Delos Santos, Daniella Kate A.

BSN 3C
D&C Charting
Time

08:30:00 AM  Received patient from Emergency Room/stretcher with intravenous fluid of

D5 LRS 1 L KVO.
 NPO
 Conscious and coherent
 with complaint of vaginal bleeding for 2 weeks ptc
 With admitting orders from Dr. Nika Sampoleo:
To admit as OPD patient under Dr. Sampoleo service
 Refer once admitted
 For Dilatation and Curettage procedure
 With consent for the procedure and anesthesia signed by the patient and
secured to chart
 Dr. Manuel notified as anesthetist
 Delivery Room notified
 To delivery room as ordered by Dr. Sampoleo

09:00:00  Intravenous fluid inserted at emergency room

09:15:00 AM  Patient transferred to Delivery Room
09:30:00 AM  Intravenous sedation started by Dr. Manuel
09:45:00 AM  Procedure started by Dr. Sampoleo
Dilatation and Curettage
10:00:00 AM  Procedure ended.
10:15:00 AM  Patient was transferred to recovery room
10:30:00 AM  The client verbalizes “gising na ako, pwede na ba akong umuwi”
 FOUR STAGES OF LABOR
1. First stage
 Thinning (effacement)
 Opening of the cervix (dilation)
 During the first stage of labor, contraction helps the cervix to thin and begin to open. This is
called effacement and dilation. As the cervix dilates, the healthcare provider will measure
the opening in centimeters. It has three parts:
 Early labor
 the cervix opens to 4cm
 Active labor
 Opens from 4 to 7 cm. The contraction of 3 to 4 min and will last for about 60 seconds.
 Transition to second stage
 Cervix will open from 7 to 10 centimeters and contraction last for about 60 to 90 seconds.

2. Second stage
 The baby will move to the birth canal
 It begins when the cervix is completely dilated and ends with the birth of the baby.
3. Third stage
 After birth of the baby, the uterus of the mother continues to contract to push out the
placenta.
 Placenta usually delivers about to 5 to 15 minutes after the baby arrives.
4. Fourth stage
 Recovery
 The baby is born, the placenta delivered and the mother and father will probably feel joy
and relief.