Medical Transcription: Summary of Labor and Delivery
A summary of labor and delivery, or delivery note, is a brief recap of events that occur immediately before and during childbirth, and is a common report in medical transcription. If the mother undergoes a C-section, a separate operative note is dictated. A delivery note may be dictated with preoperative (pregnant) and postoperative (delivered) diagnoses or as a descriptive narrative with no subheadings. In either case, it describes
The mother’s condition on arrival, including stage of labor and results of prenatal lab tests
Any interventions, such as anesthesia, an episiotomy, or the use of Pitocin to augment labor or forceps or suction to aid delivery
The mother’s condition after delivery
The infant’s time of birth, delivery position, gender, weight and length, and condition at birth
Special terminology is used to summarize the mother’s obstetric history. There are two systems used for this: GPA and TPAL. GPA is an acronym for gravida (number of pregnancies), para (number of live births), and abortus (miscarriages or induced abortions). The A (sometimes referred to as Ab) is frequently dropped if zero.
A 23-year-old G2, P1 white female
describes a woman in her second pregnancy, with the first one resulting in a live birth. A dictator may use the actual terms instead of the letters; in either case, separate them with commas.
TPAL is an acronym for term births (T), premature births (P), abortions (A), and living children (L). TPAL numbers should be separated by hyphens. If a dictator gives a series of four numbers as the obstetric history, it should be transcribed like this:
A 23-year-old 2-2-0-2 white female
A dictator may mix and match GPA and TPAL systems. You should transcribe it however she dictates it.
Another term specific to delivery notes is Apgar score. Apgar is an eponym (Dr. Virginia Apgar invented the test) that’s also used as an acronym.
The acronym, which shouldn’t be expanded, stands for appearance, pulse, grimace, activity, and respiration — a checklist used to quickly assess a newborn’s condition on a scale of zero to ten. Every delivery note mentions at least two Apgar scores, one from one minute after birth and one at five minutes, like this:
A viable female infant with Apgar scores of 7 and 9.