Gambler Sir Rena Ava 10880256

December 11 2024
SIRRENA AVA GAMBLER

Box 83
WABASCA, Alberta T0G 2K0
Dear SIRRENA AVA GAMBLER,
Re: Sirrena Ava Gambler

Release ID: 10880256
Records from: Royal Alexandra Hospital
Thank you for contacting Alberta Health Services. This letter is in response to your request received on
11/12/2024 (DD/MM/YYYY).
Enclosed is the information available at the time of processing.
Fees are being waived due to financial hardship. Please be aware that should additional information be
requested, fees may apply.
If you have questions, please contact us at 780-735-4230 .
Sincerely,
Jonelle Sandahan
Access & Disclosure
Health Information Management
Royal Alexandra Hospital
10240 Kingsway Avenue, Edmonton, Alberta T5H 3V9
P:780-735-4230 F:780-735-4048
Alberta Health Services
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EDM Royal Alexandra Hospital Gambler, Sirrena Ava
10240 Kingsway Avenue MRN: 3050121569, DOB: 04/03/2002, Sex: F
Edmonton AB T5H 3V9
Patient
Confirmation of Stay
Date Type Location Department Provider
07/07/2024 - 11/07/2024 Admission Royal Alexandra EDM RAH LH 2E Wang, Jingwei, MD
(Discharged) Hospital POSTPARTUM
Printed on 11/12/2024 10:14 Page 1

Edmonton AB T5H 3V9 Adm: 07/07/2024, D/C: 11/07/2024
07/07/2024 - Admission (Discharged) in EDM RAH LH 2E POSTPARTUM
Reason for Visit
Chief complaint: Contractions
Hospital problem: Active labor
Visit Information
Admission Information
Arrival Date/Time: 07/07/2024 14:45 Admit Date/Time: 07/07/2024 14:45 IP Adm. Date/Time: 07/07/2024 16:55
Admission Type: Direct Point of Origin: Non-healthcare Admit Category: Scheduled/elective
Facility
Means of Arrival: Ground Ambulance Primary Service: Obstetrics Secondary Service: N/A
Transfer Source: Service Area: AHS CONNECT Unit: EDM RAH LH 2E
CARE SERVICE POSTPARTUM
AREA
Admit Provider: Wang, Jingwei, MD Attending Provider: Tankel, Jonathan, Referring Provider:
MD
Discharge Information
Date/Time: 11/07/2024 11:45 Disposition: Home Destination: Home
Provider: Tankel, Jonathan, MD Unit: EDM RAH LH 2E POSTPARTUM
Discharge Summary
Discharge Summary by Onyeowuzoni, Okwuchukwu, MD at 08/07/2024 07:35
Author: Onyeowuzoni, Okwuchukwu, MD Service: Obstetrics Author Type: Associate Physician
Filed: 11/07/2024 10:31 Date of Service: 08/07/2024 07:35 Status: Cosign Needed
Editor: Onyeowuzoni, Okwuchukwu, MD (Associate Physician) Cosign Required: Yes
Cosigner: Tankel, Jonathan, MD
Obstetrical Discharge Summary
Admission Date: 07/07/2024
Discharge Date: 11/07/2024
Most Responsible Diagnosis:

Preterm Gestation
Spontaneous rupture of membranes
Spontaneous labor
Spontaneous Vaginal Delivery
Delivery Notes:
Delivery Type: Vaginal, Spontaneous
Anesthesia: None
Baby:
Time of delivery: 06:38
Birth Weight: 2.34 kg
Patient's Course in Hospital:

Sirrena Ava Gambler was admitted to the hospital on 07/07/2024 with Term Gestation
Spontaneous Labour.
She was admitted to the L&D ward in labour. She required oxytocin to augment her labour. She progressed well
Printed on 11/12/2024 10:14 Page 2
07/07/2024 - Admission (Discharged) in EDM RAH LH 2E POSTPARTUM (continued)
Discharge Summary (continued)
through labour and went on to deliver a live baby girl vaginally. Her delivery was complicated by a 2nd degree tear
that was repaired.
Post-partum course:
The patient's post-partum course was uncomplicated. Her pain has been well-controlled with the medications
ordered.
Plan For Discharge:

The patient is discharged today. She has been instructed to book a post-partum visit will be seen in follow-up in clinic
in 6 weeks time and was given instructions as to when to return to hospital if she were to experience increased vaginal
bleeding, signs or symptoms of infection or VTE.
Electronically signed by Onyeowuzoni, Okwuchukwu, MD at 11/07/2024 10:31
H&P Notes
H&P by Elloumi, Yesmine, MD at 07/07/2024 18:35
Author: Elloumi, Yesmine, MD Service: Obstetrics Author Type: Resident
Filed: 07/07/2024 18:41 Date of Service: 07/07/2024 18:35 Status: Signed
Editor: Elloumi, Yesmine, MD (Resident) Cosigner: Wang, Jingwei, MD at
07/07/2024 19:41
OBSTETRICS HISTORY
ID: 22 y.o. G1P0 at 35w4d presenting with labor assess
GBS unknown
Rh positive
EDD: Estimated Date of Delivery: 07/08/2024
HPI:
Contracting 2 in 10 minutes
SROM 1200
No vaginal bleeding
Feeling fetal movements
Uncomplicated pregnancy
Past Obstetrical History:

Primip
Medical History:
No past medical history on file.
Patient Active Problem List
Diagnosis
• Active labor
Past Surgical History:

No past surgical history on file.
Medications:
No current outpatient medications
Printed on 11/12/2024 10:14 Page 3

H&P Notes (continued)
Allergies:
Patient has no known allergies.
Physical Examination:
Vitals:
07/07/2024 18:06
BP: 131/87
Pulse: 67
Temp:
FHR: baseline 125 bpm, with accelerations, no decelerations, moderate variability

Vaginal Exam: cervix 2 cm dilated
Investigations:
Labs:
Lab Results
Component Value Date
HGB 134 07/07/2024
WBC 8.1 07/07/2024
PLT 231 07/07/2024
ALT 16 07/07/2024
Most Recent Ultrasound:

July 3, 2024
(2.3kg) EFW 30%, anterior and not previa, AFV normal, anatomy normal, cephalic, BPP 8/8
IMPRESSION & PLAN:

Admission to caseroom
ROM at 12:00
Ctx 2/10
Cervix 2cm dilated, 1-2 cm thick
Uncompliated pregnancy
Elevated BP - PEC labs, not needing treatment
Pen G
Yesmine Elloumi, MD PGY2

On behalf of Dr. Wang
Obstetrics & Gynecology
Electronically signed by Elloumi, Yesmine, MD at 07/07/2024 18:41

Electronically signed by Wang, Jingwei, MD at 07/07/2024 19:41
Clinical Notes (group 1 of 2)

Consent Note
Watt, Kerry M, RSW at 09/07/2024 10:11
Author: Watt, Kerry M, RSW Service: — Author Type: Social Worker
Editor: Watt, Kerry M, RSW (Social Worker)
Royal Alexandra Hospital • Social Work
Printed on 11/12/2024 10:14 Page 4

Clinical Notes (group 1 of 2) (continued)
Consent to Social Work Assessment and Intervention
Date: 09/07/2024
Writer met with patient at bedside, provided overview of role of Social Work in inpatient acute care context and
explained limitations of privacy and disclosure. Patient made aware consent can be revoked at any time upon their
request. Writer obtained verbal consent to proceed with psychosocial support and intervention during current
inpatient admission to hospital.
Kerry Watt BA BSW RSW

Social Work
Electronically signed by Watt, Kerry M, RSW at 09/07/2024 10:11
Consults
Consult Orders
1. Inpatient Consult to Social Work [1163518761] ordered by Tankel, Jonathan, MD at 09/07/2024 08:28
Writer attended bedside and met with Pt and her partner Tommy Yellowknee (2002-03-22). Writer explained the role
of SW in the hospital. Pt and Tommy were noted to be providing appropriate care to baby, with Pt changing Baby's
diaper. Tommy was able to document baby's bowel movement.
Tommy was able to confirm the address where the family will be staying, 11711-101 Street, Unit 5.
Tommy advised that he is not currently working however would like to go back to firefighting as soon as possible.
Tommy advised that while they couple was not planning for a baby, they are excited. Tommy stated that he does not
want to be absent in baby's life as was his father. Tommy and Pt were both coming back and forth from Wabasca and
staying with family prior to coming to Edmonton.
Tommy stated there has been no issues with domestic violence and was open to SW suggestions around taking a
break, walking away to cool down and utilizing family members.
Writer and Tommy spoke about substance abuse, where Tommy confirmed no use for PT, stating that she had never
really used anything. Tommy stated that he has been struggling with alcohol and occasional cocaine use, however not
in the family home. Tommy did not feel he needed any resources for addiction at this time as he was motivated to stay
clean. PT last used cocaine approximately 1.5 weeks ago. Alcohol use has been more regular for the past three months.
Writer advised both parents that there needs to be a sober caregiver at all times for baby, no exceptions. Both parents
were in agreement with this plan. Tommy advised that he has relatives that can babysit as needed as well as his sister.
Tommy stated that his sister only drinks on occasion and does not allow any drug use in her home.
Writer agreed to continue to follow and provide supports around Alberta Works Applications, resources etc.
Printed on 11/12/2024 10:14 Page 5
Both parents were agreeable to Healthy Beginnings.

