At this new facility, they are very short...just "SVD female" then "placenta delivered".
I was trained to be more detail from my old facility.... "Spontaneous vaginal delivery of viable female/male.... Stimulated and dried with towel... Vigorous cry...quick pinkening...cord clamped and cut. Skin to skin with mom......(or to preheated radiant warmer for assessments, meds given and id bands applied x2 or wrappedx2 with hat on to mom).
As far as placenta, "placenta delievered. Pitocin started as ordered."
Am Im charting too much? What do you chart? Please share.
I still, after 5 years, pay a lot of attention to delivery notes! Something like this:
1526: vacuum applied after bladder emptied by Dr. X.
1529: head delivered and vacuum removed.
1530: delivery of live female, not vigorous, to warmer immediately for assessment by resusc OR
1530: delivery of vigorous live female placed directly skin to skin for dry & stim (insert name of baby nurse here if you want, I don't since they sign our Apgars off).
1535: placenta delivered spontaneously and intact. 2nd degree laceration repaired by Dr. X.
1540: peri care provided and pt continues to hold baby; fundal checks & VS normal (see PP flow sheet for details).
Our oxytocin with the shoulder etc and in/out volumes are recorded electronically as are our post partum vitals. I don't double chart those.
Ultimately it's your practice and you get to decide what works for you!
As baby nurse, I write a more detailed note in the baby's own record:
1530 birth of live female, vigorous immediately, pink with good tone, loud cry, clearing secretions spontaneously skin to skin with mother. HR 150 bpm @ 1 minute, easily palpated at unbilicus. Apgars 9, 9. No interventions required. Remains skin to skin with mother. ID bands applied to baby and mother. Initial VS stable. Continue to monitor.
Last edit by Fyreflie on Mar 22, '13