Date
Time
Time mounted
Focus
Safe
Delivery
Date
Time
(time of
delivery)
Focus
Immediate
Newborn
Care
Notes
A case of (Name of pt, age, address, OB score)
admitted due to labor pains
D – grimaced face, guarded behavior noted,
sweating profusely, (with IVF D5LR 1 L @ 30
gtts/min. infusing well @ R/L arm, with pain score of
10.
A – received from labor / IE room per
wheelchair/stretcher, cautiously mounted on the DR
table, perineal prep done aseptically, put on sterile
drapes, encouraged to bear down, (episiotomy done
by ROD) delivered an alive term baby (girl/boy) via
NSVD in cephalic presentation, (thickly/ moderately /
slightly meconium stained) @ (time of delivery)(with
perennial laceration mediolateral or midline), placed
baby on the abdomen to promote skin to skin
contact, felt cord pulsation, oxytocin 10 units given
IM by NOD, cord clamp and cut aseptically, delivered
placenta completely in (Schultz/ Duncan
presentation) @ (time), kept uterus firm and
contracted, BP taken @ (120/80mmhg) incorporated
( ) units oxytocin to the above IVF by NOD and
regulated @ 30 gtts/min., (episiorraphy done by
ROD), perennial care done, put on clean diapers,
changed clean clothes, encouraged to exclusively
breastfeed baby, vital signs monitored and recorded,
watched for profuse vaginal bleeding.
R – Endores to NOD with well contracted uterus, and
no signs of profuse vaginal bleeding.
(Name of Student / Name of CI)
UCCN – SN UCCN – CI
Notes
Delivered an alive term baby (girl/boy) via NSVD,
cephalic presentation with an initial APGAR score of
@ (time).
D – with strong / weak cry, acrocyanosis noted with
good reflexes, moderate amount of lanugo and
vernix caseosa noted on some parts of the body,
APGAR score of 9 and 10.
A – put on mothers abdomen for skin to skin
contact, wiped head, face and body to promote
thermoregulation, put on cap, felt cord pulsation,
cord clamp and cut aseptically, kept warm, put on ID
band @both ankles, anthropometric measurements
taken and recorded, Vitamin K given IM @ Right
thigh, eye prophylaxis done on both eyes, Hep B
vaccine given IM @ left thigh by NOD, put on diaper
and clean clothes, latched on to mother with good
sucking reflex, kept warm at all times.
R – endorsed to NICU NOD, with dry and intact cord
dressing, not in respiratory distress, still for Ballard
Scoring, Still for continuous newborn monitoring.
(Name of Student/ Name of CI)
UCCN – SN
UCCN – CI