Social Work
Handover Note
MacDonald, Julia, RN at 08/07/2024 07:14
Author: MacDonald, Julia, RN Service: Nursing Author Type: Registered Nurse
Editor: MacDonald, Julia, RN (Registered Nurse)
Handover Note: from 4E to 2E
Report given to: 2E nurse
G1P0101 at 35w5d
GBS: negative Blood Type: A Positive
Allergies: Patient has no known allergies.
Past medical history/ Risk factors:

(Mom)
Patient Active Problem List
Diagnosis
• Active labor
Maternal Recent Asssessments:

Vital Signs: Visit Vitals
BP 135/70
Pulse 73
Temp 36.9 °C (Axillary)
LDA's:
Peripheral IV 07/07/2024 Right;Dorsal Hand (Active)
Number of days: 1
I/O:
Intake/Output Summary (Last 24 hours) at 08/07/2024 07:20
Last data filed at 08/07/2024 07:12
Gross per 24 hour
Intake —
Output 5 ml
Net -5 ml
Printed on 11/12/2024 10:14 Page 6

Recent Medications: oxytocin 3 mu IV push, oxytocin 20 mu infusion 125 mL/hr post partum, lactated ringers
infusion
Postpartum:
Delivery Date and Time: 08/07/2024 06:38
Type: Vaginal, Spontaneous
COMPLICATIONS: none
Episiotomy: None
Tears: 2nd
QBL: Delivery Blood Loss 07/07/2024 16:30 - 08/07/2024 07:20
Lochia weight (g) Hospital Encounter 5 grams
Total 5 mL
Upcoming Tasks: fundal checks, baby vitals
Documentation Completed:
PNOB: Yes
Delivery Summary: Yes
Patient Stability:
Stable- Low risk of patient condition declining or worsening
Electronically signed by MacDonald, Julia, RN at 08/07/2024 08:29
Wyrostok, Katherine Ruth, RN at 08/07/2024 23:06

Author: Wyrostok, Katherine Ruth, RN Service: Nursing Author Type: Registered Nurse
Editor: Wyrostok, Katherine Ruth, RN (Registered Nurse)
MOM
Vitals & Oxygen:

08/07/2024 20:45
BP: 124/76
Pulse: 72
Temp: 36.4 °C
Resp: 18
SpO2: 99%
History:
Type of Del: 08/07/2024 06:38
Blood Loss: 70 mL
Epidural/spinal/General: none
Lacerations: 2nd degree
Dressing: none
Printed on 11/12/2024 10:14 Page 7

Diet: DAT
Mobility: AAT
Fundus: firm midline U/1
Flow: small rubra
IV: d/c'd
Foley or Voiding: voiding
PRN meds:
PNOB initiated:
What to watch for:
Electronically signed by Wyrostok, Katherine Ruth, RN at 08/07/2024 23:07
Adigun, Oyinlade Dorcas, RN at 09/07/2024 06:39

Author: Adigun, Oyinlade Dorcas, RN Service: Nursing Author Type: Registered Nurse
Editor: Adigun, Oyinlade Dorcas, RN (Registered Nurse)
MOM
Vitals & Oxygen:

09/07/2024 05:40
BP: (!) 134/93
Pulse: 65
Temp: 36.1 °C
Resp:
SpO2: 100%
History:
Type of Del: 08/07/2024 06:38
Blood Loss:70
Epidural/spinal/General:
Lacerations:2nd degree
Dressing:
Diet:DAT
Mobility:UP AD LIB
Fundus:WDL
Flow:WDL
IV:
Foley or Voiding:Voiding
PRN meds: none
Printed on 11/12/2024 10:14 Page 8
PNOB initiated:
What to watch for:
Electronically signed by Adigun, Oyinlade Dorcas, RN at 09/07/2024 06:40
Poier, Jennifer Laura, LPN at 09/07/2024 14:06

Author: Poier, Jennifer Laura, LPN Service: — Author Type: Licensed Practical Nurse
Editor: Poier, Jennifer Laura, LPN (Licensed Practical Nurse)
HANDOVER NOTE
Recent changes: None.
Anticipated changes:
What to watch out for: Increased BP's
Stability of the patient: Stable- Low risk of patient condition declining or worsening
Summary: MOM
Vitals & Oxygen:

09/07/2024 11:44
BP: 130/85
Pulse: 86
Temp: 36.3 °C
Resp: 18
SpO2: 96%
History:
Type of Del: 08/07/2024 06:38
Blood Loss: 70 mls
Lacerations: 2nd degree tear
Dressing:
Diet:DAT
Mobility:Up & Lib
Fundus:Firm U/2
Printed on 11/12/2024 10:14 Page 9

Flow: small rubra

IV:
Foley or Voiding: Voiding
PRN meds:
PNOB initiated:
What to watch for:
Electronically signed by Poier, Jennifer Laura, LPN at 09/07/2024 14:13
Wyrostok, Katherine Ruth, RN at 09/07/2024 21:54

Author: Wyrostok, Katherine Ruth, RN Service: Nursing Author Type: Registered Nurse
Editor: Wyrostok, Katherine Ruth, RN (Registered Nurse)
MOM
Vitals & Oxygen:

09/07/2024 20:40
BP: 131/89
Pulse: 60
Temp: 36.4 °C
Resp: 18
SpO2: 98%
History:
Type of Del: 08/07/2024 06:38
Blood Loss: 70 mL
Epidural/spinal/General: none
Lacerations: second degree
Dressing: none
Diet: DAT
Mobility: AAT
Fundus: firm midline U/2
Flow: small rubra
IV: none
Foley or Voiding: voiding
PRN meds:
PNOB initiated:
What to watch for: needs encouragement to feed baby Q3H and to pump
Printed on 11/12/2024 10:14 Page 10

Electronically signed by Wyrostok, Katherine Ruth, RN at 09/07/2024 21:55

MOM
Vitals & Oxygen:

10/07/2024 05:50
BP: 126/82
Pulse: 62
Temp: 36.4 °C
Resp: 18
SpO2: 97%
History:
Type of Del: 08/07/2024 06:38
Blood Loss:70ml
Dressing:
Diet:DAT
Mobility:UP AD LIB
Fundus:WDL
Flow:WDL
IV:
PRN meds: none
PNOB initiated:
What to watch for:
Yorke, Jessica Kathryn Solbritt, LPN at 10/07/2024 14:34

Author: Yorke, Jessica Kathryn Solbritt, Service: — Author Type: Licensed Practical Nurse
LPN
Filed: 10/07/2024 14:34 Date of Service: 10/07/2024 14:34 Status: Addendum
Editor: Yorke, Jessica Kathryn Solbritt, LPN (Licensed Practical Nurse)
Printed on 11/12/2024 10:14 Page 11

MOM
Vitals & Oxygen:

10/07/2024 08:16
BP: 133/81
Pulse: 58
Temp:
Resp: 18
SpO2: 97%
History:
Type of Del: 08/07/2024 06:38
Blood Loss:70ml
Diet:DAT
Mobility:UP AD LIB
Fundus:WDL
Flow:WDL
IV: none
PRN meds: none
PNOB initiated:
What to watch for:
BP 133/81, 124/77
Electronically signed by Yorke, Jessica Kathryn Solbritt, LPN at 10/07/2024 14:34
Poier, Jennifer Laura, LPN at 10/07/2024 22:10

Author: Poier, Jennifer Laura, LPN Service: — Author Type: Licensed Practical Nurse
Editor: Poier, Jennifer Laura, LPN (Licensed Practical Nurse)
HANDOVER NOTE
Recent changes: Milk came in and she is pumping lots.
Anticipated changes:
What to watch out for: Increased BP
Stability of the patient: Stable- Low risk of patient condition declining or worsening
Summary: MOM
Printed on 11/12/2024 10:14 Page 12

Vitals & Oxygen:

10/07/2024 19:45
BP: 120/72
Pulse: 70
Temp: 36.5 °C
Resp: 17
SpO2: 96%
History:
Type of Del: 08/07/2024 06:38
Blood Loss:70mls
Lacerations: 2 nd degree tear repaired.
Dressing:
Diet:DAT
Mobility:UP & Lib
Fundus: firm u/2
Flow:small to scant dark rubra.
IV:No
PRN meds:
PNOB initiated:
What to watch for:
Mom needs reminders to feed baby and top her up with EBM & not let her cry for long lengths of time.
Electronically signed by Poier, Jennifer Laura, LPN at 10/07/2024 22:13

MOM
Vitals & Oxygen:

11/07/2024 04:00
BP: 131/82
Printed on 11/12/2024 10:14 Page 13

Pulse: 65
Temp: 36.4 °C
Resp: 20
SpO2: 95%
History:
Type of Del: 08/07/2024 06:38
Blood Loss:70ml
Dressing:
Diet:DAT
Mobility:UP AD LIB
Fundus:WDL
Flow:WDL
IV:
PRN meds: none
PNOB initiated:
What to watch for:
L&D Delivery Note

Dhaliwal, Rupinder Kaur, MD at 08/07/2024 06:56
Author: Dhaliwal, Rupinder Kaur, MD Service: Obstetrics Author Type: Physician
Editor: Dhaliwal, Rupinder Kaur, MD (Physician)
Delivery Note - Spontaneous Vaginal Delivery
Date of Delivery: 08/07/2024

Time of Delivery: 06:38
Gestational Age: G1P0 at 35w5d
Delivery Type: Vaginal, Spontaneous
Placenta: spontaneous, intact with 3VC. sent to pathology
Vaginal Tear: Vaginal Laceration - 2nd degree tear
EBL: average
Printed on 11/12/2024 10:14 Page 14
Baby
Gender: female
Weight: 2.34 kg
MD paged for delivery and patient had delivered fetus after one push.
Following the infant's delivery the cord was clamped and cut after 60 seconds of delayed cord camping.
The placenta spontaneous, intact, with a 3VC.
2nd degree - repaired with 2-0 vicryl
Patient was stable in early postpartum period. Events of the labour & delivery discussed with patient and questions
answered.
Complications: None
Yesmine Elloumi OBR2

On behalf of Dr. Dhaliwal
OBGYN
08/07/2024
Sirrena Ava Gambler
22 y.o.
Gambler, Sirrena'sGirl [3096171305]
Labour Events
Preterm labour?: Yes
Antenatal steroids: None
Antibiotics received during labour?: Yes
Rupture date/time: 07/07/2024 13:00
Rupture type: Spontaneous
Fluid color: Clear
Augmentation: Oxytocin
Augmentation date/time: 08/07/2024 00:48
Indications for augmentation: Ineffective Contraction Pattern
Labour Event Times
Labour onset date/time: 16:30

