Maternity Care Package Page 3
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44. Determine pertinent abdominal examinations
(+)
(-)
regular uterine contractions
FHT= __________
(+)
(-)
bloody show
fundic ht= _______________
(+)
(-)
active fetal movements
estimated fetal wt: _________
5. Perform IE
BOW:__________________
Cervical Effacement: _______________ Presentation: ____________
Cervical dilatation: ___________________ Station: ________________
B. Ascertain that patient is in true active labor
Time of start of labor:
C. Admit and obtain informed consent
Time of Admission:
D. Monitor course of labor, accomplish partogram
E. Prepare Delivery Room
F. Attend to Delivery of Baby
Time of delivery of newborn:
G. Get APGAR score of Newborn
APGAR :
H. Routine Newborn Care
I. Perform Delivery of Placenta
Time of delivery of placenta:
J. Check if placenta is complete
K. Ensure good uterine contraction
L. Inspect for perineal and vaginal lacerations
M. Explain to patient the procedure of perineal repair
N. Suture perineal laceration under Local Anesthesia
O. Check repair and ensure hemostasis
P. Transfer patient to recovery area
Q. Monitor during Immediate Postpartum Period
BP: ____ HR: ____RR: ____T: ____
R. Discharge Clearance (D/C IE)
Vagina:
Cervix:
Uterus:
S. Give Complete Diagnosis
OB Score : G ____ P ____ ( ____ , ____ , ____ , ____ )
Maternal Outcome:
_________________ ,
_________________ ,
_________________ ,
________________
Pregnancy Uterine
AOG by LMP
Manner of Delivery
Presentation
Birth Outcome:
____________ ,
____________ ,
____________ ,
____________
Sex
Birthweight
APGAR Score
Live
T. Accomplish documents for PHIC Reimbursement
U. Schedule Postpartum and Newborn Care follow-up
Date: ______________________
consult - 1 week after delivery
V. Discharge Patient
Date and Time of Discharge: ______________________
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