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    Labor Room and DNC Chart Begh

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    Teanu Jose Gabrillo Tamayo
    This document summarizes the labor and delivery of a patient. It details the patient's admission to the labor room, monitoring and care during labor, artificial rupture of membranes, administration of medications including oxytocin and anesthesia, and transfer to the operating room for an emergency c-section due to arrest of cervical dilation. Vital signs and progress of labor are recorded at various times. The patient is provided health teaching and informed consent is secured prior to the c-section procedure.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Labor Room and DNC Chart Begh

    Uploaded by

    Teanu Jose Gabrillo Tamayo
    1K views3 pages
    This document summarizes the labor and delivery of a patient. It details the patient's admission to the labor room, monitoring and care during labor, artificial rupture of membranes, administration of medications including oxytocin and anesthesia, and transfer to the operating room for an emergency c-section due to arrest of cervical dilation. Vital signs and progress of labor are recorded at various times. The patient is provided health teaching and informed consent is secured prior to the c-section procedure.

    Original Description:

    Charting sample; all rights to BegH

    Original Title

    Labor Room and Dnc Chart Begh

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    This document summarizes the labor and delivery of a patient. It details the patient's admission to the labor room, monitoring and care during labor, artificial rupture of membranes, administration of medications including oxytocin and anesthesia, and transfer to the operating room for an emergency c-section due to arrest of cervical dilation. Vital signs and progress of labor are recorded at various times. The patient is provided health teaching and informed consent is secured prior to the c-section procedure.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    1K views3 pages

    Labor Room and DNC Chart Begh

    Uploaded by

    Teanu Jose Gabrillo Tamayo
    This document summarizes the labor and delivery of a patient. It details the patient's admission to the labor room, monitoring and care during labor, artificial rupture of membranes, administration of medications including oxytocin and anesthesia, and transfer to the operating room for an emergency c-section due to arrest of cervical dilation. Vital signs and progress of labor are recorded at various times. The patient is provided health teaching and informed consent is secured prior to the c-section procedure.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    LABOR ROOM

    Date and Focus Data, Action, Response


    Time
    TIME Labor pain D> Into/received labor room a ___y/o, G_P_ from OB
    ward/ER accompanied by IWOD/RNSE/SNOD on
    duty; With ongoing IVF of ____1L+____u oxytocin
    at __ml level infusing well at
    metacarpal/cephalic/basilica vein.
    D>grimaces, moans occasionally, irritable at times,
    guarding lumbosacral area noted; with vital signs of
    BP_____mmHg, Pr__bpm, RR___cpm, Temp ___C
    TIME Patient care A> Assessed level of pain; Assessed progress of
    labor; Monitored vital signs and recorded; Assisted
    on ambulation; Massaged lumbosacral area.
    TIME Positioning and A> Assisted to DR table and positioned to lithotomy
    comfort for IE done by _________ revealing ___cm cervical
    dilatation; Perineal shaving done; Ushered to LR for
    further monitoring.
    TIME Fluid and A> IVF of _____1L+____u oxytocin inserted by
    administration ____at the L/R metacarpal/cephalic/basilis vein and
    of medication regulated to ____gtts/min
    A> First dose of HNBB 1 amp given IV push by
    NOD/RNSE.
    A> Blood specimen extracted by medtech on duty
    for CBC, ABO typing and HB sag.
    TIME Health teaching A> Instructed on proper deep breathing techniques;
    squatting to facilitate descent; Maintained on NPO
    as ordered and encouraged to verbalize feelings
    and concerns.
    R> Increased intensity of pain with pain scale of ___
    and uterine contractions occurring every 2-3
    minutes; With duration of 60-90 seconds.
    TIME Unit Transfer A> Brought to DR ambulatory with same IVF
    accompanied by ______________.
    TO BE INCLUDED IF IT WAS DONE
    A> Bag of water ruptured artificially/spontaneously
    by _________.
    A> Seen and examined by Dr. ___________. Ordered
    for E caesarean section due to arrest of cervical
    dilatation/arrest of descent;
    Scheduled for E CS; informed OR NOD,
    paediatrician and Anesthesiologist.
    TIME Consent Secured consent for the procedure/operation signed
    by the patient/parent/husband/relative.
    DILATATION AND CURRETAGE
    Date and FOCUS DATA, ACTION, RESPONSE
    Time
    Time Safe Operation D> Into/received labor room a ___y/o, G_P_ mother
    from OB ward/ER per
    wheelchair/stretcher/ambulatory accompanied by
    IWOD/RNSE/SNOD on duty with ongoing IVF of
    ___1L+___ u oxytocin at ___ml level infusing well
    at the left/right metacarpal/basilica/cephalic vein,
    conscious and coherent; with moderate/minimal
    bleeding noted, weak and pale in appearance with
    initial vital signs as follows: BP_____mmHg,
    Pr__bpm, RR___cpm, Temp ___C
    D> Into delivery room, ambulatory accompanied by
    NOD,RNSE,SNOD on duty with ongoing IVF of
    ____1L+___u oxytocin at ___ml level infusing well
    Consent A> Ushered to bed, secured consent for D&C signed
    by _______/ consent for D&C attached to chart
    Positioning and A> Assisted to DR table and positioned to lithotomy,
    comfort administered oxygen inhalation per nasal cannula at
    2-3Lpm, shaved perineal area and draped
    aseptically.
    Start of A> Nubain 1 amp given IV by NOD/RNSE as per
    anesthesia verbal order of Dr. _____________
    sedation
    IV incorporation A> Additional 10 u oxytocin incorporated to
    above IVF as per verbal order of Dr. __________
    D and C A> Completion/ Evacuation/ Dilatation curettage
    done by Dr. _________, specimen saved then given to
    watcher for histopathology.
    Medication A> Methylergometrine 1 amp given IV/IM at
    right/left deltoid as per verbal order of Dr.
    _________________
    Post-op care A> Perineal care done and adult diaper placed
    snugly.
    Transferred to stretcher and brought to labor room
    Health teaching A> instructed on proper breathing technique and
    proper personal hygiene and to report excessive
    bleeding and other concerns to NOD
    Unit Transfer A> Brought to ward per stretcher/wheelchair with
    above IVF of ___1L +___u oxytocin infusing well
    with the latest vital signs of BP_____mmHg,
    Pr__bpm, RR___cpm, Temp ___C

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