lOMoARcPSD|3013804
Maternity Clinical Amelia Sung
Documentation
Basic Adult Health Care (Keiser University)
, lOMoARcPSD|3013804
Maternity Case 3: Amelia Sung
Documentation Assignments
1. Document the fetal status and the progression of Ms. Sung’s labor from the time you took over care
of Ms. Sung until the provider takes her to the delivery room.
● Ms. Sungs cervical exam was at 2 cm dilation, 80% effaced at -1 station with fetus in vertex
position. At 0100 hours, dilation was 4 cm, 100% effaced, still at -1 station and fetus in
vertex position. She received an epidural shortly after that, and 1 hour later, her membranes
ruptured; the fluid was clear.
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.
● 0820 The fetus head started crowning. Encouraged the patient to push.
● 0837 The fetus head was delivered.
● 0900 The fetus head retracted. 0905 Placed patient in McRobert’s position per provider’s
orders.
● 0910 Applied suprapubic pressure per provider’s order. 0920 the fetus shoulders were
delivered.
3. Document the application of suprapubic pressure and the response and outcomes.
● Supapubic pressure performed to dislodge the shoulder that is being obstructed by pubic
bone. Intervention was successful and the fetus was delivered
4. Document your communications with the neonatal intensive care unit (NICU) about the impending
birth.
● 0900 NICU was called. The patient is in birthing room 2. Patient pushed and head was
delivered at 0837. Turtles sign positive. Estimated fetal weight 4,000 grams. The fetal heart
rate is 90 bpm with decreased variability. McRoberts maneuver performed. Need NICU team
for possible neonatal asphyxia or fetal injury.
Maternity Clinical Amelia Sung
Documentation
Basic Adult Health Care (Keiser University)
, lOMoARcPSD|3013804
Maternity Case 3: Amelia Sung
Documentation Assignments
1. Document the fetal status and the progression of Ms. Sung’s labor from the time you took over care
of Ms. Sung until the provider takes her to the delivery room.
● Ms. Sungs cervical exam was at 2 cm dilation, 80% effaced at -1 station with fetus in vertex
position. At 0100 hours, dilation was 4 cm, 100% effaced, still at -1 station and fetus in
vertex position. She received an epidural shortly after that, and 1 hour later, her membranes
ruptured; the fluid was clear.
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.
● 0820 The fetus head started crowning. Encouraged the patient to push.
● 0837 The fetus head was delivered.
● 0900 The fetus head retracted. 0905 Placed patient in McRobert’s position per provider’s
orders.
● 0910 Applied suprapubic pressure per provider’s order. 0920 the fetus shoulders were
delivered.
3. Document the application of suprapubic pressure and the response and outcomes.
● Supapubic pressure performed to dislodge the shoulder that is being obstructed by pubic
bone. Intervention was successful and the fetus was delivered
4. Document your communications with the neonatal intensive care unit (NICU) about the impending
birth.
● 0900 NICU was called. The patient is in birthing room 2. Patient pushed and head was
delivered at 0837. Turtles sign positive. Estimated fetal weight 4,000 grams. The fetal heart
rate is 90 bpm with decreased variability. McRoberts maneuver performed. Need NICU team
for possible neonatal asphyxia or fetal injury.
