D&E Op Note Builder

Date of surgery Surgeon Anesthesia IV moderate sedation Monitored anesthesia care (MAC) / deep sedation General anesthesia via LMA General endotracheal anesthesia Local anesthesia (paracervical block) only Local anesthesia with oral anxiolysis Setting outpatient procedure roomoperating room Disposition Recovery area in stable condition PACU in stable condition Discharged home from recovery in stable condition Admitted for observation

Age Gravida Para GA weeks GA days Dating by ultrasoundLMP consistent with ultrasoundfirst-trimester ultrasoundLMP Indication — select — Patient request / elective Fetal anomaly / genetic diagnosis Maternal medical indication Previable PPROM Intrauterine fetal demise Indication detail Rh status — select —Rh positiveRh negative Rh immune globulin 300 mcg IM givendeclinedgiven prior to procedure Prior cesareans Placenta posterioranteriorfundallaterallow-lying

Osmotic dilators noneDilapan-SlaminariaDilapan-S and laminaria Number placed Placed (hours prior) Misoprostol none400 mcg buccal400 mcg vaginal400 mcg sublingual200 mcg buccal600 mcg buccal Misoprostol (hours prior) Mifepristone none200 mg PO Mifepristone (hours prior)

Induction of fetal demise nonedigoxin 1 mg, intrafetaldigoxin 1 mg, intra-amnioticpotassium chloride, intracardiac Given (hours prior)

Antibiotic prophylaxis doxycycline 200 mg POazithromycin 500 mg POmetronidazole 500 mg POcefazolin 2 g IVnone given Paracervical block 1% lidocaine, 20 mL1% lidocaine 20 mL with vasopressin 4 units1% chloroprocaine, 20 mLnot performed Additional dilation with none neededPratt dilatorsHegar dilatorsDenniston dilators To (mm / Fr) Suction cannula (mm) Forceps SopherBiererHernKelly placentalSopher and Bierer Ultrasound guidance real-time transabdominal, throughouttransabdominal, intermittent and at completionnone Final curettage nonegentle sharp curettagefinal suction pass

Placed today none levonorgestrel 52 mg IUD copper T380A IUD etonogestrel implant DMPA 150 mg IM Implant armleftright Strings trimmed to (cm)

Estimated blood loss (mL) IV fluids Specimen disposition products of conception to pathology products of conception, disposition per institutional protocol products of conception to pathology and for genetic testing products of conception released per patient request Complications None Cervical laceration, repaired Hemorrhage, managed as described Suspected uterine perforation Other (describe in narrative)