NURSERY [ pate Ano | Focus DATA, ACTION, RESPONS Time Immediate D> Born an alive baby boy/girl via NSD attond Newborn care | Gyne doctor). For private patients, please received by (Pediatrician). | *For babies from OR. | D> Into DR from OR an alive baby boy/girl cuddled by Dr. by (OB- | | i | With loud/weak cry; with 1-2 looseltight cord loop, | thinithick meconium stain, pinkish/acrocyanotic In color; caput succedaneum; with abundant/moderate/scanty vernix casseosa noted all ‘ever the body/bach/buttocks/groin/armpit; with moderate Lanugo at the back; with strong flexion and ‘extension of extremities; with positive stool, APGAR score of _,__ at 1 and 5 minutes respectively; with initial vital signs of Tomp. °C; CR _ bpm; RR __cpm. Promoting A> Rendered immediate newborn care, placed on bonding, mother's abdomen, Immediate drying of oronasal secretions and blood stain done, initiated bonding with | airway and cord care mother through skin to skin contact, cord cut | aseptically when pulsation stopped; put on bonnet; (oronasal secretions suctioned; administored oxygen inhalation via oxygen) (if it was done). Nutrition and | A>Cleansed breast of mother, latching done with f bonding good/fair sucking reflex noted. A>Hopatitis B vaccine 0.5m given at right vastus Time immunization lateralis and Vitamin K 0.1m! at loft vastus lateralis. Data and A>Anthropometric measurement taken as follows Wt. | \aentification | __ kg; cms; HE __ em; CC __ em; Arm ‘clothed and placed name tag on left foot, crede’ oy prophylaxis applied on both e} | R> Pinkish, with good sucking reflex, with latest vital signs of Temp. °C; CR _ bpm; RR __ cpm. Time Unit transfer _ | >Brought to OB ward beside mother per stretcher accompanied by IWOD/RNSE/SNOD. | C |__RECEIVING BABIES UNDER RADIANT WARMER | Time Immediate ‘A> Received and alive baby boy/girl under radiant newborn care | warmer with and ongoing oxygen per nasal cannula st | __ 1pm; with loudiweak ery, pinkishiacrocyanotic; with | Initial vital signs of Temp. °C; CR bpm RR __ cpm | | nasal flaring/grunting/clubfoot. | | A>Promoted safety by putting pillows at the side, | monitored vital signs and recorded (more intervention: j Nutrition and | A>Latching done to mother at PA\ | | | a CU with good/fair bonding sucking reflex. ‘A>Roomed in to mother at OB wa bpm; RR rd with latest vital ‘cpm cuddled by | signs of Temp. _"C; CR | oS em {bd omDATE AND TIME Time LABOR ROOM |[D>into labor room a__ylo, GI P_from OB ward/ER accompanied by IWOD/RNSE/SNOD on duty; with ongoing IVF of ___1L +___“u” oxytocin at __ mL level infusing well at the | metacarpal/cephalic/basilic vein. D>Grimaces noted, moans occasionally, irritable at times, guarding lumbosacral area noted; with vital signs as follows: BP ___ mmHg; PR __ bpm; RR __ cpm; Temp. _°C. ,| Patient Care ‘A>Assessed level of pain; assessed progress of || labor; monitored vital signs and recorded; assisted on ambulation; massaged lumbosacral | area. | Positioning and Comfort ‘A>Assisted to DR table and positioned to lithotomy for IE done by revealing cervical dilatation; perineal shaving done; ushered to LR for further monitoring. _ Time Fluid and Administration of Medication ADIVE of ___1L + __ “u” oxytocin inserted by "__at the LIR metacarpal/cephalicibasilic vein _—_ atts/min. | ‘A>First dose HNBB 1 amp. given IV push by NOD/RNSE. A>Blood specimen extracted by Medtech on duty for CBC, ABO typing and HB sag Health Teaching | Unit Transfer Consent | A>Brought to DR ambulatory with same IVF ‘A>instructed on proper deep breathing techniques; squatting to facilitate descent; | maintained on NPO as ordered and encouraged to | verbalize feelings and concems. R>Increased intensity of pain with pain scale of _ and uterine contractions occurring every 2-3 minutes; with duration of 60-90 second: lL \ccompanied by __ i TOBE INCLUDED IF IF IT WAS DONE A>Bag of water ruptured artificlally/spontaneously by A>Seen and examined by Dr.__ ordered for “E” Cesarean section due to arrest of cervical dilatation/arrest of descent; scheduled for “E” CS; | Informed OR NOD, Pediatrician and Anesthesiologist. | Secured consent for the procedure/operation signed by the patientiparenthusbandirelative._D AND C “DATA, ACTION, RESPONSE TIME } — “" Time | Safe ‘p> Into Labor room a__ y/o G_P_ Female from ER/ | \Operation _| OB ward per wheelchair! stretcher! ambulatory | | accompanied by IWOD/ RNSE/ SNOD with ongoing | | | | IVF of __1L+__ ‘u’ oxytocin at__mb infusing | i | well at the left/ right metacarpal basillic/ cephalic | | vein; conscious and coherent; with moderate! j minimal bleeding noted; weak and pale in | | appearance; with initial vital signs as follows: BP | ___ mmiig; PR __ bpm; RR __ cpm; Temp. _°C. | | D> Into Delivery Room ambulatory accompanied by | | | NOD/ RNSE/ SNOD with an ongoing IVF of _1L+ | | _—_‘u’ oxytocin at __ mL level infusing well at the left/ right metacarpal basillic! cephalic vein. Consent ‘A> Ushered to bed Consent for D and C signed by | - and attached to chart. / Consent for D and C | checked and attached to chart. | __jPositioning | A> Assisted to DR table and positioned to ~| and Comfort | lithotomy, administered oxygen inhalation per nasal cannula at 2-3 Ipm; shaved perineal area and draped aseptically. [Time | Start of ‘A> IV sedation done by Dr. . [Anesthesia | | sedation Time wv A> Additional 10 ‘w’ oxytocin incorporated to above incorporation | IVF as per verbal order of Dr. - Time Dandc ‘A> Completion / Evacuation/ Dilation curettage done by Dr. Specimen saved then given to watcher for histopathology. | [Time Medication | A> Methylergometrine 1 amp given IM by NOD/ i at right/ left deltoid as per verbal order of re 7 ___;Pest-Op | A> Perineal care done and adult diaper placed | Care snugly; transferred to stretcher and brought to abor room, fr Health D> Conscious and Coherent I Teaching A> Assessed level of consciousness; Instructed on L Iysieneandtorepor excerete eee eat | Time —_| Unit Transfer | > Brought to OB ward per stretcher! SetioslcRa | |with above IVF of 4L+ ; — ‘u’ oxytocin infusing | Well; with the latest vital signs as follows: BP mmHg; PR __ bpm; RR __ cpm; Temp.