Cebu Institute of Technology – University

college of nursIng
N. Bacalso Avenue, Cebu City

RECORD OF ASSISTED DELIVERY

Assist No. _____

Name of Institution : Case/Hospital Number:
Name of Mother : Age: ___ Marital Status:
Address : Contact #:
Gravida : Parity: G-T-P-A-L-M:
LMP : EDC: AOG:
Date and Delivery : / AM / PM Mode of Delivery:
Diagnosis :

Date & Time of Placental Expulsion : AM / PM Type of Placental Delivery:

Episiotomy : Absent [ ] Present [ ] Specific Type :
Post-Partum Vital Signs: T = °C PR = bpm RR = cpm BP = / mmHg

Name of Baby : Gender:

Case/Hospital Number:
Anthropometric Measurements: Length (cm): cm
Weight (grams): g
Head Circumference (cm): cm
Chest Circumference (cm): cm
Mid-Arm Circumference (cm): cm
APGAR Score (1&5 mins): / Ballard’s Score (weeks): WEEKS
Crede’s Prophylaxis: Name of Medication: Time:
Vital Signs :T= °C PR = bpm RR = cpm BP = / mmHg

Physician (OB) : Physician (Pedia):

Handled By :
Cord Dressed Done By:

Name & Signature of Student Name & Signature of D.R. Staff Nurse

Name & Signature of Student Name & Signature of D.R. Supervisor

Supervising Clinical Instructor