TITLE: GUIDELINE FOR THE USE OF THE LABOR PROGRESS CHART

INSTRUCTIONS:  This guideline is used in conjunction with the Maternal/Infant Division Documentation Policy.

1. Affix patient identification label in upper right hand corner.
2. Fill in the blanks provided for the patient’s gravida, term, pre-term, abortions, living, and estimated date of confinement.
3. Record the admission date.
4. Record the admission time.
5. Record the patient’s age.
6. Record the patient’s blood type and Rh factor.
7. Indicate if the patient’s membranes are intact or ruptured by placing an "X" in the appropriate box. If membranes are ruptured, state the date and time this occured and color of fluid.
8. Record page number in appropriate space provided.
9. Record time of vital signs in the area indicated at the top of graphic chart. Complete across page.
10. Indicate dilation and station of patient by placing a dot for dilation and an "X" for station in the graphic area of the Labor Progress Chart. Then, draw a line from dot-to-dot to indicate the labor curve.
11. Record % of effacement in the indicated area each time the patient is checked.
12. Record the initials of the examiner in the appropriate column.
13. Record the patient’s blood pressure in the space provided. Each little box is a 15 minute interval. The big boxes are hour intervals.
14. Record the fetal heart rate (FHR).
15. Record amount of oxytocin the patient is receiving. Indicate if amount increases or decreases. Place an "0" if the patient is not receiving pitocin.
16. Record the frequency, duration, and quality of the patient’s contractions.
17. Record the vital signs every hour.
    Note:  Items 13-19 are documented every hour unless ordered differently.
18. Record any optional information, such as urine output or temperature in this area.
19. Record any other pertinent information that relates to the patient’s care while she is in labor.
20. Record progress notes as needed. 

KEYPOINT:  Biophysical assessment q shift done in eChart.  Pain medications, pain scale, reason and response to medication are done in eChart.

RESOURCE PERSON(S) Marie Patterson RN, CSM; Stephanie Beall, RN

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