剖宫产手术记录

Cesarean Section Operative Report剖宫产手术记录Preoperative Diagnosis:术前诊断1. 23 year old G1P0, estimated gestational age = 40 weeks 23岁G1P0，估计孕周402. Dystocia 难产3. Non-reassuring fetal tracing 不确定Postoperative Diagnosis: Same as above术后诊断：同前Title of Operation: Primary low segment transverse cesarean section 手术名称：首次子宫下段横切口剖宫产Surgeon:术者Assistant:助手Anesthesia: Epidural麻醉：硬膜外Findings At Surgery: 术中所见：Male infant in occiput posterior presentation.男婴，枕后位Thin meconium with none below the cords, pediatrics present at delivery, APGAR's 6/8, weight3980g. Normal uterus, tubes, and ovaries. 稀薄胎粪，分娩时有儿科医生陪伴。

阿氏评分1分钟6分，5分钟8分，体重3980g。

子宫、卵管、卵巢正常。

Description of Operative Procedure:手术过程描述：After assuring informed consent, the patient was taken to the operating room and spinalanesthesia was initiated. The patient was placed in the dorsal, supine position withleft lateral tilt. The abdomen was prepped and draped in sterile fashion.得到（麻醉师）确认许可后，患者进入手术室，应用腰麻。

患者采用仰卧左倾斜位，腹部准备，无菌覆盖。

A Pfannenstiel skin incision was made with a scalpel and carried through to the level of the fascia. The fascial incision was extended bilaterally with Mayo scissors. The fascial incision was then grasped with the Kocher clamps, elevated, and sharply and bluntly dissected superiorly and inferiorly from the rectus muscles.用手术刀行凡能斯提尔切口（耻骨上腹部横行半月状切口），穿过筋膜层。

用Mayo 剪刀向两侧延长切口。

Kocher钳夹持筋膜切口，提起，然后钝性上下分离腹直肌。

The rectus muscles were then separated in the midline, and the peritoneum was tented up, and entered sharply with Metzenbaum scissors. The peritoneal incision was extended su periorly and inferiorly with good visualization of the bladder.腹直肌被从中间分开，腹膜自动膨出，用Metzenbaum剪刀锐性剪开。

在看清膀胱的基础上，上下延长腹膜切口。

A bladder blade was then inserted, and the vesicouterine peritoneum was identified, grasped with the pick-ups, and entered sharply with the Metzenbaum scissors. This incision was then extended laterally, and a bladder flap was created. The bladder was retracted using the bladder blade. The lower uterine segment was incised in a transverse fashion with the scalpel, then extended bilaterally with bandage scissors. The bladder blade was removed, and the infants head was delivered atraumatically. The nose and mouth were suctioned and the cord clamped and cut. The infant was handed off tothe pediatrician. Cord gases and cord blood were sent.置入膀胱压板，确认膀胱子宫腹膜，向上提起，用Metzenbaum剪刀锐性剪开。

然后向侧方延长切口，膀胱被压成片状。

膀胱压板压回膀胱。

用手术刀横行切开子宫下段，用bandage剪刀向两侧延长切口。

膀胱被移走，胎儿头自动娩出。

吸净口鼻后，钳夹切断脐带。

胎儿递给儿科医生。

脐带气和脐血被送走。

The placenta was then removed manually, and the uterus was exteriorized, and cleared of allclots and debris. The uterine incision was repaired with 1-O chromic in a running locking fashion.A second layer of 1-O chromic was used to obtain excellent hemostasis. The bladder flap was repaired with a 3-O Vicryl in a running fashion. The cul-de-sac was cleared of clots and the uterus was returned to the abdomen. The peritoneum was closed with 3-0 Vicryl. The fascia was reapproximated with O Vicryl in a running fashion. The skin was closed with staples.人工取出胎盘，外置子宫，清除所有的血块与（胎盘胎膜）碎片。

1-O铬制线连续锁边缝合子宫切口。

第二层1-O铬制线缝合以确保良好的止血效果。

3-0维乔线连续修补膀胱（皮瓣）。

陷凹血块清除干净后，子宫置入腹腔。

3-0维乔线关闭腹膜。

0号维乔线连续缝合筋膜复原。

staples 关闭（缝合）皮肤。

The patient tolerated the procedure well. Needle and sponge counts were correct times two. Two grams of Ancef was given at cord clamp, and a sterile dressing was placed over the incision.术中患者平稳。

针和纱布清点两次，无误。

钳夹脐带时给予2克头孢哌酮，切口上方移走无菌敷料。

Estimated Blood Loss (EBL): 800 cc; no blood replaced(normal blood loss is 500-1000 cc).估计失血：800cc；没有回收（正常失血量为500~1000cc）Specimens: Placenta, cord pH, cord blood specimens.标本：胎盘，脐血pH，脐血标本Drains: Foley to gravity.引流：Foley管自然引流Fluids: Input - 2000 cc LR; Output - 300 cc clear urine.液体：入量2000cc；出量300cc清亮尿液Complications: None.并发症：无Disposition: The patient was taken to the recovery room then postpartum ward in stable condition.处置：在稳定的状态下，患者移入苏醒室，然后转入产后病房。

Postoperative Management after Cesarean Section剖宫产术后管理I. Post Cesarean Section Orders 剖宫产术后医嘱A. Transfer: to post partum ward when stable.转移：平稳时到产后病房B. Vital signs: q4h x 24 hours, I and O.生命体征：q4h x 24 hours，I and OC. Activity: Bed rest x 6-8 hours, then ambulate; if given spinal, keep patient flat on back x 8h. Incentive spirometer q1h while awake.活动：卧床休息6~8小时，然后下床活动；如果是腰麻，患者平卧8小时。

在清醒时，每小时均需鼓励患者深呼吸D. Diet: NPO x 8h, then sips of water. Advance to clear liquids, then to regular diet as tolerated. 饮食：禁食8小时，然后呷水（clear liquids），然后在以耐受的程度规律饮食。

E. IV Fluids: IV D5 LR or D5 ½ NS at 125 cc/h. Foley to gravity; discontinue after 12 hours. I and O catheterize prn.静脉用液体：以125 cc/h的速度静滴D5 LR 或D5 ½ NS ；Foley管自然引流；12小时后停止。