Case Study With Obstetric Soap Notes: Arrest of Dilation - HealthProAdvice - Health and Wellness
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Case Study With Obstetric Soap Notes: Arrest of Dilation

Caitlin Goodwin is a Certified Nurse-Midwife and birth nerd with 12 years in obstetric nursing.

What happens when birth plans and facility policy conflict?

If you're looking for the basics of how to write an obstetric SOAP note, see the introductory article I wrote on the same topic. If you're feeling a bit more advanced, follow along with this women's health case study.

There is a fine line between promoting and empowering women, performing within our professional framework, and adhering to our facility’s policies. The hallmarks of midwifery include “measures to support psychosocial needs during labor and delivery” (American College of Nurse-Midwives, 2015).

However, patient desires are relevant to care and include communication and shared decision making regarding birth plans, values, culture, and beliefs. It’s complicated to initially navigate the management of a case when the experts haven’t come to a consensus with one another. There is no one correct answer for many topics within labor and childbirth.

I am a huge advocate for midwifery care and empowering women. However, birth can be an exhausting and challenging time for both professionals and mothers.

This case deals with the conflict between facility policy and patient desires while trying to promote the hallmarks of midwifery.

Case Study: Admission

2/19/20 2230

Subjective

CC/HPI: 30 y.o. G2P1 at 39 weeks 4 days gestation by certain LMP who presents with contractions q 5 minutes for the last two hours. She states that she “delivered within 2 hours of starting labor last time” and wanted to “make it into the hospital before the blizzard”. Positive FM, bloody show present, membranes intact, contractions palpate varying intensities. Pt rating pain 4/10. Would like unmedicated water birth, FOB & doula support present.

OB Hx: PNC began @ 8w1d X 12 visits. No complications. Hx precipitous birth 2018.

EDD: 2/22/2020 LMP: 5/18/2019

Labs: ABO type/RH: A+, Antibody screen: neg; Hgb/Hct 12/38; Rubella: Immune; RPR neg; HbsAg: neg; HIV: neg; GC: neg, CT: neg; 1 hr Glucose Challenge Test: 105; GBS: neg.

Tdap/Flu: declined. Pap WNL 4/2012

Weight gain: 26 lbs. Initial BMI: 18.6

Allergies: Sulfa- hives

Current Meds: PNV

PMH: Pyelonephritis 2004

PSH: none

Family: Mother: Hyperlipidemia; Other family hx: noncontributory

Social: Married. English speaking. No history of tobacco or drug use. 2 small glasses of wine per week prior to pregnancy.

Objective

Vital Signs: BP 110/70 P 64 WT 131 HT 63” BMI 23.2

Labs: UA: Neg proteinuria, neg glucose

PE: General: Healthy, Alert and oriented X4 female in mild distress

CV: S2S2 regular rate & rhythm

Lungs: Clear to auscultation

Breast: Soft & symmetric, no masses, dimpling or puckering, no nipple discharge bilat. No palpable axillary lymph masses

Abdomen: Normal, gravid, fundal ht: 38 cm

Female Genitourinary: External: Genitalia normal, perineum intact, no lesions, skin tags, or lymphadenopathy.

SVE: 4/60/-2, soft, posterior, vertex.

Extremities: no edema, neg Homan’s, FROM all extremities, DTR +2

FHT: Baseline 145, moderate variability, + accels, no decels.

Toco: q 5 mins X 45-60 secs, palpate mild to moderate

Assessment

1) IUP at 39 weeks 4 days gestation by sure LMP

2) Early labor

3) Category I fetal heart tracing

4) GBS negative

Plan

1) Pt was given options: *Admit: Expectant management with Intermittent Auscultation (IA) FHTs q 30 mins, or;

*Discharge: Pt in early labor, return when more active

Patient opts for admission.

2) Labs: T&S, H/H

3) Pain management: warm water immersion when patient ready. Discussed risks & benefits. Pt verbalizes understanding and wishes to enter the tub at 5 cm.

