Case Labor & Delivery Care

Name: Julia S.
Morales Age: 26 Birthday: 09/01/1995

Gravida: 1 Para: 0 Date Admitted: September 21, 2021
Address: Tanauan City Batangas Attending Physician: Dra Cruz
Clinical Data/Diagnosis: G1P0 38 weeks Medical Case #: 202100101
Cephalic in Labor
LABOR & DELIVERY CASE PRESENTATION

NOVEMBER 12, 2021 – DISCUSSION OF CASE
NOVEMBER 13, 16, 19 – CONSULTATION
NOVEMBER 20 – PRESENTATION OF CASE
Name: Julia S. Morales Age: 26 Birthday: 09/01/1995
Cephalic in Labor
HISTORY OF PRESENT ILLNESS
Chief Complaint: Labor pain

Admitting Diagnosis: G1P0 38 weeks Cephalic in Labor
Date Admitted: September 21, 2021 @ 4:00 PM
History of Present Illness: PATIENT HAS REGULAR PRE NATAL-CHECK UP WITH
REGULAR INTAKE OF MULTIVITAMINS AND FOLIC ACID. DENIES EXPOSURE TO
NEITHER ILLNESS NOR RADIATION.
PATIENT CAME IN FOR LABOR PAINS
LMP 12/27/2020
EDC 10/03/2021
G1P0
Past Medical History: None
Family Medical History:
Father: Hypertension
Mother: Dyslipidemia
Occupation: Factory worker
Vital Signs: BP 110/70 HR: 80 RR: 20 Temperature: 36.6
Cephalic in Labor
Height: 158cm Weight: 62 kg
Physical Examination
HEENT: PINK PALPEBRAL CONJUNCTIVAE, ANICTERIC SCLERA, NO CERVICAL
LYMPHADENOPATHY
CHEST/LUNGS: SYMMETRICAL CHEST EXPANSION, CLEAR BREATH SOUNDS, NO
WHEEZES NO RETRACTIONS
CVS: ADYNAMIC PRECORDIUM, NORMAL RATE, REGULAR RHYTHM, NO MURMUR
ABDOMEN: GLOBULAR ABDOMEN, (+) FETAL MOVEMENT, FHT (+)
GU (IE): PATULOUS CERVIX
SKIN/EXTREMITIES: NO DEFORMITY
NEURO-EXAM: NO DEFICIT
DATE / SIDE NOTES PHYSICIAN’S ORDERS

September 21, 2021 - Please admit to Delivery Room
4pm under my care.
- Secure consent for admission
- NPO
Cephalic in Labor
LMP: December 27, 2020 - IVF: D5LR 1L + 10 units Oxytocin

EDC: October 03, 2021 to run for 10 gtts/min
- Check for Vital signs and Fetal
Cervix Dilatation: 4cm
Heart rate
Cervical Effacement: 60% - Please do Internal Examination
(IE)
Cephalic
- Inform Pediatrician: Dra. Lee
FHT – 140’s - For Antigen Test and Chest Xray
(+) Spontaneous Rupture of Membrane - Secure Laboratory: Urinalysis,
HBSAg, Blood Typing, CBC, and
Ultrasound Report.
- Secure 1 Unit of Packed RBC for
possible use.
- Give Nalbuphine (Nubain) 5mg IV

now
- Give Diphenhydramine (Diphen)
25 mg IV now.
- Give Nalbuphine (Nubain) 5mg IV

September 21, 2021 now
- Give Diphenhydramine (Diphen)
Cephalic in Labor
4:30 pm 25 mg IV now.
- Give Diazepam (Valium) ½ amp IV
now.
September 21, 2021
5:30 pm
Pain scale 8/10
DATE / SIDE NOTES PHYSICIAN’S ORDERS

September 21, 2021 Post Partum Orders:
6:19 Pm - To Recovery Room (RR) for 2 hours

then to room
Baby out - IVF to consume then discontinue
- Start Liquid diet then Soft diet if
tolerated may proceed to Diet as
(+) Urine output Tolerated once fully awake
- Oral Medications as follows:
(+) Lochia Rubra moderate in amount
- Cefuroxime 500 mg/tablet 1 Tablet PO
Estimated blood loss of 650ml BID
- Mefenamic 500 mg/capsule 1 Capsule
Cephalic in Labor
(+) Pallor PO TID

