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40

2. 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, weight

3980g. 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 spinal

anesthesia was initiated. The patient was placed in the dorsal, supine position with

left 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 The bladder was retracted using the bladder blade.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 to

the 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 all