DR NOTES at BENGUET GENERAL HOSPITAL

Date
and Focus Data, Action, Response
Time
From LR to DR D > Into delivery room ambulatory accompanied by
RNSE/RMSE/SNOD/IWOD, with ongoing IVF of _______ 1L + ______ u
oxytocin at _____ ml level infusing well at the _____
metacarpal/cephalic/basilic vein.
From ward to LR
D > Into DR a _____ year old G__P__ mother from ER/OB ward per
Time wheelchair/stretcher/ambulatory accompanied by IWOD/RNSE/RMSE
with ongoing IVF of _______ 1L + _____ u oxytocin at _____ ml level infusing
well at the _____ metacarpal/cephalic/basilic vein.
For Direct DR
D > With full cervical dilatation and continuous uterine contractions occurring 2-3
minutes and duration of 30-60 seconds, bloody mucoid and bulging perineum
noted.
A > Assisted to DR table and positioned to dorsal lithotomy; IE done by
___________________ revealing full cervical dilatation; administered oxygen
Positioning and
Time inhalation per nasal cannula at 2-3 LMP; coached on proper bearing down.
Comfort
A > RMLE done by Dr. ________________ / Perineal support done by
Dr. ____________________.
A > Delivered to an alive baby boy/girl via NSD in cephalic presentation with a
Safe Delivery of
Time birth weight of ____ kg and a birth length of ______ cm attended by Dr.
the Baby
_________________.
A > Nubain 1 amp given intravenously by NOD/RNSE as per verbal order of Dr.
Start of
__________________.
Time Anesthesia and
A > Midazolam / 1 amp given intravenously by NOD/RNSE as per verbal
Sedation
order of Dr. __________________.
Safe delivery of A > Placenta out completely in Schultz/Duncan presentation; with BP of
Time
placenta _______mmHg, PR of ______bpm, RR of ______ cpm, Temp of _____ C.
A > Methylergometrine 1 amp administered IM/IV at _____ deltoid by
Time Medication
NOD/RNSE as ordered.
Time IV incorporation A > Additional 10 uoxytocin to present IVF as per verbal of Dr. __________.
A > Evacuation of blood clots and placental fragments done by Dr. ___________
Time Episiorrhaphy using curette/manually; Episiorrhaphy done by Dr. __________. Massaged
uterus until firm and contracted.
Postpartum A > Transferred to stretcher then brought to LR; Advised to massage uterus until
Time Care/Health firm and contracted; to wash perineal area with tap water and to report
teaching excessive bleeding to NOD.
A > Breastfeeding initiated, bonding monitored, vital signs monitored and
recorded, breastfeeding per demand and proper burping encouraged.
Nutrition and
TIME
Bonding R> Delivered safely with minimal vaginal bleeding; with firm and contracted and
with the latest vital signs of: BP of _______mmHg, PR of ______bpm, RR of
______ cpm, Temp of _____ C.
> Brought to OB ward per stretcher/wheelchair accompanied by _____ and
Time Unit Transfer with ongoing IVF of _______ 1L + _____ u oxytocin at _____ ml level.

Signature over printed name