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) 

 

8 thoughts on “

  1. Pingback: Deciphering your hospital records « Woman to Woman Childbirth Education

  2. 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.

  3. 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.

  4. 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!

  5. Pingback: Links for Thought (Dec 11) « Williamsburg Mothering

  6. 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

  7. Pingback: RT @birthsage: Deciphering your own hospital records http://www.glorialemay.com/blog/?p=79 #doula #midwife #VBAC | ChildBirth 101

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