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  • Delivery Case A 1

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    Trisha
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    A 26-year-old primigravida woman presented at the hospital in labor and delivered a baby boy via normal spontaneous vaginal delivery. The baby was transferred to the nursery where assessments were made, including Apgar scores of 8, 9, 10 and measurements. The placenta was expelled and the mother's uterus was explored without complications.

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    DELIVERY-CASE-A-1

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    A 26-year-old primigravida woman presented at the hospital in labor and delivered a baby boy via normal spontaneous vaginal delivery. The baby was transferred to the nursery where assessments were made, including Apgar scores of 8, 9, 10 and measurements. The placenta was expelled and the mother's uterus was explored without complications.

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    29 views5 pages

    Delivery Case A 1

    Uploaded by

    Trisha
    A 26-year-old primigravida woman presented at the hospital in labor and delivered a baby boy via normal spontaneous vaginal delivery. The baby was transferred to the nursery where assessments were made, including Apgar scores of 8, 9, 10 and measurements. The placenta was expelled and the mother's uterus was explored without complications.

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    of 5

    DELIVERY CASE A

    Hospital Number: 021919


    Name of Hospital: University of Cebu Banilad
    Room Number: Nursing Skills Lab 3

    A case of a normal spontaneous vaginal delivery of Ms. Ava A. Avenido, 26 years old, married, primi-
    gravida mother. She currently lives at Barangay Sambag 1 Cebu City. Upon admission patient has an I.E
    of 9cm with 80% - 90% effaced. Intact bag of water. She complained of labor pains that had prompted her
    seek medical attention. She experienced contractions every 3-5 minutes. OB resident on duty Dr.
    Amethyst Gonzaga obtained her OB history. Based from the interviewed, her LMP was last August 14,
    2021. After the assessment made by the OB resident, the attending physician Dr. Eleanor Casquejo did an
    internal examination and found out that the patient is fully effaced and it is fully dilated. The patient was
    transferred immediately to the Delivery room. Patient was mounted at the DR Bed, the handled nurse,
    prep the patient by doing perineal care and draped it. The team is ready for the delivery of the baby. The
    attending physician give a local anesthesia – lidocaine hydrochloride 2% to the perineum area and made
    a medio-lateral episiotomy cut. After a successful bearing down of the mother, she then delivered an
    alived baby boy via normal spontaneous vaginal delivery at 1.30pm May 18, 2022. Placental presentation
    of Duncan was noted and expelled at 1.40pm. Episiorrhaphy and exploring of the uterus was done.
    Diagnosis: Pregnancy uterine full term delivered via NSVD, male, neonate, cephalic, AGA, BW 3kgs, AS 8,
    9, 10.

    Hospital Number: 021920


    Name of Hospital: University of Cebu Banilad
    Room Number: Nursing Skills Lab 3

    After the unang yakap, the immediate newborn nurse transferred the newborn baby boy to the working
    area. She then proceeds in doing the INC, wherein medications was given to the baby, cord care was done.
    Anthropometric measurements was taken and noted. An Apgar Score of 8,9,10 and a ballard score of 38
    weeks was duly assessed by the Pediatrician Dr. Edgardo Serafica. Diagnosis: Live, term, male, neonate,
    cephalic, delivered via NSVD, AGA, BW 3kgs, AS 8, 9, 10.

    Anthropometric measurements:
    Head circumference – 32cm
    Chest circumference – 31cm
    Abdominal girth – 28cm
    Mid arm circumference – 10cm
    Length – 49cm
    Weight – 3kgs.

    Vital Signs
    Temperature – 37 degree celcius
    Respiratory rate – 58 cpm
    Heart rate – 148 bpm
    DELIVERY ROOM CASES

    HANDLED DELIVERY NO: 1 (SIMULATION)

    Hospital Number: 021919


    Name of Hospital: UNIVERSITY OF CEBU BANILAD
    Patient’s Name: AVA A. AVENIDO
    Age: 26 YEARS OLD
    Address: BARANGAY SAMBAG 1 CEBU CITY
    Status: MARRIED
    Room Number: NURSING SKILLS LAB 3
    Parity: G₁T₀P₀A₀L₀M₀
    LMP: AUGUST 14, 2021
    EDC: MAY 21, 2022
    AOG: 39 ⁴/7 WEEKS
    Type of Delivery: NORMAL SPONTANEOUS VAGINAL DELIVERY
    Date of Delivery: MAY 18, 2022
    Time of Delivery: 1:30 PM
    Gender of the Baby: MALE
    Anesthesia: LOCAL ANESTHESIA LIDOCAINE HYDROCHLORIDE 2%
    Attending Physician: DR. ELEANOR CASQUEJO
    OB-Resident: DR. AMETHYST GONZAGA
    Diagnosis: PREGNANCY UTERINE FULL TERM DELIVERED VIA NSVD, MALE, NEONATE, CEPHALIC, AGA, BW
    3kgs, AS 8, 9, 10.
    Type of Placental Presentation: DUNCAN
    Time of Placental Separation: 1:40 PM
    Type of Episiotomy: MEDIO-LATERAL

