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
Dystocia -stuck
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
Bicitra -antacid
Abd shave -abdomen shaved
EFM -electronic fetal monitor
Dc’d -discontinued
EBL -estimated blood loss
Drain: Foley –the catheter used to drain the bladder if it is indwelling
Dx -diagnosis
Flatus -farts
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)
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Do you have any idea what MPS means? In the context of, “if head on view proceed as per MPS.” I don’t have Myofasical Pain Syndrome so that’s out. Maybe Maternal Position Supine (which I was) or Multiple Pregnancy Study? If you have any info, I’m very interested. The m/w in this hospy birth said if I did not remain flat on my back that my husband would be ejected from my room. I was in that position for 2 hours. I know this could have ended all 3 of our lives (twins), and that if they had just let me be it wouldn’t have ended in a c/s for “FTP”. Yes, I did request to be upright, and requested another opinion. I was laughed at.
It’s a document called “Making Pregnancy Safer”. You can read more about it at:]
http://www.euro.who.int/document/MPS/2003MDAMidwifery.pdf
I apologize to you for the way you were treated, it was inexcusable. Let me know if you need anything else interpreted. Do you live in Britain?
Thanks. We’re over in Australia. I have a feeling when I get my eyes onto the document you’ve kindly supplied that the prone supine position will not be on the list of safe birthing positions, as the WHO put out the Fortuleza Declaration in ’85. I appreciate the info as the hosp. & OB, and m/w have declined to answer this particular question which was included in the complaint. If I had known how effective primary midwifery care was I’d have gone with an independent midwife from the beginning.
Not sure if it applies in the UK, but here in the US, some other terms you might add: Multip and Grand Multip. I think there’s another Multip name in there, but I don’t remember!
I was so confused when they kept calling me a “Grand Multip” after my last baby (first C-sec), baby #8!
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With regards to Para, I would like to reiterate that it is the pregnancy and not the number of babies that is the para, so twins would still be one para.
Cheers
Judy
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