07/07/2024
Dilation complete date/time: 06:36 MDT

08/07/2024
Anesthesia
Method: None
Printed on 11/12/2024 10:14 Page 15

Operative Delivery
Forceps attempted?: No
Vacuum extractor attempted?: No
Shoulder Dystocia
Shoulder dystocia present?: No
Presentation
Presentation: Vertex
Newborn Delivery
Birth date/time: 08/07/2024 06:38
Delivery type: Vaginal, Spontaneous
Water birth?: No
Delivery Providers
Delivering clinician: Dhaliwal, Rupinder Kaur, MD
Provider Role
Elloumi, Yesmine, MD Delivery Assist
McDonald, Olivia Grace Neufeld, RN Delivery Nurse
Bieraugle, Paige Alexandra, RN Delivery Nurse
Reason Resuscitation Team Called: Prematurity (GA <37 weeks)
Cord
Vessels: 3 vessels
Cord clamped >60 secs post delivery?: Yes
Cord clamped date/time: 08/07/2024 06:39
Gases sent?: Yes
Stem cell collection (by provider)?: No
Placenta
Placenta delivery date/time: 08/07/2024 06:45
Placenta removal: Spontaneous
Placenta appearance: Intact
Placenta disposition: pathology
Resuscitation
Initial Response: Warm, dry, stimulate
Apgars
Living status: Living
Apgar Component 1 min.: 5 min.: 10 min.: 15 min.: 20 min.:
Scores:
Skin color:
Heart rate:
Reflex irritability:
Muscle tone:
Printed on 11/12/2024 10:14 Page 16
Respiratory effort:
Total:
Skin to Skin
Skin to skin initiation date/time: 08/07/2024 06:48
Skin to skin with: Mother
Breastfeeding?: Yes
Measurements
Weight: 2340 g Weight (Imperial): 5 lb 2.5 oz
Fenton birth weight percentile (%): 32.35

Length:
Lacerations
Episiotomy: None
Perineal laceration: 2nd Repaired?: Yes
Other lacerations: no non-perineal laceration
Repair suture: 2-0 Synthetic Suture
Vaginal Counts
Initial count personnel: O. MCDONALD RN
4x4: Needles: Instrument Lap Pads: Sponges: FSE: Other:
s:
Initial counts: 2 CORD
GASES (4
PARTS); 1
HYPODER
MIC
NEEDLE (2
PARTS)
Items Added/Removed: 3 2 CORD
GASES (4
PARTS); 1
HYPODER
MIC
NEEDLE (2
PARTS)
Final counts:
Final count personnel: DR. ELLOUMI

Accurate final count?: Yes
Labour Length
No data filed
Printed on 11/12/2024 10:14 Page 17

Delivery Blood Loss 07/07/2024 16:30 - 08/07/2024 06:56
None
Yesmine Elloumi, MD
Electronically signed by Dhaliwal, Rupinder Kaur, MD at 10/07/2024 19:22
Lactation Note
Rathwell, Samantha Nicole, RN at 11/07/2024 09:54
Author: Rathwell, Samantha Nicole, RN Service: Lactation Author Type: Registered Nurse
Editor: Rathwell, Samantha Nicole, RN (Registered Nurse)
Initial lactation consult with mom of late preterm infant. Writer met with mom in postpartum room, introduced self,
role, reason for visit.
Infant age at visit: 75 hours old

Feeding Goals: breast and bottle feed expressed breast milk
Pertinent Maternal 22 years old, G1 L1, SVD
and Birth History:
Current Feeding: bottle feeding expressed breast milk, occasionally putting infant
to breast
Reason for Consult: late preterm infant
Assessment & Writer spoke with Sirrena at infant's bedside. Sirrena reports that
Teaching: infant is bottle feeding well, starting to latch to breast
occasionally, and she has no questions regarding feeding.
Declined offer for support with breastfeeding, encouraged to
reach out to bedside nurses or lactation team if she changes her
mind. She stated that she has learned breastfeeding tips from
her mom as she watched her mom breastfeed her siblings, she
has also been currently speaking to her mom for support.
Writer discussed pumping, currently Sirrena is pumping about 6

times a day on top of occasionally breastfeeding, getting 60 ml or
more per pump. She reports that the pump is comfortable and
she has no concerns. Discussed flange fit options and Sirrena
stated that she feels 24 mm flange is a good fit. She potentially
has electric pump coverage through her treaty, has received all
necessary information regarding the same from SW, and will be
receiving a hand pump from the public health nurse (Health for
Two Program) to use as soon as she is discharged.
Education:  Global Health Breastfeeding Videos

 Pump comfort, frequency, and duration
 Flange fit
 Pump hygiene
 Paced bottle feeding
Printed on 11/12/2024 10:14 Page 18
 Breast milk storage

 Nipple care
 Breast health monitoring and when to seek help
 Healthy Parents, Healthy Children website
Follow Up: As per public health, lactation community resources sheet
provided.
Follow up with lactation consultant as per request.
Electronically signed by Rathwell, Samantha Nicole, RN at 11/07/2024 10:21
Printed on 11/12/2024 10:14 Page 19

Clinical Notes (group 2 of 2)
Nursing Note
Wu, Yu-Hsiao, RN at 07/07/2024 15:40
Author: Wu, Yu-Hsiao, RN Service: Obstetrics Author Type: Registered Nurse
Filed: 07/07/2024 15:58 Date of Service: 07/07/2024 15:40 Status: Incomplete
Editor: Wu, Yu-Hsiao, RN (Registered Nurse)
Dr. Henry into see patient and reviewed FHR tracing. Sterile speculum exam done by same, Cx 2cm,
Basford, Wyatt, RN at 07/07/2024 16:20

Author: Basford, Wyatt, RN Service: — Author Type: Registered Nurse
Editor: Basford, Wyatt, RN (Registered Nurse)
BP cycling q15 at this time, currently above WDL. Charge nurse Natalie RN made aware of same.
Patient denies headache, visual disturbances, RUQ pain, dizziness or lightheadedness.
Call bell in reach, no voiced concerns.
Electronically signed by Basford, Wyatt, RN at 07/07/2024 16:21
Poon, Susan, RN at 07/07/2024 17:07

Author: Poon, Susan, RN Service: — Author Type: Registered Nurse
Editor: Poon, Susan, RN (Registered Nurse)
Patient contracting 3-4/10, declining morphine and gravol. Blood work and urines sent as per doctors order.
Electronically signed by Poon, Susan, RN at 07/07/2024 17:08

Charge nurse Natalie RN made aware of patients increase in uterine activity and strength. Patient denies vaginal/ rectal
pressure at this time. Denies want for pain medication at this time.
Call bell in reach, no voiced concerns.

Call bell pressed by writer due to low FHR base line, around 103bpm. Patient repositioned for same.
Dr.Elloumi completed cervical exam for 3cm. No cord presenting.
Printed on 11/12/2024 10:14 Page 20

FHR responding to scalp stimulation.
Patient reports re life from pain after morphine administration.
IV bolus in progress.
VSS, see flow sheet for same.
Call bell in reach.

Patient repots moderate relief from contractions since morphine and Gravol.
Contracting 3 in 10, palpating mild with soft resting tone.
CEFM tracing, classifying as normal at this time.
Call bell in reach, support person at bed side. No voiced concerns
Wu, Yu-Hsiao, RN at 07/07/2024 22:54

Author: Wu, Yu-Hsiao, RN Service: Obstetrics Author Type: Registered Nurse
Editor: Wu, Yu-Hsiao, RN (Registered Nurse)
Single prolonged complicated decel noted at 2240 hrs. Writer tried to adjusted ultrasound and repositioned patient
from side to side. Fetal heart rate recovered at 2245 to baseline at 110-115 bpm.
Dr. Elloumi into see patient when decel happened. VE done by same, cx 3cm, unchanged from last exam. Will hold off
IV synto argumentation at the moment. EFM remains on. Charge nurse is aware of same.
Electronically signed by Wu, Yu-Hsiao, RN at 07/07/2024 22:58
McDonald, Olivia Grace Neufeld, RN at 07/07/2024 23:23

Author: McDonald, Olivia Grace Neufeld, Service: Nursing Author Type: Registered Nurse
RN
Editor: McDonald, Olivia Grace Neufeld, RN (Registered Nurse)
Baby Pause completed at 2318 hours by writer & S. M, RN.
Printed on 11/12/2024 10:14 Page 21

The risk factors discussed: preterm labour, PSROM @ 1300 (clear), GBS + (2 doses)
Patient present in discussion.
Fetal heart rate interpreted as abnormal.
Plan of care: start oxytocin once FHR normalized, pain management PRN, anticipate delivery.
Patient brought over from assessment. Patient settled in bed, breathing through contractions. Planning on minimal
interventions for pain. Currently managing well. CEFM applied. Call bell in reach.
Electronically signed by McDonald, Olivia Grace Neufeld, RN at 08/07/2024 00:38

RN
Baby Pause completed at 0129 hours by writer & Brie RN.

The risk factors discussed: Preterm labour, PSROM @ 1300 (clear), GBS ? (2 doses), oxytocin augmentation
Patient not present in discussion.
Fetal heart rate interpreted as normal.
Plan of care: titrate oxytocin as needed, pain management PRN, anticipate delivery.
Patient resting in bed, rouses with contractions. States still managing pain well. Call bell in reach.

RN
GBS resulted and negative, antibiotics discontinued.

RN
Patient requesting morphine and gravol. No order for morphine in MAR. Writer spoke with Dr. Kirkham and Dr
Kirkham ordered morphine.

RN
Printed on 11/12/2024 10:14 Page 22

Patient requesting to get up to void. Writer assisted patient out of bed, patient walked to washroom. Patient spent
extended time on toilet due to stronger contractions, and sat on edge of bed for extended time. CEFM tracing poorly
due to positioning, writer attempted to adjust while also repeatedly asking patient to settle back in bed to trace
properly. Patient settled back into bed eventually and EFM tracing well once back in bed
Shaw, Kyla, RN at 08/07/2024 03:57

Author: Shaw, Kyla, RN Service: Nursing Author Type: Registered Nurse
Editor: Shaw, Kyla, RN (Registered Nurse)
Baby Pause completed at 0330 hours by writer & O.M, RN.

