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OR Write-up-NSD

The document summarizes the instruments used and procedures followed for a patient who underwent a normal spontaneous delivery (NSD). It provides background on the 31-year-old patient including her medical history and pregnancy details. A brief discussion is then given of the NSD procedure, noting the steps taken which included administering spinal anesthesia, performing a right medial episiotomy, delivering a live baby boy, delivering the placenta, and suturing. A list of 30 surgical instruments used for the procedure is also included.

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Bernard
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2K views6 pages

OR Write-up-NSD

The document summarizes the instruments used and procedures followed for a patient who underwent a normal spontaneous delivery (NSD). It provides background on the 31-year-old patient including her medical history and pregnancy details. A brief discussion is then given of the NSD procedure, noting the steps taken which included administering spinal anesthesia, performing a right medial episiotomy, delivering a live baby boy, delivering the placenta, and suturing. A list of 30 surgical instruments used for the procedure is also included.

Uploaded by

Bernard
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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UNIVERSITY OF THE CORDILLERAS

COLLEGE OF NURSING
Gov. Pack Road, Baguio City

OR WRITE UP

INSTRUMENTS:

Name of patient: JB
Age:31 Sex: Female Civil Status: Married Religion: Roman Catholic
Address: Mangatarem, Pangasinan
Operation Proposed: NSD
Working Diagnosis: PU 40 wks AOG, G5P4 (5,0,0,4)
Type of Anesthesia: SAB Position: knee chest
History of Present Illness:

Prior to admission, the patient was in:


- PU 40 wks AOG, G5P4 (5,0,0,4)
- Pregnancy uterine delivered by NSD 2° to a live baby boy out G5P5 (2,0,0,2)

Pathology:

There was a sexual intercourse done by the married couple. Soon after, there was the
union of egg cell & sperm cell. Then, fertilization takes place in the woman’s uterus, and
then a fetus developed for 9 months. After 40 wks of pregnancy, the mother gave birth to
a live baby boy

Brief Discussion of Proposed Operation:

12:20 am: Brought to O.R. a 31 year old female, per stretcher, with D5LRS at
500 cc level, scheduled for NSD by Dr. Espinosa, placed at O.R. table in supine position,
repositioned to knee-chest position, SAB inducted by Dr. Ordona, and skin preparation
done. Draped properly, IFC inserted aseptically, connected to urine bag. Initial count of
sponges, needles, and instruments done.

12:46 am: operation started by Dr. Espinosa, RMLE done.


12: 52 am: a live baby boy out
12:53 am: placenta out completely. Suturing started.
01:34 am: operation ended, Betadine swabbed. Finally, then brought to PACU per
stretcher with D5LRS at 500 cc level, for further care and management.
TISSUE FORCEPS

THUMB FORCEPS

NEEDLE HOLDER

SURGICAL NEEDLES
METZENBAUM SCISSORS

STRAIGHT MAYO SCISSORS

CURVE MAYO SCISSORS

BLADE HOLDER
SURGICAL BLADES

KELLY CURVED

KELLY STRAIGHT
BOBCOCK

ARMY NAVY RETRACTOR

RICHARDSON RETRACTOR

ABDOMINAL RETRACTOR
TOWEL CLAMP

ALLIS

CAUTERY MACHINE

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