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 -interuterine 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 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)
For more about the cesarean operation, see
this page.
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