LABOR ROOM Date/Time Focus D> Into LR a y/o, G P mother/female from ER/OB ward per

wheelchair/stretcher/ambulatory accompanied by ER attendant/IWOD/NOD/RN Heals on duty/RNSE on duty; with ongoing IVF of _____ iL + ___ u oxytocin at ____ mL level infusing well at the metacarpal/cephalic/basilic vein. Labor Pain > Nasakit; Grimaces; Moans occasionally; Irritable at times; Guarding lumbosacral noted; With initial VS: T=____, PR=____, RR= ____, BP=____; with FHT of ____ per minute. Patient Care A> Assessed level of pain and progress of labor; Monitored vital signs, FHT and recorded; Assisted on ambulation and in changing gown; Massaged lumbosacral area; Instructed on proper deep breathing techniques during contraction; squatting to facilitate descent; maintained on NPO as ordered and encouraged to verbalized feelings and concerns. Oriented to LR and DR set-up. Position and Comfort Fluid and Administration of Medications Promote Progress of Labor and Uterine Contractions > Assisted to DR table and positioned to lithotomy, IE done by _________________ revealing _____ cm cervical dilatation; Ushered back to LR for further monitoring. >IVF of _____ iL + ___ u oxytocin inserted by ____________ at the metacarpal/cephalic/basilicvein and regulated to ____ gtts/min. > First dose of HNBB I amp given IV push by NOD/RNSE/RN Heals on duty. > Second dose of HNBB I amp given IV push by NOD/RNSE/RN Heals on duty. > Third dose of HNBB I amp given IV push by NOD/RNSE/RN Heals on duty. > Seen and examined by Dr. ___________. > With drequency of ____ min and duration of ____ min. R> endorsed with ongoing IVF of D5LRS 1L + 10 u oxitocin at ____ mL level. > Brought to OB ward/OB-PR per stretcher with latest BP of ______ mmHg and with ongoing IVF of _____ iL + ___ u oxytocin at ____ mL level accompanied by _________. ** To be included if it was done > Bag of water ruptured spontaneously/artificially by __________. Noted clear/ shiny stained/ thickly stained amniotic fluid. > Seen and examined by Dr. _______ and ordered E Caesarian Section; Scheduled for E Caesarian Section and informed OR NOD. >Preoperative Care > Secure consent for the procedure/operation signed by patient/parents/husband/relatives; Prepared the patient by removing jewelries, false teeth, bra and underwear.

NURSERY CHARTING Date/Time Focus Immediate Assessment >Into DR from OR, an alive baby____ cuddled by ______. >With loud cry; Pinkish in color: Caput succedaneum noted; with moderate rernix caseosa noted all over the body; with moderate lanugo at the back; with strong flexion and extension of extremitres. Immediate Newborn Care >Wiping of oronasal secretions and blood stain done; Placed under radiant warmer; Placed name tag on left foot; Credes prophylax is applied on both eyes; Vitamin K 0.1 ml given 1M at L vastus lateralis; Hep B 0.5 ml given 1M at R vastus lateralis. With patnt anus. Data and Identification ________ Thermoregulation Initial Monitoring > Anthropometric measurements taken as follows: wt= ____, L= ____, HC= ___, CC= ___, AbdC= ____, Armc= ____; footprints taken. >Clothed and swaddled with blanket; maintained under Radiant warmer.

> Vital Status taken as T*= 35*C, CR=145, RR=54.

Nutrition and Bonding

>Brought to OR for catching-on; with good sucking reflex noted.

>Back to Or, placed under Radiant Warmer; continued monitoring Unit Transfer

>Roomed into mother at OB ward cuddled by RNSE on duty with latest VS of T*= , PR = ,RR= ,

Date/Time

Focus Immediate Newborn Care D> Received an alive baby under radiant warmer with ongoing oxygen per nasal cannula at ____ LPM. > With loud/weak cry; Pinkish/acrocyanosis in color; With strong flexion/some flexion and extension of extremities; Nasal flaring/grunting/club foor noted; With initial VS of T=____, CR=____, RR=____. A> Promoted safety by putting pillows at the side; Monitored VS and recorded; > Lathing done to mother at PACU/OB with good/fair sucking reflex. Nutrition and bonding Unit transfer R> With latest VS of T=____, CR=____, RR=____. > Roomed in to mother at OB/PACU cuddled by NOD.