Progress Note #1

2/19/20 2330

S: Pt c/o increasing pressure and pain, rating 8/10. Requesting a vaginal exam in order to get into the tub.

O: Maternal VSS, afebrile

SVE 5/80/-1

FHT baseline 140, moderate variability, + accels, no decels

Toco: q 2-3 mins X 45-60 secs, palpate moderate

T&S: A+; H/H: 11/34

A: 1) Active labor

2) Category 1 FHTs

P: 1) Pt to enter tub for warm water immersion

2) The patient remains low-risk, continue IA

Progress Note #2

2/20/20 0200

S: Pt states she has the urge to push while on the birth ball.

O: Maternal VSS, afebrile

SVE 7/100/-1

FHT baseline 150, moderate variability, + accels, no decels

Toco: q 3-4 mins X 60 secs, palpate moderate

A: 1) Active labor

2) Category 1 FHTs

P: 1) Pt to get out of tub for 15 minutes per hospital protocol

2) Anticipate SVD

Progress Note #3

2/20/20 0700

S: Pt states that she feels labor has significantly slowed down

O: Maternal VSS, afebrile

SVE 7/100/-1

FHT baseline 150, mod variability

Toco q 6-15 mins

A: 1) Arrest of dilatation

2) Category I FHTs

P: 1) Discuss options with the patient, including risks and benefits:

*Nipple stimulation per protocol

*Pitocin augmentation per hospital protocol

*Amniotomy per protocol

Pt declines all options, verbalizes understanding of risks. Expectant management continues

2) Consult collaborating physician

Evaluation


  • Would you diagnose an arrest disorder?
  • If not, when would you?
  • What does the evidence say?

SBAR Summary

You discuss the situation with your attending physician.

S: Dr. Smith, Mrs. F has been 7cm/100%/-1 since 0200

B: She is a multip who arrived in spontaneous labor @2230. Her VS are stable & she is afebrile. I offered labor augmentation, and she is declining intervention.

A: She has experienced an arrest in the dilatation of active labor.

R: I would like you to come to evaluate her. When can I expect you?

OB Attending Progress note

2/20/20 0700

30 y.o. G2P1 @ 39 5/7 wks evaluated for the arrest of dilatation in active labor.

BP: 112/68 P 72 T: 36.8 C RR: 16

FHTs 150s, accelerations present, no decelerations

Toco: q 6-15 mins

SVE 7/100/-1

A: IUP @ 39 5/7 wks by LMP

GBS negative

Active labor- arrest of dilatation

Category I tracing

P: Recommended amniotomy and Pitocin. Discussed risks & benefits. Pt declines.

Pt agrees to nipple stimulation, per hospital protocol. Pt to get out of the tub.

Reactive NST prior to nipple stimulation.

Evaluation


  • What other management options would you choose?
  • Hospital policy does not mention getting out of the tub, or a Reactive NST. Do you feel that the plan of care was acceptable?

Progress Note #4

2/20/20 0800

S: Pt states she is exhausted.

O: Maternal VSS, afebrile

FHT baseline 145, moderate variability, + accels, no decels

Toco: q 6 mins X 60 secs, palpate moderate strength

SVE 7/100/-1

Pt agree to AROM for moderate amount of clear fluid @0755, aware of risks and benefits

A: IUP @ 39 5/7

Arrest of dilatation

Category 1 tracing

P: Pain management: warm water immersion with telemetry

Anticipate SVD

Birth Note

2/19/2020 0930

Complete dilation at 0855. Spontaneous vaginal birth of a viable female infant at 0908, Apgars 9/9, wt. 7#5oz, over intact perineum. Infant vigorous, placed in kangaroo care. Placenta delivered spontaneously after cord finished pulsating, and intact at 0918 via Schultz with 3 vessel cord evident. Perineum examined and found to be intact. EBL 250 ml. Fundus firm and at the umbilicus following delivery, small rubra lochia noted. No complications. Maternal VSS, afebrile. Mother breastfeeding now.