The risk factors discussed: 35 weeks.
Patient present in discussion.
Fetal heart rate interpreted as normal.
Plan of care: Continue Oxytocin, VS.
Received per baby pause. Pt lying in high fowlers with CEFM in situ. Pt breathing well through contractions. Pt
contracting 3-5/10. Pt denies rectal pressure at this time.
Aware to ring with any questions or concerns. Call bell in reach. Partner asleep at bedside.
Electronically signed by Shaw, Kyla, RN at 08/07/2024 04:05

RN
Patient breathing heavily through contractions. Denies rectal pressure but states "lots of pressure in the front". Patient
not checked since 2245. Writer asked patient if she would like the doctors to reassess progress, patient agreeable to
same.

RN
Patient asking if she can have something to eat, writer reinforced clear fluid diet, offered jello or juice, patient declined.
Patient breathing through contractions, Call bell in reach.
Printed on 11/12/2024 10:14 Page 23

RN
Patient reports intermittent rectal pressure. Denies urge to push at this time. States comfortable, does not want any
analgesia at this time.

RN
Baseline difficult to determine but seems to be trending down. Writer attempted to reposition to improve baseline, no
changes. Dr. Kirkham called to check progress and place internal lead for accurate tracing.

RN
Patient called, states feels urge to push. Urge is intermittent, goes away between contractions. Patient breathing well
with contractions, aware to to push until she is fully dilated.
MacDonald, Julia, RN at 08/07/2024 07:13

Author: MacDonald, Julia, RN Service: Nursing Author Type: Registered Nurse
Editor: MacDonald, Julia, RN (Registered Nurse)
Handover report for shift change received at bedside with pt and partner present. Post partum care ongoing. Pt
reports feeling okay with pain at this time. Tolerating fundal checks well. Baby skin to skin. Partner at bedside. Call bell
in reach.
Electronically signed by MacDonald, Julia, RN at 08/07/2024 07:14
Progress Notes
Evans, Jaylene Mackenzie, RN at 07/07/2024 14:55
Author: Evans, Jaylene Mackenzie, RN Service: Nursing Author Type: Registered Nurse
Editor: Evans, Jaylene Mackenzie, RN (Registered Nurse)
Patient received into care via EMS
Printed on 11/12/2024 10:14 Page 24

Patient contracting about every 3-5 minutes

Believed SRM at 1200 for clear
Patient feeling normal fetal movement
Has some mucousy bleeding
Efm applied
BP cycling Q10 as elevated
Denies headache, blurry vision, RUQ pain
Electronically signed by Evans, Jaylene Mackenzie, RN at 07/07/2024 15:00
Henry, Shelby, MD at 07/07/2024 15:40

Author: Henry, Shelby, MD Service: Obstetrics Author Type: Resident
Editor: Henry, Shelby, MD (Resident)
LR Resident on Call
HR resident in OR
Paged re: TPTL contracting, ? ROM
ID: G1P0 at 35+4 uncomplicated pregnancy presenting with 2/10 contractions and large gush of fluid at 12:00, ctx
started at 13:30
No bleeding, +FM, still leaking
FHR normal
Sterile spec - pooling, nitrazine positive, +ferning
VE: 2cm dilated, 1-2cm thick
A/P
Confirmed rupture, PTL
Admit to caseroom
Pen G
PEC labs sent as elevated BP in assessment
Shelby Henry, PGY2

I updated HR resident and Dr. Wang about this pt.
Electronically signed by Henry, Shelby, MD at 07/07/2024 19:06
Elloumi, Yesmine, MD at 07/07/2024 19:51

Editor: Elloumi, Yesmine, MD (Resident)
HR resident
In to assess shift in FHR baseline

Patient had M&G at 1920
Printed on 11/12/2024 10:14 Page 25
BL was 115bpm, moderate variability, accels, no decels
At 1930 BL shifted to 105bpm, moderate variability, some accels, no decels

VE- tight 3 cm, soft, 1-2 cm long, head felt, no cord
A/P
CEFM to monitor FHR
LR bolus 500 ml
Yesmine Elloumi PGY2
Elloumi, Yesmine, MD at 07/07/2024 22:52

Editor: Elloumi, Yesmine, MD (Resident)
HR resident
In to assess for FHR decel

From BL 115 down to 80 bpm x 4.5 mins
Started after contraction

VE- 3cm dilated, more soft and thin, still posterior
Bladder distended
Positive scalp stim
Recovered after VE
Plan was to start synto for labor augment

With this prolonged decel- will hold off until normal
Vanderschee, Ryleigh at 08/07/2024 01:19

Author: Vanderschee, Ryleigh Service: Obstetrics Author Type: Medical Student
Editor: Vanderschee, Ryleigh (Medical Student)
Obstetrics Progress Note
Patient laying in bed, laboured breathing, having some contractions. Partner at bedside.
Patient verbally consented for writer to be present at delivery.
No concerns or questions at present.
Ryleigh Vanderschee (SI3)

Electronically signed by Vanderschee, Ryleigh at 08/07/2024 01:21
Printed on 11/12/2024 10:14 Page 26

Onyeowuzoni, Okwuchukwu, MD at 09/07/2024 08:30

Editor: Onyeowuzoni, Okwuchukwu, MD (Associate Physician)
ROUNDING PROGRESS NOTE:

PPD# 1 - Spontaneous vaginal Delivery at 35 weeks
EBL: Average
Tears/Lacerations: Second-degree perineal tear
ISSUES:
None
SUBJECTIVE:
General outlook: Good
Pain: Well-controlled
Voiding: No issues
Lochia: Normal
Ambulation: Yes
Baby: Well, with mother
OBJECTIVE:
Last 4 readings
08/07/2024 15:20 08/07/2024 20:45 08/07/2024 23:35 09/07/2024 05:40
BP: 115/79 124/76 116/71 (!) 134/93
Pulse: 70 72 65 65
Resp: 18 18 20
Temp: 36.7 °C 36.4 °C 36.5 °C 36.1 °C
SpO2: 97% 99% 99% 100%
Weight:
RESULTS
Lab Results
HGB 134 07/07/2024
HGB 131 28/06/2024
HGB 126 16/05/2024
WBC 8.1 07/07/2024
WBC 6.2 28/06/2024
WBC 6.4 16/05/2024
PLT 231 07/07/2024
PLT 232 28/06/2024
PLT 255 16/05/2024
ASSESSMENT
A stable 22 y.o.-year-old Postpartum day 1 who had a Spontaneous vaginal Delivery of a 2.34 kg female neonate.
Printed on 11/12/2024 10:14 Page 27

PLAN:
Continue as inpatient for preterm delivery.
Okwuchukwu Onyeowuzoni, MD,

Clinical Surgical Assistant
For
Tankel, Jonathan, MD

09/07/2024 11:49
SW General Assessment Overview
Are there any legal decision-
No
making documents in place?
Identified concerns: Patient
Patient identified concerns Income and benefits;Housing
Patient Information
Alberta resident Yes
Personal identification sources Alberta Health Care
Has active health care? Yes
Specify patients active
Alberta
healthcare
Has active extended health
No
benefits
Status card Yes
Patient information comment Pt has Treaty Status with Calling Lake
This Pt's first baby, She was residing at a Safe Place
Family information however has been living with her Partner Tommy
Yellowknee and his sister Claris.
Psychosocial Factors
Family composition Pt has a Mother and Sister who reside in Calling Lake.
Primary Caregiver Self
Living Arrangements/Lives with:* Spouse/significant other
Education & Employment
Employment/education/school Pt is looking for supports on how to apply for Alberta
Comment Works.
Income Information
Do you ever have difficulties
making ends meet at the end of Y
the month?
Can we have a conversation Y
Printed on 11/12/2024 10:14 Page 28

about this so I can help connect

you to the right resources?
Pt was receving Income from her band however is no
Income Comment
longer recieving as she moved to Edmonton.
Housing
Does the client have housing Yes
Is housing adequate? Yes
Is housing affordable? Yes
Is housing suitable? Yes
Housing comment Pt and her boyfriend will be looking for an apartment.
Substance Use
Does the patient use
substances? (Alcohol, illegal or No
prescription drugs, and/or (Pt reported she does not use any substances)
Tobacco)
Domestic Violence
Is there concern for you or your
No
children?
Pt was staying in a shelter however stated no DV with
Domestic violence comment
partner.
Social Supports & Coping
Personal/Internal Strengths Personal resilience;Spirituality;Resourcefulness
Personal support systems
Cultural community;Family (specify)
available
Formal resources None identified
General Social Work Summary and Impressions
Pt is new to Edmonton and has limited resources for
Income however is commited to applying for Alberta
Works. Writer had conversation with Pt around PPD
Social Work summary and and Baby Blues what to watch for etc. Pt is staying with
Impression Boyfriend's sister and her children. Has reported this is
a safe residence. Pt stated no substance use for herself
or partner. Pt agreeable to supports for family doctor,
community resources.
General Social Work Plan and Interventions
Social Work Plan Ongoing social work involvement with client
Type of SW Involvement Finances;Housing
SW to follow up with how to Apply for Income Support,
Social Work Plan Comment Family doctor information, connect with Pt's partner and
family ensure all supplies are present.
HEALTHY BEGINNINGS TO SEE.
Current Address: 11711 101 Street, Unit 5

Social Work
Printed on 11/12/2024 10:14 Page 29



EBL: Average
ISSUES:
None
SUBJECTIVE:
Voiding: No issues
Lochia: Normal
Ambulation: Yes
OBJECTIVE:
Last 4 readings
09/07/2024 15:35 09/07/2024 20:40 09/07/2024 23:55 10/07/2024 05:50
BP: 126/80 131/89 133/86 126/82
Pulse: 66 60 63 62
Resp: 18 18 16 18
Temp: 36.7 °C 36.4 °C 36.4 °C 36.4 °C
SpO2: 98% 98% 96% 97%
Weight:
RESULTS
Lab Results
HGB 134 07/07/2024
HGB 131 28/06/2024
HGB 126 16/05/2024
WBC 8.1 07/07/2024
WBC 6.2 28/06/2024
WBC 6.4 16/05/2024
PLT 231 07/07/2024
PLT 232 28/06/2024
PLT 255 16/05/2024
ASSESSMENT
PLAN:
Printed on 11/12/2024 10:14 Page 30

Continue as inpatient for preterm delivery.

