26. Characteristics of labor and delivery

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.

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.

1st  Delivery record under –

• Maternal OB/labor summary
• Labor and delivery admission history
• Labor summary record

2nd  Physician progress note

3rd  Labor and delivery nursing admission triage form

IOL – Induction of labor

Pit Ind – Pitocin induction

ROM/NIL – Amniotomy induction
or induction for rupture of
membranes, not in labor

AROM – Artificial rupture of membranes done before labor

Balloons

Oxytocin

Prostaglandin

Luminaria

Cervidil

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.

1st  Delivery record under –

• Maternal OB/labor summary
• Labor and delivery admission history
• Labor summary record

2nd  Physician progress note

Pit stim – Pitocin stimulation

Pit aug – Pit augmentation

AROM – Artificial rupture of membranes done during labor

Cervidil

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.

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.

1st Delivery record under –

• Maternal OB/labor summary–comments
• Labor summary record–comments

2nd Maternal medication record

3rd Newborn admission history and physical (H&P)

4th Maternal physician order sheet

5th Prenatal care records

Medications (before delivery):

Betamethosone (Celestone)

Betamethasone phosphate

Beta-PO4

Betamethasone acetate

Beta-Ac

Dexamethasone

BMZ

Includes antibacterial medications given systemically (intravenous or intramuscular) to the mother in the interval between the onset of labor and the actual delivery.

Includes:

• Ampicillin
• Penicillin
• Clindamycin
• Erythromycin
• Gentamicin
• Cefataxine
• Ceftriaxone

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.

1st Delivery record under –

• Maternal OB/labor summary–comments
• Labor summary record–comments

2nd Maternal medication record

3rd Newborn admission history and physical (H&P)

4th Maternal physician order sheet

5th Prenatal care records

Medications (during delivery):

• Ampicillin
• Penicillin
• Clindamycin
• Erythromycin
• Gentamicin
• Cefataxine
• Ceftriaxone
• Vancomycin

Look for:

• SBE (sub-acute bacterial endocarditis) prophylaxis
• GBS positive or GBS + (Group B streptococcus)
• Maternal fever
• Mother febrile

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).

Check that recorded maternal temperature is at or above 38°C (100.4°F).

• Maternal OB/labor summary – comments/complications
• Labor summary record – comments/complications

2nd  Newborn admission H&P

3rd  Physician progress note

4th  Maternal vital signs record under – Temperature
recordings

Chorioamnionitis

Chorio

Temp ≥ 38°C or 100.4°F

Look for:

• Maternal fever
• Mother febrile

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.

• Maternal OB labor summary under – analgesia or anesthesia
• Labor summary record under – analgesia or anesthesia

Epidural analgesia

Epid. given

Spinal given