Deciphering Your Hospital Records
-by Gloria Lemay
The following terms are often used in the medical records of women who have had cesarean sections. If the records are typed rather than handwritten, be aware that the transcriptionist often makes errors that are not caught by the transcriber (there could be errors in your records).
Gravida -how many times you have conceived
Para -how many pregnancies that went past 22 weeks
GTT (glucose tolerance test)- a test for gestational diabetes
Thyromegaly -enlarged thyroid gland in the neck of gravid (pregnant) pregnant
Fundal -topmost part of the uterus, near the ribs
Pretibial edema -ankle swelling
Macrosomia -big baby (over 4000 grams, or over 8lb 13oz)
IUGR -intrauterine growth retardation of baby (small for dates)
IODM -infant of a diabetic mother
Vertex -baby is head down into the pelvis (normal)
Preop -preoperative, before the surgery
Post op -post operative, after the surgery
Intrauterine -within the uterus
Primary cesarean -first time the uterus is cut into
Rectus muscles -long muscles in the belly, the ones you need to do a sit up. Do not confuse with the Rectum.
Vacuum assist -baby was pulled out with a vacuum extractor Applied to his/her head. Forceps and vacuum Extractors are used in cesarean operations.
No extensions -the wound did not tear further than the cut.
The uterus was delivered from the abdominal cavity -the uterus was pulled up on to the woman’s Abdomen after the baby was out of it.
2-0 Vicryl -the type of thread used to sew with
Hemostatic -stopped bleeding
1 LTCS -primary low transverse cesarean section (bikini cut)
@ term -40 weeks gestation or more
Rh -a factor in the blood
Est’d fetal wt -estimated fetal weight
Inc clean/dry -incision clean and dry
Lochia -the blood flow from the mother’s vagina after the birth.
POD #1 -Post Operative Day 1
PAR -post-anesthetic recovery
S O A P -if you see these letters on the side of nurses Notes, this is a method of charting that stands for: Subjective findings, Objective findings, Assessment and Plan
WNL -within normal limits
Clonus -how the woman’s foot bounces when there is a highly irritated nervous system, most especially in severe pre-eclampsia
Abd shave -abdomen shaved
EFM -electronic fetal monitor
EBL -estimated blood loss
Drain: Foley –the catheter used to drain the bladder if it is indwelling
Afeb -afebrile, without a fever
NT -non tender
FF U-2 -firm fundus; two finger widths below the woman’s Umbilicus (i.e. well contracted uterus after birth)