Patient Information:
- Name: [Patient's Name]
- Age:[Patient's Age]
- Gravida/Para:[G/P status, e.g., G2P1 (Gravida 2, Para 1)]
- Gestational Age:[Weeks of gestation at delivery]
- Date of Admission:[Date of admission to the labor ward]
History:
- Patient presented with regular contractions approximately [duration] apart.
- Fetal heart rate monitored and within normal limits throughout labor.
- Membranes ruptured spontaneously/[intervention method] at [time].
- Progressed through stages of labor appropriately.
Labor Course:
- First Stage:
- On admission: [Cervical dilation, effacement, station].
- Progressed to [full dilation] at [time].
- Second Stage:
- Began pushing at [time].
- Duration of active pushing: [minutes/hours].
- Fetal head descended to [station].
- Third Stage:
- Placenta delivered spontaneously/[method] at [time].
- Estimated blood loss: [amount], managed with [interventions, e.g., uterotonic agents].
Complications/Interventions:
- No significant complications noted during labor and delivery.
- [Any additional interventions if applicable, e.g., episiotomy, perineal tear repair].
Newborn Assessment:
- [Baby's Name], [birth weight], [Apgar scores at 1 and 5 minutes].
- [Immediate newborn care, e.g., drying, stimulation, cord clamping and cutting, skin-to-skin contact].
Postpartum Course:
- Maternal vital signs stable post-delivery.
- Fundal height [appropriate/monitored], Lochia [amount/color].
- Pain management provided with [medications].
- Breastfeeding initiated successfully/[additional details].
Discharge Planning:
- Plan for postpartum care discussed.
- Follow-up appointment scheduled for [date].
- Discharge home with [instructions, medications, and contact information for emergencies].
Signed:
[Your Name], [Your Title]
[Date and Time]
This template provides a structured approach to documenting a normal vaginal delivery, ensuring key clinical details are captured for continuity of care and medical records. Adjustments can be made based on specific institutional requirements or patient conditions.
