LABOR ROOM

Date and Time Focus Data, Action, Response

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 for IE done
comfort 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 ____at the L/R
administration of metacarpal/cephalic/basilis vein and regulated to ____gtts/min
medication
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 Time FOCUS DATA, ACTION, RESPONSE
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 anesthesia A> Nubain 1 amp given IV by NOD/RNSE as per verbal order of
sedation Dr. _____________
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