Consultant on Duty: Dr.
De Leon
VAGINAL DELIVERIES
Dr. Lanto/Pare/Garcia/Batac
PATIENT ADMITTING DIAGNOSIS PLAN OUTCOME DISPOSITION/
(Details, HPI, pertinent (Delivery outcome; UPDATE
past medical, OB, family Postpartum PE &
history, ROS, PE) Labs)
1. Jacala, Mary Joy 20/S G2P1 (1001) Pregnancy Uterine spontaneous vaginal G2P2 (2002) Pregnancy Patient is on post partum
PNCU at Mayantoc HC 11x 40 weeks age of gestation delivery Uterine Delivered Term, Day 1.
BMI 22.1 (Normal) cephalic in labor Cephalic to a Live Baby Encouraged breastfeeding
EFW: 3200-3400 grams by Girl, AS 9,9, BW 3.4kg, BS and daily perineal care.
cupping 40 weeks, AGA via
IE: cervix fully dilated, fully Spontaneous vaginal Meds:
effaced, cephalic, station +2, delivery with RMLE and Coamoxiclav 625mg/tab
(-)BOW repair of 2nd degree TID
laceration under local FeSO4 tab OD
anesthesia Paracetamol + Tramadol tab
TID
Metoprolol 50mg BID
Na ascorbate + Zinc OD
Family Planning: PSI
insertion
Rivera, Ciara Mar 23/S
PNCU at PMD 7X
BMI 34 (obese class I)
EFW: 2600 (9/7/23)
IE: cervix 8 cm dilated, 80%
effaced, cephalic, station -2,
(-)BOW,
A: G1P0 Pregnancy Uterine 40
weeks age of gestation cephalic
in labor
P: spontaneous vaginal delivery
Jabel Ma. Christina 20/S
PNCU at San Jose HC 6x
BMI 28.24 (obese class I)
EFW:3500 (7/13/23)
IE: cervix 7cm dilated, 70%
effaced, cephalic, station -2,
(-)BOW,
A: G1P0 Pregnancy Uterine 39
3/7 weeks age of gestation
cephalic in labor
P: spontaneous vaginal delivery
Gomez, Joyce 21/S
PNCU at PMD 9x
BMI: 24.2 (normal)
EFW:3300 (10/3/23)
IE: cervix 6cm dilated, 70%
effaced, cephalic, station -2,
(-)BOW,
A: G1P0 Pregnancy Uterine 40
6/7 weeks age of gestation
cephalic in labor
P: spontaneous vaginal delivery
Evasco Mariciris 34/S
PNCU at Binauganan HC 4x
BMI 22.8 (normal)
EFW: 2800- 3000 by cupping
IE: cervix fully dilated, fully
effaced, cephalic, station -2,
(-)BOW,
A: G5P4 (4004) Pregnancy
Uterine 39 6/7 weeks age of
gestation cephalic in labor
P: spontaneous vaginal delivery
Outcome
G5P5 (5005) Pregnancy uterine
delivered term cephalic to a
live baby boy Apgar score 9,9
Birthweight 3 kg. Ballard score
39 weeks age of gestation via
spontaneous vaginal delivery
Llanos, Shiela 36/M
PNCU at Camiling HC 8X
BMI: 29.1(obese class I)
EFW: 3100 (7/18/23)
IE: cervix fully dilated, fully
effaced, cephalic, station -2,
(-)BOW,
A: G3P2 Pregnancy Uterine 38
4/7 weeks age of gestation
cephalic in labor
P: spontaneous vaginal delivery
Outcome
G3P3 (3003) Pregnancy Uterine
delievered term cephalic to a
live baby girl Apgar score 9,9
Ballard score 38 weeks
appropriate for gestational age
via spontaneous vaginal
delivery
Cordova, Mary Ann 27/S
PNCU at Bamban HC 9x
BMI: 28 (obese class I)
(-) HA, Bov, epigastric pain,
dizziness
BP: 160/100
Map: 120
Target: 130/70
HR: 88
RR: 18
O2 98
C/L: CBS
Initial UO: 100 cc
EFW:3100 (8/1/23)
IE: cervix 4cm dilated, 50%
effaced, cephalic, station -2,
(-)BOW,
A: G2P1 Pregnancy Uterine 39
2/7 weeks age of gestation
cephalic in labor, gestational
hypertension severe versus
preeclampsia with severe
features
P: assisted vaginal delivery
Hydralazine 5 mg IV
MgSO4 4g SIVP then MgSO4
drip maintained at 2g/hr
Htn work up
Carreon, Joanna 31/M
PNCU at PMD 4X, TPH 1x
BMI: 24.9
EFW: 3100 (10/04/23)
IE: cervix 3cm dilated, 50%
effaced, cephalic, soft,
midposition station -2, (-)BOW
