26. Characteristics of labor and delivery
Category: Labor and Delivery
BC # 45
Definitions | Information about the course of labor and delivery. |
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Instructions | Check all characteristics that apply.
If none of the characteristics of labor and delivery apply, check “none of the above.” |
Sources | See below |
Keywords and Abbreviations |
See below |
Definitions |
Initiation of uterine contractions by medical or surgical means for the purpose of delivery before the spontaneous onset of labor (i.e., before labor has begun). Examples of methods include, but are not limited to: artificial rupture of membranes, balloons, oxytocin, prostaglandin, luminaria , or other cervical ripening agents. |
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Instructions |
Check this item if medication was given or procedures to induce labor were performed before labor began. If it is not clear whether medication or procedures were performed before or after labor had begun, review records to determine when labor began and when medications were given or procedures performed. If this information is unclear or unavailable, check with the birth attendant. Induction of labor should be checked even if the attempt to initiate labor is not successful or the induction follows a spontaneous rupture of the membrane without contractions. NOTE: Does not include augmentation of labor, which applies only after labor or contractions have begun. Do not report augmentation of labor if induction of labor is reported. |
Sources |
1st Delivery record under –
2nd Physician progress note 3rd Labor and delivery nursing admission triage form |
Keywords and Abbreviations |
IOL – Induction of labor Pit Ind – Pitocin induction ROM/NIL – Amniotomy induction AROM – Artificial rupture of membranes done before labor Balloons Oxytocin Prostaglandin Luminaria Cervidil |
Definitions | Stimulation of uterine contractions by drug or manipulative technique with the intent to reduce the time of delivery (i.e., after labor has begun). |
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Instructions |
Check this item if medication was given or procedures to augment labor were performed after labor began. If it is not clear whether medication or procedures were performed before or after labor had begun, review records to determine when labor began and when medications were given or procedures performed. If this information is unclear or unavailable, check with the birth attendant. NOTE: Do not include if induction of labor was performed. Do not report induction of labor if augmentation of labor is reported. |
Sources |
1st Delivery record under –
2nd Physician progress note |
Keywords and Abbreviations |
Pit stim – Pitocin stimulation Pit aug – Pit augmentation AROM – Artificial rupture of membranes done during labor Cervidil |
Definitions | Steroids received by the mother prior to delivery to accelerate fetal lung maturation. Typically administered in anticipation of preterm (less than 37 completed weeks of gestation) delivery.
Steroids include: betamethasone, dexamethasone, or hydrocortisone specifically given to accelerate fetal lung maturation. Does not include steroid medication given to the mother for anti-inflammatory treatment before or after delivery. |
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Instructions |
Three conditions must be met for this item . Check this item when 1) steroid medication was given to the mother 2) prior to delivery 3) for fetal lung maturation. Steroids may be administered to the mother prior to admittance to the hospital for delivery . Review the mother’s prenatal care and other hospital records for mention of steroid administration for this purpose. |
Sources |
1st Delivery record under –
2nd Maternal medication record 3rd Newborn admission history and physical (H&P) 4th Maternal physician order sheet 5th Prenatal care records |
Keywords and Abbreviations |
Medications (before delivery): Betamethosone (Celestone) Betamethasone phosphate Beta-PO4 Betamethasone acetate Beta-Ac Dexamethasone BMZ |
Definitions |
Includes antibacterial medications given systemically (intravenous or intramuscular) to the mother in the interval between the onset of labor and the actual delivery. Includes:
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Instructions | Mother should have undergone labor, regardless of method of delivery; antibiotics administered solely for surgery such as cesarean delivery should not be reported.
Check the timing of the administration of the antibacterial medications. Check this item only if medications were received systemically by the mother during labor. If information on onset of labor cannot be determined from the records, check with the birth attendant. |
Sources |
1st Delivery record under –
2nd Maternal medication record 3rd Newborn admission history and physical (H&P) 4th Maternal physician order sheet 5th Prenatal care records |
Keywords and Abbreviations |
Medications (during delivery):
Look for:
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Definitions |
Clinical diagnosis of chorioamnionitis during labor made by the delivery attendant. Usually includes more than one of the following: fever, uterine tenderness or irritability, leukocytosis, fetal tachycardia, maternal tachycardia, or malodorous vaginal discharge. Any recorded maternal temperature at or above 38°C (100.4°F). |
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Instructions |
Check that recorded maternal temperature is at or above 38°C (100.4°F). |
Sources | 1st Delivery record under –
2nd Newborn admission H&P 3rd Physician progress note 4th Maternal vital signs record under – Temperature
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Keywords and Abbreviations |
Chorioamnionitis Chorio Temp ≥ 38°C or 100.4°F Look for:
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Definitions |
Administration to the mother of a regional anesthetic to control the pain of labor. Delivery of the agent into a limited space with the distribution of the analgesic effect limited to the lower body. |
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Instructions | Mother should have undergone labor, regardless of method of delivery; anesthesia administered solely for surgery such as cesarean delivery should not be reported. |
Sources | 1st Delivery record under –
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Keywords and Abbreviations |
Epidural analgesia Epid. given Spinal given |