NSD FORMAT

Endorsing a case of ___________________, ______ years old Gravida ___ Para ___ (___-___-___-___) on her ______
weeks AOG, (single/married), Filipino, _______________ (religion) from ______________________________________
admitted for the ______ time in NMMC due to ______________________________________ ________________________.

For the past medical history, patient is (a known hypertensive for ___ years taking _____________________ as
maintenance medication with ______ compliance/nonhypertensive), nondiabetic and nonasthmatic. No history
of medical hospitalizations or surgical admissions. __________________________________________________________
No known food and drug allergies.

For the family history, patient denied history of heredo-familial diseases, such as hypertension, diabetes
mellitus, bronchial asthma, and cancer. (She claimed presence of hypertension, diabetes mellitus, bronchial
asthma, and cancer on the (paternal/maternal) side.)

For the personal and social history, patient is a ____________________ graduate, currently
(unemployed/working as a ____________________), (living-in with/married to ____________________, _____ years
old, currently (unemployed/working as a ____________________.) Patient is a non-smoker, non-alcoholic
beverage drinker and nonillicit drug user.

For the gynecologic history, patient had her menarche at ______ years old with subsequent menses occuring
at (regular/irregular) intervals, lasting for _____ days in duration and consuming _____ pads per day,
(moderately/fully) soaked, with (scanty/moderate/profuse) flow (associated/not associated) with
dysmenorrhea. She had her coitarche at _____ years old with _____ sexual partner. No family planning method
was used. (Family planning used was/were _______________________________________________________________.)

For the obstetrical history, patient is a Gravida ___ Para ___ (__-__-__-__)
Type of Delivered Birth
Gravida Year AOG Where delivered Complications
delivery by Weight

For the history of present pregnancy, patient’s last menstrual period was on ___________________ with an
expected date of confinement on __________________. She is currently on her ________________ age of gestation.
She had her 1st prenatal check-up at ________________________________ at _____ age of gestation with a total of
_____ visits. She had _____ dose of tetanus toxoid vaccine. She has been taking ferrous sulfate and
multivitamins for _____ months with _______ compliance.
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Patient was admitted on her _____ hour of labor. ______ hours prior to admission, patient noted spontaneous
onset of labor pains, starting from the hypogastric area radiating to the back, with a pain score of ____/10,
occurring ____ every ____ hours, associated with ___________________________________________________________.
_____ hours prior to admission, ,patient noted progression of labor, with an increased pain score of ____/10,
and occurring ____ every ____ minutes. _____________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Persistence of labor pains prompted consult, and subsequent admission.

For the physical examination, patient was examined conscious, coherent, ambulatory, and not in respiratory
distress with the following vital signs: normotensive with a blood pressure of __________ mmHg, heart rate of
_____ beats per minute, respiratory rate of _____ cycles per minute, afebrile with a temperature of _____oC. She
weighed _____ kg and measured _____ cm.

Skin: warm with good turgor, (-) pallor

HEENT: anicteric sclerae, (pink/pale) palpebral conjunctivae; moist lips and tongue
C/L: no retractions, equal chest expansion, clear breath sounds
CVS: adynamic precordium, distinct heart sounds, regular rate and rhythm, no murmur
Abd: ovoid with a fundic height of _____ cm, leopold’s maneuver revealed the following:
L1 – breech, cephalic
L2 – fetal back at (left/right) maternal side and fetal small parts at (left/right) maternal side
L3 – cephalic, (engaged/not engaged)
L4 – cephalic prominence palpable on maternal (right/left)/negative/empty

with fetal heart tone of _____ beats per minute at the (LLQ/LUQ/RLQ/RUQ), with uterine contractions of
(2/3/4) in 10 minutes, lasting (40/50/60) seconds with (mild/moderate/strong) intensity, and with an
estimated fetal weight of _____ grams by Johnson’s rule.

Upon internal examination, cervix was _____ cm dilated, ______% effaced, ____________ presentation, station
______, with (intact/ruptured) bag of water.

For the clinical pelvimetry, sacral promontory was not easily reached, ischial spines were not prominent,
pelvic sidewalls were not convergent, sacrum was curved, and suprapubic arch was wide.