For

Writer attended bedside and noted both parents were sleeping, while baby was in bassinet. Immediately upon baby
crying, Pt awoke and went to comfort baby.
Writer provided both Income Support phone numbers for Pt and Spouse. Writer advised that either parent can call the
Emergency line for supports with food, diapers etc. Writer advised they can also complete the application online for
Income Support.
Writer agreed to follow up prior to Pt being discharged. Writer explained this will likely be tomorrow.

Social Work


EBL: Average
ISSUES:
None
SUBJECTIVE:
Voiding: No issues
Lochia: Normal
Printed on 11/12/2024 10:14 Page 31
Ambulation: Yes
OBJECTIVE:
Last 4 readings
10/07/2024 19:45 10/07/2024 23:45 11/07/2024 04:00 11/07/2024 07:27
BP: 120/72 131/86 131/82 (!) 130/92
Pulse: 70 70 65 74
Resp: 17 20 20 18
Temp: 36.5 °C 36.6 °C 36.4 °C 36.5 °C
SpO2: 96% 95% 95% 95%
RESULTS
Lab Results
HGB 134 07/07/2024
HGB 131 28/06/2024
HGB 126 16/05/2024
WBC 8.1 07/07/2024
WBC 6.2 28/06/2024
WBC 6.4 16/05/2024
PLT 231 07/07/2024
PLT 232 28/06/2024
PLT 255 16/05/2024
ASSESSMENT
PLAN:
Discharge home once baby is discharged.
Book follow-up visit in 6 weeks.

For

Writer attended bedside and met with Pt and baby Xela who was currently receiving photo therapy. Pt was awake and
Printed on 11/12/2024 10:14 Page 32
sitting up in bed, while Pt's partner was sleeping, however did answer some questions.
Writer confirmed with Pt that she receives benefits via NIHB. Writer advised that a from had been left with medical
staff to complete which would support the rental or purchase of a breast pump.
Pt and her partner confirmed they had completed the registration of Live Birth.
Pt also advised that she is still receiving ongoing supports from her worker at a Safe Place. Pt confirmed her worker will
also be assisting with completing her Income Support application. Pt also aware of Healthy Beginnings and looking
forward to nursing visits.
SW to continue to follow as needed.

Social Work
Printed on 11/12/2024 10:14 Page 33

Labs
CBC, No Differential -- Blood (Final result)
Electronically signed by: Henry, Shelby, MD on 07/07/2024 16:01 Status: Completed
Ordering user: Henry, Shelby, MD 07/07/2024 16:01 Ordering provider: Henry, Shelby, MD
Authorized by: Tankel, Jonathan, MD Ordering mode: Standard
Frequency: STAT STAT 07/07/2024 16:02 - 1 occurrence Class: Unit Collect
Quantity: 1 Lab status: Final result
Instance released by: Henry, Shelby, MD (auto-released) 07/07/2024 16:01
Specimen Information
ID Type Source Collected By
24RA-189H00477 Blood Blood Poon, Susan, RN 07/07/2024 16:30
Resulted: 07/07/2024 17:06, Result status: Final

CBC, No Differential -- Blood (Normal) result
Ordering provider: Henry, Shelby, MD 07/07/2024 16:01 Order status: Completed
Filed by: Lab, Autoverification User 07/07/2024 17:06 Collected by: Poon, Susan, RN 07/07/2024 16:30
Resulting lab: EDM ROYAL ALEXANDRA HOSPITAL LABORATORY
Components
Component Value Reference Range Flag Lab
Auto WBC 8.1 4.0 - 11.0 10*9/L — EDM RAH LAB
RBC 4.99 3.80 - 5.20 — EDM RAH LAB
10*12/L
Hemoglobin 134 120 - 160 g/L — EDM RAH LAB
Hematocrit 0.40 0.36 - 0.48 L/L — EDM RAH LAB
MCV 80 80 - 100 fL — EDM RAH LAB
MCHC 337 310 - 360 g/L — EDM RAH LAB
RDW 15.1 <16.0 % — EDM RAH LAB
Platelets 231 140 - 400 10*9/L — EDM RAH LAB
nRBC <1 <1 /100 WBCs — EDM RAH LAB
Testing Performed By
Lab - Abbreviation Name Director Address Valid Date Range
123055 - EDM RAH EDM ROYAL Unknown 10240 Kingsway 23/05/2018 15:31 - Present
LAB ALEXANDRA Avenue NW
HOSPITAL Edmonton AB T5H 3V9
LABORATORY
Alanine Aminotransferase (ALT) -- Blood (Final result)

24RA-189C00636 Blood Blood Poon, Susan, RN 07/07/2024 16:30

Alanine Aminotransferase (ALT) -- Blood (Normal) result
Components
Printed on 11/12/2024 10:14 Page 34

Labs (continued)
Alanine Aminotransferase (ALT) 16 <50 U/L — EDM RAH LAB
LABORATORY
Creatinine -- Blood (Final result)


Creatinine -- Blood (Normal) result
Components
Creatinine 53 40 - 100 umol/L — EDM RAH LAB
eGFR 130 >59 — EDM RAH LAB
mL/min/1.73m2
Comment:
Reduced muscle mass will lead to overestimation and increased muscle mass to underestimation of eGFR.
LABORATORY
Urate -- Blood (Final result)


Urate -- Blood (Normal) result
Printed on 11/12/2024 10:14 Page 35

Labs (continued)
Components
Urate 237 150 - 400 umol/L — EDM RAH LAB
Comment:
For patients with gout on serum/plasma urate lowering therapy, treat to target a urate of <350 umol/L. (American College of
Rheumatology Guidelines for the Management of Gout, Arthritis & Rheumatology, June 2020).
LABORATORY
Urinalysis -- Urine, Midstream (Final result)

24RA-189U00044 Urine Urine, Midstream Poon, Susan, RN 07/07/2024 16:31

Urinalysis -- Urine, Midstream (Abnormal) result
Components
Color, Urine Yellow Colorless, Yellow, — EDM RAH LAB
Amber
Clarity, Urine Clear Clear — EDM RAH LAB
Specific Gravity, Urine 1.020 1.005 - 1.030 — EDM RAH LAB
pH, Urine 8.0 5.0 - 8.0 — EDM RAH LAB
Leukocytes, Urine Negative Negative Leu/uL — EDM RAH LAB
Nitrite, Urine Negative Negative — EDM RAH LAB
Protein, Urine Negative Negative g/L — EDM RAH LAB
Glucose, Urine Negative Negative mmol/L — EDM RAH LAB
Ketones, Urine 1.5 Negative mmol/L A EDM RAH LAB
Blood, Urine 25 Negative Ery/uL A EDM RAH LAB
Comment:
This result should not be used for the assessment of microscopic hematuria. Please see the RBC, Urine result for this
purpose.
Printed on 11/12/2024 10:14 Page 36
Labs (continued)
LABORATORY
Protein Total, Urine, Random -- Urine, Midstream (Final result)

24DY-189C03576 Urine Urine, Midstream Poon, Susan, RN 07/07/2024 16:31

Protein Total, Urine, Random -- Urine, Midstream (Abnormal) result
Resulting lab: EDM MEDICAL LABS - BASE LABORATORY
Components
Protein Total, Urine 0.07 No reference — EDM DLH LAB
interval g/L
Protein / Creatinine Ratio, Urine 14.58 <13.00 mg/mmol H EDM DLH LAB
123046 - EDM DLH EDM MEDICAL LABS Unknown 200, 10150 102 Street 20/12/2023 15:03 - Present
LAB - BASE Edmonton AB T5J 5E2
LABORATORY
Creatinine, Urine, Random -- Urine, Midstream (Final result)

Status: Completed
Order placed as a reflex to Protein Total, Urine, Random -- Urine, Midstream ordered on 07/07/2024 at 16:01
Ordering user: Yulo, Peter J 07/07/2024 16:52 Ordering provider: Henry, Shelby, MD
Frequency: Routine Once Routine 07/07/2024 16:53 - 1 occurrence Class: Unit Collect
Instance released by: Yulo, Peter J 07/07/2024 16:52
24DY-189C03576 Urine Urine, Midstream Poon, Susan, RN 07/07/2024 16:31

Creatinine, Urine, Random -- Urine, Midstream result
Resulting lab: EDM MEDICAL LABS - BASE LABORATORY
Components
Creatinine, Urine 4.8 No reference — EDM DLH LAB
interval mmol/L
Printed on 11/12/2024 10:14 Page 37

Labs (continued)
123046 - EDM DLH EDM MEDICAL LABS Unknown 200, 10150 102 Street 20/12/2023 15:03 - Present
LAB - BASE Edmonton AB T5J 5E2
LABORATORY
Urinalysis, Microscopic -- Urine, Midstream (Final result)

Status: Completed
Order placed as a reflex to Urinalysis -- Urine, Midstream ordered on 07/07/2024 at 16:01
Ordering user: Interface, Lab Instrument Results In 07/07/2024 Ordering provider: Henry, Shelby, MD
17:21
Instance released by: Interface, Lab Instrument Results In (auto-released) 07/07/2024 17:21
24RA-189U00044 Urine Urine, Midstream Poon, Susan, RN 07/07/2024 16:31