Bishop score: 5
A: G1P0 Pregnancy Uterine 38
4/7 weeks age of gestation
cephalic in labor,
oligohydramnios
P: augmentation of labor
Castro, Mikaela 27/M
PNCU at Trinidad HC 6X
BMI: 29.1(obese class I)
EFW: 3100 (7/18/23)
IE: cervix fully dilated, fully
effaced, cephalic, station -2,
(-)BOW,
A: G3P2 Pregnancy Uterine 38
4/7 weeks age of gestation
cephalic in labor
P: spontaneous vaginal delivery
Constantino, Roselyn 25/S
PNCU at San Vicente HC 2x
BMI: 21.9 (Normal)
EFW: 3200-3400grams by
cupping
IE: cervix fully dilated, fully
effaced, cephalic, station +2,
(-)BOW
A: G2P1 (1001) Pregnancy
Uterine 40 5/7 weeks age of
gestation cephalic in labor
P: spontaneous vaginal delivery
Castelo, Roxan 36/S
PNCU at Nueva Ecija HC 2x
BMI: 22.4 (Normal)
EFW: 3400grams (7/12/23)
IE: cervix 7cm dilated, 80%
effaced, cephalic, station -2,
(-)BOW
A: G2P1 (1001) Pregnancy
Uterine 40 3/7 weeks age of
gestation cephalic in labor
P: spontaneous vaginal delivery
Calma, Analyn 25/S
PNCU at Tibagan HC 2X
BMI: 24.5
EFW: 2600 (10/4/23)
IE: cervix 6 cm dilated, 60%
effaced, cephalic, station -2,
(-)BOW,
A: G3P2 Pregnancy Uterine 37
3/7 weeks age of gestation
cephalic in labor
P: spontaneous vaginal delivery
Nartates, Maricar 25/S
PNCU at Cuyapo HC 2x
BMI: 23.4
EFW: 2800-3000 by cupping
IE: cervix fully dilated, fully
effaced, cephalic, station 0
(-)BOW,
A: G1P0 Pregnancy Uterine 37
weeks age of gestation cephalic
in labor
P: spontaneous vaginal delivery
Dela Cruz, Maricel 40/M
PNCU at Ramos HC 3x
BMI: 24.9 (overweight)
(-) HA, Bov, epigastric pain,
dizziness
BP: 160/100
Map: 120
Target: 130/70
HR: 80
RR: 19
O2 98
C/L: CBS
Initial UO: 100 cc
EFW: 2800- 3000 by cupping
IE: cervix fully dilated, fully
effaced, cephalic, station -2,
(-)BOW,
A: G3P2 (2002) Pregnancy
Uterine 38 2/7 weeks age of
gestation cephalic in labor,
gestational hypertension severe
versus preeclampsia with
severe features
P: assisted vaginal delivery
Hydralazine 5 mg IV
MgSO4 4g SIVP then MgSO4
drip maintained at 2g/hr
Htn work up
Anuciacion, Neneta 38/M
PNCU at Bamban HC 9x
BMI: 25.5 (overweight)
(-) HA, Bov, epigastric pain,
dizziness
BP: 160/100
Map: 120
Target: 130/70
HR: 88
RR: 18
O2 98
C/L: CBS
Initial UO: 100 cc
EFW: 2800- 3000 by cupping
IE: cervix fully dilated, fully
effaced, cephalic, station -2,
(-)BOW,
A: G4P3 (3003) Pregnancy
Uterine 37 weeks age of
gestation cephalic in labor,
gestational hypertension severe
versus preeclampsia with
severe features
P: assisted vaginal delivery
Hydralazine 5 mg IV
MgSO4 4g SIVP then MgSO4
drip maintained at 2g/hr
HPN work up
Gabuyo, Josephine 29/M
PNCU at Moncada HC 7x
BMI: 24.3 (normal)
EFW: 2800- 3000 by cupping
IE: cervix 9 cm dilated, 90%
effaced, cephalic, station 0,
(-)BOW,
A: G1P0 Pregnancy Uterine 38
weeks age of gestation cephalic
in labor
P: spontaneous vaginal delivery
Ocampo, Bernalyn 19/S
PNCU at Moncada HC
BMI: 22.2 (normal)
EFW:2600-2800 by cupping
IE: cervix fully dilated, fully
effaced, cephalic, station 0,
(-)BOW,
A: G1P0 Pregnancy Uterine 37
5/7 weeks age of gestation
cephalic in labor
P: spontaneous vaginal delivery
Lusung, Shaina 23/M
PNCU at PMD 7X
BMI: 28.7 (obese class I)
EFW: 3100 (10/4/23)
IE: cervix 4 cm dilated, 50%
effaced, cephalic, station -2,
(-)BOW,
A: G1P0 Pregnancy Uterine 39
weeks age of gestation cephalic
in labor
P: spontaneous vaginal delivery
