Amelia Sung Complex VSIM Documentation

Meisha Thompson
Maternity VSIM Documentation

April 9, 2023
Maternity Case 6: Amelia Sung (Complex)

Documentation Assignments
1. Document the fetal status and the progression of Amelia Sung’s labor from
the time you took over care until delivery.
Answer: Upon arrival patient was identified and hands were washed and she was
assessed for allergies. Patient’s vitals, IV, heart and lung sounds were assessed.
Heart sounds were clear of murmurs and lung sounds were clear and equal
bilaterally.
At 0242 The patients heart rate was 102 beats per minute, pulse present at 95
beats per minute, blood pressure 142/81 mm/hg, respiration 18, conscious state
appropriate, SpO2 98%, temperature 98.6F (37.0C), and EFM had occasional
accelerations and fetal heart rate 121 beats per minute.
At 0317 the baby’s head was crowning, patient encourage to push when she feels
contractions.
Delivery table, bassinet and step stool was prepared.
At 0636 the baby’s head was delivered and turtling was noted.
At 0644 The patients heart rate was 105 beats per minute, pulse present, blood
pressure 143/82 mm/hg, respiration 21 beats per minute, conscious state
appropriate, SpO2 98%, temperature 98.6F (37.0C), and EFM had early
deceleration and fetal heart rate dropped to 98 beats per minute.
At 0709 oxytocin infusion was stopped, Bolus LR open wide was given at 500ml and
non- rebreather mask given.
0806 The NICU, and charge nurse was called.
0827 Patient was provided education and was then assisted in McRoberts position
as ordered by physician. The order was also given to apply suprapubic pressure on
the left, which was done.
pressure 140/80 mm/hg, respiration 21, conscious state appropriate, SpO2 98%,
temperature 98.6F (37.0C), and EFM baseline and fetal heart rate 90 beats per
minute.
From vSim for Nursing | Maternity. © Wolters Kluwer Health.

Meisha Thompson
April 9, 2023
Patient was again encouraged to push upon when she felt a contraction. Provider
ordered to apply suprapubic pressure on the left side.
At 0958 the baby’s shoulders were delivered.
1013 The baby was delivered.
1024 The baby was handed to mother.
2. Document the essential events related to the time of birth, including all
activities and interventions from the time of crowning until delivery of the
fetus.
Answer: At 0317 the baby’s head was crowning.
Delivery table, bassinet and step stool was prepared.
At 0636 the baby’s head was delivered and turtling was noted.
pressure 143/82 mm/hg, respiration 21 beats per minute, conscious state
appropriate, SpO2 98%, temperature 98.6F (37.0C), and EFM had early
deceleration and fetal heart rate dropped to 98 beats per minute.
At 0709 oxytocin infusion was stopped, Bolus LR open wide was given at 500ml and
non- rebreather mask given.
0806 The NICU, and charge nurse was called.
0827 Patient was provided education and was then assisted in McRoberts position
as ordered by physician. The order was also given to apply suprapubic pressure on
the left, which was done.
pressure 140/80 mm/hg, respiration 21, conscious state appropriate, SpO2 98%,
temperature 98.6F (37.0C), and EFM baseline and fetal heart rate 90 beats per
minute.
Patient was again encouraged to push upon when she felt a contraction. Provider
ordered to apply suprapubic pressure on the left side.
At 0958 the baby’s shoulders were delivered.
1013 The baby was delivered.

Meisha Thompson
April 9, 2023
1024 The baby was handed to mother.
3. Document the application of suprapubic pressure and maternal positioning.

Include the response and outcomes.
Answer: I applied suprapubic pressure as indicated for the possibility of shoulder

dystocia. Firm pressure was applied to the left side and the shoulders were freed
and completion of delivery followed. The NICU and charge nurse was notified. I
made a fist and positioned it over the mother’s pubic bone in attempts to release
the baby’s shoulder.
4. Document your communications with the neonatal intensive care unit (NICU)
about the impending birth.
Answer: The NICU was advised that Ms. Sung is currently in labor, she has begun
pushing and head was delivered. The turtle sign was noted by the physician and
shoulder dystocia is a possibility. McRoberts position has been implemented and
fetal HR is currently 98 beats per minute.. NICU needs to be prepared for possible
neonatal asphyxiation, injury, and resuscitation.

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Meisha Thompson

Maternity VSIM Documentation

Maternity Case 6: Amelia Sung (Complex)

Delivery table, bassinet and step stool was prepared.

0806 The NICU, and charge nurse was called.

From vSim for Nursing | Maternity. © Wolters Kluwer Health.

At 0958 the baby’s shoulders were delivered.

1013 The baby was delivered.

1024 The baby was handed to mother.

Answer: At 0317 the baby’s head was crowning.

Delivery table, bassinet and step stool was prepared.

0806 The NICU, and charge nurse was called.

At 0958 the baby’s shoulders were delivered.

1013 The baby was delivered.

From vSim for Nursing | Maternity. © Wolters Kluwer Health.

3. Document the application of suprapubic pressure and maternal positioning.

Answer: I applied suprapubic pressure as indicated for the possibility of shoulder

From vSim for Nursing | Maternity. © Wolters Kluwer Health.

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