Name of patient: JB Age:31 Sex: Female Civil Status: Married Religion: Roman Catholic Address: Mangatarem, Pangasinan Operation Proposed: NSD Working Diagnosis: PU 40 wks AOG, G5P4 (5,0,0,4) Type of Anesthesia: SAB Position: knee chest History of Present Illness: Prior to admission, the patient was in: - PU 40 wks AOG, G5P4 (5,0,0,4) - Pregnancy uterine delivered by NSD 2° to a live baby boy out G5P5 (2,0,0,2) Pathology: There was a sexual intercourse done by the married couple. Soon after, there was the union of egg cell & sperm cell. Then, fertilization takes place in the woman’s uterus, and then a fetus developed for 9 months. After 40 wks of pregnancy, the mother gave birth to a live baby boy Brief Discussion of Proposed Operation: 12:20 am: Brought to O.R. a 31 year old female, per stretcher, with D5LRS at 500 cc level, scheduled for NSD by Dr. Espinosa, placed at O.R. table in supine position, repositioned to knee-chest position, SAB inducted by Dr. Ordona, and skin preparation done. Draped properly, IFC inserted aseptically, connected to urine bag. Initial count of sponges, needles, and instruments done. 12:46 am: operation started by Dr. Espinosa, RMLE done. 12: 52 am: a live baby boy out 12:53 am: placenta out completely. Suturing started. 01:34 am: operation ended, Betadine swabbed. Finally, then brought to PACU per stretcher with D5LRS at 500 cc level, for further care and management. UNIVERSITY OF THE CORDILLERAS COLLEGE OF NURSING Gov. Pack Road, Baguio City