What is the subjective, objective, assessment, and plan for a pregnant patient in labor?

Subjective, Objective, Assessment, and Plan for Pregnant Patient in Labor

The most effective approach to managing a pregnant patient in labor requires systematic assessment using the SOAP format (Subjective, Objective, Assessment, Plan) with continuous monitoring of maternal and fetal well-being to ensure optimal outcomes.

Subjective Assessment

• Obtain information about multiparity, previous rapid or non-hospital deliveries, presence of regular and painful uterine contractions, and urge to push to predict imminent delivery 1
• Document timing of contraction onset, frequency, duration, and intensity 1
• Assess pain level and effectiveness of current pain management strategies 2
• Record time of membrane rupture if applicable, including color and amount of fluid 2
• Note any symptoms of concern such as vaginal bleeding, severe headache, visual disturbances, or decreased fetal movement 1
• Document maternal medical history, particularly conditions that may affect labor management (cardiovascular disease, hypertension, diabetes) 1

Objective Assessment

Maternal Assessment

• Vital signs: blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation 1
• Cervical examination to determine:
  • Dilation (measured in centimeters) 3
  • Effacement (expressed as percentage) 3
  • Station of presenting part 3
  • Position and consistency of cervix 3
  • Calculate Bishop score to evaluate cervical readiness 3
• Uterine contraction pattern: frequency, duration, intensity, and resting tone 1
• Assessment for signs of infection, dehydration, or other complications 1

Fetal Assessment

• Continuous electronic fetal heart rate monitoring is recommended during labor 1
• Evaluate baseline fetal heart rate (normal: 110-160 bpm) 1, 4
• Assess fetal heart rate variability (normal: 6-25 bpm) 4
• Document presence of accelerations (reassuring) 4
• Identify and classify any decelerations as early, variable, late, or prolonged 1, 4
• Correlate decelerations with uterine contractions to determine significance 1

Assessment

• Determine stage and phase of labor based on cervical examination and contraction pattern 5
• Classify labor progress using dilation and descent curves 6, 5
• Evaluate fetal status using the NICHD three-tier fetal heart rate classification system 1:
  • Category I: Normal (reassuring)
  • Category II: Indeterminate (requires continued surveillance and reevaluation)
  • Category III: Abnormal (requires prompt intervention) 1
• Identify any labor abnormalities or complications that may require intervention 6, 5
• Assess risk factors for potential complications during labor 1

Plan

Normal Labor Management

• Position the laboring woman in lateral decubitus position to attenuate hemodynamic impact of contractions 1
• Provide appropriate pain management, considering lumbar epidural analgesia when indicated 1
• Monitor maternal vital signs and fetal heart rate at appropriate intervals 1
• For low-risk women in spontaneous labor, consider intermittent auscultation rather than continuous electronic monitoring 2
• Allow labor to progress naturally when possible, avoiding unnecessary interventions 2

Abnormal Labor Management

• For abnormal fetal heart rate patterns, implement intrauterine resuscitation measures 1:

  1. Change maternal position
  2. Assess maternal vital signs
  3. Discontinue oxytocin if in use
  4. Administer oxygen at 6-10 L/minute
  5. Perform vaginal examination to check for cord prolapse or rapid descent
  6. Administer intravenous fluids
  7. Consider amnioinfusion for recurrent variable decelerations
  8. Assess need for expedited delivery 1

• For labor dystocia or arrest of dilation (≥6 cm):

  • Consider oxytocin augmentation if contractions are inadequate 7, 6
  • Administer oxytocin per protocol for medical (not elective) indications 7
  • Reassess progress regularly using percentile rankings based on adaptive multifactorial models 5

Delivery Preparation

• Prepare for assisted vaginal delivery with forceps or vacuum extraction if indicated 1
• For women with cardiovascular disease, consider specific positioning and monitoring requirements 1
• After delivery, administer slow IV infusion of oxytocin (<2 U/min) to prevent postpartum hemorrhage 1
• Continue maternal hemodynamic monitoring for at least 24 hours after delivery in women with structural heart disease 1

Special Considerations

• For women on anticoagulation therapy with prosthetic heart valves, follow specific protocols for transitioning medications before delivery 1
• For women with severe cardiac conditions (severe aortic stenosis, pulmonary hypertension, or acute heart failure), consider cesarean delivery 1
• Be vigilant for signs of postpartum hemorrhage, especially in high-risk patients 1