Extremities: no edema, strong peripheral pulses

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

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Admitting impression is: pregnancy uterine, _______ weeks age of gestation, _____________ presentation, in
active labor, G____ P____ (__-__-__-__), ______________________________________________________________________

Plan is for normal spontaneous vaginal delivery. Expected time of delivery is ______ hours after admission, or
at ______ (am/pm).
IVF of D5LR 1 liter was started at ____ drops per minute
The following laboratories were requested: CBC, BT, HbSAg and U/A
CBC revealed WBC of __________/ul , hemoglobin of ____ g/dl, hematocrit of ____, and platelet of ________.
Blood type is ____+. HbSAg is (reactive/nonreactive). Urinalysis within normal limits.

PARTOGRAPH
For the progress of labor, patient came in on her _____ hour of labor with _____ cm cervical dilatation at
station _____ with an (intact/ruptured) bag of water, with a FHT of _____ beats per minute, with uterine
contractions of (2/3/4) per 10 minutes, (mild/moderate/strong) intensity, lasting (40/50/60) seconds, and
with a blood pressure of ________. After 2 hours, patient was reassessed, now with _____ cervical dilatation
(still/now) at station _____, with (intact/ruptured) bag of water (with clear amniotic fluid), with uterine
contractions of (2/3/4) per 10 minutes, (mild/moderate/strong) intensity, lasting (40/50/60) seconds, and
with a blood pressure of ________.

Cervical Dilatation
Station
Bag of Water
Contractions
Fetal Heart Tone
Blood Pressure

After _____ hours and _____ minutes of labor, patient spontaneously delivered to a full term, live baby
(boy/girl), with an apgar score of _______, and a birth weight of _____ kg. Placenta was delivered
spontaneously and completely, weighing ______ g. Estimated blood loss was _______ cc. Post-partum blood
pressure was __________ mmHg.

Final diagnosis is
G___ P___ (___-___-___-___)
Pregnancy uterine, full term, delivered to a live baby (boy/girl), AS ______, BW _____ kg, vertex, via normal
spontaneous delivery __________________________________________________________________________________

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1 hour postpartum, {S} patient complained of hypogastric pain, ____/10 pain score; with the following vital
signs {O} BP _____ mmHg; HR _____ bpm; RR _____ cpm; T _____ C; Skin: warm with good turgor. HEENT:
aniceteric sclerae, (pink/pale) palpebral conjunctivae; moist lips and tongue; C/L: no retractions, equal chest
expansion, clear breath sounds; CVS: adynamic precordium, distinct heart sounds, no murmur; abdominal
exam: uterus: _____ weeks size, well contracted; GUT: minimal lochia rubra, intact episiorrhaphy, no vulvar
hematoma; Extremities: no edema, strong peripheral pulses; {A} status post NSD for 1 hour, clinically
guarded; {P} plan was to monitor vital signs every 15 min for 2 hours until stable, then every 4 hours; infuse
10 units of oxytocin to in D5LR 1L at 30gtts/minute; give medications: cefalexin 500 mg tab TID,
multivitamins and ferrous sulfate capsule once a day and mefenamic acid 500 mg tablet TID for pain;
increase her oral fluid intake; initiate breastfeeding; encourage the patient to void within 6 hours; and
perineal care twice a day.

_____ hours postpartum, {S} patient had no subjective complaints; with [O] stable vital signs: BP _____ mmHg,
HR _____ bpm, RR _____ cpm, T _____ C; Skin: warm with good turgor. HEENT: anicteric sclerae, (pink/pale)
palpebral conjunctivae; moist lips and tongue; C/L: no retractions, equal chest expansion, clear breath
sounds; CVS: adynamic precordium, distinct heart sounds, no murmur; abdominal exam: uterus: _____
weeks size, well contracted; GUT: minimal lochia rubra, intact episiorrhaphy, no hematoma; Extremities: no
edema, strong peripheral pulses; {A} status post NSD for _____ hours - stable; {P} plan is to continue
medications and counsel the patient for family planning.

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