DELIVERY ROOM CHARTING Date/Time Focus D> Into DR ambulatory accompanied by NOD/SNOD/RNSE on duty; with ongoing IVF of _____ iL + ___ u oxytocin at ____ mL level infusing well at the metacarpal/cephalic/basilic vein. > Into DR a ___ y/o, G__ P__ mother/female from ER/OB ward per wheelchair/stretcher/ambulatory accompanied by ER attendant/IWOD/NOD/RN Heals on duty/RNSE on duty; with ongoing IVF of _____ iL + ___ u oxytocin at ____ mL level infusing well at the metacarpal/cephalic/basilic vein. > With full cervical dilatation and continuous uterine contractions occurring every 2-3 minutes and duration of 60-90 seconds; With bloody mucoid and bulging perineum noted. Position and Comfort A> Assisted to DR table and positioned to lithotomy; IE done by ___________ revealing a full cervical dilatation; Hooked to oxygen per nasal cannula at 2-3 LPM; Coached on proper bearing down; >IE done by Safe delivery of Baby Start of anesthesia Sedation Safe delivery of the placenta Postpartum care noted. > RMLE done by Dr. _________/ Perineal support done applied by Dr.__________. >Delivered an alive baby boy/girl via NSD cephalic/breech presentation with Birth weight of ___ and Birth length of ____ attended by Dr. _________. >Nubain I amp given IV by __________ as per verbal order of Dr. ___________. > amp midazolam given IV by _________ as per verbal order of Dr. ____________. > Placenta out completely in Schultz/Duncan presentation; With BP of _______, PR=___, RR=____, T=____. >Methergine I amp administered IM/IV at ______ deltoid. > Additional 10 u oxytocin incorporated on present IVF as per verbal order of Dr. ___. > Evacuation of blood clots and placental fragments done by DR. _________ using curette/manually; Repair of laceration/Episiorraphy done by Dr. ___________. Massaged uterus until firm and contracted; Perineal care done then put on adult diaper. Transferred to stretcher and brought to LR; Ensured safety. Health Teachings Nutrition and Bonding > Advised to massage uterus until firm and contracted; To wash perineal area with tap water and to report excessive bleeding. > Breastfeeding initiated; Bonding maintained; Vital signs monitored and recorded; Breastfeed per demand and proper burping encouraged. R>Delivered safely with minimal vaginal bleeding; With firm and contracted uterus and with latest VS of: BP= _______, PR=___, RR=____, T=____. > Brought to OB ward/OB-PR per stretcher with latest BP of ______ mmHg and with Unit transfer ongoing IVF of _____ iL + ___ u oxytocin at ____ mL level accompanied by _________. revealing a full cervical dilatation and with bulging perineum

D& C Date/Time Focus Safe Operation D> Into DR ambulatory accompanied by NOD/SNOD/RNSE on duty; with ongoing IVF of _____ iL + ___ u oxytocin at ____ mL level infusing well at the metacarpal/cephalic/basilic vein. > Into DR a ___ y/o, G__ P__ mother/female from ER/OB ward per wheelchair/stretcher/ambulatory accompanied by ER attendant/IWOD/NOD/RN Heals on duty/RNSE on duty; with ongoing IVF of _____ iL + ___ u oxytocin at ____ mL level infusing well at the metacarpal/cephalic/basilic vein. > Conscious and coherent; With moderate/minimal bleeding noted; Weak and pale in appearance; With initial VS of: BP= _______, PR=___, RR=____, T=____. Secure consent Positioning and comfort A> Ushered to bed; Secured consent for surgery signed by _____ and attached to chart. > Assisted to DR table and positioned to lithotomy; Hooked oxygen per nasal cannula at 2-3 LPM; Shaved perineal area and draped aseptically. RMLE done by Dr. _________/ Perineal support done applied by Dr.__________. Start of anesthesia IV Sedation >Nubain I amp given intravenously by __________ as per verbal order of Dr. ___________. > 1 or amp Midazolam given IV by _________ as per verbal order of Dr. ____________. Contraction of Uterus Intra-operation > Additional 10 u oxytocin incorporated on present IVF as per verbal order of Dr. _________. > Dilatation and Curettage started by Dr. ___________ whereby a vaginal speculum was placed on the vaginal wall and anterior lip of cervix was grasped using tenaculumforcep; Hysterometer inserted to measure depth; Evacuation of blood lots and products of conception done using curette by Dr. ___________; Specimen saved then gave to watcher for hispathology. Contaction of uterus and prevention of bleeding Post-op care Health Teachings >Methergine I amp administered IM/IV at ____ deltoid by ______ as per verbal order of Dr.___________. >Dilatation and curettage ended; Swabbing of the cervical endometrium and perineum with betadinized sterile gauze; Perineal care done and put on adult diaper. > Instructed on proper deep breathing exercises, proper personal hygiene and to report excessive bleeding or concerns. R>With latest VS of: BP= _______, PR=___, RR=____, T=____. Unit transfer > Brought to OB ward/OB-PR per stretcher with latest BP of ______ mmHg and with ongoing IVF of _____ iL + ___ u oxytocin at ____ mL level accompanied by _________.