What do you chart when you have a normal vaginal delivery?

  1. 1
    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.
    katm0 likes this.

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  2. 8 Comments...

  3. 1
    Hmm...I agree that seems odd. I am all for detailed charting. Does everyone at your new facility chart this way or just a few people are this brief? I write the exact same note as you do, something along the lines of "SVD of live female/male infant, bulb suction to mouth and nose on perineum, dried and stimulated with towel on abdomen. Alert, quick pinkening, spontaneous lusty cry (if applicable), moving all extremities strongly and equally, FHR 150s (or whatever number i get as soon as I check) with regular rhythm. To radiant warmer for assessment." Our newborn admission form has separate areas from the small narrative box to chart medications, apgars and a thorough assessment. All of the placenta charting is done on mom's labor and delivery form. We also chart mom's BP right after baby is delivered and then again a couple minutes after the placenta delivers.
    katm0 likes this.
  4. 0
    We chart by exception. So we don't chart any of that. The OB would chart what you wrote in their delivery note, but the RN wouldn't.

    "Placenta delivered intact" is how I would word it (and have, at other facilities where the nurse actually has to chart words).
  5. 0
    Quote from klone
    We chart by exception. So we don't chart any of that. The OB would chart what you wrote in their delivery note, but the RN wouldn't.

    "Placenta delivered intact" is how I would word it (and have, at other facilities where the nurse actually has to chart words).
    We chart in the computer and also by exception.
  6. 0
    What you chart is what I would chart on baby at delivery. If I was labor nurse, I would chart SVD viable male/female over intact peri or <insert perineal disaster here>, placenta delivery, any complications or out of the ordinary events such as vacuum or forceps, repair/suture, any local anesthesia, removal of epidural cathether, skin to skin action after delivery.
  7. 1
    Have you been getting flack for charting too much?

    If so, and since you seem uncomfortable with such minimalist charting, maybe you can meet them halfway. Or perhaps suggest a flowsheet of some sort that would involve all you would like to chart, but not have the narrative form. I do think that if all that information is in the MD's delivery notes it is redundant to chart it all again in your notes. Then again, what are nursing notes if not completely redundant most of the time....

    If no one is saying anything about your charting, and you have just noticed that others chart much less, then just keep doing what you are doing. Who cares what others are doing? You are uncomfortable with the minimalist charting, they don't mind your narrative. Just do what you want.
    DrJamesSmeltzerMFM likes this.
  8. 0
    I feel like you can never include "too much" detail. We all know OB is the most sued specialty in medicine and it is your license to protect!
  9. 0
    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
  10. 1
    And at my facility we use OB TraceVue to chart, which makes you pick-list everything in great detail anyway.
    Alikatz likes this.

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