A 30-year-old woman, G1P0, was brought to the labor room in active labor. She underwent an episiotomy and spontaneously delivered a baby boy at 9:00 PM, who had APGAR scores of 8 and 9. Some parts of the placenta were missing, causing postpartum bleeding, so an episiorrhaphy was performed. The mother and newborn were given post-delivery care instructions and medications before being transferred to the postpartum care unit, where the mother had a well-contracted uterus and minimal bleeding.

1. Aurelio, Lyca Mae M.
Mother’s Progress Notes
Date/Time Focus Data Action Response
10/07/20
8:30 PM
8:45 PM
8:55 PM
8:58 PM
9:00 PM
For
delivery
➢ In from labor
room, a 30
years old,
G1P0 in
active labor
per stretcher.
➢ With IV Fluid
of D5Lrs
850cc level
regulated
➢ After
placental
examination,
Dr. Cadena
noticed
➢ Placed
computably on
DR table in
lithotomy
position.
➢ Perineal prep
done aseptically
➢ Episiotomy
done by Dr.
Cadena thru
local anesthesia
➢ Delivered
spontaneously
to an alive baby
boy attended
by Dr. Cadena
with an APGAR
score of 8,9
respectively.
➢ 10 “U” oxytocin
incorporated to
above IV
Fluid/IM
➢ Placenta
delivered
completely thru
Schultz
presentation
➢ BP taken
➢ Carboprost 250
mcg admistered
thru IM

2. 9:30 PM
some parts of
the placenta
was missing
causing post
partum
bleeding
during the
vaginal
examination
➢ Episiorrhaphy
done by Dr.
Cadena.
➢ Perineal care
done, clean pad
applied.
➢ Health
teachings
incorporated
such:
• Manage uterus
to prevent post
partum.
• Instruct to clean
the perineum
with clean tap
water.
• Encourage early
breastfeeding.
• Take
medication as
prescribed
• Encourage to
do follow up
check up as
scheduled
➢ Affirmed by
nodding and
verbalization
of “Wen
Mam”
➢ Procedure
well
tolerated
➢ Brought to
PACU with
well
contracted

3. uterus and
minimal
vaginal
bleeding
Lyca Mae Aurelio/ Mrs. Cheryyfel Colobong/Mr. Erwin Garvida/ Ms. Rei Imencion
MMSU-SN CI MOD NOD

4. Newborn’s Progress Notes
Date/Time Focus Data Action Response
10/07/20
8:55 PM
9:30 PM
➢ Immediate
Newborn
Care
Born an alive
baby boy thru
Normal
Spontaneous
delivery
attended by Dr.
Cadena with an
APGAR score of
8,9
respectively.
➢ Immediate and
thorough
drying of skin
done
➢ Skin to skin
contact
between the
mother and
newborn
➢ Cord clamping
and cutting
done after
pulsation
stopped
➢ Breast feeding
initiated
➢ Anthropometric
measurement
taken as follows
➢ BL- 50 cm
➢ HC- 34 cm
➢ CC- 32 cm
➢ AC- 34 cm
➢ Weight Taken,
3.1 kg
➢ Anal opening
checked with
patent anus
➢ Nametag
applied
➢ Good Crying
➢ Able to adjust
to
extrauterine
life

5. ➢ Brought to
ward for
more care
and
management.
Lyca Mae Aurelio/ Mrs. Cheryyfel Colobong/Mr. Erwin Garvida/ Ms. Rei Imencion
MMSU-SN CI MOD NOD