cubbiecatz
Networker
Is there enough documentation to bill for the hernia repair? Would it be included in the cesarean section?
Post-operative Diagnosis: same, s/p RCS, hernia of cesarean scar
Procedure: Repeat Low Transverse Cesarean Section, hernia repair
Anesthesia: Spinal
Findings:
Time of Birth: 7/10/2024 12:31 PM
Gender:
Neonate Wt:
Apgars:8 & 9 at 1 and 5 min. Nuchal cord: none. Normal uterus, tubes, and ovaries. Clear amniotic fluid.
Estimated Blood Loss: 271 ml
Total IV Fluids: see anesthesia note
Urine output: clear in foley post op
Specimens: Placenta to pathology. Cord blood obtained.
Complications: None; patient tolerated the procedure well.
Indication and Consent:
Due to patient's history of prior cesarean section, a repeat cesarean section was recommended to the patient for fetal and maternal wellbeing. The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The patient concurred with the proposed plan, giving informed consent. The patient understood that the risks of cesarean section include, but are not limited to, visceral or vascular injury, infection, blood loss and need for transfusion, prolonged hospitalization, reoperation, and rare risk of death. The patient stated understanding and desired to proceed. All questions were answered.
Procedure Details:
The site of surgery properly noted/marked. The patient was taken to Operating Room, identified and the procedure verified as C-Section Delivery. A Time Out was held and the above information confirmed.
Two grams of cefazolin (Ancef) were given for infection prophylaxis. After induction of anesthesia, the patient was draped and prepped in the usual sterile manner. A Pfannenstiel incision was made and carried down through the subcutaneous tissue to the fascia. Fascial incision was made and extended laterally. Omentum was protruding through a hernia at the previous incision site. The fascia was separated from the underlying rectus tissue superiorly and inferiorly. The omentum was detatched. The peritoneum was open. Peritoneal incision was extended superiorly and inferiorly to the bladder reflection with good visualization of the bladder. The utero-vesical peritoneal reflection was incised transversely and the bladder flap was bluntly freed from the lower uterine segment. The bladder blade was positioned to keep the bladder out of the operative filed.
A low transverse uterine incision was made. The amniotic sac was ruptured with an Allis clamp and Clear amniotic fluid noted. The uterine incision was extended bluntly with lateral and upward traction. The fetus was in cephalic presentation. The head was elevated out of the pelvis with special attention paid to avoid using the uterine incision as a fulcrum. Gentle fundal pressure was applied once the head was brought into the incision
The infant was delivered with no difficulty. The mouth and nose were suctioned with a bulb. After the umbilical cord was clamped and cut cord blood was obtained for evaluation. The infant was handed off to the pediatrician. IV oxytocin was initiated to facilitate uterine contractions.
The placenta was delivered intact with manual massage of the uterine fundus. The uterus was then exteriorized. The inside of the uterus was gently wiped with a lap sponge to assure complete removal of placenta membranes.
The uterine incision was closed with running locked sutures of 0 Vicryl. Hemostasis was observed. The blood clots and fluid were wiped out of the abdomen and pelvis with moist laparotomy sponges.
The muscle layer was closed. The fascial layer was closed in a running fashion with 0 Vicryl with no remaining defect. Subcutaneous layer closed. The skin was closed with suture in a subcuticular fashion. Instrument, sponge, and needle counts were correct prior the abdominal closure and at the conclusion of the case.
A qualified resident was not available. Dr. actively participated in assisting in this case with prepping patient in the OR, aiding in adequate retraction and exposure throughout the operation, delivery of infant, helping with proper visualization, suturing when needed, and extra monitoring for potential bleeding or other intraoperative complications.
Disposition: Taken to L&D Recovery Room - hemodynamically stable.
------------------------------
I've seen a significant increase in procedures involving the old c section scar recently.
Thank you, Cathy
Post-operative Diagnosis: same, s/p RCS, hernia of cesarean scar
Procedure: Repeat Low Transverse Cesarean Section, hernia repair
Anesthesia: Spinal
Findings:
Time of Birth: 7/10/2024 12:31 PM
Gender:
Neonate Wt:
Apgars:8 & 9 at 1 and 5 min. Nuchal cord: none. Normal uterus, tubes, and ovaries. Clear amniotic fluid.
Estimated Blood Loss: 271 ml
Total IV Fluids: see anesthesia note
Urine output: clear in foley post op
Specimens: Placenta to pathology. Cord blood obtained.
Complications: None; patient tolerated the procedure well.
Indication and Consent:
Due to patient's history of prior cesarean section, a repeat cesarean section was recommended to the patient for fetal and maternal wellbeing. The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The patient concurred with the proposed plan, giving informed consent. The patient understood that the risks of cesarean section include, but are not limited to, visceral or vascular injury, infection, blood loss and need for transfusion, prolonged hospitalization, reoperation, and rare risk of death. The patient stated understanding and desired to proceed. All questions were answered.
Procedure Details:
The site of surgery properly noted/marked. The patient was taken to Operating Room, identified and the procedure verified as C-Section Delivery. A Time Out was held and the above information confirmed.
Two grams of cefazolin (Ancef) were given for infection prophylaxis. After induction of anesthesia, the patient was draped and prepped in the usual sterile manner. A Pfannenstiel incision was made and carried down through the subcutaneous tissue to the fascia. Fascial incision was made and extended laterally. Omentum was protruding through a hernia at the previous incision site. The fascia was separated from the underlying rectus tissue superiorly and inferiorly. The omentum was detatched. The peritoneum was open. Peritoneal incision was extended superiorly and inferiorly to the bladder reflection with good visualization of the bladder. The utero-vesical peritoneal reflection was incised transversely and the bladder flap was bluntly freed from the lower uterine segment. The bladder blade was positioned to keep the bladder out of the operative filed.
A low transverse uterine incision was made. The amniotic sac was ruptured with an Allis clamp and Clear amniotic fluid noted. The uterine incision was extended bluntly with lateral and upward traction. The fetus was in cephalic presentation. The head was elevated out of the pelvis with special attention paid to avoid using the uterine incision as a fulcrum. Gentle fundal pressure was applied once the head was brought into the incision
The infant was delivered with no difficulty. The mouth and nose were suctioned with a bulb. After the umbilical cord was clamped and cut cord blood was obtained for evaluation. The infant was handed off to the pediatrician. IV oxytocin was initiated to facilitate uterine contractions.
The placenta was delivered intact with manual massage of the uterine fundus. The uterus was then exteriorized. The inside of the uterus was gently wiped with a lap sponge to assure complete removal of placenta membranes.
The uterine incision was closed with running locked sutures of 0 Vicryl. Hemostasis was observed. The blood clots and fluid were wiped out of the abdomen and pelvis with moist laparotomy sponges.
The muscle layer was closed. The fascial layer was closed in a running fashion with 0 Vicryl with no remaining defect. Subcutaneous layer closed. The skin was closed with suture in a subcuticular fashion. Instrument, sponge, and needle counts were correct prior the abdominal closure and at the conclusion of the case.
A qualified resident was not available. Dr. actively participated in assisting in this case with prepping patient in the OR, aiding in adequate retraction and exposure throughout the operation, delivery of infant, helping with proper visualization, suturing when needed, and extra monitoring for potential bleeding or other intraoperative complications.
Disposition: Taken to L&D Recovery Room - hemodynamically stable.
------------------------------
I've seen a significant increase in procedures involving the old c section scar recently.
Thank you, Cathy