PHINMA UPANG General Hospital

ARELLANO ST., DAGUPAN CITY

PHILIPPINES 2400
NURSES NOTES
Name: Mrs. G Age: 38 y/o Attending Physician: Dr.Philo Sopo
Sex: Female Civil Status: Married Room No. /Bed No. Room # 89/03 Hospital No. 023589

Date Shift Focus Time D = Date / A = Action / R = Response

3/26/21 Shoulder Dystocia 1200 D: 42 weeks AOG patient experiencing 2 hours prolonged 2nd
stage of labor.
Cervix is fully dilated
+ sign of crowning
(-) BOW (rupture of membranes confirmed)

V/S are taken as follows:

BP – 140/80mmHG
PR – 89BPM
RR – 28RPM
T – 37.1oC
FHT – 148BPM

Patient was admitted directly at delivery room

1210 A: Assess the vital signs, explained to the patient the possible
need of episiotomy and asked for its consent as well for the
consent of cesarean delivery for backup in case if the delivery
method failed; educated and informed the client of the
possible complications of her case
1220 Asked for assistance and Called for help for a team approach
to the management of shoulder dystocia
1225 Performed McRobert’s Maneuver
 Asked and assist the client to a lithotomy position
and to hyper flex her both legs.

Performed Mazzanti Maneuver

 Applied by suprapubic pressure using the heel of
clasped hands from the posterior aspect of the
anterior shoulder to dislodge it.
 Fetus failed to be delivered
1230 Performed Rubin’s Maneuver/ Reverse Woodscrew Maneuver
 Attempted to deliver the fetus by adduction of
the anterior shoulder by pressure applied to
the posterior aspect of the shoulder that will
cause movements of shoulder into more
oblique
 Fetus failed to be delivered

1235 Performed Rotational of the posterior shoulder Woodscrew

Maneuver
 Applied by applying pressure to the anterior aspect of
the posterior shoulder and an attempt is made to
rotate the posterior shoulder to the anterior position
that will easily deliver the shoulder once past the
symphysis pubis.
 Fetus failed to be delivered
1240 Manual removal of the Posterior Arm
 Attempted to deliver the baby by manually removing
the posterior arm by applying pressure intravaginally
at the antecubital fossa which causes fetal arm to flex
and swept across the chest and towards the opposite
side of the fetal face.
 Fetus failed to be delivered
1245 Performed Gaskin Maneuver
 Assisted the mother to roll onto hands and
knees
 Applied downward traction repeatedly until
the shoulder of the fetus was delivered
 Fetus was successfully delivered

1250 Call out the baby’s time of birth and gender; the mother and
the infant will be monitored and observed. Assess the infant
facial symmetry, skin quality, neurologic abnormalities, and
arm and hips movements for any injury and checked for any
fractured clavicle or humerus
Checked mother’s perineum, any signs of tears and bleeding
and assesses for postpartum hemorrhage
1255 Third stage of labor commences with the completed delivery
of the infant and ends with the completed delivery of the
placenta and its attached membranes.
Essential newborn care: the care provided to a newborn
immediately after delivery which includes the time between
births to 24 hours care is essential newborn care, and it
includes to dry and stimulate, evaluate breathing, keep the
newborn warm (prevent hypothermia), initiate breastfeeding
in the first one hour, administer eye ointment, administer
vitamin K intramuscularly, weigh the newborn when it is stable
and warm, cord care, and delayed bathing of the baby for 24
hours after birth
1300 R: The Mother and the Newborn were successfully delivered
with no injury. Mother and newborn are resting and will be
continuously monitored and observed.
 PHINMA UPANG General Hospital
ARELLANO ST., DAGUPAN CITY
PHILIPPINES 2400

NURSES NOTES
Name: Mrs. D Age: 34 y/o Attending Physician: Dr. Maha Root
Sex: Female Civil Status: Married Room No. /Bed No. Room # 231/02 Hospital No.
027856

Date Shift Focus Time D = Date / A = Action / R = Response

3/26/2 Forceps Assisted Delivery 0900 D: The mother is in labor pain, 40 weeks AOG patient
1 experiencing 2 hours prolonged 2nd stage of labor.

