Detailed Treatment Process
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Female, 31 years old She gave birth in the hospital to a baby girl. The newborn’s birth record noted a cheek injury on the infant’s face. The mother explained that the cheek injury was caused by the forceps. The birth record stated that forceps were used because of a prolonged second stage of labor. Pre-delivery Bishop score = 8 points, pregnancy risk warning: green Cervical dilation (cm): 2 points (3-4 cm) Cervical effacement (%): 3 points (80-100%) Fetal station: 1 point (-2) Cervical consistency: 1 point (medium) Cervical position: 1 point (mid) The following is the forceps procedure record: Procedure date and time: February 15, from 3:55 a.m. to 5:00 a.m. Indication for procedure: prolonged second stage of labor with arrest of fetal descent Procedure diagnosis: cephalic presentation, cervix dilated 9 cm, station +1, LOA Procedure name: low forceps delivery Anesthesia: continuous epidural anesthesia plus bilateral pudendal nerve block Pre-procedure note: cervix posterior 3'/30, PV fully dilated, presenting part S+3, BO ..A position, clear amniotic fluid, moderate volume, fetal heart rate 158 bpm Pelvic assessment: ischial spines 10 cm, subpubic angle 90° Procedure steps: Patient placed in lithotomy position, standard disinfection and draping performed, urinary catheter inserted with drainage of about 50 ml of clear urine. Vaginal examination: (details omitted) The following is the delivery record: Labor onset: February 14, 4:00 p.m. Full cervical dilation: February 15, 2:00 a.m. Fetal delivery: February 15, 3:59 a.m. Placental delivery: February 15, 4:05 a.m. Membrane rupture: February 14, 11:00 p.m. First stage of labor: 10 hours 0 minutes Second stage of labor: 1 hour 59 minutes Delivery method: low forceps Third stage of labor: 0 hours 6 minutes Total labor duration: 12 hours 5 minutes Fetal delivery details: face delivered naturally, placenta intact and normal in shape, area 18×20 cm Membranes intact, umbilical cord 60 cm long with one loop around the neck Amniotic fluid: moderate volume, clear Perineal laceration: episiotomy (left side) Postpartum hemorrhage: (including 20 ml from episiotomy before delivery), third stage blood loss 350 ml, additional 30 ml in the two hours after delivery, total 400 ml; causes: episiotomy plus placental separation Apgar scores: 1 minute = 9, 5 minutes = 9 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 hospital course: After admission, the patient completed relevant ancillary tests. On February 15, she underwent forceps-assisted delivery of a baby girl weighing 3600 g. Newborn Apgar scores were 9–9. The placenta delivered spontaneously and appeared intact. Blood loss during delivery was 400 ml. Postpartum care was routine. The patient recovered day by day, with normal temperature, normal uterine involution, and minimal lochia, and was discharged. Delivery date: February 15, 03:59:00 Delivery method: dystocia, singleton Procedure name: low forceps delivery plus left mediolateral episiotomy and repair Special examinations: none. Condition at discharge (symptoms and signs): The patient reported no specific discomfort. Physical examination: alert and oriented, normal temperature, unremarkable heart and lungs, soft abdomen with no obvious tenderness, uterine fundus two fingerbreadths below the umbilicus and firm, breasts without engorgement, episiotomy incision healing grade I/A, scant lochia without odor.