This document contains the course of treatment for a 17-year old female patient who was admitted for labor pains. It details her admission, delivery of a healthy baby girl via normal spontaneous delivery, postpartum care, and subsequent discharge from the hospital after her condition stabilized with minimal vaginal bleeding and contracted uterus. Her vital signs, fetal heart tones, and progress of labor were monitored throughout her stay. She was instructed on personal hygiene and breastfeeding before being discharged home in stable condition.

1. 48
IX. COURSE IN THE WARD
DATE/TIME DOCTOR’S ORDER NURSE’S NOTE
9-05-12  Please advice to OB-LR  arrived 17y/o female, single,
11:10AM  secure consent for with CC of labor pains,
admission BP:120/90
 BP, TPR by 4⁰  assisted; referred to Dra.
 NPO Tumamao
 IVF: D5LRS, 1L + 10 I  seen and examined by Dra.
oxytocin at 10-15gtts. Tumamao with order for
 CBC, blood typing admission , consent for
,HBsAg,CTG admission signed by her
 medication: HUBB, 1amp mother ; NPO instructed;
IV q1⁰, 3 doses ANST perineal prep done; IVF
 monitor paces of labor, FHT inserted of D5LRS, inserted
and VS aseptically then regulated @
 refer accordingly 30 gtts/min.
 request forwarded to
laboratory
 transmitted to LR per wheel
chair
11:35 AM  In from OB-ER via
wheelchair accompanied by
NOD, conscious and
coherent
 assisted on bed safely and
comfortably
 V/S, FHT, POL, monitored
and record
 NPO maitain
12:45 PM  Transfer to OB-LR via
stretcher
12:50 PM  In from OB-LR via stretcher;
conscious and coherent
 assisted or DR table safely;
perineal prep done; sterile
drape applied
 cooperated

2. 49
1:00 PM  Postpartum order:  delivered via NSD with MER
 DAT to a live baby girl with AS of
 IVF x 30 gtts/ L then to 8/9
consume  kept warm and dry; cord
 Cefalexin 500mg 1 cap OD clamping and latching done;
 FeSO4 1 tab OD brought to NICU to NB care
 Mefenamic Acid 500mg 1
cap OD
 Keep uterus contracted
 Perineal hygiene
 VS q 4⁰
 Refer accordingly
1:05 PM  Delivered placenta
completely: blood clots
evacuated
 Massage uterus
 with contracted uterus; with
minimal vaginal bleeding
 encourage breastfeeding;
burping advised; hygiene
emphasized
 endorsed back to ward via
stretcher
1:20 PM  In from DR via stretcher
with minimal vaginal
bleeding and well contracted
uterus
 Assited to bed safely and
comfortably, hygiene
rendered; DAT advised,
breastfeeding encouraged,
instructed to report if profuse
bleeding occurs.
 Understood
3:00 PM  In bed awake with minimal
vaginal bleeding
 -hygiene rendered, advised
and watched for profuse
bleeding occurs
 Understood
11-7 SHIFT  On bed with minimal vaginal
bleeding
 Hygiene emphasized;
continuously monitored
 Understood
9-06-12  MGH  With minimal lochial

3. 50
7:00 AM  Continue meds @ home discharge
 On ff-up  Encourage to continue
 Advised breastfeeding, personnal
hygiene advised
3:00 PM  On bed awake, still for
discharge
 Advised to settle bills
 Understood
11-7 SHIFT  Still for discharge  Awake on bed with slight
vaginal bleeding
 Perineal care advised
9-7-12  Awake on bed with light
7:00 AM vaginal bleeding
 Advised to use betadine
vaginal wash for perineal
care
 Still for discharge
 Advised to settle bills
3:00 PM  On bed; still for discharge
 Emphasized hygiene; advised
to settle bills
 Bill settled
 Home needs instructed; ff-up
check-up reminded
4:00 PM  Went home ambulatory