- Keep uterus well contracted.
- Put Ice pack on hypogastric area.
- Closely monitor.
- Transfuse a properly typed and
crossmatched Packed RBC to run for 4-
6 hours.
- Pre BT medications: Paracetamol
300mg IV as stat dose
- For repeat CBC 6 hours post Blood

transfusion.
- Monitor for blood reactions.
- Refer accordingly
7:00 PM
11:30 PM
Packed RBC 1 unit was consumed.
September 22, 2021 - May Go Home after 24 hours of

delivery.
12 noon
- Home Medications:
- Cefuroxime 500 mg/tablet 1 Tablet po
Cephalic in Labor
BID x & days

- Mefenamic Acid 500 mg/capsule 1
(+) Uterus well contracted
Capsule PO every 6 hours x 5 days
(+) Urine output - Ascorbic Acid 500 mg/tablet 1 Tablet
PO x 10 days
(+) Bowel movement - Ferrous Sulfate tablet 1 tablet PO x 30
days
(+) Lochia Rubra minimal in amount
- Follow up on September 1, 2021 at
(-) pallor Room 204 MAB Building.
OBSTETRICS ULTRASOUND REPORT
General Survey:
No. of Fetuses: Single
Presentation/Lie: Cephalic
Fetal Heart Rate: 141 bpm
Placenta:
Location: Anterior
Grade: II
Impression:
Single Live, Intrauterine Pregnancy in Cephalic Presentation

Cephalic in Labor
Normohydramnios
Sonographic Estimated Fetal weight is appropriate for Gestational Age of 38

weeks and 2 days. ( 2000 – 2300 grams).
ANTIGEN TEST
COVID – 19 Ag NEGATIVE
Cephalic in Labor
CHEST PAL (FILMLESS)
RESULT:
The lungs are clear
The Pulmonary vasculature is within normal limits
The heart is not enlarged
The trachea is midline with due allowance for obliquity

Cephalic in Labor
The hemidiaphragms and costophrenic angles are intact
No other remarkable findings noted.
Impression:
NORMAL CHEST FINDINGS
HEMATOLOGY
CBC/PLATELET
TEST RESULT NORMAL RANGE

Hemoglobin 98.0 125.00-160.00 g/L
Cephalic in Labor
Hematocrit 0.32 0.37 – 0.47 Ratio

RED Blood Cells 3.81 2.50 – 5.50 10^6/uL
MCV 83.7 78-100 fL
MCH 28.6 27-31 pg
MCHC 34.2 32-36 g/dL
White Blood Cells 7.78 4.00-10.50 10^3/uL
Segmenters 66.2 37-72 %
Lymphocyte 26.0 20 -50 %
Monocyte 7.3 0 – 14 %
Eosinophils 0.4 0-6 %
Basophils 0.10 0–1%
Platelet Count 277 150 -450 10^3/uL
Cephalic in Labor
BLOOD TYPE
ABO TYPING “A”

RH TYPING POSITIVE
Cephalic in Labor
HBSAG
NON REACTIVE
Cephalic in Labor
URINALYSIS
MACROSCOPIC EXAMINATION
COLOR YELLOW
TRANSPARENCY SLIGHTLY TURBID
CHEMICAL EXAMINATION
pH 7.0
Sp. Gravity 1.010
Protein NEGATIVE
Glucose NEGATIVE
Ketone NEGATIVE
Bilirubin NEGATIVE
Blood NEGATIVE
Leukocytes NEGATIVE
Cephalic in Labor
Nitrite NEGATIVE
Urobilinogen NEGATIVE
MICROSCOPIC/URINE RESULT REFERENCE RANGE

