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Operative Report, Cesarean Section In this report, you will report the diagnoses of the twin pregnancy, breech delivery due to the malposition of the first infant, premature labor with delivery, multiple gestation placenta status (Z code), twins as the outcome of delivery (Z code), and sterilization (Z code). LOCATION: Inpatient, Hospital PATIENT: Joan Corcoran ATTENDING PHYSICIAN: Andy Martinez, MD SURGEON: Gary Sanchez, MD PREOPERATIVE DIAGNOSIS: Uterine pregnancy at 34 weeks 4 days with twin gestation, spontaneous rupture of membranes, in active labor with breech presentation of the first twin. Multiparity, desires permanent sterilization. POSTOPERATIVE DIAGNOSIS:Uterine pregnancy at 34 weeks 4 days with twin gestation, spontaneous rupture of membranes, in active labor with breech presentation of the first twin. Multiparity, desires permanent sterilization. PROCEDURE PERFORMED:Primary low transverse cervical segment cesarean section with postpartum tubal ligation. ANESTHESIA: Spinal ESTIMATED BLOOD LOSS: 800 cc URINE OUTPUT: 125 FLUIDS: 2000 COMPLICATIONS: None FINDINGS:Two viable female infants with breech presentation of Infant B. Infant A weighed 5 pounds 6.2 ounces with Apgar of 9 at 1 minute and 9 at 5 minutes. Infant B had Apgar of 9 at 1 minute and 9 at 5 minutes weighing 4 pounds 12 ounces. PROCEDURE: The patient was prepped and draped in the supine position with left lateral displacement of the uterine fundus under spinal anesthesia with Foley catheter indwelling. A transverse incision was made in the lower abdomen. The fascia was divided laterally. The rectus muscles were divided in the midline. The peritoneum was entered in a sharp manner. The incision was extended vertically. The bladder flap was created using sharp and blunt dissection and reflected inferiorly. The uterus was entered in a sharp manner in the lower uterine segment. The incision was extended laterally with blunt traction. The membranes were ruptured, and the buttocks of the first infant was grasped and delivered. The infant was delivered to the chest, the arms were swept forward, and the head was delivered spontaneously. The infant was bulb suctioned while the cord was doubly clamped and divided. The infant was given to the intensive nursery staff in apparent good condition. Palpation of the second infant revealed that it was breech. The hips were grasped; membranes were ruptured. The infant was delivered to the chest, the arms were swept forward, and the head was delivered spontaneously. The infant was bulb suctioned while the cord was being doubly clamped and divided. The infant was given to the intensive nursery staff in apparent good condition. The placenta was manually expressed. The uterus was delivered from the abdominal cavity and placed on a wet lap sponge. A dry lap sponge was used to ensure that the remaining products of conception were removed. The cervical os (opening) was ensured to be patent with ring forceps. The uterine incision was closed with 0 Vicryl interlocking suture in two layers with the second layer imbricating the first. Figure-of-eight sutures were also placed as required for hemostasis. The operative site was irrigated and hemostatic. The bladder flap was reapproximated using 2-0 Vicryl continuous sutures. The left tube was then identified in its entirety, including fimbriated end. It was grasped in its midportion and elevated. The mesosalpinx was transected using the Bovie. Approximately 3 cm (centimeter) of tube was isolated and excised. The proximal end of the distal portion and the distal end of the proximal portion were ligated with 0 chromic suture. Operative sites were inspected and were hemostatic. The uterus was placed back within the abdominal cavity. Pelvic gutters were irrigated. Operative sites were inspected and were hemostatic. The anterior peritoneum was reapproximated using 2-0 Vicryl continuous suture. The incision was irrigated. The skin was closed with staples. All sponges and needles were accounted for at the completion of the procedure. The patient left the operating room in apparent good condition having tolerated the procedure well. The Foley catheter was patent and draining clear yellow urine at completion of the procedure. SERVICE CODE(S): ICD-10-CM DX CODE(S):

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