∙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 gment transver cesarean ction 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
如何保养头发
Findings At Surgery: 术中所见：Male infant in occiput posterior prentation.男婴，枕后位 Thin meconium with none below the cords, pediatrics prent 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 connt, 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 diss
ected 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 parated in the midline, and the peritoneum was tented up, and entered sharply with Metzenbaum scissors. The peritoneal incision was extended superiorly 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 inrted, 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 The bladder was retracted using the bladder blade.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 gment was incid in a transver fashion with the scalpel, then extended bilaterally with bandage scissors. The bladder bla
de was removed, and the infants head was delivered atraumatically. The no and mouth were suctioned and the cord clamped and cut. The infant was handed off to
the pediatrician. Cord gas and cord blood were nt.
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 clots and debris. The uterine incision was repaired with 1-O chromic in a running locking fashion. A cond layer of 1-O chromic was ud 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 clod with 3-0 Vicryl. The fascia was reapproximated with O Vicryl in a running fashion. The skin was clod 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. 孕妇长痔疮怎么办
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
复习字谜Fluids: Input - 2000 cc LR; Output - 300 cc clear urine.
液体：入量 2000cc；出量 300cc清亮尿液
Complications: None.
利水渗湿并发症：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 O
C. 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。必要时插入导管I and O
F. Medications药物
1. Cefazolin (Ancef) 1 gm IVPB x one do at time of cesarean ction.
头孢哌酮 1克，术中 IVPB 一次 快递公司几点上班
2. Nalbuphine (Nubain) 5 to 10 mg SC or IV q2-3h
OR
盐酸环丁甲羟氢吗啡 5~10mg SC 或IV，每2~3小时
或
3. Meperidine (Demerol) 50-75 mg IM q3-4h prn pain.
盐酸哌替啶 50~75mg，IM，每3~4小时，（疼痛）必要时
4. Hydroxyzine (Vistaril) 25-50 mg IM q3-4h prn naua.
如何做调查问卷羟嗪 25~50mg，IM 每3~4小时，（恶心）必要时
5. Prochlorperazine (Compazine) 10 mg IV q4-6h prn naua OR
甲哌氯丙嗪 10 mg IV 每4~6小时，（恶心）必要时 或
6. Promethazine (Phenergan) 25-50 mg IV q3-4h prn naua
盐酸异丙嗪 25-50 mg IV 每3~4小时，（恶心）必要时
猪棒骨怎么炖好吃G. Labs: CBC in AM.
实验室检查：上午全血细胞检查
II. Postoperative Day #1
术后第一天
A. Asss pain, lungs, cardiac status, fundal height, lochia, passing of flatus, bowel movement, distension, tenderness, bowel sounds, incision.
评估疼痛，肺，心脏状况，基础体重，恶露，排气，肠蠕动，腹胀，压痛，肠鸣音，切口。
B. Discontinue IV when taking adequate PO fluids.
当可以经口足量进食，停用静滴液体。
C. Discontinue Foley, and I and O catheterize prn.
停用Foley引流，必要时 I and O 插入导管
D. Ambulate tid with assistance; incentive spirometer q1h while awake.
帮助下地活动；，每小时均需鼓励患者深呼吸
E. Check hematocrit, hemoglobin, Rh, and rubella status.
检查HCT，HGB，Rh，和风疹状况
F. Medications药物
1. Acetaminophen/codeine (Tylenol #3) 1-2 PO q4-6h prn pain OR
扑热息痛 1~2片，当疼痛(必要时)时，每4~6小时口服一次，
2. Oxycodone/acetaminophen (Percocet) 1 tab q6h prn pain.
盐酸羟基可待酮 1片，q6h，当疼痛(必要时)时
3. FeSO4 325 mg PO bid-tid.
蚝油生菜的做法硫酸亚铁 325mg，口服，2~3次/日
4. Multivitamin PO qd, Colace 100 mg PO bid. Mylicon 80 mg PO qid prn bloating.
多种维生素 口服，qd；多糜酯钠 100mg，口服， bid；二甲硅油 80 mg PO，bloating必要时
III. Postoperative Day #2
术后第二天
A. If passing gas and/or bowel movement, advance to regular diet.
如果排气和/或肠鸣音（正常），鼓励规律饮食。
B. Laxatives: Dulcolax supp prn or Milk of magnesia 30 cc PO tid prn. Mylicon 80 mg PO qid prn bloating.
轻泻药：Dulcolax supp 必要时，或氧化镁牛奶30cc，必要时tid。二甲硅油 80 mg PO qid，bloating必要时
IV. Postoperative Day #3
术后第三天
A. If transver incision, remove staples and place steri-strips on day 3. If a vertical incision, remove staples on post op day 5.
如果是横切口，在第三天拆除staples，无菌包扎。如果是纵切口，在第五天拆除staples。
B. Discharge home on appropriate medications; follow up in 2 and 6 weeks.
适当带药出院；2周及6周随访。
