Detailed Treatment Process
Female, 31 years old In the hospital for delivery, she gave birth to a baby girl. The newborn's birth record noted a cheek injury on the baby's face. As for why there was a scar on the face, the mother explained that it was because the forceps injured the cheek. And the newborn's birth record stated that forceps were used for assisted delivery because of prolonged second stage of labor. Prenatal Bishop score=8 points, pregnancy risk warning: green Cervical dilation (cm): 2 points (3-4cm) Cervical effacement (%): 3 points (80-100%) Fetal presentation position: 1 point (-2) Cervical consistency: 1 point (medium) Cervical position: 1 point (mid) The following is the forceps surgery record Surgery date: February 15, from 3:55 a.m. to 5:00 a.m. Surgical indication: Prolonged second stage of labor, fetal head descent arrest Surgical diagnosis: Cephalic presentation, cervical dilation 9cm, presenting part +1, LOA Surgical name: Low forceps Anesthesia: Continuous epidural anesthesia + bilateral pudendal nerve block Preoperative notes: Posterior cervix 3’/30. PV: cervix fully dilated, presenting part S+3, BO ..A position, amniotic fluid clear, moderate volume, fetal heart 158bpm Pelvic estimation: Ischial spines 10cm, pubic arch 90° Surgical steps: Patient placed in lithotomy position, routine disinfection and sterile draping, urinary catheterization about 50 ml, clear Vaginal examination: (omitted) The following is the delivery record Labor onset: February 14, 16:00 Full cervical dilation: February 15, 2:00 Fetal delivery: February 15, 3:59 Placental delivery: February 15, 4:05 Membrane rupture: February 14, 23:00 First stage: 10 hours 0 minutes Second stage: 1 hour 59 minutes Delivery mode: Low forceps Third stage: 0 hours 6 minutes Total labor: 12 hours 5 minutes Fetal delivery method: Face natural, placenta intact, normal morphology, area 18*20cm Membranes intact, umbilical cord length 60 cm, nuchal cord 1 loop Amniotic fluid volume moderate clear Perineal laceration: Episiotomy (left) Postpartum hemorrhage: (including 20 ml from episiotomy before delivery), third stage blood loss 350 ml, blood loss in two hours postpartum 30 ml, total 400 ml, causes of bleeding: episiotomy + placental separation Apgar score: 1 minute=9 points, 5 minutes=9 points The following is the discharge summary Department: Inpatient Obstetrics Admission date: February 14 Discharge date: February 17 Admission diagnosis: G1P0 39 weeks pregnant LOA GDM? Discharge diagnosis: Forceps delivery G1P1 39+1 weeks pregnant LOA GDM?, nuchal cord, postpartum hemorrhage Summary of maternal hospitalization: After admission, the pregnant woman completed relevant auxiliary examinations. On February 15, forceps-assisted delivery of a baby girl, birth weight 3600g, newborn Apgar score 9-9, placenta delivered spontaneously, appearance intact, intrapartum blood loss 400ml. Postoperative routine care, the mother recovered day by day, normal temperature, normal uterine involution, lochia not excessive, discharged. Delivery date: February 15 03:59:00 Delivery mode: Dystocia, singleton Surgical name: Low forceps assisted delivery + left episiotomy and suture Special examinations: None. Discharge condition (symptoms and signs): The mother had no special discomfort complaints; physical examination: alert, normal temperature, normal heart and lungs, soft abdomen, no obvious tenderness, uterine fundus 2 fingers below umbilicus, firm, no breast engorgement, Perineal incision healed I/A, lochia scanty, odorless Post-discharge medications and advice Outpatient follow-up at 42 days postpartum; Keep perineal incision clean and dry, seek medical attention immediately if pain increases or there is abnormal discharge; Seek medical attention if vaginal bleeding exceeds menstrual volume or if there is severe abdominal pain or fever; If there is poor lactation or persistent breast pain, visit the breast surgery clinic of this hospital for examination. The above is the discharge summary Review of temporary medical orders showed that painless labor was performed under continuous epidural anesthesia.