Urinalysis, Microscopic -- Urine, Midstream (Abnormal) result
Filed by: Loreto, Jamie 07/07/2024 17:33 Collected by: Poon, Susan, RN 07/07/2024 16:31
Components
WBC, Urine 0-5 0 - 5 /HPF — EDM RAH LAB
RBC, Urine 11-20 0 - 2 /HPF A EDM RAH LAB
Comment:
According to the Canadian Urological Association Guidelines, microscopic hematuria is defined as greater than 2 RBCs/hpf on
two microscopic urinalysis without recent exercise, menses, sexual activity or instrumentation.
Bacteria, Urine 0-20 0 - 20 /HPF — EDM RAH LAB

Squamous/Transitional Epithelial Cells, Urine >10 0 - 5 /HPF A EDM RAH LAB
LABORATORY
Surgical Pathology (Final result)

Electronically signed by: Elloumi, Yesmine, MD on 08/07/2024 06:59 Status: Completed
Ordering user: Elloumi, Yesmine, MD 08/07/2024 06:59 Ordering provider: Elloumi, Yesmine, MD
Instance released by: Elloumi, Yesmine, MD (auto-released) 08/07/2024 06:59
Questionnaire
Question Answer
Source(s): Enter 1 specimen per line, this will default to A,B,C Placenta
Printed on 11/12/2024 10:14 Page 38
Labs (continued)
etc. Select the SOURCE (e.g. skin) in the box on the left; and
then fill in the EXACT ANATOMICAL SITE including
LATERALITY (e.g. Right arm, Left cheek, etc.) in the comment
box to the right
Relevant Clinical History/Information late preterm delivery- G1P0 at 35+4, SROM, spontaneous vaginal
delivery
Document type: Lab Result Document - Media type: Document Date: 16/07/2024 13:05 (below)
Printed on 11/12/2024 10:14 Page 39

Labs (continued)
A Surgical Pathology Placenta 08/07/2024 08:27

Surgical Pathology result
Printed on 11/12/2024 10:14 Page 40

Labs (continued)
Ordering provider: Elloumi, Yesmine, MD 08/07/2024 06:59 Order status: Completed
Filed by: Mandziuk, Jake John, MD 16/07/2024 13:05 Collected by: 08/07/2024 08:27
Components
Case Report -- — — EDM RAH LAB
Result:
Surgical Pathology Case: RAS24-014559
Authorizing Provider: Tankel, Jonathan, MD Collected: 08/07/2024 08:27
Ordering Location: EDM RAH LH L&D Received: 08/07/2024 10:33
Pathologist: Mandziuk, Jake John, MD
Specimen: Placenta
Clinical Information -- — — EDM RAH LAB
Result: late preterm delivery- G1P0 at 35+4, SROM, spontaneous vaginal delivery
Gravida: 1 /Para: 1
Term: 0 /Preterm: 1 /Livebirth: 1
Prolonged Membrane Rupture: No
Infant ID: 1
Sex of Infant: Female
Birthweight: 2340g
APGARS 1 min: 9 /5 min: 9 /10 min:
Rupture Fluid Color: Clear
Gestational Age: 35 completed weeks
Mode of Delivery: Vaginal, Spontaneous
Final Diagnosis -- — — EDM RAH LAB

Result: A. Singleton placenta, 35 weeks gestational age, vaginal delivery:
- Appropriately sized and mature for gestational age (360 g; 30th percentile).
- Trivascular umbilical cord with acute phlebitis (fetal inflammatory response stage 1, grade 1).
- Fetal membranes with no significant abnormality.
- Villous parenchyma with no significant abnormality.
- Maternal decidual arteriopathy with retained muscularization and fibrinoid necrosis of vessel walls (maternal
vascular malperfusion).
Electronically signed by Mandziuk, Jake John, MD on 16/07/2024 at 13:05

Gross Description -- — — EDM RAH LAB
Result: A. Container Labeled: Gambler, Sirrena Ava and PLACENTA
Placenta Type: Singleton
Umbilical Cord:
Length: 35.5 cm
Diameter: 1.2 cm
Insertion: Central
Number of Vessels: 3
Cord Twist: Left, 2 coils per 10 cm of cord
Other Comments: N/A
Membranes:
Insertion: Marginal
Rupture Site: 7.0 cm from placental margin
Color: Gray and semitransparent
Other Comments: N/A
Placental Disc:
Weight: 360 g
Printed on 11/12/2024 10:14 Page 41
Labs (continued)
Size: 15.4 x 15.1 x 2.8 cm

Shape: Irregular
Fetal Surface: Bluegrey
Fetal Vessels: Appears thin and well distributed
Maternal Surface: Appears grossly complete
Parenchyma: Red-brown and spongy
Sections:
A1: Proximal cord and membrane roll
A2: Distal cord and placenta
A3-A4: Placenta
/BC
Embedded Images — — — EDM RAH LAB
Media type: Document Date: 08/07/2024 08:27 Acquired by: Mandziuk, Jake John, MD (below)
Printed on 11/12/2024 10:14 Page 42

Labs (continued)
Printed on 11/12/2024 10:14 Page 43

Labs (continued)
Printed on 11/12/2024 10:14 Page 44

Labs (continued)
LABORATORY
Prenatal Syphilis Rescreen -- Blood (Final result)

Electronically signed by: Elloumi, Yesmine, MD on 08/07/2024 07:00 Status: Completed
Ordering user: Elloumi, Yesmine, MD 08/07/2024 07:00 Ordering provider: Elloumi, Yesmine, MD
Frequency: Routine Once Routine 08/07/2024 08:39 - 1 occurrence Class: Lab Collect
Instance released by: Roy, Alanna Joyce, RN (auto-released) 08/07/2024 08:38
Questionnaire
Question Answer
Is rescreen being done at delivery/in-labour? Yes
Enter estimated delivery date (if unknown, indicate unknown in 07/08/2024
comment box and enter the following date: 2/2/1888)
Enter gravida 1
24PN-190S00573 Blood Blood Pangilinan, Alleyah 08/07/2024 11:44

Prenatal Syphilis Rescreen -- Blood (Normal) result
Filed by: Lab, Autoverification User 08/07/2024 21:01 Collected by: Pangilinan, Alleyah 08/07/2024 11:44
Resulting lab: EDM PROVINCIAL LAB NORTHERN ALBERTA LABORATORY
Components
Syphilis Antibody See Note — — EDM PLNA LAB
Comment:
This patient has previously tested positive for Syphilis. Syphilis EIA and TPPA will not be repeated and a Rapid Plasma
Reagin (RPR) test will be performed and reported separately.
For advice on interpretation of serology, syphilis treatment or to obtain prior syphilis history on your patient, please call AHS
STI Centralized Services at 1-855-945-6700, option 4 (business hours only).
When clinically indicated, EIA and TPPA can be reinstated by contacting the microbiologist on call for the Public Health
Laboratory (Provlab) (Calgary: (403) 944-1110, Edmonton: 780-407-8822)
Date of previous positive:07/12/2021
123053 - EDM PLNA EDM PROVINCIAL Unknown 8440 112 Street NW 08/03/2021 14:51 - Present
LAB LAB NORTHERN Edmonton AB T6G 2B7
ALBERTA
LABORATORY
RPR -- Blood (Final result)

Status: Completed
Order placed as a reflex to Prenatal Syphilis Rescreen -- Blood ordered on 08/07/2024 at 07:00
Printed on 11/12/2024 10:14 Page 45
Labs (continued)
Ordering user: Szymczyk, David 08/07/2024 15:37 Ordering provider: Elloumi, Yesmine, MD
Frequency: Routine Once Routine 08/07/2024 15:38 - 1 occurrence Class: Lab Collect
Instance released by: Szymczyk, David 08/07/2024 15:37
24PN-190S00573 Blood Blood Pangilinan, Alleyah 08/07/2024 11:44

RPR -- Blood (Abnormal) result
Filed by: Shah, Hiralben, MLT 09/07/2024 13:01 Collected by: Pangilinan, Alleyah 08/07/2024 11:44
Resulting lab: EDM PROVINCIAL LAB NORTHERN ALBERTA LABORATORY
Narrative:
Test Performed for Prenatal Screening
Components
Syphilis Rapid Plasma Reagin Reactive — A EDM PLNA LAB
Syphilis Rapid Plasma Reagin Dilution 2 Dils — A EDM PLNA LAB
123053 - EDM PLNA EDM PROVINCIAL Unknown 8440 112 Street NW 08/03/2021 14:51 - Present
LAB LAB NORTHERN Edmonton AB T6G 2B7
ALBERTA
LABORATORY
Printed on 11/12/2024 10:14 Page 46

Notice of Live Birth Birth Registration Number (Vital Statistics only)
or Stillbirth
Surname of Newborn Full Given Name (if known) Date of Birth Time of Birth
Gambler Sirrena'sGirl 08/07/2024 06:38
Surname of Mother Maiden Name Full Given Name (if known) Date of Birth Age
Gambler Same as current Sirrena 04/03/2002 22
Full Given Name of Father/Co-Parent (if known) Date of Birth Mother’s Marital Status
Tommy Yellowknee 22/03/2002 common law
Mother’s Home Phone Physical Address/Reserve on Discharge City/Reserve Province Postal Code
11711 101 street Unit 5 Edmonton Alberta T5G 25B
Mother’s Cell/Other Phone Mother’s Mailing/Reserve Address City/Reserve Province Postal Code
587-784-7809 11711 101 Street Unit 5 Edmonton Alberta T5G 25B
Pregnancy (Singleton vs. Multiple Delivery) Birth Order (if multiple) Living Status Sex
Singleton Live Birth Female
Total number including this newborn Gestational Age (weeks) Birth Weight (g) Newborn for Adoption
1
Live Births __________ Stillbirths 0
__________ 35w5d 2,340 ■ No o Yes o Undecided
o
Birth Site Name and Address of Birth Site Attendant at birth
■ Hospital
o o Birth Centre Royal Alexandra Hospital, Dhaliwal, Rupinder Kaur, MD
o Home/Planned o Home/Unplanned 10240 Kingsway Avenue NW,
o En Route Edmonton, AB, T5H 3V9
o Other ______________________
If the “Notice of Live Birth or Stillbirth” is not submitted to Vital Statistics by a hospital administrator, please indicate who
delivered the newborn and provide the information below.
Name (please print) Signature Relationship Telephone Number
20587-mother-Epic (Rev2024-03) Page 1