    ____________________ ___________________ ___________________


    Student’s Name Midwife On Duty Staff Nurse on Duty

    ____________________ ____________________
    Clinical Instructor Evaluator

    (Please show computation on EDC< LMP< & AOG)

    8 14 2021 AUG 17
    -3 +7 +1 SEPT 30
    5 21 2022 OCT 31
    NOV 30
    EDC: MAY 21, 2022 DEC 31
    JAN 31
    FEB 28
    MARCH 31
    APRIL 30
    MAY 18
    AOG: 277
    DELIVERY ROOM CASES

    ASSISTED DELIVERY NO: 1 (SIMULATION)

    Hospital Number: 021919


    Name of Hospital: UNIVERSITY OF CEBU BANILAD
    Patient’s Name: AVA A. AVENIDO
    Age: 26 YEARS OLD
    Address: BARANGAY SAMBAG 1 CEBU CITY
    Status: MARRIED
    Room Number: NURSING SKILLS LAB 3
    Parity: G₁T₀P₀A₀L₀M₀
    LMP: AUGUST 14, 2021
    EDC: MAY 21, 2022
    AOG: 39 ⁴/7 WEEKS
    Type of Delivery: NORMAL SPONTANEOUS VAGINAL DELIVERY
    Date of Delivery: MAY 18, 2022
    Time of Delivery: 1:30 PM
    Gender of the Baby: MALE
    Anesthesia: LOCAL ANESTHESIA LIDOCAINE HYDROCHLORIDE 2%
    Attending Physician: DR. ELEANOR CASQUEJO
    OB-Resident: DR. AMETHYST GONZAGA
    Diagnosis: PREGNANCY UTERINE FULL TERM DELIVERED VIA NSVD, MALE, NEONATE, CEPHALIC, AGA, BW
    3kgs, AS 8, 9, 10.
    Type of Placental Presentation: DUNCAN
    Time of Placental Separation: 1:40 PM
    Type of Episiotomy: MEDIO-LATERAL

    ____________________ ___________________ ___________________


    Student’s Name Midwife On Duty Staff Nurse on Duty

    ____________________ ____________________
    Clinical Instructor Evaluator

    (Please show computation on EDC< LMP< & AOG)

    8 14 2021 AUG 17
    -3 +7 +1 SEPT 30
    5 21 2022 OCT 31
    NOV 30
    EDC: MAY 21, 2022 DEC 31
    JAN 31
    FEB 28
    MARCH 31
    APRIL 30
    MAY 18
    AOG: 277
    DELIVERY ROOM CASES

    CORD DRESSED: 1 (SIMULATION)

    Hospital Number: 021920


    Name of Hospital: UNIVERSITY OF CEBU BANILAD
    MOTHER’S NAME:
    Patient’s Name: BABY BOY AVENIDO / AVA A. AVENIDO
    Age: NEWBORN
    Address: KAMPUTHAW CEBU CITY
    Status: CHILD / MARRIED
    Room Number: NURSING SKILLS LAB 3
    Parity: G₁T₀P₀A₀L₀M₀
    LMP: AUGUST 14, 2021
    EDC: MAY 21, 2022
    AOG: 39 ⁴/7 WEEKS
    Type of Delivery: NORMAL SPONATANEOUS VAGINAL DELIVERY
    Date of Delivery: MAY 18, 2022
    Time of Delivery: 1:30 PM
    Gender of the Baby: MALE
    Anesthesia: LOCAL ANESTHESIA LIDOCAINE HYDROCHLORIDE 2%
    Attending Physician: DR. EDGARDO SERAFICA
    OB-Resident: DR. AMETHYST GONZAGA
    Diagnosis: LIVE, TERM, MALE, NEONATE, CEPHALIC, DELIVERED VIA NSVD, AGA, BW 3KGS, AS 8, 9, 10
    Type of Placental Presentation: DUNCAN
    Time of Placental Separation: 1:40 PM
    Type of Episiotomy: MEDIO-LATERAL

    ____________________ ___________________ ___________________


    Student’s Name Midwife On Duty Staff Nurse on Duty

    ____________________ ____________________
    Clinical Instructor Evaluator

    (Please show computation on EDC< LMP< & AOG)

    8 14 2021 AUG 17
    -3 +7 +1 SEPT 30
    5 21 2022 OCT 31
    NOV 30
    EDC: MAY 21, 2022 DEC 31
    JAN 31
    FEB 28
    MARCH 31
    APRIL 30
    MAY 18
    AOG: 277
    ANTHROPOMETRIC MEASUREMENTS:

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