L&D Unit Post Conference Report

Slide 1 of 1

L & D Unit Post Conference Report Form (Don’t forget your prepsheet) Student Name _____________________ Unit________ Patient Initials _________Pt’s Date of admission: __________ GTPAL ________________ Maternal Age_______ Marital status _____ Ethnicity _________ Allergies_________ Clinical Date _____________________ Current Chief Complaint (Why are they in hospital)______________________________________ Reason for Admission: _________________________________________ (IE: SROM, Labor, Scheduled Induction etc) LNMP__________ EDC___________ EGA __________ Current Diet: _________________________ MOB Blood type /Rh ____ Infant Blood type/Rh _____ Rubella _____ HIV _____HBsAG ____ GBS ____ VDRL____ STDs______ HCT/HGB _______ OB HX ______________________________ Medical History ___________________________ Pain Management ______________________ (Including this pregnancy) (If pertinent) FOB Involved? __________ Support System: __________________ Hx Drugs/ETOH/Smoking _____________ CPS Involvement ? _____________ Delivery Summary AROM / SROM Date/ Time: _______ FHTs: ________ Clear / Malodorous / Meconium: Thin /Mod/Thick Date/Time of Delivery: ________________________ SEX: _________________ Type NSVD / C-Section Assist If C/S Forceps / Vacuum Reason:_____________ Episiotomy: None midline Mediolateral Laceration: None 1o 2o 3o 4o Perineal / Labial (bilateral) / Periurethral / Cervical Infant Vital Signs: Temp ______ Other: _________________________________ Apgar Score (Each parameter 0. 1 or 2) 1 min ——–5 min ______ Resuscitation: HR ______ Resp _____ B/P ____ HR 0 1 2 0 1 2 Resp 0 1 2 0 1 2 Tone 0 1 2 0 1 2 Reflex 0 1 2 0 1 2 Color 0 1 2 0 1 2 Position and Presentation OA Vertex: ROA / ROT / ROP / LOA / LOT / LOP Breech: Complete / Frank / Footling / Shoulder Cord Characteristics # of Vessels _________ Nuchal Cord x _______ Birth Weight: Gms ______ lbs _____oz _____ SGA / AGA / LGA Infant to Nurs/NICU/ PP unit with mom Other Contributing Medical Issues: Other Concerns: Pitocin: Hemabate: Post Delivery Medications Methergine: Cytotec: Number of days Old ___________ Infant Medications Erythromycin Date/Time: ________ Hepatitis B Date/Time: ____________ Other? ________________________________ Vitamin K Date/Time: ________ EBL: In Recovery Room: Breastfeeding ______ min Bottle feeding _____ oz QBL: Concerns during Labor/Delivery: L&D Assessment (Complete L&D Flowsheet at least 5-6 entries) L&D Unit Post Conference Report

Major Focus/ Concern: L&D/Delivery Complications? Maternal fever / Nonreassuring FHR Nursing action for focus/concern: Other: _______________ __________________ Birth Trauma: EFM: External / Internal SVD / C/S Reason for C/S: _________________ Forceps Assist / Vacuum Extraction L&D Assessment (Complete L&D Flowsheet at least 5-6 entries) See L&D Flowsheet for Vital Signs: Yes / No Systems Assessment: Cardiovascular: Regular rate/rhythm / Murmur / Pedal Pulse / Radial Pulse Cap Refill ________ Resp: Rm Air / O2 ___ L/min Breath Sounds: _______________ WOB:_______________ Breasts: Soft, Non-tender / Filling / Firm Abdomen: Soft / Non-Tender / Firm / Distended GI: Bowel Sounds: Active X4 quad Last B/M ____________ Date/time last food___________ Last Oral intake _____________ GU: Voiding ________ Bladder distention _____________ Foley _________ Placed: ________ Color: ______________ Breastfeeding/Skin to Skin in delivery room? Issues? Iv Fluids: Type GBS Status? (+) / (-) Treated? Med/Dose _________________ Total # doses________________________________ Education Topics : Be SPECIFIC – not just the topic Minimum of 5 Bonding Behaviors/Concerns: _________________________________________________ 2. ________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 3. __________________________________________________________________________ __________________________________________________________________________ 4. _________________________________________________ Any Other Concern not listed? ______________________ __________________________________________________________________________ __________________________________________________________________________ / L&D Unit Post Conference Report

Unable to control due to epidural Time of Epidural Placement: _______________ Assessment Treatments Legs: Pedal Pulses __________ DTR’s _____________ Movement: Normal Site Other: Medications (Type, Dose etc) 1. Sensation Normal / Numb due to epidural Rate __________________________________________________________________________ __________________________________________________________________________ 5. __________________________________________________________________________ __________________________________________________________________________ Labor and Delivery Flowsheet Time (at least q 1 hour) VS Temp RR HR BP FHR Assessment Baseline Variability (1)* Periodic changes (2)** Reassuring or Nonreassuring (Category) Contraction Pattern Assessment (3)*** Frequency Duration Intensity KEY *(1) V=Variability; Abs=absent; M=minimal, Mo= moderate, Ma= marked **(2) A=acceleration; E=early decelerations; L=late decelerations V=variable decelerations ***(3) Mi=mild; Mo=moderate; F=firm Delivery Summary Time Sex Weight Length Anesthesia Episiotomy/Lacerations Recovery Record: Look up Appropriate Recovery V/S Frequency Times VS Temp BP HR RR DTR’s Fundal Height & Position Lochia/Perineum Delivery Type ___________ APGARS____/____ Infant to NBN or NICU? EBL Electronic Fetal Monitoring And L&D Assessment Passed _____ Fail _____ Student Name______________________________ Attempt______ Clinical Instructor__________________ Goal: Student will be able to clearly state essential elements needed to assess an electronic fetal monitoring strip. Student will be able to accurately document the assessment of an L&D patient. Critical Elements YES 1. Able to verbalize how many minutes needed to determine a baseline fetal heart rate on Electronic fetal monitoring. Able to define a change in baseline. 2. Able to state normal range for fetal heart rate 3. Able to describe Accelerations 4. Able to describe the different type of decelerations and interventions needed if necessary. Early, Variable, Late 5. Able to clearly state the difference between variability and variable. 6. Able to accurately describe the categories of variability and specify what each indicates. 7. Able clearly define the measures to calculate duration of a contraction. 8. Able to clearly define the criteria to calculate the frequency of a contraction. 9. Able to accurately describe the nursing interventions for minimal/ absent variability, early/late/variable decelerations and accelerations. Created S Buckler 3/17; Rev 4/21 bkh NO COMMENTS