Notice of Live Birth
or Stillbirth
Mother’s Surname Newborn’s Surname Maternal PHN/ULI
Gambler Gambler 807354321
Maternal Transfer Transfer from Reason for transfer
■ No
o o Yes
Prenatal History
Maternal PHN 807354321 Maternal Chart Number 3050121569
Gravida Term Pre term Number of Abortions Living Neonatal Postnatal Number of children living at
0
Spontaneous _______ Deaths Deaths home
1 0 0 Induced __________
0 0 0 0 0
Ectopic ___________
0
Number Prenatal visit Trimester of 1st Prenatal visit Prenatal Education Folic Acid
■ No
o o Yes prior to conception
o None o 1-3 ■ 4-8
o o 9+ o 1 st ■2
o nd
o3 rd ■ No
o o Yes
o Yes 1st Trimester
Height and Weight Weight Gain during Pregnancy Language spoken by mother Translator required
175
Height _______ cm 104
Weight ________ kg 6
________________ kg English No
Tobacco Use ■ No o Yes
o Type of Use: o Cigs o Nicotine Product o e-cigarette o Other ______________
o Quit o Pre-pregnancy Trimester o 1st o 2nd o 3rd Exposure 2nd hands smoke o Home o Work
■ No o Yes
Alcohol Use o o Daily o Weekly o Occasionally Max. # of drinks on any one occasion _______
o Quit o Pre-pregnancy Trimester o 1st o 2nd o 3rd
Other Substance/Drug Use o ■ No
o Quit o Pre-pregnancy Trimester o 1st o 2nd o 3rd
o Yes o Cocaine o Crystal Meth o Ecstasy o Marijuana o Solvents o Heroin o Methadone o Oxycodone
o Illicit use of prescription drugs ____________ o Other ____________ How often ________ Last used _________
Hypertension o No Diabetes ■ No
o Insulin ■ No
o
o Pre-pregnancy ■ Gestational
o o Pre-pregnancy o Gestational o Pre-pregnancy o During pregnancy
Mental Health Other illness
■ No concerns
o o Anxiety o Depression o History of postpartum depression
o Other ____________________ o On medication ____________________
Completed by Signature Date (dd-Mon-yyyy) Time (hh:mm)
wyatt basford 07/07/2024 17:43
Labour and Delivery

Induction Method Anesthesia Method GBS Status Antibiotics in labour First dose before delivery
None No o No ■ Yes
o o less than 4 hrs
■ 4 hrs or more
o
Delivery Method Perineum o Intact ■ Lacerations
o o Cervical
Spontaneous o1 st
■2
o nd
o 3rd o 4th o Episiotomy o Labial ■ Sutures
o
O. McDonald Rn 08/07/2024 07:00

Notice of Live Birth
or Stillbirth
Mother’s Surname Newborn’s Surname Maternal PHN/ULI

Gambler Gambler 807354321
Postpartum
Maternal Problems/Complications in labour or postpartum
o Hemorrhage o Blood Transfusion o Retained Placenta o Uterine Rupture o Hysterectomy
o Preeclampsia o Seizures o Infection/Chorioamnionitis o Admission to ICU o Death
o Other ___________________________________________________________________________________
Hepatitis B Positive Rubella - Immune Varicella - Immune
o Yes ■ Yes
o o Unknown o No o Yes o Unknown ■ No
o
o Unknown Vaccine Given: Vaccine Given:
■ No
o ■ No
o o Yes, Lot # __________________ ■ No
o o Yes, Lot # _________________
C/S Incision
o Sutures Remove on _____________________ o Clips/Staples Remove on _____________________
o Dressing __________________________ Remove on _____________________
Breast o No Concerns ■ Pumping

o o Engorged o Other _____________________________
Nipples o No concerns o Inverted o Trauma o Piercings o Other ____________________

Maternal Blood Group RhIG Last BP Medication on Discharge Voiding Problems
■ N/A
o ■ L Arm
o ■ No
o ■ No
o
A Positive
o Given o R Arm o Yes _________________ o Yes
134/79 o Med REC Attached _________________
Support System
■ Significant Other
o o Family o Friends o No Support o Agency _________________________
Referral completed
o Social Worker o MH/Addictions o Other _____________________________________________
Full name of follow-up Physician/Midwife for Mother Discharge Date for Mother Time
Jonathan Tankel 11/07/2024 11:47
Additional Comments

Jessica Yorke 08/07/2024 07:00
AFTER VISIT SUMMARY
Sirrena A. Gambler MRN: 3050121569
Active labor 07/07/2024 - 11/07/2024 EDM RAH LH 2E POSTPARTUM
Instructions
Instructions
These are after care instructions following your hospital admission. Keep this
document for reference and if there are any questions, contact your health care
provider. Once registered, this summary is also available in your MyAHS Connect.
Attachments
Read
Read these attachments
• Postpartum (English)
What's Next
You currently have no upcoming appointments scheduled.
Additional Information
Schedule an appointment to follow up with your doctor in 6 weeks
Medication List
You have not been prescribed any medications.
Resources
Resources
Health Link
Call Health Link by dialing 811 for quick and easy advice from a registered nurse 24/7. They will ask questions,
assess symptoms and determine the best care for you. Health Link support is available in more than 240
languages.
Remember, in a medical emergency, always call 911 or visit the nearest emergency department.
Health Link can also be accessed through the Canada-wide toll-free number, 1-866-408-5465. Outside of Alberta,
this number should be used to reach Alberta's Health Link services.
If you would like more information about the Health Link service please email us at
healthlink@albertahealthservices.ca.
MyHealth.Alberta.ca
Sirrena A. Gambler (MRN: 3050121569) • Printed by [92806] at 11/07/2024 10:53 Page 1 of 7

Resources (continued)
MyHealth.Alberta.ca provides evidence based, easy-to-understand online health information and tools at https://
myhealth.alberta.ca/. If you would like more information please review the About Us page at https://
myhealth.alberta.ca/Pages/About-Us.aspx or email us at feedback@myhealth.alberta.ca.
Patient Relations Department

Patient Relations is a department within Alberta Health Services (AHS) where patients, family members, and the
public can bring forward suggestions, compliments or concerns. Patients are also encouraged to speak directly
with their care team about their health care experiences. Patient Relations acts as a resource for both patients and
AHS staff and practitioners during the Patient Concerns Process.
Contact the Patient Relations Department by telephone, fax or mail:
• Telephone: 1-855-550-2555
• Fax: 1-877-871-4340
• Mail: Patient Relations Department
10030 107 Street NW
Edmonton, AB
T5J 3E4
• Online feedback form
Green Sleeve
A Green Sleeve is a plastic pocket that holds your advance care planning documents; think of it like a medical passport.
Within the Green Sleeve there may be:
• Your Personal Directive copy, when one exists
• A Goals of Care Designation Order, when one exists
• Advance Care Planning Goals of Care Designation Tracking Record
• Guardianship Orders, if one is in place for the individual
At home keep your Green Sleeve on or near the fridge. If Emergency Medical Services (EMS) personnel come to your
home they know to look for your Green Sleeve there. Your Green Sleeve is your property and you should only have one
with the most up-to-date documents. It goes with you to all care settings, so that all healthcare providers know your
current or future healthcare goals and wishes.
For more information www.conversationsmatter.ca

MyAHS Connect
MyAHS Connect is the patient portal provided by Alberta Health Services that offers you personalized and secure
access to your Connect Care health information. MyAHS Connect empowers you to partner in your care and together
with your healthcare team use the features to
• Prepare for upcoming appointments
• Communicate about ongoing treatment
• Stay up to date on test results
It is available to Albertans 14 years of age or older with an Alberta Driver’s License or Alberta Identification Card.
MyAHS Connect is not for urgent medical needs. For medical emergencies, dial 911.
To sign up for MyAHS Connect:
1. Create an Alberta.ca Account http://account.alberta.ca/. You will need your Alberta Driver's License or Alberta
Identification Card for this step. While waiting for your Alberta.ca Account verification code to arrive in the mail,
move to step 2. If you already have an Alberta.ca Account, move to step 2.
2. Log in to MyHealth Records https://myhealth.alberta.ca/MyHealthRecords with your Alberta.ca Account

username and password. You will need your Alberta Personal Health Number for this step.
3. Click on MyAHS Connect.
Important Final Step: Within 10 business days, you will receive an Alberta.ca Account verification code in the
mail. Follow the instructions provided to have permanent access to MyAHS Connect.
Is there an app for that? Yes, MyChart is a portable mobile version of MyAHS Connect and it is available in the App
Store or Google Play. You can use it to manage your health information on the go.
Visit www.ahs.ca/connectcare for more information or call 1-844-401-4016 if you have any questions.

Attached Information Postpartum (English)
After Your Delivery (the Postpartum Period): Care Instructions

Overview
Congratulations on the birth of your baby. Like pregnancy, the newborn period can be a time of excitement, joy, and
exhaustion. You may look at your wondrous little baby and feel happy. You may also be overwhelmed by your new sleep
hours and new responsibilities.
At first, babies often sleep during the days and are awake at night. They do not have a pattern or routine. They may make
sudden gasps, jerk themselves awake, or look like they have crossed eyes. These are all normal, and they may even make
you smile.
In these first weeks after delivery, try to take good care of yourself. It may take 4 to 6 weeks to feel like yourself again, and
possibly longer if you had a caesarean birth. You will likely feel very tired for several weeks. Your days will be full of ups
and downs, but lots of joy as well.
Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your
doctor or nurse advice line (811 in most provinces and territories) if you are having problems. It's also a good idea to
know your test results and keep a list of the medicines you take.
How can you care for yourself at home?