FLOWCYTMETRY
Pus Cells 1.41 0-3.00 HPF
RBC 0.09 0-2.00 HPF
Epithelial Cells 1.50 0-3.00 HPF
Bacteria 128.57 0-50.00 HPF
Casts 2.00 0-3.00 LPF
VITAL SIGNS MONITORING SHEET – PRE DELIVERY
DATE/TIM BP HR RR OXYGEN INTERVAL DURATION IE FHT URINE NOD

E SATURATION OUTPUT
09/21/21 110/70 74 20 99% 5-10 40-60 7-8 156 300 RDM

Cephalic in Labor
4:10 PM MINS SECONDS CM
5:00 PM 110/70 78 20 99% 5-10 40-60 9 CM 138

MINS SECONDS
RDM
6:00 PM 120/70 75 20 99% 3-5 MINS 40-60 10 CM 145

SECONDS
RDM
Cephalic in Labor
DELIVERY REPORT
Anesthesia Local & IV Sedation

Anesthetist None
Fully Dilated at: 6:00 PM
Delivered at: 6:19 PM
Gender of Baby Male
Baby’s Weight 2400 grams
Type of Delivery Normal Spontaneous Delivery
Placenta Complete
Delivered at: 6:24 PM
Repair RMLE (Right Mediolateral Episiotomy)
Vaginal Packing None
Remarks None
Nurse Assistant Ran V. Del Mundo
Cephalic in Labor
RECOVERY ROOM – MONITORING SHEET

DATE/TIME BP HR RR TEMPERATURE OXYGEN URINE LOCHIA
SATURATION OUTPUT
09/21/2021
6:45 PM 110/70 76 20 36.8 99% 300 Moderate

amount
7:00 PM 110/70 76 20 36.8 99%
7:15 PM 110/70 78 20 36.8 99%

Cephalic in Labor
7:30 PM 110/70 80 20 36.8 99%
8:00 PM 120/70 80 20 36.6 99%
8:30 PM 120/70 84 20 36.6 99% 200 Minimal

amount
BLOOD TRANSFUSION RECORD

DATE SERIAL BLOOD RATE TIME TIME TRANSFUSION TRANSFUSION
NUMBER COMPONEN INFUSED CONSUMED INITIATED BY: COMPLETED
Cephalic in Labor
T PRODUCT BY:
September PRS45601 Packed RBC 4-6 Hours 7:00 PM 11:30 PM Ran V. Del Ran V. Del
21, 2021 Blood type Mundo Mundo
A Positive
7:00 PM
MEDICATION GIVEN BEFORE/DURING/AFTER TRANSFUSION

DATE TIME MEDICATIONS FREQUENCY GIVEN BY: REMARKS
09/21/2021 6:25 PM Paracetamol 300 STAT Ran V. Del N/A

mg IV Mundo
Cephalic in Labor
BLOOD TRANSFUSION REACTION

DATE: 09/21/2021
TIME STARTED: 7:00 PM
VITAL SIGNS PRIOR BT DURING 15 MINS 30 MINS 1 HOUR

HEIGHT OF AFTER BT AFTER BT AFTER BT
BT
BP 110/80 110/70 110/70 110/70 110/70
RR 18 18 20 20 18
PR 84 82 82 82 82
TEMPERATURE 36.2 36.4 36.2 36.2 36.4
NAME & Ran V. Del Ran V. Del Ran V. Del Ran V. Del Ran V. Del
SIGNATURE Mundo Mundo Mundo Mundo Mundo
Clinical Signs & Symptoms (Check if present)
Manifestations During BT After BT

YES NO TIME YES NO TIME
Fever ∕ ∕
Vomiting ∕ ∕
Cephalic in Labor
Difficulty of ∕ ∕
Breathing
Headache ∕ ∕
Itchiness ∕ ∕
Rashes ∕ ∕
Chilling sensation ∕ ∕
Others N/A N/A
HEMATOLOGY
DATE: SEPTEMBER 22, 2021 @ 05:30 AM
CBC/PLATELET
POST BLOOD TRANSFUSION
TEST RESULT NORMAL RANGE

