Professional Regulation Commission

RECORD OF NORMAL DELIVERIES HANDLED

Please Check:
✓
Name of Applicant:
Graduate
School: DR. JOSE FABELLA MEMORIAL HOSPITAL – SCHOOL OF MIDWIFERY
Registered
Date & Time Full Name, Address
Midwife Nurse
Supervised
Name and Address of Case by:
Performed of Facility & Contact License No./
Patient No. Complete Diagnosis
Number Printed Name Position/
Signature Expiration
& Contact Designation
No. Date
1. Gravida 3 Para 3 (3003) Pregnancy Uterine 40 weeks, cephalic, Dr. Jose Fabella Memorial Hospital, Eleonor B. Diaz Clinical Instructor RM License#: 0129315
delivered spontaneously to an alive baby girl ( 2635 grams – 46 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 02/24/2027
cms.) Apgar Score 8,9 Perineal Support 87345561 loc. 135

2. Gravida 3 Para 3 (3003) Pregnancy Uterine 38-39 weeks, cephalic, Dr. Jose Fabella Memorial Hospital, Eleonor B. Diaz Clinical Instructor RM License#: 0129315
delivered spontaneously to an alive baby boy (3345 grams – 48 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 02/24/2027
cms.) Apgar Score 8,9 Repair of 1st degree laceration 87345561 loc. 135

3. Gravida 4 Para 4 (4004) Pregnancy Uterine 39-40 weeks, cephalic, Dr. Jose Fabella Memorial Hospital, Sarah Jean S. Turbolencia Clinical Instructor RM License#: 0146667
delivered spontaneously to an alive baby girl (3500 grams – 50 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 09/26/2026
cms.) Apgar Score 8,9 Perineal Support 87345561 loc. 135

4. Gravida 2 Para 2 (2002) Pregnancy Uterine 40 weeks, cephalic, Dr. Jose Fabella Memorial Hospital, Sarah Jean S. Turbolencia Clinical Instructor RM License#: 0146667
delivered spontaneously to an alive baby girl (2610 grams – 48 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 09/26/2026
cms.) Apgar Score 7,9 Repair of 1st degree laceration. 87345561 loc. 135

5. Gravida 4 Para 4 (4004) Pregnancy Uterine 39 weeks, cephalic, Dr. Jose Fabella Memorial Hospital, Marjorie M. Palconit Clinical Instructor RM License#: 0164737
delivered spontaneously to an alive baby boy. (2810 grams – Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 05/25/2025
47cms.) Apgar Score 8 , 9 Perineal Support 87345561 loc. 135

6. Gravida 4 Para 4 (4004) Pregnancy Uterine 39 weeks, cephalic, Dr. Jose Fabella Memorial Hospital, Marjorie M. Palconit Clinical Instructor RM License#: 0164737
delivered spontaneously to an alive baby girl ( 2840 grams – 47 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 05/25/2025
cms.) Apgar Score 8,9 Repair of 1st degree laceration 87345561 loc. 135

7. Gravida 2 Para 2 ( 2002 ) Pregnancy Uterine 38 weeks, cephalic, Dr. Jose Fabella Memorial Hospital, Mabel Angelique M Martinez Clinical Instructor RM License#: 0168834
delivered spontaneously to an alive baby boy (2725 grams – 49 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 04/13/2027
cms.) Apgar Score 8,9 Repair of 1st degree laceration 87345561 loc. 135

8. Gravida 4 Para 4 (4004) Pregnancy Uterine 39 weeks, cephalic, Dr. Jose Fabella Memorial Hospital, Eleonor B. Diaz Clinical Instructor RM License#: 0129315
delivered spontaneously to an alive baby boy ( 3080 grams – 47 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 02/24/2027
cms.) Apgar Score 8,9 Perineal Support 87345561 loc. 135

9. Gravida 2 Para 2 (2002) Pregnancy Uterine 38-39 weeks, cephalic, Dr. Jose Fabella Memorial Hospital, Russel Shane R. Pontillas Clinical Instructor RM License#: 0153520
delivered spontaneously to an alive baby girl (2985 grams – Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 10/30/2025
48.5 cms.) Apgar Score 8,9 Repair of 1st degree laceration 87345561 loc. 135

10. Gravida 2 Para 2 (2002) Pregnancy Uterine 38-39 weeks, cephalic, Dr. Jose Fabella Memorial Hospital, Sarah Jean S. Turbolencia Clinical Instructor RM License#: 0146667
delivered spontaneously to an alive baby boy (2630 grams – 48 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 09/26/2026
cms.) Apgar Score 8,9 Repair of 1st degree laceration 87345561 loc. 135

