LScoder2016
Networker
Can modifier 22 be added for a vacuum assisted delivery or is that apart of 59400/59409? this is patients first child.
Vaginal Delivery: vacuum assist
Number of Attempts: 2
Presentation: vertex
Vertex Presentation: occiput anterior
Episiotomy: midline/median
Episiotomy Detail: 2nd degree Laceration
Location: sulcus
Vaginal Delivery Anesthesia: epidural
Vaginal Delivery Details: chorioamnionitis; maternal fever; meconium stained amniotic fluid
Procedure Note: After progression to complete dilatation under epidural anesthesia, delivery was prolonged and baby was not progressing with maximum efforts of pushing. Baby's heart rates was in the 170s. It was decided to proceed with vacuum assisted delivery. Vacuum was attached 3cm in front of the posterior fontanelle. Vaccuum was applied during contractions with maternal pushing effort. 4 total pulls were performed over 2 contractions with 0 pop-offs. Fetal head was delivered with controlled tract. Vacuum was released prior to full delivery of the head. Umbilical cord was doubly clamped and cut after a 60 second delay, and the infant was handed from the field in good condition. Umbilical cord blood was drained as IV Pitocin was administered. The placenta was delivered spontaneously and intact approximately 4 minutes after the infant and was found to have a three-vessel cord. The birth canal was inspected and found to be 2nd degree tear and bilateral superior sulcus tears. Perineal muscles and vaginal mucosa edges were reapproximated with 3-0 Vicryl in usual fashion. Hemostasis achieved with no tension.. All debris was expressed from the vaginal vault. A digital exam revealed no retained sponges. A rectal exam was performed and there were no sutures noted and the rectum is completely intact. The patient tolerated the procedure well and plans on breast/bottle-feeding. Sponge and instrument count correct.
Vaginal Delivery: vacuum assist
Number of Attempts: 2
Presentation: vertex
Vertex Presentation: occiput anterior
Episiotomy: midline/median
Episiotomy Detail: 2nd degree Laceration
Location: sulcus
Vaginal Delivery Anesthesia: epidural
Vaginal Delivery Details: chorioamnionitis; maternal fever; meconium stained amniotic fluid
Procedure Note: After progression to complete dilatation under epidural anesthesia, delivery was prolonged and baby was not progressing with maximum efforts of pushing. Baby's heart rates was in the 170s. It was decided to proceed with vacuum assisted delivery. Vacuum was attached 3cm in front of the posterior fontanelle. Vaccuum was applied during contractions with maternal pushing effort. 4 total pulls were performed over 2 contractions with 0 pop-offs. Fetal head was delivered with controlled tract. Vacuum was released prior to full delivery of the head. Umbilical cord was doubly clamped and cut after a 60 second delay, and the infant was handed from the field in good condition. Umbilical cord blood was drained as IV Pitocin was administered. The placenta was delivered spontaneously and intact approximately 4 minutes after the infant and was found to have a three-vessel cord. The birth canal was inspected and found to be 2nd degree tear and bilateral superior sulcus tears. Perineal muscles and vaginal mucosa edges were reapproximated with 3-0 Vicryl in usual fashion. Hemostasis achieved with no tension.. All debris was expressed from the vaginal vault. A digital exam revealed no retained sponges. A rectal exam was performed and there were no sutures noted and the rectum is completely intact. The patient tolerated the procedure well and plans on breast/bottle-feeding. Sponge and instrument count correct.