This document is a medical record from a hospital in the Philippines documenting a normal spontaneous delivery with episiotomy and laceration repair. It includes information about the patient, pre-operative and operative diagnoses, the surgeons involved, and details of the procedure. The procedure involved delivering the baby, performing essential newborn care steps, delivering the placenta, repairing a laceration, and examining and cleaning the vagina. The patient tolerated the procedure well.
This document is a medical record from a hospital in the Philippines documenting a normal spontaneous delivery with episiotomy and laceration repair. It includes information about the patient, pre-operative and operative diagnoses, the surgeons involved, and details of the procedure. The procedure involved delivering the baby, performing essential newborn care steps, delivering the placenta, repairing a laceration, and examining and cleaning the vagina. The patient tolerated the procedure well.
This document is a medical record from a hospital in the Philippines documenting a normal spontaneous delivery with episiotomy and laceration repair. It includes information about the patient, pre-operative and operative diagnoses, the surgeons involved, and details of the procedure. The procedure involved delivering the baby, performing essential newborn care steps, delivering the placenta, repairing a laceration, and examining and cleaning the vagina. The patient tolerated the procedure well.
This document is a medical record from a hospital in the Philippines documenting a normal spontaneous delivery with episiotomy and laceration repair. It includes information about the patient, pre-operative and operative diagnoses, the surgeons involved, and details of the procedure. The procedure involved delivering the baby, performing essential newborn care steps, delivering the placenta, repairing a laceration, and examining and cleaning the vagina. The patient tolerated the procedure well.
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Republic of the Philippines
Department of Health Central Luzon Center for Health Development DR. PAULINO J. GARCIA MEMORIAL RESEARCH AND MEDICAL CENTER Cabanatuan City ISO QMS Certified
Name: Age: Address: Case No:
RECORD OF OPERATION OPERATION PERFORMED: NORMAL SPONTANEOUS DELIVERY WITH RIGHT MEDIOLATERAL EPISIOTOMY AND REPAIR OF ___ DEGREE LACERATION PRE-OPERATIVE DIAGNOSIS:
OPERATIVE DIAGNOSIS:
SURGEON: SURGEON:
CONSULTANT: CONSULTANT:
TISSUE REMOVED: TISSUE REMOVED:
Operative Technique:
Patient placed on semi-recumbent position
Asepsis and antisepsis. Application of sterile drapes at the perineal area Insertion of straight catheter to empty the bladder Right mediolateral episiotomy done after infiltration of local anesthesia Delivery of___________________________ 4 Core steps of essential newborn care performed 1. Immediate and thorough drying 2. Early skin to skin contact 3. Properly timed cord clamping 4. Non separation of the newborn and mother for early initiation of breastfeeding Delivery of the placenta. Evacuation of Blood clots Repair of ___ degree laceration done. Vaginal inspection. Cleaned with providone iodine antiseptic followed by perineal washing. Patient tolerated the procedure well.
Obstetrics and Gynecology:
Republic of the Philippines Department of Health Central Luzon Center for Health Development DR. PAULINO J. GARCIA MEMORIAL RESEARCH AND MEDICAL CENTER Cabanatuan City ISO QMS Certified