Supervised by:
Date & Full Name,
Name and Case License
Time Address of Printed Name Position/
Address of No. Complete Diagnosis Signature No./
PRBSEC-49
Rev. 00
January 24, 2020
Page 1 of 1
 Patient Expiration
Performed Facility & Contact & Contact Designation Date
Number No.
11. Gravida 3 Para 3 (3003) Pregnancy Uterine 38-39 weeks, Dr. Jose Fabella Memorial Hospital, Marjorie M. Palconit Clinical Instructor RM License#: 0164737
cephalic, delivered spontaneously to an alive baby boy (3410 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 05/25/2025
grams – 50 cms.) Apgar Score 8,9 Repair of 1st degree 87345561 loc. 135
laceration
12. Gravida 4 Para 4 (4004) Pregnancy Uterine 39-40 weeks, Dr. Jose Fabella Memorial Hospital, Sarah Jean S. Turbolencia Clinical Instructor RM License#: 0146667
cephalic, delivered spontaneously to an alive baby girl (3465 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 09/26/2026
grams – 49 cms.) Apgar Score 8,9 Repair of 1st degree 87345561 loc. 135
laceration
13. Gravida 3 Para 3 (3003) Pregnancy Uterine 37 weeks, cephalic, Dr. Jose Fabella Memorial Hospital, Sarah Jean S. Turbolencia Clinical Instructor RM License#: 0146667
delivered spontaneously to an alive baby boy (2868 grams – 45 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 09/26/2026
cms.) Apgar Score 8,9 Repair of 1st degree laceration 87345561 loc. 135

14. Gravida 5 Para 5 (5005) Pregnancy Uterine 38-39 weeks, Dr. Jose Fabella Memorial Hospital, Erwin C. Daag Clinical Instructor RM License #: 0173761
cephalic, delivered spontaneously to an alive baby boy (3100 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiration Date: 10/15/2026
grams – 49 cms.) Apgar Score 8,9 Perineal Support 87345561 loc. 135 RN License # 0595434
Expiration Date: 10/15/2025
15. Gravida 2 Para 2 (2002) Pregnancy Uterine 39 weeks, cephalic, Dr. Jose Fabella Memorial Hospital, Lyrica Mae G. De Ade Clinical Instructor RM License#: 0178851
delivered spontaneously to an alive baby boy (2690 grams – 46 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 04/08/2025
cms.) Apgar Score 8,9 Perineal Support 87345561 loc. 135

16. Gravida 1 Para 1 (1001) Pregnancy Uterine 39 weeks, cephalic, Dr. Jose Fabella Memorial Hospital, Lyrica Mae G. De Ade Clinical Instructor RM License#: 0178851
delivered spontaneously to an alive baby girl (2865 grams – 46 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 04/08/2025
cms.) Apgar Score 8,9 Repair of 1st degree laceration 87345561 loc. 135

17. Gravida 2 Para 2 (2002) Pregnancy Uterine 38 weeks, cephalic, Dr. Jose Fabella Memorial Hospital, Lyrica Mae G. De Ade Clinical Instructor RM License#: 0178851
delivered spontaneously to an alive baby girl (2690 grams – 48 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 04/08/2025
cms.) Apgar Score 8,9 Repair of 1st degree laceration 87345561 loc. 135

18. Gravida 3 Para 3 (3003) Pregnancy Uterine 39 weeks, cephalic, Dr. Jose Fabella Memorial Hospital, Sarah Jean S. Turbolencia Clinical Instructor RM License#: 0146667
delivered spontaneously to an alive baby girl (2460 grams – 46 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 09/26/2026
cms.) Apgar Score 8,9 Perineal Support 87345561 loc. 135

19. Gravida 2 Para 2 (2002) Pregnancy Uterine 38-39 weeks, Dr. Jose Fabella Memorial Hospital, Eleonor B. Diaz Clinical Instructor RM License#: 0129315
cephalic, delivered spontaneously to an alive baby girl (2899 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 02/24/2027
grams – 49 cms.) Apgar Score 8,9 87345561 loc. 135
Perineal Support
20. Gravida 4 Para 4 (4004) Pregnancy Uterine 39-40 weeks, Dr. Jose Fabella Memorial Hospital, Eleonor B. Diaz Clinical Instructor RM License#: 0129315
cephalic, delivered spontaneously to an alive baby boy (3577 Lope de Vega St. Sta. Cruz, Manila, 87345561 loc. 135 Expiry date: 02/24/2027
grams – 50 cms.) Apgar Score 8,9 87345561 loc. 135
Repair of 1st degree laceration
Note: 1) The Clinical Instructor should ensure the competence of the students in the performance of actual deliveries before signing this form.
2) Registered Midwives/Clinical Instructors who supervise Students/Graduate Midwives/Registered Nurses and affix their signature in this Form must present a
Certificate of Training on Expanded Functions of Midwife (R.A. 7392) pursuant to Board Resolution No. 07, Series of 2017, dated September 8, 2017.

CERTIFIED CORRECT:
Signature: Date:
Printed Name: Maria Ursulita R. Umali
Designation: __Midwifery School Principal II______
License Number: _________
RM - 0141611 Expiry Date: _________
RN – 0361258

PRBSEC-49
Rev. 00
January 24, 2020
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