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