Cervical dilation = 10 cm (cervix is fully dilated)

(-) BOW (rupture of membranes confirmed)
(+) Meconium stain

V/S are taken as follows:

BP – 120/80mmHG
PR – 81BPM
RR – 20/MIN
T – 36oC
FHT – 167BPM

Operative Vaginal Birth (Forceps Assisted Delivery) ordered by

the OB’s
0910 A: Assess the fetal heart rate. Confirmed that fetal position
and size of maternal pelvis is compatible and adequate for
forceps assisted delivery.
0920 Put the patient on oxygen inhalation running at 3-4LPM; and
at IVF of D5 liter with 10 units of oxytocin running at
20gtts/min
0925 Secured consent for forceps assisted delivery as well as
cesarean delivery; explained the procedures that will be done
and the risks that are associated, created back up plan in case
if the delivery method is failed
0930 Call out the baby’s time of birth and gender; the mother and
the infant will be monitored and observed. Assess the infant
facial symmetry, skin quality, neurologic abnormalities, and
arm and hips movements for any injury.
0930 Third stage of labor commences with the completed delivery
of the infant and ends with the completed delivery of the
placenta and its attached membranes.
Essential newborn care: the care provided to a newborn
immediately after delivery which includes the time between
births to 24 hours care is essential newborn care, and it
includes to dry and stimulate, evaluate breathing, keep the
newborn warm (prevent hypothermia), initiate breastfeeding
in the first one hour, administer eye ointment, administer
vitamin K intramuscularly, weigh the newborn when it is stable
and warm, cord care, and delayed bathing of the baby for 24
hours after birth
0935 R: The Mother and the Newborn were successfully delivered
with no injury. Mother and newborn are resting and will be
 continuously monitored and observed.

PHINMA UPANG General Hospital

ARELLANO ST., DAGUPAN CITY
PHILIPPINES 2400

NURSES NOTES
Name: Mrs. F Age: 36 y/o Attending Physician: Dr. Malou Peet
Sex: Female Civil Status: Married Room No. /Bed No. Room # 135/01 Hospital No. 023489

Date Shift Focus Time D = Date / A = Action / R = Response

3/26/21 Vacuum Assisted
Delivery/Vacuum Extraction
1100 D: 41 weeks AOG patient experiencing 2 hours prolonged 2 nd
stage of labor.
Cervix is fully dilated
+ sign of caput succedaneum
(-) BOW (rupture of membranes confirmed)

V/S are taken as follows:

BP – 130/80mmHG
PR – 84BPM
RR – 26RPM
T – 37oC
FHT – 118BPM

Operative Vaginal Birth (Vacuum Assisted Delivery) ordered by

the OB’s
1110 A: Assess the fetal heart rate. Confirmed that fetal position
(vertex presentation and if the head is engaged) and size of
maternal pelvis is compatible and adequate with vacuum
assisted delivery/vacuum extraction.
1120 Put the patient on oxygen inhalation running at 3-4LPM; and at
IVF of D5 liter with 10 units of oxytocin running at 20gtts/min
1125 Secured consent for forceps assisted delivery as well as cesarean
delivery; explained the procedures that will be done and the risks
that are associated, created back up plan in case if the delivery
method is failed
1130 Call out the baby’s time of birth and gender; the mother and the
infant will be monitored and observed. Assess the infant facial
symmetry, skin quality, neurologic abnormalities, and arm and
hips movements for any injury. Checked the mother’s perineum
and any signs of tears and bleeding
1130 Third stage of labor commences with the completed delivery of
the infant and ends with the completed delivery of the placenta
and its attached membranes.
Essential newborn care: the care provided to a newborn
immediately after delivery which includes the time between
births to 24 hours care is essential newborn care, and it includes
to dry and stimulate, evaluate breathing, keep the newborn
warm (prevent hypothermia), initiate breastfeeding in the first
one hour, administer eye ointment, administer vitamin K
intramuscularly, weigh the newborn when it is stable and warm,
cord care, and delayed bathing of the baby for 24 hours after
birth
1135 R: The Mother and the Newborn were successfully delivered with
no injury. Infant delivered within 2-3 pulls without any
complication. Mother and newborn are resting and will be
continuously monitored and observed.