Managing Labor And Delivery

Documents to Request

• Admission history and physical
• Prenatal record summary (OB flow sheet)
• Prior operative reports (if VBAC candidate)
• EFM tracing records
• Nursing labor flowsheet
• Anesthesia records
• Medication administration record (oxytocin log)

Step 1: Assess Cervical Status Using the Bishop Score

The Bishop score determines cervical favorability for induction:

• Bishop score ≥ 8: Favorable cervix — high likelihood of successful induction
• Bishop score < 6: Unfavorable cervix — consider cervical ripening (misoprostol, dinoprostone, mechanical balloon)

Document the Bishop score at admission and before any induction agent is administered.

Step 2: Monitor Labor Progress per ACOG/SMFM Criteria

First Stage — Latent Phase

• Cervix 0–6 cm
• No strict time limit per ACOG Safe Prevention consensus
• Prolonged latent phase: > 20 hours (nulliparas), > 14 hours (multiparas) — this alone is NOT an indication for cesarean
• Interventions: ambulation, hydration, rest, consider amniotomy if membranes intact

First Stage — Active Phase

• Begins at 6 cm (redefined from older 4 cm threshold)
• Expected dilation rate: ≥ 1 cm/hour is NOT required
• Arrest of active phase = ≥ 6 cm dilation with ruptured membranes AND no cervical change for:
  • ≥ 4 hours with adequate contractions (≥ 200 Montevideo units)
  • ≥ 6 hours with inadequate contractions despite oxytocin augmentation

Second Stage

• From complete dilation to delivery of the infant
• Allow at least:
  • 3 hours for nulliparas (4 hours with epidural)
  • 2 hours for multiparas (3 hours with epidural)
• Arrest of second stage requires these minimums to be met before diagnosing arrest
• Active pushing should be documented with maternal effort assessment

Document every cervical exam with: time, dilation, effacement, station, position, and contraction adequacy.

Step 3: Manage Oxytocin Augmentation

When augmentation is indicated, document using a standardized protocol:

Tachysystole management (> 5 contractions in 10 minutes averaged over 30 minutes):

1. Decrease or discontinue oxytocin
2. Maternal repositioning (lateral decubitus)
3. IV fluid bolus
4. Consider terbutaline 0.25 mg SQ if persistent
5. Assess FHR tracing for associated decelerations

Document: oxytocin start time, each dose change with time, contraction frequency/strength, and any tachysystole episodes with management.

Step 4: Document the Delivery

Vaginal Delivery Summary

• Time of delivery
• Presentation and position at delivery (e.g., OA, OP, OT)
• Delivery mechanism (spontaneous, vacuum-assisted, forceps-assisted)
• Episiotomy (type) or laceration (degree: 1st through 4th)
• Cord management (delayed cord clamping duration, nuchal cord, cord gases sent)
• Placenta delivery (spontaneous vs. manual, time, completeness)
• Estimated blood loss (EBL)
• Infant status: sex, weight, Apgar scores (1 min, 5 min, 10 min if needed)
• Skin-to-skin initiation

Shoulder Dystocia Documentation (if applicable)

Document using the HELPERR mnemonic: time of head delivery, time of body delivery, maneuvers used (McRoberts, suprapubic pressure, Rubin, Wood screw, delivery of posterior arm, Gaskin), and total head-to-body delivery interval.

Step 5: Immediate Postpartum Assessment

• Uterine tone (firm vs. boggy)
• Fundal massage performed
• Active management of third stage (oxytocin 10–40 units in 1 L, or IM 10 units)
• Laceration repair details (suture type, technique)
• Hemodynamic stability (vital signs q15 min × 1 hour, then q30 min × 1 hour)
• Quantitative blood loss (QBL) measurement
• Hemorrhage risk assessment per CMQCC bundle

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Are all cervical exams documented with time, dilation, effacement, station, and contraction adequacy?
2. Does the arrest diagnosis meet ACOG/SMFM criteria — 4 hours adequate or 6 hours inadequate contractions at ≥ 6 cm with ruptured membranes?
3. Is oxytocin management fully logged — start time, dose changes, tachysystole events?
4. Is the delivery summary complete — including Apgars, EBL, laceration degree, and cord management?
5. Is the timeline internally consistent — admission → active labor → complete → delivery → placenta → postpartum, with no unexplained gaps?

Quality Audit

• Bishop score documented before induction initiation
• Cervical exams documented at minimum every 2–4 hours in active labor
• Membrane rupture time, fluid character (clear, meconium-stained, bloody), and GBS prophylaxis status recorded
• ACOG/SMFM arrest criteria applied correctly before cesarean diagnosis
• Oxytocin titration log is complete with dose, time, and contraction response
• Fetal heart rate category documented at each cervical exam
• Delivery time recorded to the minute
• Apgar scores at 1 and 5 minutes documented
• Estimated blood loss documented (quantitative preferred)
• Laceration degree and repair documented
• Placenta delivery time and completeness documented
• Third-stage active management documented
• Shoulder dystocia (if occurred) documented with maneuvers and time intervals
• Postpartum vital signs and uterine tone documented

Guidelines

1. Never diagnose labor arrest before 6 cm — per ACOG, the latent phase should be given adequate time and is not an indication for cesarean.
2. Document contraction adequacy — use Montevideo units when IUPC is in place; otherwise describe frequency and palpated strength.
3. Time-stamp every event — cervical exams, membrane rupture, medication changes, delivery, and placenta delivery all require exact times.
4. Use standardized laceration grading — 1st degree (mucosa/skin only), 2nd degree (into perineal muscles), 3rd degree (into anal sphincter), 4th degree (through rectal mucosa).
5. Document VBAC counseling — if applicable, record the discussion of risks (0.5–0.9% uterine rupture rate for one prior low-transverse cesarean), benefits, and patient decision.
6. Report quantitative blood loss — replace "EBL" with measured QBL where institutional protocol supports it.
7. Flag meconium — document consistency (thin vs. thick) and whether neonatal team was present at delivery.