LABOR ROOM and DELIVERY ROOM TEMPLATE Benguet General Hospital

DATE & TIME

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FOCUS
Labor Pain

PROGRESS NOTES (DAR CHARTING)

D> Into labor room a ______ y/o, G__P__ mother/female from OB ward/ER per wheelchair/stretcher/ambulatory accompanied by ER attendant/IWOD/NOD/RNSE on duty; with an ongoing IVF fluid of ________ 1L + ______ u oxytocin at ________ ml level infusing well on the left/right metacarpal/cephalic/basilica vein. >Masakit, grimaces, moans occasionally, irritable at times, guarding lumbosacral area noted, with vital signs of BP- _______ mmHg; PR-_____bpm; RR-_______cpm; FHT of ______ per minute. A>Assessed level of pain, assessed progress of labor, Monitored vital signs, FHT and recorded, Assisted on ambulation, Massaged lumbosacral area. >Assisted to DR table and positioned to lithotomy for IE done by ________________________ revealing ______ cm cervical dilation, shaved perineal area, ushered to LR for further monitoring. > IVF of ______ 1L + _____ u oxytocin inserted by ______ at the left/right metacarpal/cephalic/basilica vein and regulated to ________ gtts/min. >First dose of HNBB 1 amp given IV push by NOD/RNSE. >Second dose of HNBB 1 amp given IV push by NOD/RNSE. >Third dose of HNBB 1 amp given IV push by NOD/RNSE. >Seen and examined by Dr._____________________. >Blood specimen extracted by Medtech on duty for CBC, typing, HBsag. >Demonstrated on proper deep breathing techniques, squatting to facilitate descent, maintained on NPO as ordered and encouraged to verbalize feelings and concern. R>Increased intensity of pain with pain scale of _______ and uterine contractions occurring every 2-3 minutes with duration of 60-90 seconds. >Accompanied to DR ambulatory with the same IVF. (**Direct DR patients) **>Into DR from ER ambulatory a ______y/o G__P__ mother A>Assisted to DR table and positioned to dorsal lithotomy, IE done by ________________ revealing a full cervical dilatation, administered oxygen per nasal cannula at 2-3 LPM; coached on proper bearing down. >RMLE done by Dr. _______________/ Perineal support done by Dr.________________. >Bag of water ruptures spontaneously/artificially by Dr._________________. > Seen and examined by Dr.______________; ordered E caesarian section due to failed descent; scheduled for E CS and informed OR NOD, Pediatrician and Anesthesiologist >Secured consent for operation; signed by patient/parents.husband/relative; removed jewelries, dentures, bra and underwear.

Patient Care Positioning and Comfort Fluid and administration of medication

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Health Teaching

Unit Transfer __________________ __________________ Positioning and comfort

ADDITIONAL:
Time:____________ Time:____________ Time:____________ Pre-operative preparation Rupture of membranes

DATE & TIME

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FOCUS
Safe delivery of the baby Start of Anesthesia and sedation

PROGRESS NOTES
>Delivered to an alive baby boy/girl via NSD in cephalic presentation, with _____ cord loop/s, with a birth weight of ______ kgs and a birth length of _______cms. Attended by Dr. ____________. >Nubain 1 amp given intravenously by _______________ as per verbal order of Dr. _______________.

LABOR ROOM and DELIVERY ROOM TEMPLATE Benguet General Hospital >Midazolam 1 ampule/ ampule given intravenously by ___________________ as per verbal order of Dr. __________________. >Placenta out completely in Schultz/Duncan presentation, with BP of ________mmHg, PR- ______bpm, RR-______cpm, Temp-______C. >Methylergometrine 1 ampule administered IM/IV at left/right deltoid by NOD/RNSE as per verbal order of Dr._____________. >Additional 10 u oxytocin incorporated to present IVF as per verbal order of Dr. _______________. >Evacuation of blood clots and placental fragments done by Dr._______________ using curette/manually. Episiorraphy/repair of laceration done by Dr. ________________. >Massaged uterus until firm and contracted. >Transferred to stretcher then brought to LR. >Instructed mother to massage uterus until firm and contracted; to wash perineal area with tap water, and to report excessive bleeding to NOD. >Breastfeeding initiated, bonding maintained, vital signs monitored and recorded, breastfeeding per demand and proper burping encouraged. R>Delivered safely with minimal vaginal bleeding, with firm and contracted uterus and with latest vital signs of BP- ________mmHg, PR-_______bpm, RR_______cpm, Temp-______C. >Brought to OB ward per stretcher accompanied by NOD/IWOD/RNSE/SNOD.

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Safe delivery of the placenta Post Partum Care

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Health Teaching Nutrition and Bonding

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Unit Transfer