COLLEGE OF NURSING

DR Write-UP

Date of Admission: September 20, 2021

Ward: Labor Room
Age: 33 years old Civil Status: Married Religion: Roman Catholic
Occupation: Housewife
Admitting Diagnosis: G2P0 (1010 )
Final Diagnosis: delivered to a live baby boy via normal spontaneous delivery with episiotomy
Type of Delivery: Normal Spontaneous delivery
History of Present Delivery:

8:30 am – admitted at the labor room

Pathophysiology:

Station 1:
 internal exam was done at the OB-ER by Dr. Bacilos revealed that the cervix is 8cm dilated, 70 percent
effaced
intact bag of water

Brief Discussion of the procedure

The incision should only be started during a contraction when the presenting part is stretching the perineum.
Doing the episiotomy too early may cause severe bleeding and will not immediately assist the delivery. The
incision is started in the midline and most posterior in the vaginal opening (intriotus) with the scissors pointed at
45° away from the anus. It is usually directed to the patient’s left but can also be to the right. 2 fingers of the left
hand are slipped between the perineum and the presenting part when performing a mediolateral episiotomy.

Instruments (place at the back of this sheet)

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 COLLEGE OF NURSING

Mayo curve, Mayo straight, Metzen Baum, Needle holder, Tissue forceps

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