COLLEGE OF NURSING

DR Write-UP

Date of Admission: February 25, 2022

Ward: Delivery Ward
Age: 29 years old  Civil Status: Married Religion: Roman Catholic
Occupation:
Admitting Diagnosis: G4P1 (1021) Pregnancy Uterine 41 weeks AOG by LMP, in labor
Final Diagnosis: G4P2 (2022) Pregnancy Uterine, Cephalic, Delivered, Term Birth (38-34 weeks) Live Baby
Boy appropriate for gestational age 2.8 kg by vaginal delivery after cesarean section
Type of Delivery: Normal Spontaneous Delivery
History of Present Delivery:
G4P2 (2022) Pregnancy Uterine, Cephalic, Delivered, Term Birth (38-34 weeks) Live Baby Boy appropriate for
gestational age 2.8 kg by vaginal delivery after cesarean section
Pathophysiology:

Labor usually begins with the passing of a woman’s mucous plug. This is a clot of mucous that protects the
uterus from bacteria during pregnancy. Soon after, a woman’s water may break. This is also called a rupture of
membranes. The water might not break until well after labor is established, even right before delivery. As labor
progresses, strong contractions help push the baby into the birth canal.
Brief Discussion of the procedure

Patient is placed on dorsal lithotomy. Asepsis and antisepsis. Drapes, straight catheterization. The index and
middle finger are placed into the vagina between the fetal head and the perineum. A right mediolateral incision
(about 3-4cm) is begun at the posterior fourchette and continued downwards at an angle of at least 45 degrees
relative to the perineal body. Angle of incision at 90 degrees. Delivery of the baby, double cord clamping and
cutting between clamps after cessation of cord pulses, delivery of the placenta, intact uterine scar. Examine the
laceration after delivery, with 2 fingers placed in the vagina for retraction, the apex of the episiotomy site is
identified. The submucosal tissue and vaginal mucosa are reapproximated in a continuous fashion. A deep
episiotomy was repaired with submucosal sutures for appropriate treatment, reapproximation and closure of dead
space. The bulbospongiosus muscle was repaired. The fascial sheath of the muscle on both sides of the incision
was repaired in an interrupted fashion before closure of the skin, suture was placed perpendicular to the angle of
incision. Anti-sepsis. Perineal care.

Instruments (place at the back of this sheet)

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