Crystel Danielle Ll.

Mendioro
BSN 2D – G14

Case:
25 F/M, G2P1, 4cm cx dilatation at 8am.
EDC: April 6, 2024

Find the following:

a. LMP – June 29, 2023

April 6, 2024 + 3 months - 7 days – 1 year = June 29, 2023

b. AOG – 40 weeks and 2 days

Month Number of days

June 1
July 31
August 31
September 30
October 31
November 30
December 31
January 31
February 29
March 31
April 13
Total number of days: 289
289/7 = 41 weeks and 2 days

c. OB Score - G2P1 (G2P10010)

Gravida Term birth Pre-term Abortion Living child/ Multipara
birth Children
2 1 0 0 1 0

d. Expected time to delivery – 2:00 pm

The pt is 4 cm dilated upon admission at 8 AM. Thus, it is at the active phase of labor and full
cervical dilatation is anticipated by 2 PM of the same day.

MOTHER’S PROGRESS NOTES

Date/Time Focus Data Action Response

4/6/2024 Active labor • a 25 yo, G2P1 • Perform general
8:00 AM phase in active labor, assessment and document
4 cm cervical VS, PR, RR, and Temp.
dilation.
• Perform abdominal
examination and
auscultate the fetal heart
and evaluate the uterine
contraction.

• Perform vaginal
examination and inspect
presentation, position, and
engagement.

8:30 AM • Inform the attending

physician of the patient's
present status.

8:35 AM • Assist in use of

appropriate
breathing/relaxation
 techniques and abdominal
effleurage.

• Adjust the mother’s

position to enhance
comfort and labor
progression. The pt may
walk about or may be in
bed, as she wishes.

8:40 AM • Monitor FHT and note if

there is any sign of
decreased variability or
bradycardia.

• Monitor the progress of

labor and record on a
partograph.

1:45 PM • Regular
contractions of
progressively
increasing frequency
and labor.

• During the onset of

labor, the pt
demonstrates
effective tolerance
and maintains good
uterine contractions
conducive to the
delivery of the baby.

Date/Time Focus Data Action Response

4/6/2024 For delivery • Fully dilated • The patient was
2:00 PM cervix positioned on the delivery
room table in the lithotomy
position.

• Aseptic technique was

employed for perineal
preparation to reduce the
risk of microbial
contamination.

2:15 PM • An episiotomy was

performed under local
anesthesia to facilitate the
delivery.

2: 35 PM • The infant (bb boy) was

spontaneously delivered,
scoring an APGAR of 10,
indicative of optimal
neonatal health at birth.

2:40 PM • Intravenous
administration of 10 units
of oxytocin was
implemented to enhance
uterine contractions and
decrease the likelihood of
postpartum hemorrhage.
 • Complete placental
2:45 PM expulsion was achieved
through the Schultz
method, characterized by
the delivery of the shiny
fetal side first.

• Continuous monitoring of
blood pressure was
performed to observe
maternal hemodynamic
status.

2:47 PM • Examination the placenta

for completeness and • The placenta was
abnormalities. observed to be
intacted without gross
abnormalities and no
sign of cotyledons
remain in the uterus.
2:50 PM • Surgical repair of the
episiotomy, or
episiorrhaphy, was
performed by the attending
physician

• Post-delivery perineal
care was provided,
including the application of
a sterile pad.

3:10 PM • Postpartum health

education included:
- Active management of • Nodded in
the uterus to prevent understanding and
complications, highlighting also showed
the significance of engagement by
sustained uterine asking questions and
contractions. expressing concerns
- Guidelines were provided about breastfeeding
for the hygienic care of the techniques.
perineum with sterile water
to aid in healing and
reduce infection risks.
- The initiation of
breastfeeding was
encouraged immediately
post-delivery to benefit
neonatal nutrition and
maternal bond.
- Compliance with
prescribed medications
was emphasized to
manage discomfort and
prevent infectious
complications.
- Follow-up appointments
were strongly
recommended to monitor
postpartum recovery and
address any emerging
health issues promptly.

NEWBORN’S PROGRESS NOTES

Date/Time Focus Data Action Response
4/6/2024 Immediate Delivered an • Immediately and • Initiated breathing of
2:35 PM Newborn active baby boy thoroughly dry the baby, the newborn
care NVSD in starting from the face and
cephalic head, going down to the
presentation at trunk and extremities while
2:35 pm; performing quick check for
vigorous cry, breathing.
active pull of
extremities and • Back rubs to stimulate • The baby cried well
pinkish color of skin-to-skin contact. and appeared pinkish
extremities in color.
noted. • Placed baby in skin-to-
skin contact on the • Allows progression
mother's abdomen or of mother-infant
chest. bonding.

• Assessed APGAR Score • Observed an

APGAR score of 10
• Placed identification tags and good overall
on baby’s legs physical state of
newborn.
• Cover baby with the dry
cloth and the baby's head
with a bonnet.

3:20 PM • Palpate umbilical cord to • Prevents anemia

check for pulsations. After and protects against
pulsations stops, clamp brain hemorrhage.
and cut the cord.

3:25 PM • Initiate breastfeeding and

wait for full breastfeed to
be completed.

3:40 PM Receives baby at the

transition area.

• Checks Baby’s ID tag or

band against mother’s
name. Checks baby’s
gender.

• Checks the patency using

rectal thermometer

• Vital statistics or
Anthropometric
measurement and weight
taken as follows.

• Put on baby’s clothes.

• Injects Vit. K, Hepatitis B • Crucial for the

vaccine on the left
anterolateral thigh
intramuscularly.
• Injects BCG at the left
deltoid intradermally.
formation of clotting
factors and
vaccination against
any exposure of hepa
b virus.

• Wraps the baby warmly.

• Applies erythromycin • Prevents opthalmia

ointment on both eyes neonatum and
inflammatory eye
disease.
 • Bring the baby back to
3:55 PM the mother at the transition
area for continuous STS
(skin-to-skin) and early
breastfeeding.
• Observed signs of
good attachment and
sucking: Mouth wide
open and lower lip
turned outwards.