Hemoglobin 128.0 125.00-160.00 g/L
Hematocrit 0.37 0.37 – 0.47 Ratio
RED Blood Cells 3.81 2.50 – 5.50 10^6/uL
MCV 83.7 78-100 fL
MCH 28.6 27-31 pg
Cephalic in Labor
MCHC 34.2 32-36 g/dL

White Blood Cells 8.78 4.00-10.50 10^3/uL
Segmenters 66.2 37-72 %
Lymphocyte 26.0 20 -50 %
Monocyte 7.3 0 – 14 %
Eosinophils 0.4 0-6 %
Basophils 0.10 0–1%
Platelet Count 280 150 -450 10^3/uL

Case Labor & Delivery Care

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Case Labor & Delivery Care

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Name: Julia S.

Morales Age: 26 Birthday: 09/01/1995

LABOR & DELIVERY CASE PRESENTATION

HISTORY OF PRESENT ILLNESS

Chief Complaint: Labor pain

PATIENT CAME IN FOR LABOR PAINS

Family Medical History:

Height: 158cm Weight: 62 kg

DATE / SIDE NOTES PHYSICIAN’S ORDERS

LMP: December 27, 2020 - IVF: D5LR 1L + 10 units Oxytocin

- Give Nalbuphine (Nubain) 5mg IV

- Give Nalbuphine (Nubain) 5mg IV

September 21, 2021

Pain scale 8/10

DATE / SIDE NOTES PHYSICIAN’S ORDERS

6:19 Pm - To Recovery Room (RR) for 2 hours

(+) Pallor PO TID

- For repeat CBC 6 hours post Blood

Packed RBC 1 unit was consumed.

September 22, 2021 - May Go Home after 24 hours of

BID x & days

OBSTETRICS ULTRASOUND REPORT

No. of Fetuses: Single

Fetal Heart Rate: 141 bpm

Single Live, Intrauterine Pregnancy in Cephalic Presentation

Sonographic Estimated Fetal weight is appropriate for Gestational Age of 38

CHEST PAL (FILMLESS)

The lungs are clear

The Pulmonary vasculature is within normal limits

The heart is not enlarged

The trachea is midline with due allowance for obliquity

The hemidiaphragms and costophrenic angles are intact

No other remarkable findings noted.

NORMAL CHEST FINDINGS

TEST RESULT NORMAL RANGE

Hematocrit 0.32 0.37 – 0.47 Ratio

ABO TYPING “A”

MICROSCOPIC/URINE RESULT REFERENCE RANGE

VITAL SIGNS MONITORING SHEET – PRE DELIVERY

DATE/TIM BP HR RR OXYGEN INTERVAL DURATION IE FHT URINE NOD

09/21/21 110/70 74 20 99% 5-10 40-60 7-8 156 300 RDM

4:10 PM MINS SECONDS CM

5:00 PM 110/70 78 20 99% 5-10 40-60 9 CM 138

6:00 PM 120/70 75 20 99% 3-5 MINS 40-60 10 CM 145

Anesthesia Local & IV Sedation

RECOVERY ROOM – MONITORING SHEET

6:45 PM 110/70 76 20 36.8 99% 300 Moderate

7:00 PM 110/70 76 20 36.8 99%

7:15 PM 110/70 78 20 36.8 99%

7:30 PM 110/70 80 20 36.8 99%

8:00 PM 120/70 80 20 36.6 99%

8:30 PM 120/70 84 20 36.6 99% 200 Minimal

BLOOD TRANSFUSION RECORD

MEDICATION GIVEN BEFORE/DURING/AFTER TRANSFUSION

09/21/2021 6:25 PM Paracetamol 300 STAT Ran V. Del N/A

BLOOD TRANSFUSION REACTION

TIME STARTED: 7:00 PM

VITAL SIGNS PRIOR BT DURING 15 MINS 30 MINS 1 HOUR

BP 110/80 110/70 110/70 110/70 110/70

TEMPERATURE 36.2 36.4 36.2 36.2 36.4

Clinical Signs & Symptoms (Check if present)

Manifestations During BT After BT

DATE: SEPTEMBER 22, 2021 @ 05:30 AM