Date and Time: 07-17-XX 7:15pm Presentation: Vertex Position: Occiput Anterior Delivery Type: C-Section, Low Transverse VBAC Attempted: No information available If C-section was performed, was this primary or repeat? No information available Forceps: None Vacuum: None Breech: N/A Placenta Date and Time: No information available Removal: Manual removal Appearance: Intact Disposition: Pathology Cord Information Vessels: 3 Vessels Complications: Nuchal Cord Blood Disposition to Lab: Yes Gases Sent: Yes APGAR scores 1 minute: 7 5 minutes: 9 10 minutes: 9 Admitting CM Diagnosis: __________________________________ ICD-10-CM codes(4):___________________, ______________________, ___________________, ______________________ ICD-10-PCS codes(1):__________________
The process of labor and delivery is a crucial phase in the journey of pregnancy, and each case is unique. In this summary, we will discuss a specific labor and delivery scenario involving a preterm birth at 36 weeks and 6 days of gestation. The delivery was necessitated by fetal distress, leading to a low transverse cesarean section (C-section) and other notable events.
At 36 weeks and 6 days of gestation, the patient experienced preterm labor, which is defined as labor occurring before 37 weeks of pregnancy. In this case, no induction was performed, and the labor was not augmented. The artificial rupture of membranes (AROM) took place on 07-17-XX at 3:45 pm, with clear fluid noted.
During the delivery, there were no episiotomies or lacerations reported. The blood loss in milliliters was not documented. The primary low transverse cesarean section (C-section) was performed due to cat 2 fetal tracing, indicating fetal distress remote from delivery. A post-procedure examination confirmed the absence of retained sponges.
The umbilical cord contained the standard three vessels. Notably, there was a complication reported, with a nuchal cord detected. The cord and related gases were sent for further analysis and evaluation.
The APGAR scores, which assess the newborn’s physical condition at one, five, and ten minutes after birth, were recorded as follows: 7 at one minute, 9 at five minutes, and 9 at ten minutes, indicating favorable overall health.
The admitting clinical modification (CM) diagnosis and corresponding ICD-10 codes were not provided in the summary, which may require further documentation for complete medical records.
This labor and delivery summary outlines the key events and interventions in the case of a preterm birth at 36 weeks and 6 days gestation. Fetal distress prompted the need for a low transverse cesarean section, emphasizing the importance of vigilant monitoring and timely medical interventions in managing labor and delivery complications. The nuchal cord, while a complication, was appropriately addressed, and the newborn exhibited good APGAR scores, indicating a positive outcome. Complete documentation of clinical diagnosis and ICD-10 codes would be essential to ensure comprehensive medical records.
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