Evaluation


  • Do you feel that this patient gave true consent?
  • How could this birth have been managed differently?
  • What expectations were we, as providers, not able to meet?

Review and Evaluation of Course of Labor

The patient is a multiparous woman who arrived in spontaneous labor @2230. She has been at 7cm/100% effaced/-1 station for 5 hours. Her vital signs are stable & she is afebrile. I recommended labor augmentation, and she declined augmentation with Pitocin, AROM, or nipple stimulation. She wishes for an unmedicated birth without any interventions.

  • The literature shows that normal labor lasts longer than most clinicians expect. There are many variations of normal, dependent on parity, anesthesia, and a decrease in the rate of dilation towards the end of the first stage of active labor (Neal, Lowe, Patrick, Cabbage & Corwin, 2010; Incerti et al., 2011; Albers, 1999). However, this labor still progressed more slowly than normal.
  • After AROM, the patient was completely dilated within one hour and had a healthy baby girl after 13 minutes of second stage labor.
  • Normal labor lasts longer than most clinicians expect. There are many variations of normal (Albers, 1999).
  • Friedman’s curve is 1.2 cm/hr dilation for nulliparas, and 1.5cm/hr for multiparas (Friedman, 1972).
  • One study found the rate of 0.5 cm/hr to be the slowest, normal cervical dilation for low-risk nulliparous women (Neal, Lowe, Patrick, Cabbage & Corwin, 2010).
  • A different study found cervical dilation rate was approximately 1.5 cm/hr. A deceleration phase was present towards the end of the active phase of labor, where the rate slowed down (Incerti et al., 2011).
  • Labor dystocia is the primary indication for cesarean section in the US. (Incerti et al., 2011; Neal et al., 2010).
  • The overall theme is this: normal labor lasts longer than most clinicians expect. There are many variations of normal (Albers, 1999).
  • In 2016, the California Maternal Quality Care Collaborative developed the Toolkit to Support Vaginal Birth and Reduce Primary Cesareans(source). There are universal definitions and guidelines to promote OB provider patience during labor and to decrease the national cesarean rate.

Click through if you need more information about how to write a SOAP note with OB examples.

I hope the case study was thorough. I am interested in your responses and feedback. Please comment below!

References

  • Albers, L. L. (1999). The Duration of Labor in Healthy Women. Journal Of Perinatology, 19(2), 114.
  • American College of Nurse-Midwifes. (2015). Core competencies for basic midwifery practice. Retrieved from http://ourmomentoftruth.midwife.org/index.asp?bid=114
  • Friedman, E. (1972). An objective approach to the diagnosis and management of abnormal labor. Bull. N.Y. Acad. Med. 48. 842-858.
  • Incerti, M., Locatelli, A., Ghidini, A., Ciriello, E., Consonni, S., & Pezzullo, J. C. (2011).
  • Variability in Rate of Cervical Dilation in Nulliparous Women at Term. Birth: Issues In Perinatal Care, 38(1), 30-35. doi:10.1111/j.1523-536X.2010.00443.x
  • Neal, J. L., Lowe, N. K., Patrick, T. E., Cabbage, L. A., & Corwin, E. J. (2010). What is the slowest-yet-normal cervical dilation rate among nulliparous women with spontaneous labor onset?. Journal Of Obstetric, Gynecologic, And Neonatal Nursing: JOGNN /

This content is for informational purposes only and does not substitute for formal and individualized diagnosis, prognosis, treatment, prescription, and/or dietary advice from a licensed medical professional. Do not stop or alter your current course of treatment. If pregnant or nursing, consult with a qualified provider on an individual basis. Seek immediate help if you are experiencing a medical emergency.

© 2017 Caitlin Goodwin

Comments

waqas ali from abbottabad on February 28, 2017:

Nice Article Dear

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