Take care of your body after delivery
• Use pads instead of tampons for the bloody flow that may last as long as 2 weeks.
• Ease cramps with ibuprofen (Advil, Motrin).
• Ease soreness of hemorrhoids and the area between your vagina and rectum with ice compresses or witch hazel
pads.
• Ease constipation by drinking lots of fluid and eating high-fibre foods. Ask your doctor or midwife about over-the-
counter stool softeners.
• Cleanse yourself with a gentle squeeze of warm water from a bottle instead of wiping with toilet paper.
• Take a sitz bath in warm water several times a day.
• Wear a good nursing bra. Ease sore and swollen breasts with warm, wet face cloths.

• If you aren't breastfeeding, use ice rather than heat for breast soreness.
• Your period may not start for several months if you are breastfeeding. You may bleed more, and longer at first, than
you did before you got pregnant.
• Wait until you are healed (about 4 to 6 weeks) before you have sex. Ask your or midwife when it is okay for you to
have sex.
• Try not to travel with your baby for 5 or 6 weeks. If you take a long car trip, make frequent stops to walk around and
stretch.
Avoid exhaustion
• Rest every day. Try to nap when your baby naps.

• Ask another adult to be with you for a few days after delivery.
• Plan for child care if you have other children.
• Stay flexible so you can eat at odd hours and sleep when you need to. Both you and your baby are making new
schedules.
• Plan small trips to get out of the house. Change can make you feel less tired.
• Ask for help with housework, cooking, and shopping. Remind yourself that your job is to care for your baby.
Know about help for postpartum depression
• "Baby blues" are common for the first 1 to 2 weeks after birth. You may cry or feel sad or irritable for no reason.
• Rest whenever you can. Being tired makes it harder to handle your emotions.
• Go for walks with your baby.
• Talk to your partner, friends, and family about your feelings.
• If your symptoms last for more than a few weeks, or if you feel very depressed, ask your doctor or midwife for help.
• Postpartum depression can be treated. Support groups and counselling can help. Sometimes medicine can also help.
Stay healthy
• Eat healthy foods so you have more energy.

• If you breastfeed, avoid drugs. If you quit smoking during pregnancy, try to stay smoke-free. If you choose to have a
drink now and then, have only one drink, and limit the number of occasions that you have a drink. Wait to
breastfeed at least 2 hours after you have a drink to reduce the amount of alcohol the baby may get in the milk.
• Start daily exercise after 4 to 6 weeks, but rest when you feel tired.
• Learn exercises to tone your belly. Try Kegel exercises to regain strength in your pelvic muscles. You can do these
exercises while you stand or sit. (If doing these exercises causes pain, stop doing them and talk with your doctor.)
◦ Squeeze your muscles as if you were trying not to pass gas. Or squeeze your muscles as if you were stopping
the flow of urine. Your belly, legs, and buttocks shouldn't move.
◦ Hold the squeeze for 3 seconds, then relax for 5 to 10 seconds.
◦ Start with 3 seconds, then add 1 second each week until you are able to squeeze for 10 seconds.
◦ Repeat the exercise 10 times a session. Do 3 to 8 sessions a day.
• Find a class for you and your baby that has an exercise time.
• If you had a caesarean birth, give yourself a bit more time before you exercise, and be careful.
When should you call for help?
Share this information with your partner, family, or a friend. They can help you watch for warning signs.

Call 911 anytime you think you may need emergency care. For example, call if:
• You have thoughts of harming yourself, your baby, or another person.
• You passed out (lost consciousness).
• You have chest pain, are short of breath, or cough up blood.
• You have a seizure.
Where to get help 24 hours a day, 7 days a week
If you or someone you know talks about suicide, self-harm, a mental health crisis, a substance use crisis, or any
other kind of emotional distress, get help right away.
• Call or text Canada's suicide and crisis hotline at 988.
• Call Talk Suicide Canada: 1-833-456-4566 or text 45645 (4 p.m. to midnight ET).
• Go to the Talk Suicide Canada website at https://talksuicide.ca for more information.
Consider saving these numbers in your phone.
Call your doctor, midwife, or nurse advice line now or seek immediate medical care if:
• You have signs of hemorrhage (too much bleeding), such as:
◦ Heavy vaginal bleeding. This means that you are soaking through one or more pads in
an hour. Or you pass blood clots bigger than an egg.
◦ Feeling dizzy or light-headed, or you feel like you may faint.
◦ Feeling so tired or weak that you cannot do your usual activities.
◦ A fast or irregular heartbeat.
◦ New or worse belly pain.
• You have signs of infection, such as:
◦ A fever.
◦ Frequent or painful urination or blood in your urine.
◦ Vaginal discharge that smells bad.
◦ New or worse belly pain.
• You have symptoms of a blood clot in your leg (called a deep vein thrombosis), such as:
◦ Pain in the calf, back of the knee, thigh, or groin.
◦ Swelling in the leg or groin.
◦ A colour change on the leg or groin. The skin may be reddish or purplish, depending
on your usual skin colour.
• You have signs of preeclampsia, such as:
◦ Sudden swelling of your face, hands, or feet.
◦ New vision problems (such as dimness, blurring, or seeing spots).
◦ A severe headache.
• You have signs of heart failure, such as:
◦ New or increased shortness of breath.
◦ New or worse swelling in your legs, ankles, or feet.
◦ Sudden weight gain, such as more than 1 to 1.3 kilograms (2 to 3 pounds) in a day or
2.3 kilograms (5 pounds) in a week.
◦ Feeling so tired or weak that you cannot do your usual activities.
• You had spinal or epidural pain relief and have:
◦ New or worse back pain.
◦ Increased pain, swelling, warmth, or redness at the injection site.
◦ Tingling, weakness, or numbness in your legs or groin.
Watch closely for changes in your health, and be sure to contact your doctor, midwife, or nurse advice line if:

• Your vaginal bleeding isn't decreasing.
• You feel sad, anxious, or hopeless for more than a few days.
• You are having problems with your breasts or breastfeeding.
Where can you learn more?
Scan the QR code or To see this information online and learn more, go to https://
myhealth.alberta.ca/.
Enter A461 in the search box to learn more about 'After Your Delivery (the
Postpartum Period): Care Instructions.'
For 24/7 nurse advice and general health information call Health Link at 811.
This material is not a substitute for the advice of a qualified health professional. This material is intended for general
information only and is provided on an "as is", "where is" basis. Although reasonable efforts were made to confirm the
accuracy of the information, Alberta Health Services does not make any representation or warranty, express, implied or
statutory, as to the accuracy, reliability, completeness, applicability or fitness for a particular purpose of such information.
Alberta Health Services expressly disclaims all liability for the use of these materials, and for any claims, actions, demands
or suits arising from such use.
Current as of: February 22, 2024 Content Version: 13.8
© 2006-2023 Healthwise, Incorporated.
Care instructions adapted under license by your healthcare professional. If you have questions about a medical condition
or this instruction, always ask your healthcare professional. Healthwise, Incorporated disclaims any warranty or liability for
your use of this information.

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Gambler Sir Rena Ava 10880256

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December 11 2024

SIRRENA AVA GAMBLER

Dear SIRRENA AVA GAMBLER,

Re: Sirrena Ava Gambler

Enclosed is the information available at the time of processing.

If you have questions, please contact us at 780-735-4230 .

Alberta Health Services

Printed on 11/12/2024 10:14 Page 1

Obstetrical Discharge Summary

Admission Date: 07/07/2024

Discharge Date: 11/07/2024

Most Responsible Diagnosis:

Birth Weight: 2.34 kg

Patient's Course in Hospital:

Plan For Discharge:

Electronically signed by Onyeowuzoni, Okwuchukwu, MD at 11/07/2024 10:31

Past Obstetrical History:

Past Surgical History:

Printed on 11/12/2024 10:14 Page 3

FHR: baseline 125 bpm, with accelerations, no decelerations, moderate variability

Most Recent Ultrasound:

IMPRESSION & PLAN:

Yesmine Elloumi, MD PGY2

Electronically signed by Elloumi, Yesmine, MD at 07/07/2024 18:41

Clinical Notes (group 1 of 2)

Royal Alexandra Hospital • Social Work

Printed on 11/12/2024 10:14 Page 4

Consent to Social Work Assessment and Intervention

Kerry Watt BA BSW RSW

Electronically signed by Watt, Kerry M, RSW at 09/07/2024 10:11

Both parents were agreeable to Healthy Beginnings.

Kerry Watt BA BSW RSW

Electronically signed by Watt, Kerry M, RSW at 09/07/2024 14:20

Handover Note: from 4E to 2E

Report given to: 2E nurse

Allergies: Patient has no known allergies.

Past medical history/ Risk factors:

Maternal Recent Asssessments:

Printed on 11/12/2024 10:14 Page 6

Upcoming Tasks: fundal checks, baby vitals

Electronically signed by MacDonald, Julia, RN at 08/07/2024 08:29

Wyrostok, Katherine Ruth, RN at 08/07/2024 23:06

Vitals & Oxygen:

Printed on 11/12/2024 10:14 Page 7

Electronically signed by Wyrostok, Katherine Ruth, RN at 08/07/2024 23:07

Adigun, Oyinlade Dorcas, RN at 09/07/2024 06:39

Vitals & Oxygen:

Electronically signed by Adigun, Oyinlade Dorcas, RN at 09/07/2024 06:40

Poier, Jennifer Laura, LPN at 09/07/2024 14:06

Recent changes: None.

What to watch out for: Increased BP's

Vitals & Oxygen:

Printed on 11/12/2024 10:14 Page 9

Flow: small rubra

Electronically signed by Poier, Jennifer Laura, LPN at 09/07/2024 14:13

Wyrostok, Katherine Ruth, RN at 09/07/2024 21:54

Vitals & Oxygen:

Printed on 11/12/2024 10:14 Page 10

Electronically signed by Wyrostok, Katherine Ruth, RN at 09/07/2024 21:55

Adigun, Oyinlade Dorcas, RN at 10/07/2024 06:12