Outlet Forceps Delivery

DELIVERY: Outlet forceps of viable female infant with Apgars of 3 at one minute and 7 at five minutes, weight pending.

ADDITIONAL DIAGNOSIS: Tight nuchal cord.

BRIEF HISTORY: The patient is a 21-year-old gravida 1, para 0 with a last menstrual period of ….. with an EDC of ......., consistent with both 15 and 22-week ultrasounds, who presented to labor and delivery after spontaneous rupture of membranes at approximately 3:15 a.m. on the ..... She was observed for several hours and then started on Pitocin Augmentation.

Her prenatal course initiated at 13 weeks. She had a completely unremarkable prenatal course without any complications and was compliant with all of those visits.

PAST MEDICAL HISTORY: Significant for some anxiety and depression, but currently not on any medication. There is question of a seizure disorder. Her last seizure was 6 years ago. They could have been syncopal episodes as well. She was never on seizure medication.

PAST SURGICAL HISTORY: Negative.

MEDICATIONS: Prenatal vitamins.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: The patient is single. She has been in a 1-1/2 year relationship with ….. She quit smoking during the pregnancy. She denied alcohol. She did have a history of marijuana use early on prior to her pregnancy but did not use during her pregnancy.

PRENATAL LABS: Blood type A positive, antibody screen negative, H&H of 12.7 and 36.5 with platelets of 331. Rubella immune, RPR nonreactive, hepatitis negative, quad marker negative, one-hour PPG is 111. GC and Chlamydia negative. Pap initially with low-grade squamous epithelial lesion. Repeat within normal limits. HIV negative. U-tox negative. Beta strep negative.

HOSPITAL COURSE: The patient was admitted and started after several hours on Pitocin augmentation. She then progressed to 5 cm and received an epidural and progressed from there to full dilatation and pushed for approximately an hour and a half. Due to maternal exhaustion the patient requested assisted delivery. A PAR-Q conference and verbal consent were obtained to apply forceps. Fetal vertex was in occiput anterior position at +3 station. The forceps, Luikart-Simpsons, were applied without difficulty and over the next 2 contractions downward traction was applied while the patient’s expulsive effort was encouraged. The patient desired removal of the forceps. She then pushed on her own for approximately another 15-20 minutes and then requested further assistance. At that point the vertex was at +4 station and forceps were reapplied easily and with the next contraction vertex delivered occiput anterior. There was a tight nuchal cord and moderate shoulder dystocia. The cord was clamped and cut at the neck and then with McRoberts positioning and suprapubic pressure the shoulders delivered and infant was handed to waiting pediatric nurses who assigned Apgars of 3 at one minute and 7 at five minutes. Infant weight is still pending. The cord gas was obtained. There was a midline vaginal tear which was sutured with 3-0 Polysorb in a running locking fashion and two short bilateral vaginal tears which were sutured with 3-0 Polysorb in a running locking fashion. There was good reapproximation of tissues. The placenta delivered shortly thereafter intact with a 3-vessel cord. Mother is doing well. Infant has been taken to the nursery for tachycardia and for observation.

codes: 
Code: 
10D07Z4
Code Type: 
ICD-10
Code: 
10E0XZZ
Code Type: 
ICD-10
Code: 
0UQGXZZ
Code Type: 
ICD-10
Code: 
72.29
Code Type: 
ICD-9
Code: 
73.59
Code Type: 
ICD-9
Code: 
75.69
Code Type: 
ICD-9
Code: 
?
Code Type: 
CPT