Maternity
Patient Case Number: MM08-Matloff, Karen
Patient Name: Karen Matloff | DOB: 08-03-95 | Sex: F
Date of Service: 04-27-XX | Physician: Michael Williams, MD

# Obstetrical Delivery Discharge Diagnoses:

1. VBAC, delivered

2. Anemia complicating pregnancy in third trimester

# History:

23 y/o G2P2002 at 40w5d with an uncomplicated SVD of liveborn female infant in the OA position. No nuchal cord, both shoulders delivered without complications. Cord clamped and cut, gases sent. Spontaneous delivery of placenta intact with 3VC. Second degree perineal lacerations were repaired with 3-0 Vicryl suture. Patient’s uterus boggy; bimanual exam performed, oxytocin infused through IV, and miso 1000mcg administered per rectum. Bleeding improved and uterus firm at umbilicus. QBL 195ml. Counts correct x 2

# Delivery Date: 04/27/XX Delivery Time: 2:30 PM Gestational Age: 40 5/7

# Method of Delivery: Vaginal, Spontaneous Delivery

# Birth Weight: 3.161 kg (6 lb 15.5 oz)

# Sex: Female

# Apgar Score (1 min): 9

# Apgar Score (5 min): 9

Laceration

# Episiotomy: None

# Laceration Type: Vaginal

# Perineal Laceration: 2nd degree

# Quantified Blood Loss (ml): 195

# Procedures performed: SVD

# APGARs

APGARs | One Minute | Five Minutes
Skin Color | 1 | 1
Heart Rate | 2 | 2
Grimace | 2 | 2
Muscle Tone | 2 | 2
Breathing | 2 | 2
Assigned By | Marshall, Nina | Marshall, Nina
Totals | 9 | 9

Presentation/Position | Cephalic-Occiput Anterior
Resuscitation | Tactile Stimulation Bulb Suction
Resuscitation Comments | None
| None

# Cord Info

Vessels | 3 Vessels
Cord Complications | None
Nuchal Type | ---
Cord Comments | ---
Cord Blood Disposition | Lab
Gases Sent | Yes

# Placenta

Date/Time | 04-27-XX 2:30 PM
Removal | Expressed
Placenta Disposition | Discarded

# Newborn Measurements

Weight | 6lb 15.5oz (3161g)
Height | 19” (48.3cm)
Head Circumference | 35cm
Chest Circumference | ---
Infant Complications | ---

# Electronically Signed By: Michael Williams, MD

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