Maternity Case 5: Amelia Sung (Core)
Documentation Assignments
1. Document Ms. Sung’s admission to the labor unit, including the plan of care and appropriate
referrals.
Ms. Sung is a 36 y/o Filipino woman, G2P1 admitted approx. 6 hours ago in active
labor. She was 4cm dilated and 100% effaced and station -1. Epidural anesthesia
was initiated at 0230. The membrane ruptured at 0330 and the amniotic fluid was
clear. Since then she has dilation 6 cm and the fetus is presently at -1 in the vertex
position. She is fully dilated and began pushing. The fetal heart rate is within
normal limits with moderate deceleration. Fetal began to crown and was given O2
via nonrebreather mask at 10 L and LR running at 125ml/hr. Ms. Sung’s last baby
was a shoulder dystocia.
2. Document the essential events related to the time of birth, including the activities and
interventions from the time of crowning to the complete expulsion of the fetus.
16:55 Performed at vaginal exam. The head was
crowning 05:12 Checked for blood, lochia and fluid on
the bed 05:33 Changed and weight the bed pads
05:56 Notified NICU of risk
06:27 Prepared the delivery table
06:44 Prepared the bassinet
06:57 Check for presence of step stool in the room in case it is needed for suprapubic
pressure
07:10 Instructed patient to start pushing
07:14 Encourage pushing
07:33 Called the Charge Nurse
08:58 Repositioned the patient
10:01 Baby head was delivered
Documentation Assignments
1. Document Ms. Sung’s admission to the labor unit, including the plan of care and appropriate
referrals.
Ms. Sung is a 36 y/o Filipino woman, G2P1 admitted approx. 6 hours ago in active
labor. She was 4cm dilated and 100% effaced and station -1. Epidural anesthesia
was initiated at 0230. The membrane ruptured at 0330 and the amniotic fluid was
clear. Since then she has dilation 6 cm and the fetus is presently at -1 in the vertex
position. She is fully dilated and began pushing. The fetal heart rate is within
normal limits with moderate deceleration. Fetal began to crown and was given O2
via nonrebreather mask at 10 L and LR running at 125ml/hr. Ms. Sung’s last baby
was a shoulder dystocia.
2. Document the essential events related to the time of birth, including the activities and
interventions from the time of crowning to the complete expulsion of the fetus.
16:55 Performed at vaginal exam. The head was
crowning 05:12 Checked for blood, lochia and fluid on
the bed 05:33 Changed and weight the bed pads
05:56 Notified NICU of risk
06:27 Prepared the delivery table
06:44 Prepared the bassinet
06:57 Check for presence of step stool in the room in case it is needed for suprapubic
pressure
07:10 Instructed patient to start pushing
07:14 Encourage pushing
07:33 Called the Charge Nurse
08:58 Repositioned the patient
10:01 Baby head was delivered
