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NSD + Rmle

This document is a medical record from a hospital in the Philippines documenting a normal spontaneous delivery with episiotomy and laceration repair. It includes information about the patient, pre-operative and operative diagnoses, the surgeons involved, and details of the procedure. The procedure involved delivering the baby, performing essential newborn care steps, delivering the placenta, repairing a laceration, and examining and cleaning the vagina. The patient tolerated the procedure well.

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OB-GYNE DEPARTMENT
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508 views2 pages

NSD + Rmle

This document is a medical record from a hospital in the Philippines documenting a normal spontaneous delivery with episiotomy and laceration repair. It includes information about the patient, pre-operative and operative diagnoses, the surgeons involved, and details of the procedure. The procedure involved delivering the baby, performing essential newborn care steps, delivering the placenta, repairing a laceration, and examining and cleaning the vagina. The patient tolerated the procedure well.

Uploaded by

OB-GYNE DEPARTMENT
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Republic of the Philippines

Department of Health
Central Luzon Center for Health Development
DR. PAULINO J. GARCIA MEMORIAL RESEARCH
AND MEDICAL CENTER
Cabanatuan City
ISO QMS Certified

Name: Age:
Address: Case No:

RECORD OF OPERATION
OPERATION PERFORMED:
NORMAL SPONTANEOUS DELIVERY WITH RIGHT MEDIOLATERAL EPISIOTOMY AND REPAIR OF ___ DEGREE
LACERATION
PRE-OPERATIVE DIAGNOSIS:

OPERATIVE DIAGNOSIS:

SURGEON: SURGEON:

CONSULTANT: CONSULTANT:

TISSUE REMOVED: TISSUE REMOVED:

Operative Technique:

Patient placed on semi-recumbent position


Asepsis and antisepsis.
Application of sterile drapes at the perineal area
Insertion of straight catheter to empty the bladder
Right mediolateral episiotomy done after infiltration of local anesthesia
Delivery of___________________________
4 Core steps of essential newborn care performed
1. Immediate and thorough drying
2. Early skin to skin contact
3. Properly timed cord clamping
4. Non separation of the newborn and mother for early initiation of breastfeeding
Delivery of the placenta. Evacuation of Blood clots
Repair of ___ degree laceration done.
Vaginal inspection. Cleaned with providone iodine antiseptic followed by perineal washing.
Patient tolerated the procedure well.

Obstetrics and Gynecology:


Republic of the Philippines
Department of Health
Central Luzon Center for Health Development
DR. PAULINO J. GARCIA MEMORIAL RESEARCH
AND MEDICAL CENTER
Cabanatuan City
ISO QMS Certified

Estimated Blood Loss:


PJG-MED-OBG-Form014-Rev02 Effective Date: 04/27/2016

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