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Case Study With Obstetric SOAP Notes: Arrest of Dilation

Updated on April 24, 2017
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NurseFlood is a self-proclaimed birth nerd with three babies and 8+ years of nursing experience, most of which is in women's health.

Introduction

Looking for how to write an obstetric SOAP note? Otherwise, follow along with this case study.

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

Patient desires are also extremely relevant to care, including 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.

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

Case Study

Admission: 2230

Subjective

CC/HPI: 30 y.o. G2P1 at 39 weeks 4 days gestation by certain LNMP 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 in to the hospital before the blizzard”. Positive FM, bloody show present, membranes in tact, contractions palpate varying intensities. Pt rating pain 4/10. Would like an unmedicated water birth, FOB & doula support present.

OB Hx: PNC began @ 8w1d X 12 visits. No complications. Hx precipitous birth 2012.

EDB: 2/22/2015 LMP: 5/18/2014

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 OGTT: 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 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: Neg proteinuria, neg glucose in urine

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 in tact, 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 LNMP

2) Early labor

3) Category I fetal heart tracing

4) GBS negative

Plan

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

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

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 tub at 5 cm.

Progress Note: 2330

S: Pt c/o increasing pressure and pain, rating 8/10. Requesting vaginal exam in order to get into 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) Patient remains low-risk, continue IA

Progress Note: 0200

S: Pt states she has urge to push while on 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: 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 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

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 an arrest in dilatation of active labor.

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

OB Attending Progress note: 0700

30 y.o. G2P1 @ 39 4/7 wks evaluated for 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 4/7 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 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: 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: Arrest of dilatation

Category 1 tracing

P: Pain management: warm water immersion with telemetry

Anticipate SVD

Birth Note: 2/19/2014 0930

Complete dilation at 0855. Spontaneous vaginal birth of viable female infant at 0908, Apgars 9/9, wt. 7#5oz, over in tact perineum. Infant vigorous, placed in kangaroo care. Placenta delivered spontaneously, after cord finished pulsating, and in tact at 0918 via Schultz with 3 vessel cord evident. Perineum examined and found to be in tact. 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 multip who arrived in spontaneous labor @2230. She has been at 7cm/100% effaced/-1 station for 5 hours. Her VS 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 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. However, there is no universal definition for labor dystocia. There is no consensus among arrest disorders or protracted labor definitions (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).

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 /

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    • waqasali101 profile image

      waqas ali 5 months ago from abbottabad

      Nice Article Dear