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Student Name: Normal FIT: Pt. Initial Age Date of delivery Date of Care LABOR AND DELIVERY RECORD Time Drip DIL Eff Sta FIT B×P Contraction Pattern Nurses Notes.
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How to fill out labor and delivery record
How to fill out labor and delivery record?
01
Start by gathering all necessary information, including the patient's name, date of birth, and contact information.
02
Record the date and time of labor initiation, as well as any relevant medical history or complications.
03
Document the patient's vital signs, such as blood pressure, heart rate, and temperature, at regular intervals.
04
Record the progress of labor, including the frequency, duration, and intensity of contractions.
05
Note any medications administered during labor, including the drug name, dose, and route of administration.
06
Document any medical interventions or procedures performed, such as epidural anesthesia or fetal monitoring.
07
Record the patient's pain level using a standardized pain scale, such as the Wong Baker FACES scale.
08
Monitor the fetal heart rate and document any abnormalities or changes in the pattern.
09
Document the patient's pushing efforts and the delivery of the baby, noting any complications or interventions.
10
Finally, record the condition of the baby at birth, including its Apgar score and any immediate medical interventions.
Who needs a labor and delivery record?
01
The labor and delivery record is essential for obstetricians and midwives who are providing medical care during the childbirth process.
02
It is also useful for nurses and other healthcare professionals involved in caring for the mother and baby during labor and delivery.
03
The labor and delivery record provides a comprehensive and accurate account of the events and interventions that occurred, which can be beneficial for future medical reference, research purposes, and legal documentation.
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