PATIENT NAME: RESURRICION, JEAN D. CASE NO.

12376

03/08/2023; 6:15 am
1. Received from ER via stretcher conscious, this Garvida2 Para1 in labor with
the latest IE of 8cm, maternal V/S: BP=120/80 mmHg CR= 82 bpm RR=20
cpm Temp.=36.8°C. (-) any past health problem. Attached initial assessment
from ER.

2. Set AC room temperature 28°C for thermoregulation.

3. Handwash and gloving done aseptically
4. Prepared sterile delivery pack and perineal pack.
5. Prepared sterile instruments and supplies.
6. Attached BP apparatus, Placed on lithotomy position,
7. Perineal Prep and draping done aseptically.

6:45 am
8. Dr. Grace P. Bulay informed of the latest maternal V/S: BP=120/80 mmHg,
CR= 82 bpm, RR=20 cpm, Temp.=36.8°C taken at 6:40 am.
9. Noted FHT=120 bpm taken at 6:46 am using doppler.

7:50 am
10. Observed crowning baby head completely at cervix, latest IE of 10 cm, noted
strong contraction of the uterus.
11. Performed pant like a puppy technique.
12. Performed Ritgen maneuver.

8:20 am
13. Delivered out this full term baby boy Resurricion at exactly 8:20 am, in
Cephalic presentation via normal spontaneous vaginal delivery.
14. Placed baby in mother abdomen in prone position with head facing at the side
between breast to stimulate skin to skin contact.
15. Baby dried thoroughly with in 30 seconds, Initial APGAR Score is performed
and noted, covered with bonnet, socks, and blanket, and placed identification
band untight nor too loose on the left ankle.
16. Checked and noted no expulsion of 2nd birth via palpitation of uterus and
doppler.

8:30 am
17. Maternal BP taken of BP=128/85mmHg and informed Dr. Grace P. Bulay.

8:35 am
18. Dr. Grace P. Bulay verbalized the approval of administration of 10U of
oxytocin via IM at deltoid muscle.
 19. Mother verbalized consciously and informed about the medication being
administered.
20. Completely administered 10U of oxytocin via IM at deltoid muscle
21. Removed first set of gloves
22. Umbilical cord was palpated with in 3 mins. for pulsation until it stopped and
clamped using sterile plastic cord clamp at 2 cm from the umbilical base and
5 cm straight forcep.
23. Umbilical cord cut done using surgical scissor.
24. Applied counter / controlled traction on lower abdomen
25. Observed 3 signs of placental separation

9:15 am
26. Called out of placenta at exactly 9:15 am, Duncan presentation (maternal
side) checked and noted placental completeness and AVA are completed.
27. Mother was informed verbalized about her placenta and appealed to discard.
28. Prepared for vaginal repair, as follows 2% lidocaine of 10cc of syringe for
local anesthesia, suture w/ needle, handed to Dr. Grace Bulay and assisted
vaginal repair
29. Episiorraphy done by Dr. Grace P. Bulay.
30. Removed patient leggings
31. Performed perineal care and applied maternal pad properly
32. Removed Kelly pad, moved up folded half of the table, Brought downed
patient legs simultaneously.

10:10 am
33. Dr. Grace P. Bulay instructed to be taken the VS every 5 mins. for 30 mins.
and every hr for the next 4 hours until all are in stable and monitor maternal
pad for every hr.

10:15 am
34. Checked first 5 mins. latest BP taken V/S: BP=110/80 mmHg, CR= 82 bpm
RR= 20 cpm, Temp= 36.7°C .

11:16 am
35. Checked first 1 hr maternal pad has light amount of blood.
36. IVF of oxytocin regulated accordingly, 5 gtts/min every 30 mins of 500 mLbag.
37. Inventory of used instruments is done.

11:30 am
38. Forwarded to room of choice

11:40 am
39. Endorsed to Nurse on Duty, Ms. Melanie P. Cagapan.

Resurricion, Ronel, RN