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For Delivery FDAR Charting

1. A 30-year-old woman was admitted in active labor and delivered a baby boy spontaneously with Apgar scores of 8 and 9. 2. During the vaginal examination, the doctor noticed some missing parts of the placenta, causing postpartum bleeding, so an episiotomy and episiorrhaphy were performed. 3. The newborn was dried thoroughly, initiated breastfeeding, measurements were taken, and was brought to the ward for further care.

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Lyca Mae Aurelio
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9K views5 pages

For Delivery FDAR Charting

1. A 30-year-old woman was admitted in active labor and delivered a baby boy spontaneously with Apgar scores of 8 and 9. 2. During the vaginal examination, the doctor noticed some missing parts of the placenta, causing postpartum bleeding, so an episiotomy and episiorrhaphy were performed. 3. The newborn was dried thoroughly, initiated breastfeeding, measurements were taken, and was brought to the ward for further care.

Uploaded by

Lyca Mae Aurelio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Aurelio, Lyca Mae M.

Mother’s Progress Notes

Date/Time Focus Data Action Response


10/07/20
8:30 PM For ➢ In from labor ➢ Placed
delivery room, a 30 computably on
years old, DR table in
G1P0 in lithotomy
active labor position.
per stretcher. ➢ Perineal prep
➢ With IV Fluid done aseptically
of D5Lrs
850cc level
regulated

8:45 PM ➢ Episiotomy
done by Dr.
Cadena thru
local anesthesia

8:55 PM ➢ Delivered
spontaneously
to an alive baby
boy attended
by Dr. Cadena
with an APGAR
score of 8,9
respectively.
8:58 PM
➢ 10 “U” oxytocin
incorporated to
above IV
Fluid/IM
9:00 PM
➢ Placenta
delivered
completely thru
Schultz
presentation

➢ BP taken
➢ After
placental ➢ Carboprost 250
examination, mcg admistered
Dr. Cadena thru IM
noticed
some parts of
the placenta
was missing
causing post
partum
bleeding
during the
vaginal
examination

➢ Episiorrhaphy
done by Dr.
Cadena.

➢ Perineal care
done, clean pad
applied.
➢ Affirmed by
➢ Health nodding and
teachings verbalization
incorporated of “Wen
such: Mam”
• Manage uterus
to prevent post
partum.
• Instruct to clean
the perineum
with clean tap
water.
• Encourage early
breastfeeding.
• Take
medication as
prescribed
• Encourage to
do follow up
check up as
scheduled

9:30 PM ➢ Procedure
well
tolerated

➢ Brought to
PACU with
well
contracted
uterus and
minimal
vaginal
bleeding

Lyca Mae Aurelio/ Mrs. Cheryyfel Colobong/Mr. Erwin Garvida/ Ms. Rei Imencion
MMSU-SN CI MOD NOD
Newborn’s Progress Notes
Date/Time Focus Data Action Response
10/07/20
8:55 PM ➢ Immediate Born an alive ➢ Immediate and ➢ Good Crying
Newborn baby boy thru thorough
Care Normal drying of skin
Spontaneous done
delivery
attended by Dr. ➢ Skin to skin
Cadena with an contact
APGAR score of between the
8,9 mother and
respectively. newborn

➢ Cord clamping
and cutting
done after
pulsation
stopped

➢ Breast feeding
initiated

➢ Anthropometric
measurement
taken as follows
➢ BL- 50 cm
➢ HC- 34 cm
➢ CC- 32 cm
➢ AC- 34 cm

➢ Weight Taken,
3.1 kg

➢ Anal opening
checked with
patent anus

➢ Nametag
applied

9:30 PM ➢ Able to adjust


to
extrauterine
life
➢ Brought to
ward for
more care
and
management.

Lyca Mae Aurelio/ Mrs. Cheryyfel Colobong/Mr. Erwin Garvida/ Ms. Rei Imencion
MMSU-SN CI MOD NOD

Aurelio, Lyca Mae M. Mother’s Progress Notes Date/Time Focus Data Action Response 10/07/20 8:30 PM
9:30 PM some parts of the placenta was mis
uterus and minimal vaginal bleeding Lyca Mae Aurelio/ Mrs. Cheryyfel Colobong/Mr. Erwin Garvida/ Ms. Rei Imencion
Newborn’s Progress Notes Date/Time Focus Data Action Response 10/07/20 8:55 PM
➢ Brought to ward for more care and management. Lyca Mae Aurelio/ Mrs. Cheryyfel Colobong/Mr. Erwin Garvida/ Ms. Re

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