Operative Report Cesarean Explained for Students (Easy Guide)

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T11-3 OPERATIVE REPORT, CESAREAN SECTION LOCATION: Inpatient, Hospital PATIENT: MaryBelle Wilson ATTENDING PHYSICIAN: Andy Martinez, MD SURGEON: Andy Martinez, MD PREOPERATIVE DIAGNOSIS: Intrauterine pregnancy, 39 weeks, previous cesarean section, and declined vaginal birth after cesarean. POSTOPERATIVE DIAGNOSIS: Intrauterine pregnancy, 39 weeks, previous cesarean section, and declined vaginal birth after cesarean. PROCEDURE: Repeat low transverse cervical segment cesarean section. ANESTHESIA: Spinal. COMPLICATIONS: None. FINDINGS: Viable female infant weighing 8 pounds 14.5 ounces, with Apgars of 9 at 1 minute and 10 at 5 minutes. PROCEDURE: The patient was prepped and draped in the supine position with left lateral displacement of the uterine fundus under spinal anesthesia with a Foley catheter indwelling. A transverse incision was made in the lower abdomen, removing the old scar. The fascia was divided laterally. The rectus muscle was divided in the midline. The peritoneum was entered in the sharp manner. An 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, and the incision was extended laterally with blunt traction. The amniotic fluid was clear. The infant’s head was delivered. The infant was then delivered and bulb suctioned while the cord was being doubly clamped and divided. The infant was given to the intensive care nursery staff in apparent good condition. The placenta was manually expressed. The uterus was delivered from the abdominal cavity and placed on wet lap sponges. A dry sponge was used to ensure remaining products of conception were removed. The cervical os (opening) was ensured patent with a ring forceps. The uterine incision was closed with 0 Vicryl interlocking suture in two layers, with the second layer imbricating the first. A figure-of-eight suture was also placed, which was required for hemostasis. The operative site was irrigated. The bladder flap was reapproximated using 2-0 Vicryl continuous suture. The tubes and ovaries appeared normal bilaterally. The uterus was placed back within the abdominal cavity. The pelvic gutters were irrigated. The anterior peritoneum was reapproximated using 2-0 Vicryl continuous suture. The incision was irrigated. The fascia was closed with 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 the completion of the procedure. T11-3: CPT CODE: 1 (Code cesarean delivery, routine care) ICD-10-CM CODES: 2 (Code delivery, cesarean previous, cesarean delivery) (Code outcome of delivery, single, liveborn)

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